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Overview of Health Policies/strategies/acts in relation to Human Rights

Dr. T.GakuruhSPMD/MoHHENNET: HEALTH AND HUMAN RIGHTS WORKSHOP

KSMS

31st March 2008

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Kenya’s Health Policy Framework (1994)

Kenya’s Health Policy Framework goal to 2010- “ to promote and improve the health of all Kenyans through the deliberate restructuring of the health sector to make all health services more effective, accessible and affordable”.

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'90 '95 '00 '02 '05 '10 '15

U<5MR

IMR

Sector performance trends

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Health Related MDGs4. Reduce Child Mortality i.e. Reduce 2/3

(67%) between 1990 and 2015, the under five mortality rate.

5. Improve Maternal Health i.e reduce by ¾ (75%) between 1990 and 2015, the maternal ratio.

6. Have halted by 2015 and began to reverse the spread Of HIV/AIDS. Combat HIV/AIDS, Malaria, TB and other diseases.

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The Goal of NHSSPII is to reduce health inequalities and to reverse the downward trend in health-related

outcome and impact indicators.

NHSSPII development Policy objectives

Programme areas of JPWF and AOPS

Overall development Goal (ERS): Expand economic growth, enhance social development and reduce poverty

Programme areas of AOPS

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NHSSPII Objectives1. Increase equitable access to health

services:

2. Improve quality and responsiveness of services in the sector:

3. Improve the efficiency and effectiveness of service delivery;

4. Foster partnerships in improving health and delivering services; and

5. Improve financing of the health sector.

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LEVELS OF CARE IN KEPH

Level 6

Tertiary Hospital

Level 5 Secondary Hospital

Level 4 Primary Hospital

Level 3 health Centre, Maternity and Nursing Home

Level 2 Dispensary/Clinics

Level 1 Community: Village/Household/Family/Individuals

Interface

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KEPH Principles – Human Capital Development

Dispensary/Dispensary/

clinic clinic

Health Health Centre/maternityCentre/maternity/Nursing home/Nursing home

Primary Primary HospitalHospital

Secondary HospitalSecondary Hospital Tertiary HospitalTertiary Hospital

Essential Essential PackagesPackages

CommunityCommunity

FamilyFamily

HouseholdHousehold

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Fig xx.xx: Managing health sector performance *

Support systemsService Delivery

Health sector performance

Health outcomes

1. Interface between Services and Community …

2. District Health Planning…

3. Financial Management …

4. Monitoring and Evaluation…

5. Human Resources…

6. Standards and Quality Assurance …

7. Commodity supply (pharmaceuticals / equipment) …

8. Maintenance (infrastructure, equipment, transport) …

9. Communication systems / ICT…

* adapted from Chen and Evans (2004)

IMPROVED HEALTH of

the POPULATION

KEPH

Quality and responsiveness

to demand

Equitable access

Efficiency and effectiveness

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Results Based Management elements

1. Performance planning

2. Performance target setting (organisation, group & individual)- Performance Contracts

3. Performance appraisal (organisation, group & individual)

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Kenya’s Health PolicyFramework 1994

Annual O

perational P

lan 2006/07

National Health Strategic Plan2005/10

Per

form

ance

App

rais

al

Performance Contract

Health sector programming process

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AOP TargetsCoast Central Eastern Nairobi North Eastern Nyanza Rift Valley Western National Indicators

Baseline Target Baseline Target Baseline Target Baseline Target Baseline Target Baseline Target Baseline Target Baseline Target Baseline Target % deliveries conducted by skilled health staff in facility 14% 25% 10% 27% 7% 32% 2% 4% 15% 19% 4% 26% 6% 14% 2% 8% 5% 19%

# LLITN distributed to pregnant women in health facility 14,880 18,840 7,140 24,000 56,483 24,688

3 1,532 3,519 1,179 4,071 47,124 78,127 59,084 118,805 75,435 112,855 203,773 488,295

% pregnant women sleeping under LLITNs 27% 36% 26% 36% 0% 14% 1% 2% 0% 38% 30% 43% 9% 26% 14% 32% 15% 28% % pregnant women attending four ANC visits 25% 31% 57% 62% 0% 17% 24% 31% 19% 24% 32% 36% 46% 53% 17% 33% 25% 36%

% Pregnant women receiving IPT 2x 26% 31% 24% 42% 0% 27% 0% 2% 17% 22% 32% 39% 35% 44% 16% 42% 16% 34% % deliveries by skilled health staff 21% 33% 50% 56% 0% 43% 11% 14% 5% 9% 21% 28% 28% 30% 21% 40% 23% 37% % WRA receiving FP commodities 44% 53% 54% 70% 0% 37% 19% 26% 1% 3% 19% 22% 24% 31% 8% 41% 21% 38% % newborns receiving BCG 48% 45% 68% 78% 0% 48% 69% 88% 20% 26% 47% 53% 65% 62% 32% 43% 39% 55% % HIV + pregnant women receiving nevirapine 4% 44% 0% 0% 0% 5% 0% 0% 0% 0% 38% 53% 24% 34% 6% 16% 9% 19%

# LLITNs distributed to children < 5 yrs in health facility 102,264 119,18

3 25,701 94,000 50,857 107,089 6,126 13,416 1,207 32,173 166,526 312,83

4 262,830 455,608 140,500 1,108,936 493,181 1,787,630

% children sleeping under LLITN 30% 39% 14% 46% 0% 7% 1% 2% 8% 16% 40% 50% 30% 23% 7% 79% 13% 46% % children at 6 months on exclusive breastfeeding 20% 60% 0% 0% 0% 13% 0% 0% 0% 0% 0% 18% 0% 3% 0% 8% 0% 14%

% children fully immunized at 1 year of age 74% 86% 83% 91% 0% 81% 53% 54% 41% 48% 59% 66% 56% 60% 26% 48% 42% 66% % children < 1yr vaccinated for measles 41% 47% 50% 69% 0% 62% 34% 38% 50% 57% 53% 58% 46% 53% 30% 50% 34% 54% % children receiving Vitamin A (1-2 doses) 30% 44% 69% 83% 0% 50% 28% 34% 53% 60% 35% 44% 46% 51% 6% 153% 22% 111% # of trained village health committees 13 92 17 54 6 151 3 4 303 57 14,536 18,130 169 771 286 42,184 15,164 60,672 # condoms distributed 8.53 3.00 0.40 3.60 0.31 0.88 8.59 1.30 0.51 0.63 0 30 0.77 1.20 9.90 11.5 28.25 31.8 # CORPs selected/trained 210 500 450 860 464 1210 70 100 32 376 0 0 5476544 11321000 3,692 45,957 4,918 49,003 New outpatient visits 774,600 400,00

0 403,779 251,206 547,030 400,00

0 314,640 319,80 230,400 140,000 0 0 4,318,333 3,978,370 837,566 72,057 3,108,015 1,582,743

# VCT clients 7672 47129 14790 15816 19233 23100 49955 60043 120 340 0 0 50832 76710 45654 87062 137424 233490 # HIV+ patients starting ART 525 1250 2334784 1757 340 500 2150 3450 12 31 0 0 9108 12600 12578 56557 2350389 63545

** Note: Seven districts ( Baringo, Garisa, Mwingi, Mbeere,Tana River, Mombassa, Kakamega) have not submitted their plans at all and two districts plans (Tharaka, and Kisimu municipality) did not have service delivery baselines and targets. The above consolidated sheet therefore does not include these omissions.

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2006 2007 2008 2009

Total GOK Expenditure 457.0 526.7 581.1 650.3

Total MOH Expenditure (excl. aid) 35.0 38.9 43.1 53.0

% of total GOK 7.7 7.4 7.4 8.2

Total MOH Expenditure (incl. aid) 53.7 61.4 48.6 58.3

% of total GOK 11.8 11.7 8.4 9.0

Total MOH as share of Total Revenue 14.9% 18.5% 12.0% 14.6%

Source: BSP 2007

Allocations Projections

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Trend in recurrent (gross) expenditure by economic categories (% share of total MOH recurrent expenditures)

  2002/03

2003/04

2004/05

2005/06

2006/07

Salaries and Other Personnel costs

54.1 52.5 51.9 52.7 52.7

Transfers, Subsidies & Grants 8.0 9.4 9.0 8.3 7.7

Drugs and Medical Consumables

9.4 11.1 10.6 10.5 11.1

Operating & Maintenance 8.7 8.3 10.1 7.5 8.2

Purchase of Plant & Equipment 0.7 0.1 0.5 2.9 2.4

Kenyatta National Hospital 16.2 15.6 15.3 14.5 14.4

Moi Referral & Teaching Hospital

2.9 3.0 2.6 3.6 3.5

Total % 100.0 100.0 100.0 100.0 100.0

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Country Public expenditureon health (% of GDP)2003–04

GDP perCapita (US$)

Kenya 1.7 481

Tanzania 2.4 288

Uganda 2.2 245

Zambia 2.8 471

Malawi 3.3 149

Zimbabwe 2.8 363

Rwanda 1.6 208

Burundi 0.7 90

Ethiopia 3.4 114

Source: UNDP: Human Development Report 2006

Total Public Spending on Health - Selected East and Central African Countries.

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District resource allocation criteria

Population 30%Women in reproductive age

25%

Under-five children 20%HIV prevalence rate 5%Government facilities 15%Area (sq km) 5%

17Kenya – Health Sector JPWF

Page 1

SECTOR COORDINATION STRUCTURE

DISTRICT HEALTH STAKEHOLDERS FORUM

VILLAGE HEALTH COMMITTEE

HEALTH FACILITY COMMITTEES

4. Implementation management

HEALTH FACILITY -CHARGE

Implementing Partners

Development Partners

Roles

Stewardship

MINISTER’S OFFICE JOINT INTERAGENCY COORDINATING COMMITTEE (JICC)

HEALTH SECTOR COORDINATING COMMITTEE (HSCC)

PROVINCIAL STAKEHOLDERS FORUM

TECHNICAL STAKEHOLDERS COMMITTEE (TSC)

Secretariat

GIC & other sub committees

PS

2. Technical strategic direction

1. Policy Level

3. Support System PMO

DMOH

DMS

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Responsiveness to client needs Service Charter developed rolled out to

hospitals 2007/8, lower levels 2008/10 inclusive of fee schedules in health facilities, suggestion boxes & quality indicators commitments

Complaint procedures are being installed in public sector through corruption prevention mechanisms

Community intervention by Community Health Committees and Workers to enhance their participation in health care and facilitate accountability of health facilities

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CITIZENS’ SERVICE DELIVERY CHARTER FOR A HEALTH FACILITYPreamble

This health facility and its staff is committed to provide high quality health care services to all our clients with dignity, professionalism and within the shortest time possible.

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Services rendered User charges (Kshs) Waiting time

1.Attendance and customer care desk/enquiries Free 5 minutes

1.Payment for hospital charges Free 30 minutes

1.Registration cardProvincial/District hospitals/sub districtHealth centerDispensaries

502010

30 minutes

1.ConsultationAdults & children above 5 yrs (Hospitals)Children below 5 yrs

30Free

20 minutes20 minutes

1.Dispensing medicineProvincial/District HospitalsHealth centers & dispensaries

30 – 400Free

20 minutes20 minutes

1.Vaccinations Free 20 minutes

1.Laboratory Services 50 – 400 30 minutes

1.X-Ray services 300 – 500 20 minutes

1.Emergency – admission Payable after treatment 10 minutes

1.Non emergency admission Payable after treatment 5 minutes

1.Emergency operation services 3,000 (payable after treatment) 30 minutes

1.Non emergency operation 3,000 24 hrs

13. Collecting body from mortuaryMortuary chargesTransfer from ward to mortuaryEmbalming

Free 200 per dayFree 500

1 hr1 hr1 day

Medical superintendents to ensure full accountability for all medicines, equipment and commodities

TREATMENT FRO MALARIA, TB, HIV/AIDS AND EPIDEMICS IS FREE

Any service that does not conform to the above standards or an officer who does not live up to the commitment to courtesy and excellence in service delivery should be reported to the Outpatient Matron/Nursing OfficerHUDUMA BORA NI HAKI YAKO

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Key challengesThe pace and ability to jointly:

Develop a district-wide plan Hold regular performance reviews

The pace and resources to empower the communities

Pace, resources and commitment of civil societies to engage

Innovative, realistic and acceptable strategies for vulnerable groups in the society.

Ability to respond concerns on attainment of the MDGs

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Health system and agency bottlenecks and constraints Increase equitable access to health services:

Absence of appropriate and comprehensive implementation guides and frameworks to implement some of the priority services especially for cohort 1.

Lack of a comprehensive view of implementation of services for cohort 3 and 6.

Uncoordinated investment in service delivery inputs. Dissemination of comprehensive community approach

not comprehensively done. Delay in initiating the referral strategy resulting into lack

of implementation of a comprehensive approach to referral.

Inadequate dissemination of the essential package

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Health system and agency bottlenecks and constraints (cont) Improve the quality and responsiveness of services in the sector

The challenge of the RBM is to relate the results specified to resources, which will involve the development of programme budgeting.

The role of supportive supervision is being hampered in many districts due to lack of transport, and other facilitating inputs.

There is lack of a tracking system for commodities and supplies to confirm how much of the procured items reach the intended beneficiaries.

Delays in elaboration of service charters at the different levels of the health system resulting in limited implementation and follow up of the service charter

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Health system and agency bottlenecks and constraints (cont) Improve the efficiency and effectiveness of service delivery

Inadequate information on investment from off budget partners The resource allocation criteria are still not appropriately poverty focused Health Sector Services Fund (HSSF):

modality for inclusion of f non-state service providers not clear. Inadequate financial resources.

Weak linkage between planning and budgeting processes Inadequate capacities for planning and monitoring at the implementation

levels DP’s Finally, willingness and commitment to abide by the planning

calendar and ensure that their resources are reflected at the appropriate levels of implementation.

The extent to which outputs from operations research are implemented and the policy findings assist in decision making is not verifiable.

There are still significant risks in procurement and financial management Lack of strategic approach to management of infrastructure,

communication and ICT in the sector that appropriately supporting service delivery

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Health system and agency bottlenecks and constraints (cont)Foster partnerships in improving health and delivering

services Implementation follow up is still disjointed. Capacity for the implementing partners to engage in the sector is

still weak. The mechanisms for ensuring adherence to COC implementation

are yet to be spelt out. MOH structure and functions are still largely based on the vertical

program approach, with poor linkages between technical and administrative functions.

Accountability to the sector by different constituent actors is still weak.

Ensuring that the quality of plans at all levels (by facilities, districts, provinces, divisions, implementing agencies and development partners) have improved and interlinked to support each other.

There is still weak predictability of resources from all sources and linking them to the strategic objectives and priorities of the sector.

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Health system and agency bottlenecks and constraints (cont)Improve financing of the health sector The weak ability to mobilise, and coordinate off budget

resources available for health limits the level of financing for the sector.

In addition, contributions from some of the key funding partners are not adequately captured in the budget and expenditure estimates for the sector. Accuracy of cost sharing contributions is also not verified.

In general, it appears that decisions regarding expenditure allocations to health are influenced largely by decisions and factors outside the sector.

There is need to ensure that, while focus is made on financing interventions at the lower levels of the system, the higher levels are not financially deprived to a level where they are not able to carry out their supporting functions for the rest of the health system.

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What is the purpose of the legal framework?To provide an enabling

environment for implementation

Enhance partner participationProvide appropriate sector

structure for coordination

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Current Legal Framework The legislative framework comprises: The Public Health Act,CAP 242 (the principal

Act for Health) established 1921!Public health orientation:

Disease preventionInternational health regulationsLimited role in regulation of health

personnel,drugs and medical supplies and services

Established the offices of the DMS and the Medical Officer of Health in law

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Current Legal Framework (2)Old Act that set up a small

government department of healthNot suitable for current complex health sector

Only minor amendments have been made to date

Structure not inclusiveLimited stakeholder participation (SWAp)

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Current Legal Framework (3) 24 different Acts relating to health service

provision, e.g.: Medical & Dental Practitioners Act (CAP 253), the Pharmacy and Poisons Act (CAP 244) the Nurses Act (CAP 257)

DMS office is the only link with Public Health Act, CAP 242

There are many cadres which are yet to be covered by specific regulatory legislation

MoH initiatives to review and harmonize health related Acts – not complete

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Challenges with Current Legal Framework Administration of the many Acts The mixed nature of the Acts

(personnel/service regulation) Problems with coordination and

implementation Dormant Central Board Health Serious limitations i.e. updating, clear

enforcement framework, and conflicts Duplication and confusion (Acts vs policy

guidelines)

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Challenges with Current Legal Framework (contd.) The DMS office is linked to all health

acts making effective implementation difficult

DMS is the chair, registrar,secretary or member of numerous boards/regulatory bodies!!

Lack of separation between regulatory and service delivery functions

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Where do we want to go? A clear legal framework which:

Is harmonized and coordinated for smooth service provision e.g. Council of regulatory bodies

De-links service regulation from human resource regulation and provide autonomy to regulatory authorities

outlines the roles, responsibilities of and linkages with stakeholders (GoK, Mission,Private and NGO sectors)

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Where do we want to go?(2)Underpins the implementation of the

NHSSP II through SWAp especially in the following areas:Coordination of the sectorProcurementBudgetting,financing and financial management

Human resource managementGovernance and regulation

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Where do we want to go?(contd.) Give direction on decentralization of

service delivery to the districts Will give clear framework for review

of the existing acts Factors the focus of the country in

matters of health as outlined the proposed constitution (health sector) – Bill of Rights, devolution, Health Services Commission etc.

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END