Kenya: The Big Picture on Health

 Overview

Since achieving independence from Great Britain in 1963, Kenya has worked to improve the health of its nearly 40 million people, more than half of whom live in rural areas.  By the late 1980s Kenya had more than quadrupled the number of health facilities serving its growing population; extended life expectancy from 40 years to 62 years; and improved child survival rates.

An economic downturn in the 1980s and the intensification of the HIV/AIDS pandemic in the 1990s exacerbated a number of health challenges for Kenya, where at least 45.9% of the population currently lives in poverty. These include the challenges of extending health services to impoverished and geographically dispersed populations; providing adequate financing to maintain and extend health infrastructure at the national, provincial and district levels; and ensuring the availability of health care providers where they are most needed.  Beyond grappling with a persistent high burden of infectious disease, including malaria, HIV/AIDS, and tuberculosis, Kenya faces an emerging chronic diseases problem characterized by increasing rates of cardiovascular disease, cancers, and diabetes.  Since the 1990s some of Kenya’s early achievements in health have begun to reverse: Over the past two decades life expectancy has declined to 53 years, and mortality among children under the age of five has risen slightly. 

Kenya’s dependence on donor country contributions to supplement the national health budget has deepened in recent years. In 2006 14.8% of Kenya’s health funding came from donor sources; the figure is up from 4.9% in 1995 but still lower than some other regional countries, where external funds account for 30-40% of all expenditures on health. Despite the infusion of donor funds, Kenya, like many other countries in sub-Saharan Africa, is not presently on track to meet the health-related Millennium Development Goals by the 2015 target.  Since 2007 Kenya has initiated several processes to strengthen its health system and coordinate its work with donors and other development partners to avoid additional health-related reversals.

Background

At the time of independence in 1963, Kenya’s government proposed providing free healthcare to all Kenyans in the belief that a healthy population could lead the new country toward greater economic development.  By 1965 the government had formalized this “free health for all” concept and abolished user fees for people seeking care in public clinics, which at the time were managed at the local level.  In 1970 the Ministry of Health nationalized the health system and assumed responsibility for operating all public health facilities.  However, economic stagnation after 1973 and a dearth of funds available for operating clinics at the community level led the Ministry of Health to reinstate user fees in 1989.   A reform process in 1992 led to the creation of District Health Management Boards to facilitate cost-sharing and ensure the availability of funds for health services in peripheral areas. Persistent financial difficulties led the government to undertake a more intensive restructuring of the health system by the mid-1990s.

Current structure

In 1994 the government published the Kenya Health Policy Framework Paper, which envisions providing “quality health care that is acceptable, affordable, and accessible to all” in Kenya by 2010.     With decentralization as the guiding strategy for managing the country’s health care needs, the policy framework has been implemented through two five-year plans.  The first National Health Sector Strategic Plan covered the period from 1999-2004, and the second covers the period from 2005-2010.  Under the framework the country’s health system is organized in a hierarchical pyramid.  Village dispensaries comprise the largest – and lowest – level of the pyramid.  District health centers and provincial hospitals are fewer and higher on the pyramid, and the Kenyatta National Hospital in the capital city, Nairobi, sits at the top.  The Ministry of Health sets policies, develops standards, and allocates resources for health care services; however, in accordance with the decentralization scheme, the district is the level at which most management takes place.  The government reports that there are more than 5,000 health facilities in Kenya. The government oversees 41% of health centers, NGOs run 15%, and the private sector operates 43%.  The government operates most hospitals, health centers, and dispensaries, while the private sector operates nursing homes and maternity facilities catering to higher income clientele.

Kenya faces a significant shortage of physicians, with only 4,500 in the entire country, according to the World Health Organization.  Whereas the United States counts on 26 physicians per 10,000 people, Kenya has just one doctor per 10,000 residents, a ratio that is below average for the Africa region.  More than 50% of Kenyan physicians practice in Nairobi, which, with an estimated 3 million people, represents a small fraction of the country’s population.  Only 1,000 physicians work in the public sector, which serves the majority of Kenyans. A corps of 37,000 nurses supplements physician care, as do traditional midwives, pharmacists, and community health workers.  The migration of trained health workers from the public sector to higher paying positions in the private sector, or away from Kenya altogether, has made retaining qualified health personnel a persistent challenge.   Kenya has one of the highest net emigration rates for doctors in the world, with 51% leaving the country to work elsewhere according to a 2000 study.

The presence of so few health personnel in Kenya can make it difficult for the government to carry out adequate disease surveillance, maintain accurate statistics regarding disease outbreaks, and report relevant findings to neighboring countries and international organizations.   To improve its information gathering and to better track its progress in meeting the health-related Millennium Development Goals, Kenya has developed a Health Management Information System (HMIS) and is currently working with international partners to improve its capacity to provide timely and relevant data regarding the country’s health situation to policymakers and other stakeholders. 

Financing

Kenya’s total expenditure on health as a percentage of GDP was 4.6% in 2006, according to the 2009 World Health Statistics Report.  In 2006 Kenya spent 29 USD per capita on health services, several dollars below the 34 USD the WHO recommends countries spend to provide a minimum health package for their citizens. 

Kenyans who are formally employed and whose income exceeds a set threshold participate in the National Health Insurance Fund. By the early 1990s there were an estimated 1.3 million workers and 8 million dependents covered by the insurance scheme, which was established in 1966.  Recent efforts to reform the NHIF and to extend its services to a greater portion of the population through the creation of a National Social Health Insurance Fund failed due to political opposition.  Proponents envisioned the fund as a “pay-in-advance” insurance scheme that would enable a greater number of Kenyans to set aside funds for necessary physician visits, medical procedures, and pharmaceuticals.  But private medical associations opposed the reform on the grounds that the scheme would designate preferred providers and facilities, causing their members to lose business from “pay as you go” clients. Civil service and teachers’ unions mobilized against the plan because members did not want to forego receiving their medical benefits as cash disbursements, which some use to supplement their salaries.

As far as government spending is concerned, the Ministry of Finance sets three-year budget ceilings for each sector in Kenya. In practical terms this means that the Ministry of Health creates a budget based on what the Ministry of Finance has said it will allocate for health expenditures rather than submits a budget request based on actual needs. The Ministry of Health then disseminates the funds it receives through its District Health Management Boards.  There are two components of the Kenyan health budget – a recurrent budget which covers staff salaries, maintenance, and pharmaceutical procurement, and the development budget, which funds construction of new facilities and program implementation. According to the WHO, the Government of Kenya covers about 38.7% of the overall expenditures on health, while private expenditures account for 61.3% of overall spending.  In 2006 80% of private expenditures were out of pocket payments for health services.

Donor issues

Kenya is moderately dependent on donor funds, many of which supplement the development component of the national health budget.  In 2006 external resources accounted for 14.8% of all health spending in Kenya.  The United States is the largest bilateral donor, channeling funds through PEPFAR, the President’s Malaria Initiative, and USAID. In 2009 the United States is expected to spend $529.1M through PEPFAR programs alone. The United Kingdom also commits significant bilateral funds to the health sector, followed by Denmark, Germany, Japan and the Netherlands.  The European Union has committed funds to health programming in Kenya, and Kenya receives support from the World Bank and agencies within the United Nations system, including WHO, UNAIDS, UNICEF and UNFPA. The Clinton Foundation is active in Kenya’s health sector, as are faith-based organizations such as Catholic Relief Services, Lutheran World Relief, and the Aga Khan Foundation. The Global Fund to Fight AIDS, Tuberculosis and Malaria has supported several projects in Kenya and earlier this year invited Kenya to submit a proposal to join the “first learning wave” of national strategy applications (NSAs).  Through the NSA, countries will submit national disease strategies rather than general applications to request monetary support.  The Fund will then use the initial “learning wave” process to determine the feasibility of adopting the NSA for all future applications in an effort to enhance its application review process.

The proliferation of donors in Kenya since the 1990s, coupled with the desire to avoid duplication of donor-agency efforts, led the government and its development partners to formalize a Kenya Health Sector Wide Approach (SWAp) Code of Conduct in August of 2007.  The non-binding document was signed by the United States, Denmark, the United Kingdom, Germany, Japan, and the European Union, as well as representatives of multilateral agencies. It commits the signatories working to strengthen Kenya’s health sector to align their goals and cooperate to reverse “the decline in the health status of Kenyans…through an efficient, high quality health care system that is accessible, equitable, and affordable for every Kenyan.” The SWAp’s basic principles follow the 2005 Paris Declaration on Aid Effectiveness.  The SWAp agreement emphasizes the need for donor agencies to align their health-related commitments with the Government of Kenya’s development agenda.  At the same time, it envisions that the government, NGOs and donor agencies will develop and employ common methodologies for planning, disbursement of funds, procuring commodities and reporting on program outcomes.  The SWAp Code of Conduct also underscores the need for donors in Kenya to provide reliable commitments of aid over a multi-year framework in order to facilitate the Ministry of Health’s planning process.

Following the formalization of the Kenya Health SWAp and Code of Conduct, the government further strengthened its commitment to using multi-party collaborations as a means of improving health by seeking to engage with the International Health Partnership (IHP+).  The IHP+ was launched in London in September of 2007 in order to “achieve better health results by improving the way developing countries, international agencies, and donors work together to develop and implement national health plans.”   By December 2007 Kenya had articulated a strategic approach to facilitating partnerships for health and has since then received funds from the World Bank, the WHO and the United Kingdom’s Department for International Development (DFID) to facilitate health-related planning and expenditure tracking. 

Effects of political violence in 2007-2008:  The two months of violence that followed the December 2007 elections affected the health sector in Kenya in several ways.  Not only did the conflict between rival political factions and ethnic groups kill an estimated 1,500 people and displace thousands more, but opposing groups used sexual violence against their targets to humiliate and punish them.  In western Kenya, where the fighting was severe, HIV/AIDS patients reported that they were unable to get to clinics to receive fresh deliveries of crucial anti-retroviral drugs because they believed they would be in danger of being attacked if they left their homes.  Reports suggest that psychological stress following the political violence affected Kenyans throughout the country.

The resolution of the conflict through the creation of a power-sharing government between President Mwai Kibaki and Prime Minister Raila Odinga has had implications for health policy, as well.  In 2008 the Ministry of Health’s functions were split, and two ministers for health were named: Hon. Beth Mugo, as Minister of Public Health and Sanitation, and Hon. (Prof) Peter Anyang' Nyong'o, as Minister of Medical Services. With two ministries but still just one budget, the importance of inter-agency coordination has never been higher. However, recent reports suggest that the two ministries have begun competing over roles and access to resources.  A December 2008 assessment of progress regarding the IHP+ over the previous year noted that the division had negatively affected the government’s ability to organize development partner/donor activities and that the entire Kenya Health SWAp process requires re-activation and renewed focus

Written by Katherine Bliss, Senior Adviser, Global Health Policy Center

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