Kenya's Health Policy Framework, 1994

GOVERNMENT Of KENYA
MINISTRY OF HEALTH
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KENYA'S HEALTH POLICY FRAMEWORK
NOVEMBER t 994
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CONTENTS
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PART I - SITUATIONAL ANALYSES
MACROECONOMIC PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
PAST POLICIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
HEALTH MANAGEMENT INFORMATION SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
SECTORAL ECONOMIC PROFILE . . . .. . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DEMOGRAPHIC PROFILE .......................................... . 14
EPIDEMIOLOGIC PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
INFRASTRUCTURE PROFILE 18
PROVIDERS OF HEALTH SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
CURATIVE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
PREVENTIVE/PROMOTIVE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
HEALTH PERSONNEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DRUGS AND PHARMACEUTICAL SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DECENTRALISATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
PART II - STRATEGIC IMPERATIVES
GOAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
STRATEGIES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
PART Ill - mE AGENDA FOR REFORM
STRENGTHENING PUBLIC HEALTH POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
REDUCING THE BURDEN OF DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
DECENTRALISATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
STRENGTHENING NON-GOVERNMENT PROVIDERS . . . . . . . . . . . . . . . . . . . . . . . . . . 37
GENERATION OF FINANCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
HEALTH INSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
CONSTRUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
MAINTENANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
MANPOWER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
AIDS........................................................... 43
DRUG POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
MANAGEMENT INFORMATION SYSTEMS................................. 46
COST CONTAINMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
MOH STRUCTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
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FOREWORD
This policy framework paper is devoted to the Kenya's rapidly growing population will only occur
health sector, and takes as its particular theme that when the state plays a more prominent role in
of Investing In Health. It begins with a series of promoting individual good health. The focus of the
situational analyses which highlight the problems Government's future health policies will thus be to
faced by the health sector in Kenya. Next it provide an enabling environment for good health.
elaborates general strategies to address the
particular problems identified, and finally defines This enabling environment will first and foremost
the horizon of the Government's health policies ensure that sufficient finances are mobilised to
into the next century. support the entire health sector, and that effective
and efficient use is made of those resources to
The health sector in Kenya is at a crossroads, at a provide the best quality care and services at the
point where a bold and major change in the lowest possible cost. The chronic underfunding of
direction of health policy is to be mapped out. primary health care will end, and future
Future investments in the health sector have the investments will be used to encourage individuals
potential to promote good health rather than and communities to play a more active role in
simply treat disease and disability, but they will preventing disease and ill health. At the same
require a sea-change in the manner in which the time, curative care will be made more cost
Government supports the sector. efficient by encouraging and rewarding
professionalism and by stimulating competition
Despite a massive expansion of the health amongst the wide panoply of providers of care in
infrastructure since independence, it is widely both the Government and private and mission
recognised that increasing population and demand sectors.
for health care outstrip the ability of Government
to provide effective services. To markedly change Throughout, the locus for the executive control of
the burden of sickness and disease in Kenya. the resources will undergo further, functional
Government will embark upon a bold programme decentralisation. This will ensure that local health
of health sector reforms. These will transform the authorities become both more autonomous and
patterns of Government investment in health away more responsive to local needs. The role of the
from capital intensive projects for the construction central Ministry of Health will be transformed from
of new curative care facilities towards investment that of provider of services to that of policy maker
in Kenya's most precious capital, her people. and regulator of seivice provision. This will make
it more effective both as guarantor of equity in the
As health sector reforms proceed however, the distribution of resources, and protector of the poor
Government will ensure that they do so in a and needy.
manner which offsets the undesirable effects of the
general structural adjustment programme.
Good health begins with the individual, and HON. JOSHUA M. ANGATIA, EGH, MP.
sustainable improvements to the health status of MINISTER FOR HEALTH
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HEALTH POLICY FRAMEWORK
UST Of ABBREVIATIONS
ADB African Development Bank

AJA Appropriations in Aid
AIDS Acquired Immunodeficiency Syndrome
COD Childhood Diarrhoeal Disease
CHS College of Health Sciences
co Clinical Officer
DALY Disability Adjusted Life Year
DOC District Development Committee
DH District Hospital
DHMB District Health Management Board
DHMT District Health Management Team
DPM Directorate of Personnel Management
EDF European Development Fund
EDL Essential Drugs List
FY Financial Year
GDP Gross Domestic Product
GOK Government of Kenya
HCF Health Care Financing
HIS Health Information Systems
HIV Human Immunodeficiency Virus
!DA International Development Association
!FAD International Fund for Agricultural Development
IPPF International Planned Parenthood Federation
KEPI Kenya Expanded Programme of Immunisation
KHRP Kenya Health Rehabilitation Project
KNH Kenyatta National Hospital
MLG Ministry of Local Government
MoF Ministry of Finance
MoH Ministry of Health
NACP National AIDS Control Programme
NOP National Drug Policy
NGO Non Government Organisation
NHIF National Hospital Insurance Fund
PGH Provincial General Hospital
PHO Public Health Officer
PHT Public Health Technician
PTPP Part time private practice
SDH Sub District Hospital
STD Sexually Transmitted Disease
UNICEF United Nations Childrens Fund
USA United States of America
WHO World Health Organisation
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INTRODUCTION
CRITICAL PROBLEMS FOR THE could be equivalent to the entire 1993/94

KENYAN HEALTH SECTOR recurrent budget of the Ministry of Health by
the year 2000.
There are a number of critical problems which
constrain the ability of the Ministry of Health
to legislate for and ensure the delivery of CAPACITY Of THE PUBLIC HEALTH CARE
adequate levels of quality health care in SYSTEM Kenya's health infrastructure has
Kenya. These are described in detail in this grown rapidly since independence, and
document, but those of particular importance currently there are well over 3,200 health care
are summarised here. institutions nationwide. With approximately
1, 100 MoH dispensaries, 400 health centres
FINANCES The Ministry of Health is seriously and 100 hospitals, the Ministry of Health has
underfunded. Per capita expenditures on built an impressive, pyramidal health referral
health were US$9.50 in 1980/81, but since system, o~en with considerable support from
then have dropped to about US$4.50 in harambee efforts. Despite these major gains
1991/92, and due to the devaluation of the population growth outstrips the capacity of
Kenya shilling in early 1993, are unlikely to the Ministry of Health to cater for the demand
rise above US$3.50 per capita by 1996/97. for services, and currently over 70% of the
This is despite a rise in local currency recurrent budget is devoted to the payment
expenditures from K£50 million in 1979/80 to of staff salaries and benefits to the detriment
over K£ 175 million in 1991 /92, and an of expenditures on other essential.. items,
anticipated rise to over K£350 million by particularly medicines. This lack of resources
1996/97. Furthermore the share of general has meant that a number of facilities have
Government recurrent expenditures allocated been constructed but have never been
to the Ministry of Health has declined from opened, and has caused the referral system to
9.26% of the Government total for 1979/80 to fail, resulting in unnecessary congestion of
8.51 % in 1991 /92, and is expected to fall hospitals by patients who should be treated at
further to 7.61 % by 1996/97. In addition, lower cost in health centres and dispensaries.
health centres and dispensaries belonging to Plans for the expansion of coverage of public
the Ministry of Local Government were taken health services must take into account the
over by the Ministry of Health in 1970 availability and utilization of Private, NGO and
without any increase in its recurrent budget. Mission Sector facilities and must also
Finally, the costs of caring for AIDS patients guarantee improvements to the efficiency of
public resource allocation and utilization.
HEALm POLICY FRAMEWORK
STAFFING The Ministry of Health has a surplus In the light of these and other issues, this
of staff in lower cadres and deficits in the policy framework paper presents a first,
numbers professional staff. The distribution of comprehensive vision of current Ministry of
professional staff does not reflect real needs, Health policies. It is designed to be used by
and there is a concentration of key personnel health policymakers to regularly review and
in urban areas and in in-patient services This revise policies within a set framework, which
is compounded by increases in the numbers will evolve with time as information relevant
of staff leaving public service to engage in to the health sector develops and improves.
private practice, Furthermore, although not
legally entitled to do so, many are engaging
in part-time private practice while in the Part l consists of a set of situational analyses,
employment of the Government, often to the and within the confines of available
detriment of the patients who come for information, examines the health sector in the
medical attention in Government health context of general Government policies since
institutions. Furthermore the mushrooming of Independence, identifies strengths and
unregistered ciinics run by staff not licensed weaknesses, and presents the constraints
under the existing laws has threatened the which impinge upon future growth and
well-being of the general public. development.
LAWS The Laws governing the health sector

require to be enforced, and in some cases Part 2 presents a series of strategic
amended to respond better to present imperatives developed by Senior Ministry
circumstances. Ethical and clinical standards Officials which mirror the situational analyses,
need to be set and maintained, private and which identify the major strategies to be
practice needs to be regulated for the public employed in improving the overall function of
good, and the land belonging to the Ministry the sector.
of Health must be protected and must not be
encroached upon.
Part 3 contains a description of those policies
adopted by the Ministry of Health as a means
of applying the strategies identified in Part II
to address the constraints described in Part I.
It also identifies where in the absenc,e of clear
policies, these will be formulated after careful
study as part of an overall policy reform
program.
The document is presented in such a manner

that it may either be read in its entirety, or
section by section for those with particular
interests in its content.
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Part 1
SITUATIONAL
ANALYSES
GDP has continued to slide below 4 per cent

t. MACROECONOMIC PROFILE and fell dramatically to a mere 0.4 per cent
The Kenyan economy has generally in 1992, the lowest since independence. This
undergone mixed experiences since slowdown in GDP growth since 1991 could
independence The growth in Gross Domestic be explained in terms of the actual decline in
Product (GDP) averaged 6.5 per cent over the real output and value added in agriculture,
period 1964 to 1970, however, the first oil due to below average amount of rainfall,
crisis of 1972 brought an abrupt halt to this sluggish growth in aggregate private
level of achievement. Consequently the domestic demand and foreign exchange
growth rate decelerated to below 4 per cent shortages leading to reduced _ imports of
for much of the early 1970s until the intermediate goods, and perhaps due to the
unexpected "coffee boom" of 1976 and 1977 immediate impacts of the suspension of donor
when growth rate in GDP averaged 8.2 per aid. The Government has taken remedial
cent. The situation worsened when the price measures to reverse this trend.
of crude petroleum doubled from US$ 13 per
barrel in 1978 to US$ 2 7 in 1979, generally One other general observation is that, as
pushing up the inflation rate, and the cost of would be expected of a modernizing
imported input and raw materials resulting in economy, the contribution of the traditional
the slowdown of economic growth. non monetary sectors of the economy have
steadily declined from 24. 7 per cent i11 1964
For much of the early 1980s the rate of compared to 5.4 per cent in 1992. Similarly,
growth in GDP remained below 5 per cent the contribution of the agricultural sector has
and for the first time in Kenya's history, the steadily declined from over 45 per cent of
growth rate fell below 1 per cent in 1984. GDP in 1963 to about 28 per cent in 1992.
This was largely attributed to the severe What this implies is that the contribution to
drought of that year. Favourable weather GDP from manufacturing and government
conditions coupled with Government services have steadily expanded.
budgetary discipline and improved
management enabled Kenya to achieve
Inflation trends The rate of inflation in Kenya
significant 4.8 per cent and 5.5. per cent
is currently measured by the Nairobi
growth rates in 1985 and 1986 respectively.
Consumer Price Index which is a weighed
average index for each of the three income
Since 1990, however, the rate of growth in
groups in a calendar year. During the first
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decade or so of independence, Kenya enjoyed 1. PAST HE.Alm POUGES

a single digit inflation rate, mainly due to the Since the attainment of Independence in
effects of the prices control system and good 1963, the Government has given high priority
economic performance. However, after the to the improvement of the health status of
first oil shock of 1973, the inflation rate rose Kenyans. It recognizes that good health is a
to 17.0 per cent in 1974 and subsequently to prerequisite to socioeconomic development,
19.1 per cent in 1975. Apart from the years and its commitment to the provision of health
1973, 1979, 1984, 1986 and 1987 the rate of services is evident from the phenomenal
inflation has ranged between 10 to 20 per
cent per year with the exception of 1982 and
growth of the local currency health budget
and the expansion of the network of
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1992 when the inflation rates were 21.54 and
27.50 respectively, the latter being the
government health facilities across the I
highest inflation rate ever recorded since
country.
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Independence. In a number of Government policy documents
and in successive National Development
While it is true that the inflation rate has been Plans, it is set forth that the provision of
determined by domestic policies and price health services should meet the basic needs of
control regimes, it has also been determined the population, be geared to providing health
by the state of the international economic services within easy reach of Kenyans and
recession in the early eighties and the second place emphasis upon preventive, promotive
oil crisis in 1980, compounded by a rapid and rehabilitative services without ignoring
increase in money supply, the introduction of curative services.
price decontrol of some consumer items and
the devaluation of the Kenyan Shilling under Achievements, successes and failures The
the continued implementation of the policies that the Government has pursued
Structural Adjustment Programme and the over the years have had a direct impact in
1991 freeze of donor aid to Kenya. improving the health status of Kenyans.
Despite a deciine in economic performance,
The overall performance of the economy has cumulative gains have been made in the
had both a direct and an indirect adverse health sector as evidenced by the
effect upon the health sector and the health improvement in basic health indicators.
status of the Kenyan population. The
macroeconomic policy for growth and The crude death rate dropped from 20 per
sustainability described in the seventh 1000 at independence to 12 per 1000 in
development plan will help to alleviate the 1993 and the crude birth rate from 50 per
undesirable effects of poverty, which constrain 1000 to 46 per 1000 over the same period.
the ability of the Ministry of Health to Likewise, both infant mortality and life
ameliorate the burden of disease. Therefore, expectancy, basic indicators of health status,
within this general macroeconomic improved dramatically. It is however
framework, the Ministry of Health will present important to note that although the above
policies designed to improve the health status national health indicators look impressive,
of the Kenyan people. there are significant geographic disparities
which need to be addressed in order to
achieve some equity.
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HEALTH POUCY FRAMEWORK

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Three recent policy initiatives have met with facilities was not matched by the growth of
considerable success. These are: recurrent budget allocations. This has resulted
in both chronic and sometime acute shortages
Cost Sharing Amended in 1989 to introduce of essential and critical inputs for health care
consultation fees in Government health deliveiy. Investments made through donor
facilities, and modified in 1992 to convert and community financing have greatly
user charges from a consultation fee to a expanded the network of health facilities,
treatment fee, this program has increased the however there has not been proper
level of resources available at the local level coordination to ensure that future
for improving the functions of the health requirements for the correct balance of
system. Three quarters of the revenues are recurrent inputs are catered for and are
used at the collecting facility, and one quarter sustained after the commissioning of new
are set aside for district level expenditure on facilities.
primaiy health care.
There are also indications that urban slums are
District Health Management Boards Created without organized health care deliveiy
by legal notice in 1992, these Boards provide systems and thus the health status of their
residents is far below national indicators.
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local oversight of the cost sharing2rog,:_an:L
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Civil Seivice Health Manpower Reform. Civil 3. MINISTRY Of HEALTH

service reform in general seeks to trim the MANAGE.ME.NT INFORMATION
size of the civil service, and as part of this
reform program, in 1993 the Ministiy of
SYSTEMS
Health began implementation of a voluntaiy The Ministiy of Health operates a variety of
early retirement scheme for those in lower job management information systems at both
groups. headquarters and elsewhere. These systems
are characterised by a lack of integration, and
However, not all policies formulated over the are disjointed and widely dispersed, with no
period were translated into actions or realised effective central coordination to ensure that
their desired outcomes. The decline in the information which they contain is readily
resource availability and to some extent the available to all who need it. Many systems
mismanagement of resources limited the collect and process data into management
implementation of policy and expected information accurately and in a timely manner,
benefits were not fully realized. The whereas others are barely functional. Those
Government is no longer able to provide systems which do operate effectively tend to
unlimited free care, as budgetaiy allocations be highly localised and are often relatively
are insufficient to meet nsmg costs. inaccessible. This needs to change.
Furthermore, in 1965 the late President
Kenyatta abolished fee collection in health Health manpower information To be able to
facilities, and in 1970, the Ministiy of Health manage effectively, health managers at
took over the health centres and dispensaries headquarters, province or district level need
run by local authorities without a accurate, reliable, and up-to-date information
corresponding transfer of budget from local for planning and budgeting, and for the day
authorities to the Ministiy of Health. to day management of their specialised and
highly professional human resources.
Likewise, the growth in fixed capital and Presently, the Ministiy of Health has no
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reliable, accurate, standardised information m1ss1on and NGO facilities which, though
system for personnel management, planning licensed by the MoH and subject to
and budgeting, and for evaluating and inspection, are managed privately.
tracking the performance of employees. Most
health facility managers can only provide a The MoH has begun to establish criteria for
rough estimate of how many people are defining facility types, and these include
employed on-site, and at headquarters, the services offered, physical structures, staffing
consensus is that the basic need from a health norms, catchment population, and number of
manpower information system is simply to beds. This data is critical for deriving
know who is where and how much they are workload statistics as it provides the baseline
being paid. This problem is complicated by against which expenses, human resources,
the Ministry's practice of frequently shifring and patient loads can be measured. To date,
employees from one physical location to this information has not been systematically
another. updated and verified, and because of the
importance of knowing what each facility
As a minimum, the Ministry of Health requires offers to the public, and the unavailability of
a modem information system capable of this basic information to decision makers and
providing the data necessary to manage and planners at all levels, the planning of the
monitor staffing levels and productivity and to distribution of facilities and services in Kenya
prepare staffing budgets and payroll listings. is far from ideal.
Additional requirements include the
establishment of practical staffing norms on Financial management and accounting The
which to base day-to-day deployment MoH has in place a functioning financial
decisions as well as for career development management system based on the accounting
and recruiting efforts. principles mandated by the Ministry of
Finance. As such, the system serves the
The Ministry of Health is now assembling a defined set of needs for reporting and
comprehensive database concerning its compliance with the Treasury. It does not
available manpower complement of interact readily with operational, clinical,
approximately 45,000 persons, and this inventory, or planning data from
system will identify each individual at their computerized systems to facilitate planning
place of work. Afrer careful verification, this and decision making. At the hospital and
system will become the basis for the smaller health facility level, finance/budget
preparation of all future health manpower departments account for the revenues
budgets and for long term projections of received and or incurred for the facility. They
manpower supply and demand and training maintain accounting records to provide data
needs. about the expenditures by expense
classification and by the major departments
Physical facilities and resources There are within the hospital. Similarly, provincial and
nine principal types of health facilities in the district medical officers account for
Kenyan public health system, ranging from non-hospital health facilities within their areas.
rural dispensaries to Kenyatta National The accounts do not provide accounting for
Hospital, which is the national referral, the cost of operating specific service/cost
teaching and research hospital. There are centers within departments. However,
additional specialized facilities for certain accounts, or subheads, have been established
types of ailments, maternity, etc., and private both by hospitals and in districts, to account
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HEAlffl POLICY FRAMEWORK
for funds provided by donors. These accounts 4. SECTORAL ECONOMIC PROFILE

are used for recording transactions for each
donor fund since donor funds are often Expenditure on health care Considering the
earmarked for a particular purpose. Since the sector in its entirety, Table 1 shows that in FY
introduction of user fees, more and more cash 1983/84, of a total of almost KSh2. 9 billion
handling occurs at hospitals and other health spent on health care nationwide, 42.09% was
facilities. This has brought about the need for spent on health care provided at Ministry of
good cash control systems and procedures, Health institutions, with a combined
and accounting for the management and Government total of 50. 13%. Over the
banking of funds collected. Very few of these counter expenditures on drugs and
systems are computerised. pharmaceuticals accounted for a further
23.6%, and private health institutions
Woridoad and operational Information accounted for almost KSh265 million or 9.21 %
Routine, regular workload and operational of the total. Expenditures on the services of
statistics, the numbers and types of patients, private medical practitioners totalled KSh216
procedures, diagnoses, etc form the essential million (7.51%), and Ministry of Local
core data against which other data and Government and Mission Facilities each
information for any health care facility are accounted for slightly less than 6% of the
crossed and compared for planning or total. It is therefore clear that the private
management purposes. Unit costs can be sector, particularly privately owned
derived by comparing clinical data against pharmacies, are making a considerable
expenses, catchment population served, and contribution to the provision of health care in
staff. Deficits or surpluses in any type of Kenya, and are benefitting from their
resource can be readily identified using a mix activities.
of operational and workload statistics.
Sources of finance When one examines the
At present, these statistics are compiled at sources of financial flows to the health sector
most quarterly and often only annually. shown in Table 1, one immediately recognises
Reporting rates from facilities are low and the the important role that Government plays in
headquarters does not have complete data for promoting good health. Of all health care
all facilities for any one year. Furthermore, expenditures in FY 1983/84, 41. 97% were
those workload data that are compiled are financed by the Ministry of Health, with an
often derived from morbidity and mortality additional 5.31 % coming from the Ministry of
statistics with no valid cross reference with Local Government. However, the contribution
medical records, residence of the patient, of individuals to their own good health is not
public health survey data, etc. There exist to be underestimated, since a further 40.88%
considerable opportunities for the introduction of the total was derived from their out of
of transcription and arithmetic errors in data pocket expenditures. Mandatory health
clue to the high volume of information and insurance mediated through the National
lack of computer facilities. Hospital Insurance Fund provided less than
4% of the total in 1983/84 and combined
All these management information systems donor inputs provided less than 3%.
must be operationalised at all levels of the
health system in order to provide managers
and planners with the information they
require.
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HEALTH POLICY Fll/l.MEWORK
Table 1. Total Gross Recurrent Expenditure by Provider and Source offirnmclng 1983/841
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SERVICE KSh % SOURCE OF KSh
PROVIDER FINANCES
MoH 1,210,400,000 42.09% MoH 1,206,800,000 41.97%
1
NHIF 8,400,000 0.29% NHIF 109,000,000 3.79% 1
CHS 25,400,000 0.88% CHS 25,400,000 0.88%
MLG 160,600,000 5.58% MLG 152,600,000 5.31%
OTHERGOK 36,800,000 1.28% AJA 3,700,000 0.13%
Goverm-ent Toral 1,441,600,000 50.13% Goverm-ent Total 1,497,500,000 52.07% I
MISSIONS 168,900,000 5.87% MISSIONS 29,300,000 1.02%

COMPANIES 11,400,000 0.40% COMPANIES 53,600,000 1.86%
Private l\llarket DONORS 71,000,000 2.47%
INSTITUTIONS 264,800,000 9.21% NGOS 13,400,000 0.47%
PRACTITIONERS 216,000,000 7.51% Private l\llarket
DRUGS 680,000,000 23.64% INSURANCE 35,300,000 1.23%
OUT OF 93,300,000 3.24% OUT OF POCKET 1,175,600,000 40.88%
POCKET
Private Toral 1,254,100,000 43.61% Privale Total 1,210,900,000 42.11%
GRAND TOTAL 2,876,000,000 100.00% GRAND TOTAL 2,875,700,000 100.00%
Minlst,:y of Health recummt expenditure then have dropped to about US$4.50 in

trends As one would expect, Table 2 and 1991/92, and due to the devaluation of the
figures 1 &. 2 show that Ministry of Health Kenya shilling in early 1993, are unlikely to
expenditure on the health sector is also rise above US$3.50 per capita by 1996/97
showing signs of decline, despite the efforts unless the economy makes a dramatic
of the Government to protect it. Although recovety.
Ministry of Health local currency expenditures
ii
have risen steadily, from K£50 million in When one examines the share of general
1979/80 to over K£ 175 million in 1991/92, Government recurrent expenditures allocated
and are expected to rise to over K£350 to the Ministiy of Health, it is evident from
million by 1996/97, in real terms_the trend is Table 2 that this too has been reducing
one of decline. Per capita expenditures on steadily.
health were US$9.50 in 1980/81, but since
8
MOH EXPENDITURES
(Kb"NYA POUNDS)
400
350
300
250
200
l 50
l 00
50
79/80 80/81 81/82 82/83 83/84 84/85 85/86 86/87 87/88 88/89 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96197
figure l (Above) MoH Recurrent Expenditures J 979-1997.
figure 1 (Below) MoH l'er Capita Expenditures 1979-1997.
MOH PER CAPITA EXPENDITURE

(US DOLLARS)
I 1.00
I 0.00
9 00
8 00
7.00
6.00
5.00
4.00
3 00
2.00
79/80 80/81 81/82 82/83 83/84 84/85 85/86 86/87 87/88 88/89 89/90 90/91 91/92 92/93 93/94 94/9.5 95/96 96/97
9
HEALTH POlfCY FRAMEWORK
In 1979/80 Ministry of Health recurrent hospitals. Since 1979/80, the percentage of

expenditures accounted for 9.26 of the MoH recurrent expenditure attributable to the
Government total for that year. From 1986/87 provision of curative services has remained at
onwards, this percentage has dropped and by approximately 70% of the total, although
1991/92 was only 8.51 % of total Government within hospitals a greater share of their
expenditure. This is expected to fall by almost expenditure has been on preventive services
one percentage point to 7.61 % by 1996/97. carried out in outpatient clinics. Increases to
the direct funding of primary and preventive
Internal allocations of Minist,y of Health health care from 15% in 1979/80 to 21 % in
recurrent budgets The internal allocations of 1991 /92 have occurred at the expense of
Ministry of Health recurrent budgets shown in expenditure on administration and training.
Table 2 continue to favour curative care in
Table 2. Minist,y of Health Recurrent Budget Expenditures. (Internal Allocations, As percentage

of Government Total and in US Dollars per capita) 2
YEAR TolalK£ CURATIVE RURAL& ADMIN & NON DRUG R11 as% US$ Per
P/PHC TRAINING SUPPLIES & GOK Captta
RESEARCH
79/80 42,943,415 66.69% 15.13% 11.70% 6.48% 9.26% 8.65
80/81 52,868,619 68.36% 15.74% 11.43% 4.47% 9.45% 9.55
81/82 59,075,879 72.33% 12.75% 11.98% 2.94% 9.32% 7.60
82/83 61,306,323 72.41% 13.84% 12.44% 1.31% 9.32% 6.00
83/84 61,765,853 72.39% 11.55% 14.57% 1.49% 8.83% 5.36
84/85 73,007,033 66.52% 9.71% 10.88% 12.89% 9.19% 5.24
85/86 79,653,593 71.83% 12.88% 10.10% 5.19% 9.25% 5.35
86/87 96,546,022 72.14% 10.82% 12.14% 4.90% 8.95% 6.16
87/88 101,014,500 78.18% 10.50% 9.56% 1.77% 8.38% 5.76
88189 113,686,327 72.24% 16.48% 9.63% 1.65% 7.38% 5.85

89/90 115,032,567 69.39% 18.92% 10.58% 1.11% 7.87% 5.54'
90/91 128,807,254 69.76% 19.87% 9.17% 1.19% 7.82% 5.08

91/92 147,833,073 67.77% 21.62% 9.28% 1.32% 8.51% 4.50
92/93 169,489,868 68.72% 22.02% 8.65% 0.61% 8.46% 4.60
93/94 209,125,600 62.74% 25.49% 9.17% 2.60% 7.65% 2.99
94/95 299,529,639 67.23% 20.95% 9.65% 2.16% 7.59% 3.44
95/96 315,133,200 67.11% 21.38% 9.28% 2.22% 7.60% 3.22
96/97 350,586,292 66.86% 21.39% 9.58% 2.17% 7.61% 3.09
10
HEALTH NJLICY FRAMEWORK
Table 3. Combined Recurrent and Development Budgets by Source of finance.
YEAR TOTAL(K£) GOK DONORS GOK¾

92/93 286,494,589 200,299,263 86,195,326 69.91%
93194 310,947,827 223,946,610 87,001,217 72.02%
94195 343,916,500 255,364,811 88,551,689 74.25%
95/96 375,833,659 269,227,550 106,606,109 71.63%
Table 4. Development Budget by Source.

SOURCE 1992-93 1993-94 1994--95 1995-96
Kenya 22.02% 14.49% 24.08% 16.91%
Austria 1.76% 1.13% 1.66% 2.33%
Belgium 0.32% 0.06% 0.()()% 0.00%
Britain 0.00% 6.40% 0.00% 0.00%
Canada 2.44% 0.66% "1.81% 2.54%
China 2.26% 0.00% 2.04% 1.43%
Denmark 6.50'% 4.58% 2.16% 2.80%
EDF 0.92% 0.00% 0.91% 0.64%
Finland 7.49% 6.26% 3.64% 4.93%
Germany 2.68% 1.48% 0.25% 0.17%
IDA 11.94% 11.16% 31.85% 32.04%
IDRC 0.08% 0.00% 0.00% 0.00%
IFAD 1.53% 1.21% 1.95% 1.46%
IPPF 0.30% 0.00% 0.00% Q.()0%
Italy 0.50% ().(JO% 0.00'/o 0.00'/o
Japan 0.00% 22.64% 0.00% 0.00%
Netherlands 4.12% 4.30% 0.70% 0.4S%
SWeden 17.42% 9.99% 9.86% 10.83%
UNICEF 0.36% 0.00% 0.00% 0.00%
USA 17.36% 15.62% 19.10% 23.43%
TOTAL(K£) 59,780,328 88,341,068 60,224,760 85,779,260
11
Development Expenditures When one Nevertheless, donor contributions represent

considers Development Expenditures as approximately 80% of the Development
shown in Table 3, it is evident that they Budget alone, as shown in Table 4, and there
represent approximately 25% of total Ministry exists a tendency for approximately 40% of
of Health expenditure. Despite considerable development expenditures provided by donor
increases in total donor inputs to the health agencies to be a form of recurrent budget
sector since the 1980's, these inputs still support. This is in particular for the supply of
represent less than 30% of total Ministry of commodities to the Essential Drugs
Health expenditures, making the Ministry of Programme, the Kenya Expanded Programme I
Health the single most important source of on Immunisation and the Family Planning I
!
health care financing today, and therefore Programme, as shown in Table 5.
making reform of that institution an absolute
necessity.
Table 5. Development Budget by Type of Expenditure

EXPENDITURE 1992-93 1993-94
TYPE K£ % K£ %
AIDS 1,835,175 3.07% 1,612,000 1.82%
CONSTRUCTION 14,740,638 24.66% 15,622,684 17.68%
CONSULTANTS 1,414,000 2.37% 2,486,000 2.81%
C.D.D. 28,000 0.05% 50,000 0.06%
DRUGS 5,884,500 9.84% 4,896,000 5.54%
EQUIPMENT/PLANT 2,407,680 4.03% 22,655,500 25.65%
FAMILY PLANNING 7,620,700 12.75% 13,148,504 14.88%
HCF 3,150,000 5.27% 4,300,000 4.87%
HIS 10,000 0.02% 0 Q.()0%
KEPI 1,210,000 2.02% 400,000 0.45%

KHRP 1,020,000 1.71% 1,870,000 2.12%
KNH 3,012,500 5.04% 0 Q_())¾
MAINTENANCE 1,817,000 3.04% 1,930,000 2.18%

MISCELLANEOUS 1,586,955 2.65% 3,726,230 4.22%
NGO 1,769,000 2.96% 1,942,700 2.20%
PLAN NI NG/STUDIES 780,600 1.31% 385,000 0.44%
PRIMARY HEALTH CARE 5,644,080 9.44% 8,070,050 9.14%
REHABILITATION 1,295,000 2.17% 1,550,000 1.75%
TRAINING 4,404,500 7.37% 3,521,400 3.99%
VEHICLES 150,000 0.25% 175,000 0.20%
Tr,n, co 700 000 100N)% oon•• - o ._,,, new;.
12
J,
The contribution of cost sharing to health care average quarterly NHIF reimbursements to
financing The innovative cost sharing district hospitals doubled and reimbursements
programme in Government health facilities to sub-district hospitals tripled as a result of
was introduced in phases beginning in 1989 improved claiming procedures. Nevertheless,
and its impact has recently been evaluated. It in most hospitals, NHIF reimbursements are
has been widely accepted as a means of less than one-quarter of their potential and on
generating additional revenues to be used for current NHIF collections of about Kshs. 2
the improvement of Government facilities and million per month, the annual NHIF revenue
services and revenues are maintained in a potential for facilities is KSh. 150 million. This
separate account at the district level. These suggests a revenue loss of at least KSh 125
revenues, which have steadily increased over million per year due to under collection of
the past two years, are derived from two NHIF revenue.
sources - user fees, primarily for curative
services, and from NH!F reimbursements. for Revenue losses due to exemptions and
Ministry hospitals and health centres, current waivers Potential revenue is also lost through
cost sharing revenues represent approximately waivers and exemptions, the biggest impact
7% of the non-staff recurrent budget (3% of of which is upon outpatient collections. In FY
total budget), and this is expected to rise over 93/94, with implementation of the treatment
the next five years to 30% of non-staff fee at health centres, implementation of the
expenditures ( 12% of total). treatment fee at district and sub-district
hospitals and fee increases at hospital,
Hospital revenues by source The three estimated revenue losses from exemptions
largest sources of cost sharing revenue are will be nearly Kshs. 60 million.
NHIF reimbursements, inpatient cash
collections, and the outpatient treatment fee Estimated inpatient cash collection for FY
which together account for 75% to 80% of 92/93 were roughly Kshs. 20 million. If this
revenue at hospitals. NHIF reimbursements amount represented 60% of expected
are the largest single source of revenue, revenue, then the expected revenue would
accounting for 35% of all revenues which have been Kshs. 33 million, suggesting an
totalled KSh70 million in FY 1992/93. inpatient collection gap of about Kshs. 13.
million. Comparison of FY 91/92 and FY 92/93
In contrast to NHIF reimbursements, which are expenditures also suggests the beginning of a
the greatest share of revenue for the PGHs, shift of basic operating expenses from the
treatment fee revenue represents only 20% of recurrent health budget to cost sharing
the total, and laboratory, x-ray, and mortuary revenue.
fees together account for 10% to 13% . Other
revenue sources include Mental Health Control of resource allocation and
Services fees (1.3%), medical examination fees expenditure The decline in overall economic
(3.3.%), circumcision fees (0.3%), performance in Kenya has had an adverse
physiotherapy fees (0.5%), and miscellaneous effect on the social sectors of the economy
fees (3.3%). including the health sector. As a result of the
economic decline the Ministty ofHealth's real
NHIF Revenues NHIF reimbursement now allocations per capita have declined
represent the largest single source of cost significantly, resulting in inadequate funding
sharing revenue, and during FY 1992/93, and shortages of key inputs requked to
13
HEALTH POllCY FRAMEWORK
maintain adequate standards of care. This is allocation approach. Other constraints to the
particularly true for certain categories of effective and efficient use of health sector
manpower, drugs, dressings, sera and resources are related to the limited
vaccines, equipment and other essential non- decentralisation of the executive control of
pharmaceutical supplies. The Ministry of these resources to the district level. These
Health is today faced with a crisis where issues are discussed later.
available resources cannot match the demand
for services. This has caused shortages and
under utilization of existing health manpower
and medical equipment. This situation has
been aggravated still further because over
70% of the funds actually allocated to the 5. DEMOGRAPHIC PROFILE
Ministiy's Recurrent Budget are used first and On the basis of census statistics shown in
foremost to pay staff salaries and allowances. Table 6, Kenya's population increased from
This leaves absolutely insufficient resources for 5.4 million in 1948 to 15.3 million in 1979
operational expenses and in particular the and estimated to 24.5 million people by
purchase of drugs and dressings. These fiscal 1993. Estimates from the 1979 census
constraints have been further aggravated by indicated that the population growth rate was
the 1993 devaluation of the Kenya shilling. 3.8 per cent per annum. This has now
For example, this devaluation reduced the deciined to 3.4 per cent in 1993. Preliminaiy
j I
value of the budget line items for drugs and results of 1993 Demographic and Health
I
dressings by 53% from U5.$ l 3.6 million in Survey4 have revealed that the total fertility
July 1992 to US.$5.81 million in July 1993, at rate declined from 6. 7 children per woman for
a time when the Ministiy of Health estimated the period 1984 - 1989 to 5.4 children per
its annual drugs and dressing requirements to woman in 1993. So this means that Kenya
be at least US.$25 million per year3 • has experienced a 20 percent decline in
fertility in just over four years, one of the most
The programme review and forward budget precipitous ever recorded.
are routine and rigid and imposed ceilings
have not allowed growth over and above the
traditional 4% annual increment, which does The crude birth rate decreased from 52/1000
not compensate for infiat;on, nor for the local in 1979 to 46/ l 000 in 1993 whereas the
costs of foreign exchange. Furthermore, the crude death rate declined from. 14/1000 to
recent tendency to freeze Ministry of Health 12/ l 000 over the same period. The infant
expenditures before the closure of the mortality rate also declined from l 04/ l 000 to
financial year has made control of appropriate 67/1000 in 1993. As a result almost 50 per
expenditure on health care extremely difficult. cent of Kenya's population is under 15 years
This has exacerbated the overall shortfall of of age and l O per cent above 50 years. There
resources by creating additional artificial appears to be tremendous demographic
imbalances between expenditures on momentum in Kenya, despite the impressive
manpower and operations and maintenance. decline in fertility, with a large pool of
This has again further compromised the sexually active individuals in the 15 to 49 year
quality and quantity of care offered by age cohort. Furthermore, population growth
Ministiy of Health facilities and deepened the rate in urban areas is over 7 per cent largely
Ministiy' s debt arrears. Breaking this rut will attributable to migration from the rural areas.
require more than this traditional resource
14
Predictions of population growth in Kenya are the most important causes of morbidity
must take into account these trends in fertility and mortality nationwide. Accurate statistics
and mortality, as well as the potential effect of are not available, however malaria and
the AIDS epidemic and migration into urban respiratory diseases account for almost 50% of
areas. As a result the population of Kenya is all reported diagnoses in Government health
expected to grow to between 34-38 million facilities, and intestinal parasitic infections and
over the next decade, and this will put diarrhoea increase this to almost 60% of all
increasing pressure upon the Government to reported cases.
provide adequate levels of Health Care
coverage to a young population.
Table 6. Demographic Indicators 1963 to t 993 5

INDICATOR 1963 1979 1984 1989/90 1993
Estimated Population 8.90 15.30 18.40 21.40 24.50
Population Growth rate 3.00 3.80 3.70 3.00 3.40
Fertility Rate 6.80 7.90 7.70 6.70 5.40
Population under 15 years 48.00 48.00 48.00 47.00 47.00
Females 15-49 years 27.00 21.00 22.00 22.00 22.00
Population 15-49 years 42.00 43.00 43.00 43.00 43.00
Population 50 years and 10.00 9.00 9.00 10.00 10.00
above
Crude Death Rate 20/1000 14/1000 13/1000 12/1000 12/1000
Crude Birth Rate 50/1000 52/1000 50/1000 49/1000 46/1000
Life Expectancy at Birth 44 54 56 58 60
Infant Mortality Rate 120/1000 104/1000 87/1000 74/1000 67/1000
Child Mortality Rate 156/1000 n/a n/a n/a n/a
6. EPIDEMIOLOGIC PROFILE Reported Disease Morbidity Rate

The burden of disease in Kenya is not well Malaria 26%
quantified, and much needs to be done to Respiratory Diseases 22%
improve the availability and reliability of Eyes, Ears, Anaemia.Trauma, etc 21%
available information, most of which is Others 15%
derived from reported disease statistics. It is Skin 7%
known that there exist marked regional Intestinal Parasites 5%
variations in epidemiologic patterns but in Diarrhoeal Disease 4%
general, preventable, vector-borne diseases Total 100%
15
Malaria causes more that 25% of all reported Assuming current trends continue, the HIV
illnesses countrywide. In terms of mortality, positive population is expected to rise from a
malaria accounts for 6% mortality of all cases total of 448,000 in 1990 to about 1,270,000
admitted to health institutions, but accounts by I 996, and AIDS related deaths will rise
for 30 - 50% of child death in highly endemic from 20,000 in 1990 to 86,000 in 1996.
areas.
Diarrhoeal diseases are the fourth leading

cause of death in children under five years of
These projections are presented in Table 7.
From available evidence it as been established

that the prevalence of HIV/AIDS in the regions
I
'
age in Kenya and accounts for 4% of all out- that border Uganda and Lake Victoria and
patient cases. along major trans-African transportation routes
of Kitale, Busia and Kisumu is 20 - 30 per
cent of relevant populations. The.next highest
The HIV and AIDS epidemic now poses a prevalence rates are 10 -20 per cent occurring
serious health problem. The National Aids in Nairobi and along the same route to
Control Programme (NACP) had reported Mombasa on the Indian Ocean. Lower
39,000 cases of AIDS by August 1993, when infections rate have been reported in Kisii,
it was believed there were about 110,000 Nyeri, Kitui and Garissa at between 2 - 10 per
people who had contracted the AIDS in the cent.
country. It is estimated that some 841,700
people were Human lmmuno-deficiency Virus
(HIV) positive in 1993, out of which 30,000
were children.
Table 7. HIV positive population and aids related deaths by age, sex, and rural mban location.•
1990 1993 1994 1995 1996

HIV Pcsitive Population '00Os
Rural 151 284 334 383 428
Urban 298 558 665 752 842
Male 244 457 537 617 ·689
Female 205 384 452 518 581
Total 449 841 989 1135 1270
HIV Related Deaths '00Os
Rural 7 15 19 25 30
Urban 13 29 37 46 56
Male 11 24 30 38 56
Female 9 20 26 33 40
Total 20 44 56 71 96
16
Transmission In Kenya, there are three implication of this is that those with a higher
significant modes of transmission: These are socio-economic status are more likely to be
heterosexual transmission, which accounts for infected than those in subsistence farming.
about 75%, perinatal transmission which Moreover, the epidemic imposes a double
accounts for about 23%; and blood burden on women. Already more vulnerable
transmission which historically accounted for to HIV infection, women are lil<ewise affected
between 3 - 5 %, but which is expected to by the AIDS epidemic in their role as
decline with improved blood screening. providers of care in the family and
community.
Development Issues relating to AIDS The
spread of AIDS will have significant effects not Psychiatric morbidity Empirical research
only on the demographic compositions of the studies in Kenya have consistently shown that
Kenyan population but also on the social and approximately 20% of patients seeking
economic structure of the country. outpatient care in both publlc and private
institutions do suffer from some form of
First, HIV/AIDS is likely to make an important mental illness. The majority of these patients
difference to demographic variables for Kenya, present with physical complaints which lead
including mortality, life expectancy and infant to misdiagnosis and numerous and often
survival. There will be a reduction in some of repeated wasteful and expensive
the gains made in increased child survival and investigations and prescriptions. Despite
life expectancy. Overall life expectancy could acceptance that mental well-being is essential
be reduced by up to l 7 years by the year to good health, this apparent widespread
2000. The impact on child survival will be psychiatric morbidity has not significantly
severe because it will be affected both directly influenced the planning of health services in
through perinatal infection, and indirectly Kenya to date.
through increased numbers of orphans, who
will put severe stresses on communities'
ability to maintain them. At present there are
estimated to be 150,000 such orphans,
increasing to 600,000 by the year 2000.
Secondly, the costs of caring for AIDS patients

could be equivalent to the entire 1993/94
recurrent budget of the Ministry of Health by
the year 2000. It is predicted that the total
direct and indirect costs of AIDS to Kenya
could reach 15 per cent of GDP by the year
2000, compared to current cost estimates for
1991 of between 2 - 4 per cent of GDP.
Thirdly, since the prevalence of HIV among

Kenyans working in the "modem" sector is
approximately twice as high as those working
in the small farm sector, the obvious
17
HEAllH POUCY FRAMEWORK
7. INFRASTRUCTURE PROFILE hospitals to rural health centres in major

Kenya's health infrastructure has grown towns and dispensaries in most rural
rapidly since independence, and Table 8 locations.
shows that currently there are well over 3,200
health care institutions nationwide. The Construction Despite these major gains
Ministry of Health administers over 50% of perhaps the most crucial factor influencing
these institutions, and the Ministry of Local both the quantity and quality of health care
Government just over 3%. The remainder are services to be delivered is the planning of
operated by the Private, Mission and NGO where health facilities will or will not be
sector. With approximately 1, 100 MoH constructed and the types of services they will
dispensaries, 400 health centres and 100 or will not offer. Capital investments in new
hospitals, the Ministry of Health has built an public facilities, or in the rehabilitation of old
impressive, pyramidal health referral system ones, will have substantial long term
extending from Kenyatta National Hospital in repercussions upon the recurrent budget of
the capital city through provincial and district the MoH. Currently, over 70% of that
recurrent budget is devoted to the payment
Table 8. Distribution of Health Facilities by Provider and Type7

Type MoH Private/ Mission MLG FPAK GOK TOTAL %
Company
Dispensary 1,158 409 285 28 0 2 1,882 57.36%
R.H.D.C. 32 0 0 0 0 0 32 0.98%
R.HTC. 7 0 0 0 0 _a 7 0.21%
Mobile Clinics 4 0 12 0 0 0 16 0.49%
Health Centre 350 87 68 31 0 0 536 16.34%
Sub Health Centre 13 1 2 6 0 0 22 0.67%
Health Clinic 51 230 19 39 21 3 363 11.06%
Medical Centre 8 10 3 0 1 0 22 0.67%
Health Programme 0 0 6 1 1 0 8 0.24%
Hospitals 101 43 62 1 0 1 208 6.34%
Maternity Home 2 19 4 6 0 0 31 0.94%
Nursing Home 4 34 2 0 0 0 40 1.22%
Office 103 6 1 0 0 0 110 3.35%
Special Institution 1 0 3 0 0 0 4 0.12%
Total 1,834 839 467 112 23 6 3,281 100.00%
% 55.90% 25.57% 14.23% 3.41% 0.70% 0.18% 100.00%
18
of staff salaries and benefits to the detriment pressure and bias imposed by international
of expenditures on other essential items, donors who supply many of these items, and
particularly medicines. The future viability of has made cost-efficient maintenance, repair
the public health care system is therefore and replacement extremely difficult.
dependent upon decisions affecting the
location of health facilities both by the GOK
and other providers, and the type of services,
both preventive and curative that they will 8. PROVIDERS Of HEALTH
provide. Plans for the expansion of coverage SERVICES
of public health services have seldom if ever, In the absence of workload data, Table 9
taken into account the availability to and presents a simplified comparison of the
utilization of Private, NGO and Mission Sector percentages of total health sector expenditure,
facilities and improvements to the efficiency of numbers of fixed facilities and manpower
public resource allocation and utilization can attributable to the Ministry of Health and all
only be accomplished by considering the other providers. It can be seen that the
respective roles of GOK and non Ministry of Health has the lowest percentage
governmental health care providers. of total expenditure but that this is not
reflected in its infrastructure or manpower.
Rehabilitation The physical infrastructure for
health in Kenya has expanded rapidly since
This is despite the tendency for private and
independence, but maintenance and upkeep
m1ss1on sector institutions to pay staff
ofpublic sector health facilities has become an
significantly higher salaries than the Ministry
insuperable burden for the MoH recurrent of Health. What this means is that Ministry of
budget. The MoH recognizes that many
Health institutions are overstaffed in
facilities are in need of repair, rehabilitation, comparison with non-government institutions
and replacement of basic capital equipment
and staff members are poorly paid.
essential to the effective and efficient
provision of quality health care, but the
expansion of the infrastructure has been Furthermore, in Ministry Facilities, as described
paralleled by an increasing shortfall in the elsewhere in this document, there is a general
level of resources available for maintenance of
lack of the essential inputs required for
the growing numbers of fixed facilities. This
effective patient care. None of this augers well
has resulted in physical deterioration of for providing quality care in MoH facilities,
facilities and their basic equipment, and the
and with the existence of these structural
MoH is currently engaged in a budget imbalances, it is not surprising that the
rationalization programme designed to limit
Ministry is increasingly unable to provide
new construction and to ensure that existing
adequate levels of quality care in its
facilities are brought back to their desired
institutions.
operational status.
Standardisation of equipment, fixtures and Compounded with this imbalance within the
vehicles The Ministry of Health has been Ministry of Health, there also exist trends
unable to enforce standards for the types,
indicating a decline in the quantity and quality
quality and quantity and compatibility of the
of care offered by some Mission facilities. This
vast array of equipment, fixtures and vehicles
is matched by increases in the numbers of
which it acquires. This has been due in part to
19
private health facilities, with a pronounced The assumption that in Kenya the private
urban bias, and a flow of qualified health sector is in general more cost-efficient than
professionals away from the Ministry of Health the public sector may not be true. A recent
towards the private sector. study carried out in Kenya on costs and
quality of care provided in mission, for-profit
Table 9.Provlders of Health Seivices
Provider Expenditm! Facilities Manpcmer

Ministry of Health Total 43.26% 55.34 69.48%
All Others Total 56.74% 44.66 30.52%
and Government hospitals8 suggests that for- patients who come for medical attention in
profit-hospitals (purely private) provide Government health institutions. Furthermore
comparable quality care to mission hospitals the mushrooming of unregistered clinics run
but at a very high cost. Also, many by staff not licensed under the existing laws
Government facilities may be providing care has threatened the well-being of the general
at higher than optimum cost and lower than public.
optimum quality, and considerable cost
savings may be possible through The legal position Existing health legislation
improvements to management practices stipulates that no one should engage in
without compromising the quality of care private medical practice if not licensed. In the
delivered. case of doctors and dentists the Medical
Practitioners and Dentists Board (MP&.DB) is
Other structural problems related to the required to regulate medical and dental
different providers of health care are all practice. It is also responsible for ensuring
related to the regulatory and facilitative role good standards in the practice of medicine
that the central Ministry of Health should through maintenance of professional ethics,
support and nurture. and also to protect the public from those who
may abuse their privileged position by
Private Practice In Kenya today, health care engaging in professional miscond~ct.
professionals, the great majority of whom are
trained at public expense, are tending to There is evidence to suggest that present
leave Government service as soon as they licensing arrangements have loopholes and
possibly can in search of greener pastures in that inspections of those involved in both part
the private sector where they are establishing time and full time private practice are both
private clinics, maternity homes and inadequate and too infrequent. These need to
surgeries. Although not legally entitled to do be streamlined in the interest of the general
so, many are engaging in part-time private public.
practice (PTPP) while in the employment of
the Government. In a considerable number of Public Interest In the better interest of the
cases these professionals have given more public, those health boards charged with the
time to their part time private practice than to responsibility of registering and licensing
their employer, often to the detriment of the
20
practitioners and clinics and maintaining many countries, support functions such as
professional ethics and discipline should medical laboratory, pharmacy, cleaning and
include representatives of the general public housekeeping, laundry and restaurant services
to protect the public interest by ensuring that are contracted out to private sector operators
where 'individual' interests conflict with the because they are able to provide those
public interest the latter prevails over the services at a lower cost than the parent
former. This will ensure that the interest of institution. This practice already exists in some
the public is not compromised. private sector health care facilities in Kenya.
Therefore, while the reasons for the exodus of

doctors from the Public Service to the private Quality Assurance· 1t has not been possible
sector are understood, as are the reasons for to uphold and maintain high standards of
PTPP by consultants employed by the care, and there is need for strengthening
Government, both types of services should be quality control and assurance procedures. ·
regulated to ensure that they comply with the
law and with standards of acceptable Cross Referral There are no proper
professional conduct. There exists a need to procedures on cross-referral between the
amend and strengthen the existing Law different providers due to lack of clear policy
relating to private practice to ensure that guidelines, and fee policies between providers
performance in both the public and the are inconsistent
private sector is properly regulated.
Urban Blas The coverage and distribution of
The prevailing macro-economic climate means Health Services shows an urban bias, with
that health professionals will continue leaving certain rural communities being under-served
the public sector to join the private sector especially those in geographically difficult
where remuneration is more attractive. The areas.
Government however has a responsibility to
ensure that those leaving have adequate Community Initiatives There continues to be
training and experience before leaving so that a gap between the formal health system and
the well being of the general public is the health initiatives that have been
safeguarded.
developed at the Community Level, such as
the Bamako Initiative.
Provision of support seivlces The control
and containment of costs in medical care
institutions and the regulation of the quality of
care they offer are currently issues of great
concern. Many health care institutions in the
public and private sectors tend to offer
services which are not the most cost effective
and efficient, and as a result the quality of
care they are able to offer falls short of that
required.
Mechanisms need to be developed which can

promote more efficient management and use
of the scarce resources available to them. In
21
9. HEALTH CARE SERVICES of the provincial and some district hospitals

are sufficiently equipped.
The Health care system in Kenya has been
perceived as being divided in two major Private hospitals are well equipped with
divisions, i.e. Curative services and Preventive sophisticated diagnostic facilities, but because
Health Services, and this has been reflected in of their high cost, these facilities can only be
patterns of finance. In fact, both should be afforded by a few people. Mobile outreach
regarded as elements of the essential services by both Government and NGOs for
integrated health care services that all communities that have no static health
Kenyans should have access to. facilities have been established.
Curative Seivlces in Kenya are provided by Preventive and promotive seivices A large
the Government and private/NGO sectors. proportion of patients seen in health
The Government services are organized in a institutions in Kenya suffer from
hierarchial system from the smallest and communicable diseases, which can be
simplest facility (dispensary) to the most prevented through simple public health
complicated and sophisticated (national and interventions. As a result, preventive and
teaching hospital.) In between are the health promotive health services have formed the
centres, the district hospitals, and the major emphasis of Kenya's health policy as a
provincial hospitals. The private sector runs means to reduce the burden of disease.
hospitals surgeries and clinics. However, this policy is yet to be translated
into concrete actions. As shown earlier, in
There has been a bias in the distribution of terms of resource allocation, preventive and
these services, which has tended to favour the promotive services only receive approximately
urban areas, and this inequality needs to be 20 per cent of the recurrent health budget.
addressed.
Preventive/Primary Health Care services,
Mental health services tended to remain which have been going on through
static, mainly institutionalised and centralised government, NGO, Mission and, to a lesser
until the early 1960's, when psychiatric extent, private initiatives, will need to be
services were decentralised by the integrated, intensified and expanded. These
establishment of 22 bed psychiatric units in services have been and still are largely
the Provincial General Hospitals. Since then, dependant upon financial and materiql support
only seven more psychiatric units have been from international donors and do not yet
established in District Hospitals, and some of cover the whole country.
the remaining districts have established
psychiatric outpatient services. The public health interventions that are
currently taking place require to be intensified
Although the Government clinical services are and expanded. These include immunisation
meant to have a self-regulatory referral system against vaccine preventable diseases, use of
from a lower level to the next higher level, safe water and sanitation, adequate and
this system does not necessarily work that proper nutrition, and public health education
way. Ideally only those patients needing very on health promotion and disease prevention.
highly specialized clinical care need to be Special attention will be paid to the major
referred to national teaching hospital as most causes of morbidity, mortality and disability,
such as malaria, respiratory infections,
22
diarrhoeal diseases, AIDS and STDs and road health staff are involved primarily in in-patient
traffic accidents. curative care. Out-patients services have a
manpower deficit of about 50%.
Furthermore, over 60% of the in-patients are
in the hospitals and health centers with
illnesses that are basically preventable.
10. HEALTH PERSONNEL

Preliminary results of a Ministry of Health Table 1 0. Distribution of Total Health
Manpower and Training study reveal that the Manpower by Provider
number of trained professional health cadres
(Doctors, nurses, C.O.'s, PHO/Ts etc) have MOH OTHER TOTAL
increased at twice the rate of the population.
URBAN 36.33% 47.33% 39.87%
The distribution of health personnel The RURAL 63.67% 52.07% 60.13%
current distribution of health personnel is not
equitable. When one considers all persons
TOTAL 69.48% 30.52% 100.00%
employed in the health sector, it is apparent
from Table 10 that Ministry of Health staff are
found predominantly in rural areas 63.67%
compared with only 52.07% of those staff
employed by other providers, who therefore
exhibit a bias towards the provision of ,i I
services in urban areas. t t .DRUGS AND PHARMACEUTICAL

SUPPLIES
More detailed analysis reveals the following:
This is perhaps the most critical area where
policy reforms are required. Today, the effects
Inequitable distribution among provinces of the currency devaluation and subsequent
Some provinces have less than 90 key health
cost inflation have constrained the ability of
personnel (MD's, Clinical Officers, Nurses and
the Ministry of Health to provide its health
Public Health Staff) per 100,000 population
facilities with adequate drug supplies. This ~as
while other provinces have more than 130 per
become an issue of national importance.
100,000.
Estimates reflect a need for the local currency
Concentration of key personnel in urban equivalent of US$25milllion per year to
areas. The major urban areas of Kenya which provide adequate stocks of drugs and
include about 12% of the population have 375 dressings in Government facilities, but the FY
key Health Personnel per 100,000 while the 1993/94 Ministry of Health recurrent budget
ratio in the rural areas (88% of the population) only made provision for the local currency
have less than 90, a difference of about equivalent of US$5.8rnillion. Furthermore,
400%. since a large share of total Ministry of Health
drugs and dressings supplies are provided for
Concentration of personnel In In-patient in the development budget by contributions
services. Between 70% and 80% of the key from international donors, this calls for the
23
~
H£Al1H POUCY FRAMEWORK
Government to address the question of the National Drug Polley A Kenya National
future sustainability of even these supplies. Drugs Policy has been developed which will
guide the development of pharmaceutical
Despite rising prices, there are no shortages of services and the management and control of
drugs and dressings in private sector human and veterinary medicine well into the
pharmacies. However, the prices of medicines next century. The National Drug Policy
in these retail outlets are beyond the reach of document was developed through a
most Kenyans. This places a heavy burden consultative process involving a series of six
upon vulnerable groups and the solution of major national meetings, with participation by
these problems presents a serious challenge over eighty health professionals and
to the Ministry of Health. administrators from the Ministry of Health,
other Government of Kenya Ministries, the
Currently, approximately 50% of the value of Universities, the private sector, the mission
all pharmaceuticals consumed in Kenya are sector, other NGOs, and international
those provided in Ministry of Health facilities. organizations.
Almost 45% are consumed by NGOs and the
remaining 5% is consumed by those who pay The goal of the National Drug Policy is to use
"out of pocket" in retail outlets9 Furthermore, available resources to develop pharmaceutical
over 73% of supplies are imported, a situation services to meet the requirements of all
I which imposes a heavy financial burden upon Kenyans in the prevention, diagnosis and
Ii
'
foreign exchange reserves. treatment of diseases using efficacious, high
quality, safe and cost-effective pharmaceutical
Management of Procurement and products. The NDP should serve as the
Distribution by the Ministry of Health guiding document for legislative reforms, staff
Procurement of drugs and dressings is development, and management
accomplished by the Ministry of Health improvements.
through a Departmental Tender Board. Within
the Ministry of Health, there exists a drug
storage and distribution system with a central
warehouse in Nairobi and a well developed
network of regional depots in the provinces.
Despite major improvements made through a 12. DECTNTRAUSATION
decentralisation of the distribution system, it A recent study of decentralisation in the
remains inefficient, and often drugs and health sector in Kenya 10 has shown that the
dressings do not reach their intended focus of decentralization in Kenya has been on
destination. planning. Since the inception of the District
Focus for Rural Development in the early
It is clear that in the opinion of those that SO'S, the district has been the administrative
make use of Government health services, the focus of Government and therefore of its
availability of drugs is the most important health care delivery systems. The coordination
local factor determining that use. As a result, of cross-sectoral district planning is the
management systems are required that can responsibility of the District Development
guarantee the delivery of adequate levels of Committee(DDC), with health sector plans
drugs and dressings to health facilities produced and submitted to them by District
Health Management Boards.
24
HEALTH POLICY FllJIMEWORK
In addition, local health planning currently has district health vote. However, the Ministry
no reference to a realistic resource framework, intends that eventually, these Boards assume
plans are rarely taken into consideration in more responsibility.
national planning and budgeting, and the
center does not usually provide any feedback The role of the province The provincial
to districts on their submissions. There is, medical offices have been superseded by the
therefore, little relationship between plans, district under the present decentralization
available funds and actual implementation. policy. This has been recognised as a
Local planning and self-help efforts seldom problem for the effective operation of health
take into account national policy goals, and services in Kenya, and the Ministry of Health
are usually concerned with capital is committed to reforming and strengthening
development and with time limited 'projects'. the Provinces.
Insufficient attention is paid to recurrent cost
implications and the long-term sustainability Central functions and structures Vertical
of benefits. programme management and cadre-specific
personnel management and technical support
With the introduction of the cost sharing remain powerful factors in maintaining a
scheme in Government health facilities in centrally controlled system. Information and
1989, it became clear that more local control reporting systems as well as personnel
of the funds generated by this scheme was management continue along vertical lines,
required. As a result, in May 1992 a major fostering cadre-specific loyalties rather than
and significant reform of the public health act horizontal integration at district level.
created the District Health Management
Boards. These Boards, appointed by the Apart from decentralized planning systems,
Minister of Health are in general empowered most other management systems have
to superintend the management of hospital, remained centralized. Districts and provinces
health centre and dispensary services and have little opportunity for making
support public health care programmes, and contributions to policy development.
specifically to oversee the cost sharing Although policy development must be
programme. Members of the Board represent centrally coordinated, a more structured
the Ministry of Health, the District participatory process for reviewing policy
Administration, Local NGOs and Religious options can be established. One of the
Organisations and the local community. objectives of the district focus policy is
improved equity. however, the role and
As a result a quite different model of responsibility of central government in
resources planning has emerged under Cost safeguarding equity by subsidizing poorer
Sharing. In this case, District Health districts with a weak income base, poor
Management Teams (DHMTs), District Health infrastructure and a smaller share of trained
Management Boards (DHMBs) and facility manpower, is not clearly spelled out.
management teams work closely together in
prioritizing needs to be met with funds
Setting priorities and monitoring health
available from fee income. At this time,
systems performance Standards for health
District Health Management Boards are only
systems performance, criteria for priority
concerned with the use of funds from Cost
setting, including epidemiological and
Sharing and are not directly involved in
demographic factors, cost and efficacy of
decisions regarding funds available from the
25
proposed interventions, and capacity for general pool rather than to health activities.
implementation, are not well defined.
It is therefore clear that although the
Private and NGO sector Information on the decentralisation process in Kenya, and in the
scope and scale of activities by private health health sector in particular is underway, a lot
care providers, inciuding private pharmacies, remains to done in delegating real authority
is difficult to obtain, and relations with NGOs to the districts. At the same time, it will be
and missions range from close collaboration to essential to ensure that the centre is
relatively separate and uncoordinated project appropriately oriented to fulfilling its role in
activities. spelling out national policy, and in
coordinating, monitoring and supporting
Health services operated by local councils are policy implementation in districts. The
poorly managed, underfinanced, and revitalization of the intermediate level, the
technically not well supported. In most province, will be important for facilitating this
instances, fee income appears to go to the process.
26
Parl2
STRATEGIC
IMPERATIVES
This section of the policy framework paper presents a series of strategies developed by
Senior Ministry Officials which mirror the situational analyses presented in Part 1, and
which identify the major strategies to be employed in improving the overall function of
the sector.
The strategic theme embodied in the policy reforms elaborated in Part Ill of this
document is that of Investing In Health. A number of strategic imperatives exist which
describe the general direction in which health policy should be leading the health sector
in Kenya, and these imperatives are set out here to meet a very clear and specific goal
which unifies all health policies under one banner.
The overall goal of health sector policy until the year 2010 will be
To promote and improve the health status ofall Kenyans through the
deliberate restmctudng ofthe health sector to make all health services
more effective, accessible and alliJrdable.
The strategic imperatives which have been identified are listed on the left and the
particular strategies which will be adopted to address them are listed on the right as
follows:
27
I
■
1. ENSURE THE Development of a combined epidemiological and micro-

economic framework for health planning. Planning for all
EQUITABLE
health resources to be linked to analyses of health status and
ALLOCATION OF a clear definition of the types and scale of cost-effective
GOVERNMENT interventions that will ensure nationwide, equitable access to
RESOURCES essential curative as well as preventive services.
TO REDUCE
Development, adoption and use of standard criteria for the
DISPARITIES IN geographic allocation of resources
H E A L T H
STATUS Development, adoption and use of standard criteria for the
allocation of resources to individual health facilities
2. INCREASE Estimation of the burden of physical and mental disease and

THE COST ill health in Kenya and of the local cost effectiveness of a
EFFECTIVENESS variety of interventions aimed at reducing the burden of
AND THE COST disease and ill health.
EFFICIENCY OF Definition and prioritisation of the essential and most cost

RESOURCE effective curative and preventive health services which must
ALLOCATION be provided in all regions of Kenya
AND USE
Definition of the types and levels of essential curative and
preventive health services to be provided by each type of
health care institution in each region
Adjustment of institutional health budgets to local conditions

on the basis of historical workload data, local disease
incidence and prevalence rates and Government bu,dgetary
ceilings.
Establishment of norms defining an appropriate mix of

personnel and operations and maintenance inputs at all levels
in order to obtain optimal performance and efficiency.
Control and containment of the unit costs of service delivery

through sound management practice, including the
contracting of some services to the private or mission sector
where those providers are shown to be the most cost
effective.
28
2. INCREASE Expansion of the capacity of health planners and managers at

THE COST all levels to collect, analyses, interpret and make use of health
planning and financial data at source to monitor and evaluate
EFFECTIVENESS the impact of efforts to reduce the burden of disease and
AND THE COST disability.
EFFICIENCY OF
RESOURCE Institutionalise information systems and operational research
methods to establish health service utilisation patterns and
ALLOCATION their determinants as a means of improving service coverage,
AND USE accessibility and availability
(continued)
3. CONTINUE TO Increase the numbers of service delivery points for family

M A N A G E planning services.
POPULATION
Increase and diversify the range of available family
GROWTH
planning services
Intensify efforts in fertility control by increasing

community participation
Identify and focus upon areas of unmet needs, such as

services to the youth through family life education and
promotion of safe motherhood.
Promote and increase in maternal literacy rates and

educational attainment through collaboration with the
Ministries of Education and Culture and Social Services.
Promotion of fora to examine the sensitive issue of youth

contraceptives by involving all the concerned parties
29
L
4. ENHANCE Strengthening of the central public policy-making role of the

Ministry of Health headquarters by further devolving executive
T H E operations to the provinces and districts.
REGULATORY
ROLE OF THE Strengthening the enforcement of the MOH's regulatory
GOVERNMENT powers over other health providers as stipulated in the Public
Health Act Cap 242 and related health legislation.
I N A L L
ASPECTS OF Remodelling and reinforcing the provincial tier of the health
HEALTH CARE system and devolving to it responsibility for oversight of the
PROVISION implementation of health policy, the maintenance of standards
of quality and performance, and the coordination, regulation
and control of all health services in both the public and private
sectors
Extension of the roles and responsibilities of the DHMBs to

permit them to control and oversee all health services in their
districts in both the public and private sectors.
Creation of local hospital management boards to superintend

the management of Ministry of Health hospitals.
Continuing the process of gradual decentralization of the

management and control of resources to lower level
institutions. This would result in empowerment of local
institutions to be both responsible and accountable for the
resources provided from the central level as well as from the
district and lower levels.
Building the capacity of the district and lower levels through

training in modern management and planning methods to
permit them to better fulfill their operational responsibilities
and functions.
30
I''·
5. CREATE AN Creating a formal set of fora and avenues for dialogue

ENABLING and collaboration between the Ministry of Health and
ENVIRONMENT other health providers.
F O R
Promising/Offering Government material (e.g. land) and
INCREASED financial (e.g. tax exemptions) incentives to encourage
PRIVATE the provision of essential and discretionary health
SECTOR AND services by the private sector and NGOs in underserved
COMMUNITY areas
INVOLVEMENT
IN HEALTH Effecting amendments to relevant legislation to facilitate
;
and streamline the registration and licensing of private
SERVICE '
and NGO health providers and institutions.

PROVISION AND
FINANCE
6. INCREASE Maintaining or expanding in real terms the present budgetary

AND DIVERSIFY allocations to the public health sector while striving to close
the gap of underfinancing.
PER CAPITA
FINANCIAL Developing closer functional linkages between mandatory
FLOWS TO THE health insurance and coverage of essential clinical care
H E A L T H services.
SECTOR
Reviewing NHIF to extend and diversify the range of benefits
and to overhaul fund management with a view to converting
NHIF from a Hospital to a Health Insurance Fund.
Expanding the role of other social financing mechanisms by

increasing coverage beyond the formal sector, by encouraging
private incentives through legislative measures
Expansion of beneficiary contributions through cost sharing by

review of fee levels, structure and collection efficiency, and
changes to exemption and waiver policies.
Continuing to use 75% of cost sharing revenues to protect,

strengthen and further improve the clinical performance of
hospitals. The list of contributors should be expanded and
amount of contributions increased.
Exploration of the feasibility and sustainability of Bamako

Initiative type mechanisms to mobilise resources from
communities.
31
Part3
THE AGENDA
FOR
REFORM
This final section contains a description of those policies adopted by the Ministry of Health as
a means of applying the strategies identified in Part II to address the constraints described in Part
I. It also identifies where in the absence of clear policies, these will be formulated after careful
study as part of an overall policy reform program,
Therefore, to meet the goal of strategic health policy as set out in section II of this Policy
Framework Paper, and to respond to the future health needs of the Kenyan people, the Ministry
of Health is committed to act and to implementing the following reforms of the health sector:
t. SIRINGfflINING IHI CENTRAL PUBLIC POLICY ROLE Of IHI MINISTRY

IN ALL MATTERS PERTAINING TO HEALTH.
Creation of a forum fur the periodic review and revision of comprehensive health sector
policy. This will be achieved by amending the Public Health Act to give the Central Board
of Health greater responsibility for guiding National Health Policy, and the Ministry of
Health greater responsibility for its implementation. This will lead to the
operationalisation of a high level Health Sector Policy Review and Implementation
Committee at Ministry of Health Headquarters.
• Elaboration and Implementation of Specific l'ollcies The Ministry of Health will take the
lead in ensuring that health sector policies are elaborated and implemented, and where
necessary, suitable legislation is either enacted or amended. The areas of policy to be
considered in the immediate future and described in detail later include:
adoption of an explicit strategy to reduce the burden of disease among the

Kenyan population and definition of those cost effective and essential curative
and preventive services which will be provided for by the Ministry of Health
reinforcement of the Provincial level to permit effective superintendence of the

districts and further decentralization of planning, management and resource
creation, control and use to the districts.
32
H£Al1H POUCY FRAMEWORK
strengthening of NGO, Local Authority, private and mission sector health service
providers
generation of increased levels of financial resources for the prov1s1on of cost-

effective services through widely accepted cost sharing and alternative health
financing initiatives.
shifting part of the financial burden of essential ca.re from the Ministry of Health
budget to insurance schemes.
further reduction in the rate of construction of new government facilities and a

focus on consolidation, rehabilitation and maintenance of existing ones based on
need and their cost effectiveness in delivering health care.
increasing the level of adequate human, financial and organizational resources to

properly maintain and repair facilities and equipment
reorientation, retraining and redeployment of health manpower to meet

manpower demand projections and resource availability.
prevention and control of AIDS, HIV infection and sexually transmitted diseases.
adoption and implementation of a national drug policy
consolidation and strengthening of key health management information systems

to support the policy-making role of the Ministry of Health in budgeting,
planning and management functions in the districts.
institutionalization of management tools for cost containment and cost control

particularly for the hospital and curative sector.
strengthening of health research

i
reorientation of the organization, structure and function of the Ministry of Health

to meet the proposed reforms.
Regulation and Enforcement. The Government will continue to regulate the health sector
and the provision of services through enforcement of regulatory legislation as stipulated
in the following Laws of Kenya: Cap. 242 Public Health Act, Cap. 243 Radiation
Protection Act, Cap. 244 Pharmacy and Poisons Act, Cap. 245 Dangerous Drugs Act.Cap.
246 Malaria Prevention Act, Cap. 248 Mental Health Act (1989), Cap. 253 Medical
Practitioners and Dentists Act, Cap. 257 Nurses Act,Cap. 260 Clinical Officers (Training,
Registration and Licensing) Act, Cap. 255 National Hospital Insurance Act, Cap. 254
food, Drugs and Chemical Substances Act. Cap. 364 Animal Diseases Act.
This strengthening of the public policy making role of the central Ministry of Health will
33
I
therefore focus upon the following key issues:
Expansion of Health Seivice Coverage. The Government will continue to promote the
expansion of health care services in underserved areas and will provide care to the
majority poor staying in the rural and urban areas. This will be achieved through
regulato,y measures which will encourage the proliferation of the private, Mission and
NGO sectors by providing material and financial incentives to providers operating or
establishing clinics in underserved areas.
Equity. One of the objectives of the district focus policy is improved equity. The Minist,y
of Health will develop standard criteria for the equitable allocation of its human and
financial resources to regions and to individual facilities. The subsequent utilisation of
these criteria for planning and budgeting and controlling disbursements will safeguard
equity by subsidizing poorer districts with a weak income base, poor infrastructure and
a smaller share of trained manpower.
Quality Assurance. The Government will enhance the regular quality control and quality
assurance of care through statuto,y and management inspections with the aim of
maximizing efficiency in man and machines commensurate with the investments made.
1. ADOPTION Of AN EXPLICIT major causes of morbidity and mortality can be

STAAUGY TO REDUCE THE BURDEN identified and ranked according to their
importance. Their importance will be
Of DISEASE A.MONG THE KENYAN measured in terms of their contribution to a
POPULATION AND DEHNmON Of reduction in disability-adjusted life years
THOSE COST EFFECTIVE AND (DALYs) lost by the population.
ESSENTIAL CURATIVE AND
Second, the various interventions which can be
PREVENTIVE SERVICES WHICH Will
employed to either prevent or treat these
BE PROVIDED FOR BY THE MINISTRY priority diseases and or conditions must be
OF HEALTH. costed at local prices, to that the local costs of
To be able to improve the effectiveness and averting them may be compared.
efficiency of the allocation and use of health
sector resources, it is necessa,y to first define Calculation of the local costs of specific health
those curative and preventive health care care interventions and their individual
interventions considered to be absolutely contribution to the reduction of DALYs lost will
essential to reducing the burden of disease permit comparisons to be made of the costs
amongst the people of Kenya, and which are and effectiveness of each intervention as they
affordable, to both the Government and to relate to a reduction in the burden of disease
their beneficiaries in Kenya.
Two vital steps need to be taken to define Finally, comparison of the total costs of each
those essential interventions. First, the burden intervention must be related to the estimated
of disease experienced by the people of Kenya levels of resources which will be available to
must be measured and quantified, so that the the health sector, both from the Government
34
and other sources. Then. given the future demand for non-essential curative care will be
resource constraints which will be imposed by met not through increases in Ministry services,
the Treasury, the MoH will be able to define but through increases in private, mission and
those services which it will be able to other non-government care. Over the next
guarantee, and finance, and those additional decade this should reduce the Ministry share of
services which can be provided should inpatient services roughly from 50% to 40%
incremental resources be available over and and its share of outpatient care from 40% to
above those provided by the Treasury. 30%. Such a shift will require strict control of
health facility plans and staffing, efficiency
Once those essential services have been improvements, and use cost sharing revenues
defined, all Government facilities would be to discourage unnecessary care. Government
expected and required to provide them.· The curative care will be focussed on target groups
quantity of those services to be provided and such as mothers and children, those unable to
their costs would then be determined by local pay for basic services and patients with
variations in disease incidence and prevalence communicable diseases and mental illnesses.
and the local costs of providing the services.
Hence the allocation of public health sector Preventive and Promotive Health Care. The
resources would become more equitable, as Ministry of Health will intensify and expand the
allocations would be controlled by factors coverage of its preventive and promotive
which seek to maximise the effectiveness of health care interventions through the
those resources in reducing of the local burden development of an Essential
of disease. The basic package of care would Preventive/Primary Health Care Package for
remain consistent across all regions, but local Kenya, with a concomitant preferential
costs would be determined by local disease allocation of incremental resources towards
rates. these services. This will inciude promotion of
ante- and post-natal care, well baby care,
Such reform measures are intended to reduce breast-feeding, improved diet and nutrition,
demand for curative services and to free more health education and family planning in a
financial and other resources for public health comprehensive safe motherhood programme,
interventions and primary health care. This in as well as a strengthening of Community
tum will still further reduce the demand for Based Health Care activities aimed at enabling
curative care and lead to improvements of the individuals to assume responsibility for their
quality of both preventive/promotive and own health. There will be an expansion ,and
curative services provided by the public health further integration of already existing
sector This realization will make possible preventive/promotive programmes such as the
further reforms in cost-sharing initiatives as Kenya Expanded Programme on Immunization,
public confidence is enhanced. These reforms Family Planning, AIDS and STD prevention and
will be accomplished in the following manner: control, the National Mental Health
Programme, Environmental Health including
food safety measures, the provision of safe
Curative Care. The Ministry of Health will water, proper sanitation and housing and
contain and target government expenditures vector control, This will be achieved by
on curative care, particularly in hospitals. This expansion of the Bamako Initiative which is
will be achieved by developing an essential aimed at strengthening Primary Health Care
curative care package. Projected increases in through ensuring essential or basic preventive,
promotive, curative and rehabilitative care at
35
the household level. Likewise, there will be with regard to all major management functions
further development and consolidation of will be carried out to determine which ·
programmes for the prevention of substance functions are essentially central (such as drug
abuse and for injury and accident control and procurement and basic training) and which
prevention. could be potentially decentralized. However, it
is certain that manpower management
information systems currently under
3. REINFORCE.ME.NT Of THE development will be fully decentralised to the
districts to give them far greater responsibility
PROVINCIAL LEVEL TO PERMIT for the day to day management of personnel
f.ffE.CTJ\II SUPE.RINilNDENCE OF and for planning and budgeting.
THE DISTRICTS AND FURTHER
DE.CENTRALIZATION Of PLANNING, The l'rovlnces. The Provincial Medical Offices
have were been superseded by those of the
MANAGE.MINT AND RESOURCE district level under the present decentralization
CREATION, CONTROL AND USE TO policy. This has been recognised as a problem
THI DISTRICTS. for the effective operation of health services in
Kenya, and the Ministry of Health is committed
Decentralisation l'olicy. After thorough to reforming and strengthening the Provinces.
examination of the issues, a National Policy It is proposing to the Government
concerning decentralisation in the Health supplementary legislation which will convert
Sector will be prepared, adopted and the Provincial Medical Offices to an
implemented.Consideration will be given to inspectorate arm of the Ministry, empowering
fully decentralizing decisions regarding at least the Provinces to assume a greater level of
the non-salary operating budget for health. responsibility than they enjoy at present. This
legislation will create a Provincial Health
Polley Dialogue. Districts and provinces have Inspectorate, and a number of functions which
little opportunity for making contributions to are currently centralized will be devolved to
policy development. Although policy them. These include monitoring health systems
development must be centrally coordinated, a performance, management and financial audit,
more structured participatory process for continuing education and on-the-job training,
reviewing policy options will be established. and support for problem-based operational
Regular meetings involving senior officers from research. Their responsibility will be to oversee
central, provincial and district levels to discuss the implementation of health policy, the
specific policy issues could be followed up by maintenance of standards of quality and
working groups involving different levels of the performance, and the coordination, regulation
system who would analyze policy options for and control of all health services in both the
consideration by the MOH senior public and private sectors in their areas of
management. jurisdiction. This new institution will be a
vehicle for the implementation of national
Management Systems. Apart from health policy and provide a strong
decentralized planning systems, most other intermediary between the central Ministry and
management systems have remained Districts.
centralized. A careful review of roles and
responsibilities at different levels of the system
36
I
ii'· '
'.'\.;__L
District level l'lannlng, Budgeting; and Control Management Teams. To effectively implement
of Resource Use. The current needs-based present and future health policies the DHMBs
approach to district planning and budgeting, will need greater support from the District
drawing on "wish lists" elicited from Health Management Teams (DHMTs) which
communities and locational authorities, will will be expanded and trained in modem
shift to a resowce-basedmodel. A key aspect management and planning methods to permit
of resource-based planning will be the them to better fulfill · their operational
production of budgets which are not simply responsibilities and functions. The proposed
inflated 'bidding documents' but convey a strengthening of district level planning and
sense of realism and provide sensible and management combined with effective
convincing justifications and explanations leadership from the DHMBs will make health
about trade-offs between competing priorities, management more effective and responsive to
These budgets will reflect strategies set out in local needs, thereby improving accountability
a national framework for health development, and reducing inefficiencies,
which will define those essential curative and
preventive services to be provided, but which l)iagnostk facilities. Medical diagnostic Ii
will be adjusted to locai conditions and facilities (laboratory and radiological) at the
requirements. Information about flow of funds Health Centre level will be strengthened so as '!
at district level is poor. In order to facilitate to elevate the standard of clinical care at that i:
financial management, the link between level. This will promote more cost-effective
planning, preparation and approval of clinical services,
estimates, cash-flow, release of funds and
actual expenditure needs to be improved. Manpower. The critical clinical staff (doctors,
Improved financial information systems need nurses and clinical officers) at the Health
to be put in place to ensure transparency in all Centre level will be strengthened so as to
financial transactions, improve the clinical performance of the health
centres, This will improve the referral system
Management Boards. To-date the role of the of patients,
District Health Management Boards (DHMBs)
has been limited to oversee the management Outreach and Mobile Clinical Services. These
of cost sharing monies, This will be extended will be Intensified in the remote areas with
to permit them to oversee all health sector nomadic and semi nomadic populations, as
activities within their districts, This will be well as in other under-served areas, particularly
coupled with the formation of Hospital in urban slums,
Management Boards to manage Ministry of
Health hospitals, To reinforce this important 4. STIU:.NGTHENING Of NGO,
innovation, DHMBs, DHMTs and HMBs will
LOCAL AUTHORm', PIUVAH. AND
receive training and material support to
promote more effective operations, These MISSION SECTOR HEALTH SERVICE
changes will call for amendment of the PROVIDERS
appropriate legislation !n order to enable the This will be achieved by providing an Enabling
Boards to assume much broader roles. At the Environment for their expansion to take on
lower level, health centre and dispensa,y incremental health services over and above
committees will be established to enhance the those which the Government undertakes to
functioning of these facilities and promote provide, This may include subsidizing or
community ownership. contracting these services in areas where the
37
Ministry of Health is not able to cater for the the respective Professional Boards. Consultants
population specifically. should be well informed that abuses of this
practice could lead to withdrawal of privileges
Regulating the standards of ethics and quality and discipline for professional misconduct.
of care. It will be necessary to ensure that the
quality of care and standards of medical Also, in the interest of the general public the
practice and professional ethics meet what is respective Boards will be required to define
stipulated in the regulatory health legislation in what constitutes professional misconduct and
the Laws of Kenya. To better respond to the such definition should be made available to all
needs of patients and health care professionals the professionals concerned. The training
alike, the main legislation must be amended to curricula should give more emphasis to
provide for an inspectorate and for the professional ethics than is the case at present.
institution of proper regulatory mechanisms.
This will entail regulating private practice to Increasing the share of curative care provided
ensure compliance with the relevant laws and by non-government sources. Shifting a
regulations concerning to standards of care and proportionally greater burden of curative care
maintenance of good medical practice, as well to private, m1ss1on and other non-
as the regulation of part time private practice governmental sources will require reducing
(PTPP) by Consultants employed by the government imposed costs and constraints,
Government to ensure that they provide the strengthening the financial viability of mission
se1Vices for which they are paid. health se1Vices, and expanding insurance
coverage and benefits. The government will
Licensing of practitioners. It is apparent that provide incentives to those practitioners who
the legal framework for the practice of the wish to establish private practice in under
medical professions needs to be revised so se1Ved areas.
that private practice becomes easier to initiate,
but is regulated in such a manner that the Following completion of a study currently
quality and costs of care delivered are underway, a National Policy defining the
maintained at levels acceptable to both relative roles and responsibilities of
providers and beneficiaries. At the same time, Government and Non Government Providers
those who choose to remain in practice in and Health Care will be prepared, adopted and
Government health care institutions must be implemented.
offered the necessary financial and professional
incentives to do so. The legislation governing Increased Coverage offamlly Planning Services
private practice of the medical professions and by Non Government Providers. The
the rules governing part-time private practice Government and Private, Mission and NGO
(PTPP) by consultants employed by the providers all need to increase the numbers of
Government requires revision. Currently part- se1Vice delivery points for Family Planning.
time private practice is not addressed by the Research will be carried out to establish
Medical Practitioners and Dentists Act, but is cultural factors that inhibit acceptance of family
covered by an administrative arrangement planning acceptance. The sensitive issue of
allowing doctors in Government se1Vice to youth and their use of contraceptives will also
engage in PTPP due to demand for specialized be examined and solutions developed.
se1Vices outside Ministry of Health Institutions.
In the interest of the public PTPP should be
well regulated by the Ministry of Health and by
38
j
,-, i
have to be obtained through a re-ordering of

priorities between curative and preventive and
5. GENERATION OF INCREASED
promotive health services and raising of
LEVELS Of FINANCIAL RE.SOURCES additional resources through widely accepted
FOR THE PROVISION Of COST- cost-sharing initiatives.
EFFECIIVE SERVICES THROUGH
WIDELY ACCEPUD COST SHA.RING
five Year Plan fur financing Health Care In
AND ALTERNATIVE HEALTH
Kenya This well formulated plan will be fully
FINANCING INIIIAIIVES. implemented, and iri particular there will be:
Communities and other institutions' efforts and

resources must be harnessed and directed I
• Increased public funding for primary I
towards improving the health of the individual, and preventive (1'/PHC) services. Over
;!
family, community and the Nation. Gaps the next five years Ministry financing of '
between resources and need can only be filled P/PHC should rise from the current
when bold decisions are taken to reverse the 20% to 30% of recurrent expenditures.
resources allocation. Otherwise resources will This will be achieved through
continue to be directed to curative services preferential allocation of central budget
which are not cost-effective. The Government increases and district level user fee
cannot afford to sustain huge expenditure on revenue to P/PHC.
curative care in hospitals and health centres.
In the process towards this objective three
important principles have to be recognized and
• Increased Ministry of Health Revenue
taken into account. Generation Cost Sharing revenues
should increase from the current 7% to
• Achievement of cost-effectiveness 30% of non-staff expenditures. This will
be accomplished through increases in
• Responsibility of individual, family, NHIF claiming, improved collection
community, self-help group, NGOs and efficiency, periodic fee increases and ! I
private sector in health delivery control of exemptions.

:, I
• That within Government, the Ministry

of Health is not solely responsible for
Long Term Options. Longer term options
health delivery but shares this which are under consideration include the
responsibility with others such as
provision of block grants from the Government
Ministries of Local Government, Water
to districts. Under these arrangements district
Development, Agriculture and level planners and managers will have the
Livestock, Education. option of restructuring health services in a
manner that best suits both local circumstances
and the levels of resources they are allocated
It is important to note that Government and those local funds they can raise from cost
revenue base is in-elastic while the demand for sharing and other local initiatives.
health services grows with the increasing
population. The additional resources required
to maintain the level of services, therefore, will
39
6. SHIFTING PART Of THE 7. FUIITTIIR REDUCTION IN THE

FINANCIAL BURDEN Of CURATIVE RATE Of CONSTRUCTION Of NEW
CARE FROM THE. MINISTRY Of GOVERNMENT FACILITIES AND A
HEALTH BUDGET TO INSURANCE FOCUS ON CONSOLIDATION,
SCHEMES. REHABILITATION AND
MAINTENANCE Of EXISTING ONES
This will require a review of NHIF with a view BASED ON NEID AND THEIR COST
to reforming it and seek possibility of other
IffE.CTIVENISS IN DILMRING
types of health insurance.
HEALTH CARE.
Expansion of the role of NHIF and other social National Policy on Development of Physical
financing mechanisms Through policy Facilities and Major Equipment. To guide and
leadership, legislation, regulation and improve public investments in health facilities
education the Ministry will work to strengthen and equipment, a national policy on the
the role of NHIF, increase the population development of physical facilities and
covered by health insurance (both NHIF and equipment will be prepared and implemented.
private). broaden insurance benefits, and This national policy will govern the future
increase community financing efforts. The choice of type and location of physical facilities
expansion of existing private and community and equipment by all providers, and will seek
insurance schemes will be promoted through to limit new construction only to those facilities
the forging of links with these financing considered necessary to provide equitable
institutions. access to essential curative and preventive
services. Guidelines will be developed for the
Expansion of Mandatory Insurance Coverage. provinces and districts which will permit them
The NHIF will be encouraged to develop and to decide where additional facilities or services
expand its benefits package to cover more should be located in their areas of jurisdiction.
than reimbursement for board and lodging in At the same time, the policy will define the
hospitals and nursing homes. In this manner, it requirements for the rehabilitation of existing
will become a National Health Insurance Fund. facilities and equipment and for their continued
Likewise, the creation of an enabling maintenance and repair.
environment for the expansion of private
practices into underserved areas will be Two ongoing studies are designed to assist the
examined, with a view towards NHIF offering Ministry of Health to prepare these policy
loans for the establishment of these practices guidelines. The first will examine the current
at preferential rates. distribution of facilities and services
nationwide, including those belonging to both
the Government and the Private and Mission
Sectors, and will make recommendations for
improving equity in their spatial distribution,
and will provide cost estimates for their future
operation.
40
H£Al1H POllCY FRAMEWORK
The second study will survey the rehabilitation of certain facilities, and will require
needs of existing buildings, plant and medical considerable investments over at least the next
equipment in Ministry of Health Hospitals, five years. The planning of these investments
Medical Training Centres and Rural Health will form an essential component of a Public
Training Centres, and will provide budgetary Investment Plan for the health sector in Kenya,
estimates of the investment costs required to which will seek to demonstrate the priority
bring them to a satisfactory level of areas of investment which are required to
performance. This will be combined with ensure that the MoH can advance its policy of
existing data concerning rural Health Centres ensuring that quality health care is delivered to
and Dispensaries to ensure completeness. the nation. Initially, . to ensure smooth and
effective and above all sustainable
The combination of the outputs from these two implementation, the Ministry of Health will
studies and the development of appropriate therefore focus upon the rehabilitation and re-
policy guidelines will contribute to the equipping of priority facilities in those districts
preparation of a long term Public Investment with an ongoing maintenance programme, and
Plan for the health sector by the Ministry of will thereafter continue to expand the existing
Health which will channel future investments maintenance programme to other priority
towards a more equitable and sustainable districts.
provision of health care services in Kenya.
Maintenance The Ministry will take steps to
increase the budgetary allocations and actual
8. INCREASING THE LEVEL Of expenditures on preventive maintenance as a
means of protecting its fixed assets from
ADEQUATE. HUMAN, FINANCIAL
deterioration. This will be done through
A.ND ORGANIZATIONAL requesting the Treasury to provide more funds
RESOURCES TO PROPERLY for maintenance. At the same time, resources
MAINTAIN A.ND REPAIR fA.CILmES will be mobilised from Cost Sharing revenues
A.ND EQUIPMENT to supplement those available from the
Ministry
Standardisation. For the MOH to manage a
viable preventive maintenance operation for 9. RE.ORIENTATION, RETRAINING
buildings, biomedical equipment and its fleet A.ND REDEPLOYMENT Of HEALTH
of vehicles it will have to standardize the MANPOWER TO MEET MANPOWER
equipment, vehicles and fixtures used by the
DEMAND PROJECTIONS A.ND
Ministry, and which are often imported. This
will enable the MOH to build the required RE.SOURCE AVAILABILITY.
stocks of spare parts which is currently not
possible due to lack of standardization. Health Manpower and Training Policy The
Ministry is finalising a major study designed to
RehabUitation The Ministry of Health, with reformulate its National Manpower and
investment aid from the World Bank, ADB and Training Policies. It is expected that the revised
other donors will bring these infrastructure up policies will focus upon the following issues.
the standards expected for the effective and
efficient provision of quality health care. This Priority in resource deployment, Personnel and
will involve the rehabilitation and re-equipping supplies must be directed to the peripheral
41
HEALTH POllCY FRAMEWORK
dispensaries and health centers. If effectively existing supply of health personnel. This will
managed, this should reduce the workload at include curricula reform, substantial training of
hospitals. Clear staffing norms will be trainers and administrative staff and the
developed to form the basis for future establishment of a full time professional
personnel policy geared towards making trainers scheme of service and benefits.
smaller facilities functional and adequately
staffed so as to enhance their outpatient The Organization of a Decentralized Continuing
services. Similar norms for manpower Education Strategy This will strengthen the
allocations and postings to the districts will be basic skills of personnel already in service.
set. Elements of the strategy will include:
District Health Management Teams will be Continuing Education Units with full
given greater authority with regard to time staff in each District.
personnel management, including posting,
transfers and staff discipline. A core programme based upon
epidemiological data and other
Types of Health l'roresslonal. Using staffing assessments of training needs.
norms, policies will be directed towards
ensuring that there exists a proper ratio Adaptations of the core programme to
amongst the various cadres. These ratios will local conditions.
be used to control either increases or
reductions in the numbers of certain cadres Ongoing monitoring and performance
trained at public expense. At the same time, based assessments.
training of essential clinical specialists will be
closely controlled and monitored to ensure the Management and Regulatory Reform. There
availability of the most critical cadres. will be a number of changes for strengthening
personnel management, increasing their
Redeployment It will be necessary to redeploy effectiveness and efficiency personnel retaining
some staff from in-patient services in favour of and attracting qualified staff, zero growth
out-patient and community based services. budgeting for staff and the creation of a
Priority will be given to the deployment of balance between urban and rural staff
newly trained staff to under served provinces deployment through the following measures:
and rural health facilities. Ceilings will be
imposed upon the numbers of Ministry of Harmonization of policies'·· among
Health personnel deployed to hospitals and cadres who wish to leave the public
large urban facilities, and this may mean the sector and enter into private practice
establishment of targets for the number of
Ministry of Health hospital beds which will Pay scales and terms of service.
receive support. Health professionals' terms and
conditions of service will be improved
Basic Education of Health l'roresslonals This to assure basic individual needs.
will be reformed to ensure they have a high
level of skill to deal with the problems of Hardship pay and other incentives. It
curative care and in preventive strategies. It is critical to deploy and retain staff at
will be necessary to meet projections of future facilities in the rural areas where more
demand given current attrition rates from the than 85% of the population lives. A
42
system to encourage rural staff sustain this practice and also ensure that l 00
retention will be established. The per cent screening takes place. In addition,
classification of hardship areas needs to sterile surgical procedures will be practiced by
be reviewed to improve the incentive all health workers .
and benefits structure.
Prevention of Perinatal Transmission of HIV:
Prevention of transmission of HIV to women is
Subordinate Staff. The Ministry of by far the best strategy for preventing
Health will have to drastically reduce transmission from mothers to child. Because
the number of subordinate staff on its most women are unaware of their infection
payroll. District will be empowered to status, efforts will be made to provide facilities
recruit subordinate staff in accordance for voluntary testing of pregnant women.
with the needs of their facilities and Secondary prevention of perinatal transmission
they will be expected to meet their currently depends on the avoidance of
costs from new and innovative sources. childbearing by HIV positive women.
Voluntary counselling, contraception and other
• Targets Similarly, the Ministry of Health fertility regulation services will be made
will have to set targets for other health available to women everywhere as part of
personnel to be paid in each District health services and supportive environment
using a weighted capitation formula. needed for prevention of perinatal
Additional staff could be hired and paid transmission. Research is needed to evaluate
directly at the District level. the impact of current counselling methods for
couples and women of childbearing age, and !I'
to determine how to improve this impact
through alternative methods, for example i'j
using religious leaders and traditional health

10. PREVENTION AND CONTROL Of
practitioners. Over the longer term,
AIDS, HIV INFECTION AND biomedical research needs to pursue the
SEXUALLY TRANSMITTED DISEASES. development of 'perinatal vaccines' and other
Given the potential of the AIDS/HIV epidemic such drugs for preventing HIV infection in the
to negate health gains since Independence, the unborn and newborn babies of HIV positive
Government recognises the special status it women.
must accord to this problem. The main goal of
the Government will be to slow down and Care, Indudlng Counselling and Oinlcal
eventually halt the progression of the AIDS Management. Proper care and support of HIV
epidemic in Kenya through: positive persons will be stressed to that they
be useful and productive for the rest of their
Prevention of HIV Infection through lives and their dignity safeguarded. The
information, communication and education on Government will strive to ensure that humane
measures of control and prevention of HIV and care of a quality at least equal to that provided
AIDS. for other disease is everywhere available for
HIV positive infected adults and children.
Prevention ofBioodbome Transmission of HIV: Services will be appropriate, accessible and
Transmission through blood for transfusion has continuous. At the minimum, clinical care will
already been minimized through effective include pain relief and treatment for common
screening. However, efforts will be made to opportunistic infections.
43
Social and [conomic Support for AIDS Patients 11. ADOPTION A.ND
and their families. With regard to social
security and health insurance schemes, the
IMPLEMENTATION Of A. NATIONAL
coverage afforded to people with HIV/ AIDS DRUG POLICY
should be equal to that provided for people This is called for so that available resources
with other diseases. Community Based Home may be used to develop pharmaceutical
Care for AIDS sufferers will be emphasized and services to meet the requirements of all
developed. Traditional approaches to care of Kenyans in the prevention, diagnosis and
orphans will need to be supplemented by treatment of diseases using efficacious, high
community-based foster care homes, day-care quality, safe and cost-effective pharmaceutical
centres, and a bigger parenting role for products. The National Drugs Policy will serve
schools. Other options include village as the guiding document for legislative
associations or cooperative which parents join reforms, staff development, and management
in preparation for the orphanhood or their improvements.
children, the use of religious and other
charitable institutions to protect orphans' Drug Availability -- Drug availability will be
property, and the creation of a protective increased at government health facilities
climate for widows and orphans. through improvements in the selection,
financing, procurement, distribution, and use of
pharmaceuticals. The first critical step in
National Coordination of Research aimed at making drug selections more cost-effective
sharing information and experiences, as well as was already taken in September, 1993 with the
accelerating scientific progress using launching of the revised National Essential
appropriate technologies,will be a main areas Drugs List (EDL). With assistance from the
of focus. Training and transfer of technology World Health Organisation, the list has been
will ensure that the results of biomedical and made available to all health institutions in the
other research are made easily available. country, both governmental and non-
governmental. Availability of drugs at Ministry
Meeting National Financial Needs: The financial health institutions will also be improved
burden brought about by the impact of the through financing arrangements based on
epidemic on the entire health care system is actual per capita drug requirements and on re-
enormous. There will be need to mobilize establishment of a well-managed revolving
more financial resources to meet this burden. drug fund. Good Pharmaceutical Procurement
Financial resources from various sources (e.g. Practices will be implemented: procurement by
International Agencies and Donors, NGOs, generic name, concentration on the EDL,
Government Sectors and Communities) will be rational needs assessment, pre-qualification of
coordinated. suppliers, competitive tendering among pre-
qualified suppliers, improved quality assurance,
Organisation and Management Structures: The and systematic monitoring of supplier
Government will set the National AIDs Council performance. Efforts to improve distribution
with broad representation of different sectors will also continue. The Ministry has already
and NGOs to address the problem of obtained a commitment from WHO to provide
HIV/AIDS. The Council will also be mandated financial and technical support for a senior-
to foster collaboration with international and level committee to re-structure the supply
Donor Agencies in support of the AIDS Control process. Drug availability in the private,
Programme. mission, and NGO sectors will be improved
44
HEAllll POLICY FRAMEWORK
through a strengthened registration system, a dispensing, and patient use of drugs will be
more systematic approach to determining addressed by regularly updating and widely
where particular types of drugs may be sold disseminating standard treatment guidelines
("scheduling"), and streamlining of the for hospitals and rural health facilities,
importation process. standardizing levels of authorized prescribing,
integrating the Essential Drugs Concept into all
Affordability -- The high cost of drugs in the health-related training, introducing Pharmacy
public sector will be addressed primarily and Therapeutics Committees into all major
through the improved financing and health institutions, establishing a national drug
procurement procedures described in the information system, and controlling drug
preceding section. Affordability of drugs in advertising and promotion.
pharmacies and at private health institutions
will be addressed by several measures in the Quality of Drugs -- The quality of drugs
National Drug Policy. First, a major emphasis imported into Kenya and manufactured in
will be placed on promoting generic labelling, Kenya will be controlled by making the
prescription, and substitution. Educational National Quality Control Laboratory fully
programmes for medical practitioners, operational, by enforcing international-standard
pharmacists, other health professionals, and Good Manufacturing Practices among all
the general public will emphasize the cost- manufacturers, and by actively participating in
effectiveness of generic products. Proper the WHO Certification Scheme on the Quality
registration and quality assurance procedures of Pharmaceutical Products.
should ensure that generic products are safe
and effective. Second, registration of drugs in Local Production -- Kenya has an active
Kenya will be limited to products which have pharmaceutical industry which contributes to
proven quality, safety, and efficacy and which the economy, security and health of the
meet a specific medical need. Products whose country. Continued growth of this industry will
proposed wholesale and retail prices are be encouraged through promotion of generic
excessive compared to those already on the products, local production incentives, a local-
market will not be accepted. Third, efforts will preference margin in Ministry pharmaceutical
be made to extend NHIF and other insurance tenders, review of applicable patent laws, and
coverage to include pharmaceuticals, thus harnessing of potential research and
easing the burden on individuals. Fourth, development funds to expand local technical
alternatives to the current system of know-how.
compensating pharmacists/pharmaceutical
technologists will be explored. Fifth, Drugs for veterina,y services -- The availability,
traditional medicines will be encouraged, but affordability, rational use, and quality of drugs
supervised through the new policy. Finally, for veterinary services will be improved by
though there will be no formal price control applying the same Essential Drugs Concepts to
mechanism, the Ministry will ensure that the selection, procurement, distribution, and
established wholesale prices are regularly use of veterinary drugs as are applied to drugs
published and that a mechanism is established for human consumption. This includes
to exchange price information with other preparation of a Veterinary Essential Drugs List,
countries. promotion of general prescribing, and related
activities.
Rational Use -- Rational drug use improves
health and reduces costs. Better prescribing,
45
Implementation of the National Drug Policy 12. CONSOLIDATION AND

Implementation of the National Drug Policy
will not occur over-night. Some policy
STRINGfflE.NING Of KEY HEALTH
elements require legislative changes, others MANAGE.ME.NT INFORMATION
require regulatory adjustments, while still other SYSTEMS (HMIS) TO SUPPOIIT fflE.
require changes in day-to-day Ministry POLICY-MAKING ROLE. Of fflE.
operations. Implementation of certain aspects
MINISTRY Of HEALTH IN
of the NDP rests solely with the Ministry of
Health, while the implementation of other BUDGE.TING, PLANNING AND
aspects requires collaboration among several MANAGE.ME.NT FUNCTIONS IN fflE.
Ministries. Enabling legislation already exists in DISTRICTS.
the following Acts of Parliament, in some of
which specific sections will require subsidiary Facilities and fixed assets. The Ministry of
legislation in support of the National Drug Health requires an information system which
Policy: can identify all its fixed assets and provide
accurate and timely information to planners.
he Public Health Act Cap 242, the This will necessitate the creation and routine
Pharmacy and Poisons Act Cap. 244, and continuous updating of a facility
the Dangerous Drugs Act Cap 245, the information system which would capture
Medical Practitioners and Dentists Act details of each and every health facility in
Cap 253, the Clinical Officers (Training, Kenya, both those belonging to the
Registration and Licensing) Act, Cap. Government and those belonging to private
260, the Nurses Act Cap. 257, the and mission sector organisations. There should
Malaria Prevention Act Cap. 246, the also be provision for an inventory system for
National Hospital Insurance Act Cap. all items of medical and non-medical
255, the Food, Drugs and Chemical equipment and vehicles belonging the Ministry
Substances Act Cap 254, the Animal of Health. Such information is of critical
Diseases Act Cap. 364 and the Price importance to any form of planning.
Control Act Cap. 504.
Financial resources data. To improve financial
A five-year implementation plan for the planning and budgeting in the Ministry of
National Drug Policy when operationalised will Health, it will be necessary to implement
include specific actions required, areas in which financial and accounting systems which
legislative changes will be initiated, proposed provide the data needed to generate
timing, responsibilities, resource requirements, meaningful financial management and cost
capacity building and institutional control information. Also, systems are
arrangements. required to provide the data needed to
support the development of financial planning
models of the Kenyan health care system. This
involves having a set of systems and output
reports which will provide for tracking and
control of cash, inventory, and fixed assets,
and reports to present organization unit,
service, and program costs. The availability of
budgets and standard costs would support the
46
establishment of an effective control system about appointments, promotions, and other

and financial models. matters. It is this detailed data, coupled with
baseline information concerning staffing norms
The initial requirement is to introduce a set of and authorized staffing levels that should
accounts and the appropriate ledgers to gather provide the basis for determining the numbers
actual financial and cost data in sufficient detail and types of staff employed, their qualifications
that the desired control systems, modeling and experience and suitability for promotion or
requirements and output reports can be training, where they are working, the type of
developed. The current budgetary control work they are doing, and the efficiency and
system must be strengthened and broadened acceptability of their performance. Such
to include the preparation of budgets at the information is the basis for the preparation of
service/cost center level for all health facilities. staffing budgets and operational performance
Standardised unit costs are useful for standards for different types of jobs and pay
performance measurement, for pricing services, grades. Without it there can be no effective
and for use in planning models to help
evaluate the costs of adding, expanding, or
changing services and programs within the
manpower management.
Given that over 70 per cent of recurrent health

I
i
health care system. expenditures are devoted to those of I
personnel, it is again critically important for the

Workload and operational data. Accurate, Ministry of Health to develop and maintain
timely and pertinent operational and worl<ioad accurate information systems for its health
data is needed to develop health care plans manpower. As the situational analyses
and budgets, and for support to management indicated, such a system is under
decision-making, for example to provide the development. This will continue and will
means to measure the efficiency and the eventually permit information-based health
productivity of performance, and to show the manpower planning
utilization level of a health facility, a cost center
or a department. Such information, when lnfunnatlon for Planning. Facility and workload
compared to planned levels of performance or data, when aggregated and compared with
to the performance of a similar facility or unit, those data concerning both personnel and the
also provide insight into such factors as its Ministry of Health recurrent and development
budgetary allocations, the suitability of the budgets have the potential, if they are
staffing levels compared to activity, the accurate, timely and complete, to provide the
suitability of its equipment, its supply substrate for real and effective information-
allocations, and inventories, and the types of based planning systems within the MoH. The
patients served etc. development of planning models also requires
providing information about the geographic
Manpower data. The effective management of areas where specific programs and services are
manpower requires tracking the assignment either available or are lacking. Also, the actual
and job placement of employees, managing and planned levels of service delivery can be
payroll and benefits, processing new recruits determined from this data. Staffing levels
and terminations of various types, and needed for actual and planned service levels
handling employees of different status. In and drug and medical supply needs based on
addition, human resources functions epidemiologic data should be routinely
encompass employee performance and career available to support planning needs.
tracking in order to support decision making
47
A comprehensive set of networked Health costly than others, due for example to
Management Information Systems will be geographic variations in the cost of providing
designed and rapidly implemented to provide inputs, these variations must not be excessive.
the information required to support activities at For example, under ideal circumstances, during
all levels of the health infrastructure. This will the course of one financial year the average
include elements concerned with Human cost of an inpatient bed day or of an outpatient
Resources Management, including and visit in a PGH should not vary widely between
interface with the Treasury payroll system, two such institutions. By allocating resources
financial accounting, budgeting, control of to institutions on the basis of reasonable unit
fixed assets, financial resources, tracking of costs and historical workload data, greater
operational, workload and epidemiologic data managerial efficiency can be promoted and
to permit performance of the health system to inequalities in resource allocation between
be related to costs. facilities of the same type and capacity can be
minimised.
t3. INSTITUTIONALIZATION Of Improvements to Local Management and

MANAGEMENT TOOLS FOR COST Planning . Strengthening the planning and
management skills of health personnel is
CONTAINMENT AND COST required at all levels. Simple and effective
CONTROL PARTICULARLY FOR THE management tools capable of providing
HOSPITAL AND CURATIVE SECTOR. information concerning the costs and quality of
The efficiency of the use of resources in the care provided in Government and Non-
health sector will determine how well inputs Government health institutions are currently
are translated into outputs, both in terms of under development. When finalised, they will
the cost efficiency of specific types of be implemented nationwide to provide
interventions as they relate to a reduction in managers with the tools they need to improve
the overall burden of disease, and in terms of the quality, efficiency and cost effectiveness of
the cost efficiency of individual institutions the services their institutions provide.
which provide those interventions.
Improvements to National Management and
To improve the local management of Planning The Government needs to promote
resources, particularly in resource constrained cost-effectiveness in the provision of health
public sector health care facilities, limits will care. It will develop its capacity to measure the
have to be set on local expenditures. These cost effectiveness of different interventions in
limits should be imposed to encourage more curative care and in public health, and after
effective management, which should seek to careful prioritisation direct more public sector
maintain defined standards of quality of care resources to the essential curative care and
within strict cost limits. public health packages that will benefit the
majority of Kenyans and limit public support to
The cost of an inpatient bed day or of an those that are not cost-effective e.g. highly
outpatient visit in a health care facility should specialized tertiary health care services that
be consistent between all facilities of that benefit only a small fraction of the population.
particular type and capacity. Although
variations in local costs will have an influence Support Services The Government needs to
upon these costs, since certain zones are more study the potential costs and benefits as well
as the rules and regulations governing the
48
contracting out of support services as they may

apply to Government operated heath care
15. REORIENTATION Of mE
institutions. In doing so, it may be possible to
develop and implement feasible options for the ORGANIZATION STRUCTURE AND
contracting of these services in Government FUNCTION Of mE MOH TO MEET
facilities to private sector contractors. mE PROPOSED REFORMS.
14. STRENGmENING Of HE.Alm This agenda for reform of the Health Sector is
RESEARCH ambitious, and in order for it to act as a tool
The Government recognises that health for both shaping and regulating the sector, the
research should support the activities of all Ministry of Health must itself revisit its roles
agencies operating within the health sector, and responsibilities so that it may, as the
and that research into priority diseases and preamble to this document suggests, continue
conditions and the means to combat them to play the role of protector of the poor and
must be better coordinated. needy.
Division of Research, Health Standards and Health Sector Reform Secretariat and Reform of
Inspectorate. The Government, through the the Structure, Organisation and Management
Ministry of Health has recently established the of the Minist,y of Health. The Government has
Division of Research, Health Standards and set up a Secretariat to oversee the sectoral
Inspectorate. This Division, together with the reform process, and the action plan for the
National Health Research Development Centre implementation of the DPM Study Team Report
(NHRDC), will coordinate all health research of 1993 has been accepted by the Government
services in the country inciuding the creation as the vehicie for the reorientation and
and implementation of health standards to reorganization of the structure, management
ensure compliance with the health laws. This and operations of the Ministry of Health, and
will involve:- also as the basis for Civil Service Reform in the
Health Sector as required by the Structural
Coordination of health systems as well Adjustment Program.
as clinical and biomedical research
However, in view of the need to develop a
Setting health standards as a priority small and decentralized structure for the
for patient care and management of Ministry of Health, the DPM Study 'feam
disease. Report which formed the basis for this action
plan will be revisited in order to accommodate
Reinforcing the set health standards this reform agenda. This will then establish a
smaller span of structural control than
Collaborating with all health research recommended by the DPM report, as well as
institutions (eg. NHRDC, KEMRI, ICIPE) the new Provincial Inspectorate. This reform
will demand that some of the functions of the
Collaborating with the relevant central Ministry be devolved from headquarters
Boards/Councils on matters of health in favour of a more decentralized
standards (eg. Medical Practitioners management. This will contribute to a real
and Dentists Board, Nursing Council, strengthening of rural health management and
Clinical Officers Council). health service delivery.
49
HEAllH POLICY FRAMEWORK
1. Expenditure and Financing of the Health Sector in Kenya. Ministry of Health. February 1986.
2. Expenditure on Preventive and Promotive Health Care 1979/80 to 1996/97. Trends and Projections.
Ian J. Sliney, Senior Health Planner. Ministry of Health. September 30th 1993.
3. Ministry of Health Joint Drugs and Dressings Supply Strategy 1993/94 to 1997/98. April 1993.
4. Kenya Demographic and Health Survey 1993. Preliminary Report. National Council for Population and
Development, Ministry of Home Affairs and National Heritage, Central Bureau of Statistics. September
1993
5. Source: Central Bureau of Statistics, January 1994
6. Republic of Kenya. National Development Plan 1994-1996. Page 261.
7. Ministry of Health Facility Information System. September 1993 Update.
8. Ministry of Health Curative Gap Study. Component 1, Costs and Quality of Care in a Sample of
Government and Non-Government Hospitals in Kenya. Unpublished preliminary Results. January 1994.
9. Pharmaceutical Position Paper. Covering problems, constraints to growth, prospects and

recommendations for policy makers and implementors. Gaurang Patel. Kenya Association of
Manufacturers. November 1993
10. Decentralization and Health Systems Change in Kenya. A Case Study, James Mwanzia, Isaac Omeri,
Samuel Ong'ayo. November 1993.
50

Kenya's Health Policy Framework, 1994

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GOVERNMENT Of KENYA

KENYA'S HEALTH POLICY FRAMEWORK

ADB African Development Bank

CRITICAL PROBLEMS FOR THE could be equivalent to the entire 1993/94

LAWS The Laws governing the health sector

The document is presented in such a manner

GDP has continued to slide below 4 per cent

decade or so of independence, Kenya enjoyed 1. PAST HE.Alm POUGES

HEALTH POUCY FRAMEWORK

Civil Seivice Health Manpower Reform. Civil 3. MINISTRY Of HEALTH

HEAlffl POLICY FRAMEWORK

for funds provided by donors. These accounts 4. SECTORAL ECONOMIC PROFILE

MISSIONS 168,900,000 5.87% MISSIONS 29,300,000 1.02%

GRAND TOTAL 2,876,000,000 100.00% GRAND TOTAL 2,875,700,000 100.00%

Minlst,:y of Health recummt expenditure then have dropped to about US$4.50 in

figure l (Above) MoH Recurrent Expenditures J 979-1997.

figure 1 (Below) MoH l'er Capita Expenditures 1979-1997.

MOH PER CAPITA EXPENDITURE

In 1979/80 Ministry of Health recurrent hospitals. Since 1979/80, the percentage of

Table 2. Minist,y of Health Recurrent Budget Expenditures. (Internal Allocations, As percentage

79/80 42,943,415 66.69% 15.13% 11.70% 6.48% 9.26% 8.65

80/81 52,868,619 68.36% 15.74% 11.43% 4.47% 9.45% 9.55

81/82 59,075,879 72.33% 12.75% 11.98% 2.94% 9.32% 7.60

82/83 61,306,323 72.41% 13.84% 12.44% 1.31% 9.32% 6.00

83/84 61,765,853 72.39% 11.55% 14.57% 1.49% 8.83% 5.36

84/85 73,007,033 66.52% 9.71% 10.88% 12.89% 9.19% 5.24

85/86 79,653,593 71.83% 12.88% 10.10% 5.19% 9.25% 5.35

86/87 96,546,022 72.14% 10.82% 12.14% 4.90% 8.95% 6.16

87/88 101,014,500 78.18% 10.50% 9.56% 1.77% 8.38% 5.76

88189 113,686,327 72.24% 16.48% 9.63% 1.65% 7.38% 5.85

90/91 128,807,254 69.76% 19.87% 9.17% 1.19% 7.82% 5.08

93/94 209,125,600 62.74% 25.49% 9.17% 2.60% 7.65% 2.99

94/95 299,529,639 67.23% 20.95% 9.65% 2.16% 7.59% 3.44

95/96 315,133,200 67.11% 21.38% 9.28% 2.22% 7.60% 3.22

96/97 350,586,292 66.86% 21.39% 9.58% 2.17% 7.61% 3.09

Table 3. Combined Recurrent and Development Budgets by Source of finance.

YEAR TOTAL(K£) GOK DONORS GOK¾

93194 310,947,827 223,946,610 87,001,217 72.02%

94195 343,916,500 255,364,811 88,551,689 74.25%

95/96 375,833,659 269,227,550 106,606,109 71.63%

Table 4. Development Budget by Source.

Kenya 22.02% 14.49% 24.08% 16.91%

Austria 1.76% 1.13% 1.66% 2.33%

Belgium 0.32% 0.06% 0.()()% 0.00%

Britain 0.00% 6.40% 0.00% 0.00%

Canada 2.44% 0.66% "1.81% 2.54%

China 2.26% 0.00% 2.04% 1.43%

Denmark 6.50'% 4.58% 2.16% 2.80%

EDF 0.92% 0.00% 0.91% 0.64%

Finland 7.49% 6.26% 3.64% 4.93%

Germany 2.68% 1.48% 0.25% 0.17%

IDA 11.94% 11.16% 31.85% 32.04%

IDRC 0.08% 0.00% 0.00% 0.00%

IFAD 1.53% 1.21% 1.95% 1.46%

IPPF 0.30% 0.00% 0.00% Q.()0%

Italy 0.50% ().(JO% 0.00'/o 0.00'/o

Japan 0.00% 22.64% 0.00% 0.00%

Netherlands 4.12% 4.30% 0.70% 0.4S%

SWeden 17.42% 9.99% 9.86% 10.83%

UNICEF 0.36% 0.00% 0.00% 0.00%