joint mission on harmonizing support to rh in kenya 2011 1 1 joint mission on harmonizing support to...
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Joint Mission on Harmonizing Support to RH in Kenya 2011 1Joint Mission on Harmonizing Support to RH in Kenya 2011 1
Joint Mission on Harmonizing Support
to Reproductive Health in Kenya
Preliminary Results and RecommendationsNairobi, 03-03-2011
Overview of mission
Commissioning partners:DANIDA, DFID, GDC, USAIDTogether with MOPHS, MOMS, BMGFDuration: from 13th February to 4th March, 2011Field visits to: Nyanza, Western, Eastern, Coast ProvincesNairobi: Korogocho, Dondera, Stahere slums
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Overview of presentation
1. Distribution of Commissioning DPs2. Overview of Financing3. Appraisal of Thematic Areas and Framework4. Ways of Working (“Modalities”)5. Health System re. RH (Supply Side)6. Demand Side Interventions7. Complementary Health Service Provision8. Adolescent SRH and SRH-R9. Next Steps
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1. Distribution of Commissioning DPs
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Incidences of Overall Poverty (%) 2005/2006 versus DP Presence
To be inserted
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KENYA POVERTY LINE=46%
ABOVE POVERTY LINE
BELOW POVERTY LINE
DFID
BMGF
GIZ
KFW
DANIDA
USAID
Sources: WMS series 1992,1994 and 1997;KIBHS 2005/06
49%
52.2%
21.3%
51%
69.7%
50.9%
73.9%
47.6%
Skilled Birth Attendance (%) - 2008/09 versus DP Presence
To be inserted
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Greater than national average
Less than national average
DFID
BMGF
GTZ
KFW
DANIDA
USAID
Source;KDHS
34%
26%
89%
74%,
46%
43%
32%
46%
Kenya: 44%
2. Overview of Financing
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Examples of GoK and DPHK reporting of spend
on Reproductive Health
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Ministries’ Reporting on Reproductive Health
(Printed Estimates for FY 2010- 2013)
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Program Expenditure category Projected Estimates (Kshs Millions)
FP/MCH 2009/10 2010/11 2011/2012 2012/2013
Personnel Emoluments 42.5 62.2 108.6 112.6
Purchase of commodities 37.4 26.5 30.5 35.1
OBA program (admin) 63.0 62.0 71.3 82.0
Purchase of capital goods 20.0 20.0 23.0 26.5
Others 1,215.6 1,042.1 1,198.4 1,378.2
sub-total - FP/MCH 1,378.4 1,212.9 1,431.8 1,634.4
Child Health Services - - - -
O&M 7.4 6.3 7.2 8.3
Other recurrent 0.5 0.1 0.1 0.1
sub-total - CHS 7.9 6.3 7.3 8.4
GRAND TOTAL - RH 1,386 1,219 1,439 1,643
TOTAL HEALTH BUDGET 40,826 41,500 53,772 54,431
RH as % of total health budget 3% 3% 3% 3%
Approved Estimates (Kshs Millions)
DPHK Reporting on Reproductive Health
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AOP6 PLANNED INPUTS
(2010-11)
USD($)RH
commodities condomsRH
O&MMCH
commoditiesMCH
O&Mnutrition
O&M TOTAL
AFDB $0
CLINTON $0
DANIDA $0
DFID $6,043,976 $397,630 $6,441,606
EU $1,400,727 $1,400,727
FRANCE $0
GAVI $35,053,500 $532,000
GTZ $5,599,840 $4,619,868 $10,219,708
KFW $0
ITALY $0
JICA $183,506 $183,506
UNAIDS $0
UNFPA $1,000,000 $1,429,500 $2,429,500
UNICEF $1,300,000 $6,300,000 $5,739,738 $13,339,738
USG $12,670,000 $3,675,000 $16,345,000
WFP $11,241,728 $11,241,728
WHO $497,000 $282,750 $779,750
WORLD BANK $6,400,000 $6,400,000
TOTAL $12,643,816 $6,400,000 $21,097,504 $35,053,500 $11,907,727 $17,264,216 $104,366,763
Finances for Health & RH• Two costed strategies – Average is $215 million
National Road Map for MNH and Child Survival Strategy (2008): $50 and $380 million per year respectively.
• WHO cost estimate per head for scaling up maternal health of $1.40, implying an additional cost for Kenya of $60 million.
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Finances for Health & RH
Kenya Total Resources for Health Estimated Resources
for RHin US$ mio
GoK 550 25DPs 600 104Households 275 60TOTAL 1,425 190
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Finances for Health & RH
• Could have sufficient resources for RH.• The single largest cost component in both
strategies is CHWs: $20m in the Road Map, $90 million in the Child Survival Strategy.
• Out-of pocket expenditure on (reproductive) health: private sector and demand side approaches have potential.
• BUT – Additional RH components (e.g. ASRH, gender violence) and will raise total cost.
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Health Financing- Allocation of Resources (1)
DP Resources 2009/10 WHO for RHRecommendations
Procurement 42% Drugs & supplies 48% Service Delivery 55% Staff salaries 22%Infrastructure 3%
Support Systems 2% System dev. 25% (incl infrastructure, training)
Joint Mission on Harmonizing Support to RH in Kenya 2011 14
Health Financing- Allocation of Resources (2)
• DPs spending about the right amount for commodities
• Too little being spent on systems development (and infrastructure)
• DP vertical spending - overwhelmingly on HIV/AIDS.• PETS – over 50% leakage Recommendation: • Resources looking adequate – the task for RH is to
allocate resources more effectively.
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Health Financing
2009 Health Financing Strategy has stalled – KNHIF proving difficult to tackle and progress v slow.
Recommendation:• “Plan B” carry on with demonstrating
alternatives that work on the ground with well designed pilots: social insurance (HAKI)
Joint Mission on Harmonizing Support to RH in Kenya 2011 16
Health Financing
• Vouchers / OBA scheme puts RH purchasing power into women’ hands and is effective and popular with women and service providers.
• High admin costs should be reduced if scaling up; • International evidence that voucher schemes costly
and unsustainable. Don’t seek to transfer costs to GoK, instead use OBA to direct DP resources to give more women decent, subsidised, urgently needed RH services.
Joint Mission on Harmonizing Support to RH in Kenya 2011 17
3. Appraisal of Thematic Areas and Framework
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Technical Appraisal
In mapping donor support the policies and strategies to identify gaps and areas for support we looked at DPs current support to RH against :
• Vision 2030• NHSP 2• RH Strategy• MNH Road map• AOP funding
Technical Appraisal
Policy environment: • Numerous policies and strategies
(65 strategies in RH Strategy);• Good information on unit costs;• Insufficient analysis of cost-effectiveness;But no document prioritising support to RH
- leading to a fragmented approaches and inefficient use of available resources.
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Technical Appraisal
We found • clustering of support around
SMNH and FP• seemingly much less support for
adolescent sexual and reproductive health (ASRH), gender and sexual and reproductive rights (SRH-R).
Recommendation:• More should go to ASRH and SRH-R
Policy / Community Strategy
• Concerns about cost effectiveness, opportunity cost to train more CHWs
• Concerns about SRH impactRecommendations:• Immediate: Get a common understanding about the
revised Community Strategy, its evidence base and cost implications (also in view of RH B.P.)
• Medium-term: Support if and where feasible, provide training and tools
Joint Mission on Harmonizing Support to RH in Kenya 2011 22
4. Ways of Working (“Modalities”)
Joint Mission on Harmonizing Support to RH in Kenya 2011 23
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Immediate Recommendations
DPs provide TA to DRH to develop a strategic RH costed business plan to reduce MNM – - covering public and non-state actors – - showing what is needed, - where and how it should be delivered - prioritised and highlighting gaps.
Agree on one TA plan reflecting all TA required. Agree on one RH commodity plan.
Why an RH Business Plan?
Technical Efficiency;It will help ensure more efficient use of
available resources; Can be used to mobilise resources with DPs
and MOH and MOF;Used by DRH to lead, coordinate and review
support to RH;DPs should report funding against main themes
in the BP – transparent tracking of resources.Joint Mission on Harmonizing Support to
RH in Kenya 2011 25
Ways of Working DPs with MOH (1)
• More adherence to Paris Declaration and Code of Conduct.
• Support the SWAp process, at minimum by joint planning around existing funding baskets: HR, EMMS, HSSF
• Joint annual review of RH by all partners – feeding into annual Health Summit and SWAp.
Joint Mission on Harmonizing Support to RH in Kenya 2011 26
Ways of Working DPs with MOH (2)
• Use a core set of indicators to measure and monitor RH.
• Support the TA RH plan with a pooled fund (managed independently) – at minimum joint TA RH plan
• Pool support for RH commodities to EMMS – minimum one plan reflecting all support to RH commodities.
Joint Mission on Harmonizing Support to RH in Kenya 2011 27
Ways of Working DPs with MOH (3)
• Report funding against agreed areas of RH.• Harmonize approach to per diems in RH.• Ensure that IPs work with the districts and
AOP process – include in MOU with IP.• Provide TA (Health Systems Adviser) to DRH –
maternal mortality is a systems failure , will ensure strategic planning and linkages to the SWAp process.
Joint Mission on Harmonizing Support to RH in Kenya 2011 28
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Ways of Working DPs with MOH (4)
• DRH – needs to be more strategic and tell DPs what is required and where – less advocacy more action.
• RH – ICC should play a more strategic role using the RH Business Plan to assess performance against the plan, funding and agreed priorities.
• RH - ICC commodities should be stopped and quantification covered by procurement ICC.
Ways of Working DPs with MOH (5)
• Districts – ensure effective stakeholder coordination
• Define principles of engagement at district level – should be developed into a binding code of conduct
• Provide TA to support this process in districts
Joint Mission on Harmonizing Support to RH in Kenya 2011 30
Operational research Knowledge management
• OR – fragmented as often driven from outside country (global funding).
• Lack of proactive knowledge management Recommendations:• Use RH ICC to decide on priority OR – relate to
RH B.P.• RH - support to establish focal point (TA) for
knowledge management
Joint Mission on Harmonizing Support to RH in Kenya 2011 31
5. Health System re. RH services(Supply Side)
Joint Mission on Harmonizing Support to RH in Kenya 2011 32
Leadership and Governance (1)
Insufficient leadership and governance for RHRecommendations:• Upgrade management skills• Match person-to-post to ensure leadership• Streamline data management to support planning at
all levels • Include total market approach (e.g. PPP)• Comprehensive policies and guidelines to guide
Counties Joint Mission on Harmonizing Support to
RH in Kenya 2011 33
Leadership and Governance (2)
• Health Sector Policy – A broad participation in the revision process and
ensure RH needs are sufficiently addressed
• Devolution process to Counties – Immediate: Provide TA to MOPHS in the planning of
devolution– Support professional advocacy campaign on RH– Medium-term: Support devolution process in RH– Support MOPHS to provide TA to Counties in their
planning and implementation stage Joint Mission on Harmonizing Support to
RH in Kenya 2011 34
Human Resources for Health (HRH) (1)
HRH - Maldistribution urban / ruralRecommendations:• MOH – Agree on redistribution plan and
incentives, money and non monetary• Inform further HRH planning about
implications of devolution to Counties • DPs - Support incentives through HRH pooled
fund
Joint Mission on Harmonizing Support to RH in Kenya 2011 35
Human Resources for Health (HRH) (2)
Skilled Birth attendance (SBA) not available at lower levels. i.e. dispensaries, Health Centres
Recommendations:• Immediate: Increase training on safe delivery at
levels 1 to 3 using centres of good practice and existing training modules (funded through TA pot)
• Medium Term: DPs to support recruitment of additional nurses through HR pot (after redistribution).
Joint Mission on Harmonizing Support to RH in Kenya 2011 36
High Impact Interventions
Low coverage of High Impact InterventionsRecommendations:• Integrate into RH B.P. - Focus on agreed RH
outcomes• Immediate: DP/IPs to prioritize support to the
Acceleration Plan• Address issues of access, equity, quality and
sustainability Joint Mission on Harmonizing Support to
RH in Kenya 2011 37
Low utilization of RH services at HF – level 1-3 (1)
Stock-outs, erratic delivery of FP / RH commodities to HF, no consumables, poor environment - cause of informal user fees
Recommendations Supply Side Interventions:• Review division of labour between RH
coordinator and pharmacist• Integrate all RH/FP commodities into the
supply chain management system
Joint Mission on Harmonizing Support to RH in Kenya 2011 38
Low utilization of RH services at HF – level 1-3 (2)
Recommendations Supply Side Interventions:• Support RH commodities through EMMS
earmarked pot.• Develop mechanisms to cover costs for
consumables, auxiliary staff (e.g. HSSF) • Scale up infrastructure improvements to
dispensaries for safe deliveries
Joint Mission on Harmonizing Support to RH in Kenya 2011 39
Low utilization of RH services
High unmet need for FP methodsRecommendations:• Immediate: Assure the availability of complete
range of contraceptives in HF • Train staff in IUCD and implant insertion• Scale-up promotion of LAPM and services• Include FP into combined RH OBA voucher• Integration of FP into VCT and PMTCT
Joint Mission on Harmonizing Support to RH in Kenya 2011 40
6. Demand Side Interventions
Joint Mission on Harmonizing Support to RH in Kenya 2011 41
Low utilization of RH services at HF – level 1-3 (1)
Demand side interventions for RH to reduce barriers to RH services:
• Address counterproductive practices and fears (BCC and practical solutions at HF)
• Engage women’s groups and male involvement• Create and maintain Community Fund to cover
transport or user fees• Community partnering with local transport industry
Joint Mission on Harmonizing Support to RH in Kenya 2011 42
Low utilization of RH services
Recommendations: • Organize knowledge sharing of good practices
from the different regions • Medium-term: Support further piloting and
implementation of pre-payment (e.g. voucher) and health insurance schemes
Joint Mission on Harmonizing Support to RH in Kenya 2011 43
Low utilization of RH services
High unmet need for FP methodsRecommendations:• Disseminate messages addressing particular
reservations about FP• Address particular needs of adolescents• Continue to support special promotion of
under-utilized FP methods (e.g. LAPM)• Support targeted communication campaigns
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7. Complementary Health Service Provision
(“Total Market approach”, PPP”)
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Total market approach and PPP (1)
Missed opportunities to use complementary services for different population groups, involving public and non-state actors (NGO, FBO and private sectors) in achieving Health MDGs
Recommendations:• Immediate: DPs continue to advocate for PPP • Medium-term: Include non-state actors in RH
Business PlanJoint Mission on Harmonizing Support to
RH in Kenya 2011 46
Total market approach and PPP (2)
• Continue to support social franchising and OBA scheme with non-state service providers
• Pilot sub-contracting integrated RH services to FBOs in underserved areas (performance based)
• Continue to establish PPPs with companies
Joint Mission on Harmonizing Support to RH in Kenya 2011 47
8. Adolescent SRH and
SRH-R
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Adolescent SRHR (1)
Teenage pregnancies – important part of MMR Recommendations:• Give high priority to comprehensive RH in in-
school and out-of-school programmes • Assure that RH and SRH-R aspects of existing
curricula are covered in actual teaching• Partner with youth associations to address
teenage RH and income needs
Joint Mission on Harmonizing Support to RH in Kenya 2011 49
Adolescent SRHR (2)
Bias of health service providers against adolescents and unmarried youth
Recommendations:• Train health staff to be responsive to youth needs
without prejudice (“youth lens”)• Increase set-up of Youth-friendly RH Services in HFs
and in (e.g.) youth centres• Support YFS in non-health settings (e.g. schools –
MOE, youth empowerment centres - MOYAS
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SRH-R - Gender-Based Violence
High level of gender-based domestic and sexual violence
Recommendations:• Immediate: Coordinated response among all
actors • Utilize Technical Working Group on GBV
Joint Mission on Harmonizing Support to RH in Kenya 2011 51
9. Next Steps
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Priorities on Demand and supply side interventions• Assure availability and quality of obstetric care
at Level 1 to 3 and referrals through complementary providers
• Assure availability of diverse options for family planning
• Assure demand side measures for decision-making, financial and geographic accessibility
• Assure comprehensive RH information and services for adolescents in and out-of-school
Joint Mission on Harmonizing Support to RH in Kenya 2011 53
Next Steps towards DP harmonization• Develop RH Strategic Costed Business Plan• Complete Gaps Analysis of DP Contributions• Harmonize Interventions through Stakeholder
Code of Conduct at National and District Level• Create TA Pooling Mechanism• Provide TA to devolution process re. RH• Rationalize RH Supply Chain Management• Create High Visibility of RH through Advocacy
and Targetted CommunicationJoint Mission on Harmonizing Support to
RH in Kenya 2011 54
Thank you for your attention and support!
Luise Lehmann, Kawaye Kamanga, Dhimn Nzoya,
Marilyn McDonagh, Rachel Phillipson
Joint Mission on Harmonizing Support to RH in Kenya 2011 55