Kenya: cross-programmatic efficiency analysis: policy brief

Objectives A cross-programmatic efficiency analysis was conducted in Kenya to identify and analyse criti- cal areas of functional overlap, misalignment or duplication across the country’s Tuberculosis (TB), HIV/AIDS, malaria, Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCAH), and Immunization programmes, and with the overall health system to inform plans to make the health system more efficient and sustainable as Kenya progresses on UHC and on the path to transition from external assistance. 1 Ministry of Health. 2021. Kenya National Health Accounts 2016/17 – 2018/19. Nairobi, Kenya, Government of Kenya The cross-programmatic efficiency analysis took place between August to December 2020. This policy brief is written based on that analysis, with recognition that changes in the health system will have taken place since the study was conducted. Kenyan Context Kenya renewed its commitment to moving towards universal health coverage (UHC) following the Gov- ernment’s Big 4 Agenda (2018-2022) that identified UHC as one of the top priorities. As donors transition away from providing direct support to the country’s health sector, the government is expected to take on an increased responsibility for its funding and related essential services. This process will have impli- cations on the progressive realization of UHC. From 2009/10-2018/19, there was a reduction in external health assistance as a share of total health expenditure by almost 50% (from about 35% to 18%)1. In addi- tion, the devolution of most responsibility for resource allocation to 47 elected county governments that began in 2013 raises challenges for the alignment of actual government health spending with national policy directions. Given these realities, a cross-programmatic efficiency analysis was conducted in 2020 to identify inefficiencies that may constrain the governments’ ability to sustain or improve the coverage of priority health services moving forward. Key Findings The six key cross-programmatic inefficiencies identified, their implications and potential intervention to mitigate each are discussed below. KENYA Kenya: Cross-Programmatic Efficiency Analysis POLICY BRIEF Health financing case study, no. 26 1. Existence of multiple funding streams that are not well-aligned at the implementation level There are multiple financing sources for the five programmes analysed. These vary by source and include development partner, private sector firms, government and individuals through out-of-pocket payment (OOP). Among the development partners, a significant proportion of the resources is still “off-budget” and channelled through various implementing partners. Additionally, the financial cycles of some of the development partners differ from that of government, which leads to misalignment in planning and im- plementation. The management of these funds is sometimes at the programme level, and limited pooling mechanisms exist, including with the National Hospital Insurance Fund (NHIF). The multiple streams of funding and management of funds has also led to different types of provider payment methods that are not aligned with one another. Under devolution, there are three main funding flows; the first being county governments, who are the main purchasers of health services. The Treasury provides budgets from gener- al tax revenue to the national and county governments, who then act as purchasing organizations. Next is the NHIF, where they administer the purchasing system for those with coverage for certain services (such as for Linda Mama, the government’s free maternity programme) and channels the resources to service providers. And finally, implementing partners are also responsible for direct purchase and implementation of activities including contracting of the health workforce for programmes such as HIV and Immunization. IMPLICATIONS POLICY OPTIONS • Fragmented implementation of policy vision, which complicates operations • Service delivery quality is affected due to delays in flow of funds to health facilities • Different signals and incentives to health providers • Duplications in the management of funds • Allocation and use of resources are not results/performance-driven and are not allocated equitably to mini- mizes waste • Limited accountability mechanisms • Use the current existing public financial management ar- rangements to harmonize and align use of health funds at the national and county levels (such as effective use of conditional grants) • Ensure alignment of incentives and harmonize implementation support (such as audit and monitoring functions across health sector conditional grants from the national government to the counties) • Implementation of alignment principles for enhancing donor effectiveness through “One Policy, One Strategy and One M&E Plan” principle through Joint Annual Work Plans processes • Improve public financial management capacities at county level • Shift towards more strategic purchasing linked to health out- puts/outcomes from health service delivery level 2. Multiple duplicative and fragmented data systems that compromise data quality and limits its use in making service delivery decisions Parallel data and information systems exist for the programmes analysed. For instance, although the Ministry of Health has intentions to standardize electronic medical record systems (EMR) the study found more than 17 EMR systems in hospitals in the three counties studied (Kisumu, Kajiado and Mom- basa). These systems differ in their objectives and functionality (such as capacity for basic demographic and clinical health information or order entry and prescribing), with no ability to share patient informa- tion across systems. These systems are also not interoperable with other information systems such as commodities, laboratories and health facility infrastructure. There was limited or inconsistent use of the resulting data for decision making although more use was observed among development partners. The information and data gathered was found to be primarily used for morbidity and mortality monitoring and reporting and not necessarily providing an input into service delivery decisions. KENYA IMPLICATIONS POLICY OPTIONS • Lack of sharing and aggrega- tion of data across system leads to different data sets and an incomplete picture of population health • High administrative costs and heavy burden placed on staff to report through various systems (both paper- and digitally-based) • Duplication of patient data due to lack of coordination between treatment and referral facilities • Adopt and scale-up the Kenya digital health platform that will provide for all health care settings in Kenya and, facilitate interop- erability with other systems within the Health Information System (HIS) eHealth architecture • Strengthen Kenya Health and Research Observatory (KHRO) to present all the data required for decision making at national and county level • Strengthen use of the national data quality audits (DQA) protocol and Routine Data Quality Assessment (RDQA) tool • Capacity building and/or re-orientation of the health workers on use of data for evidence-based decision-making and, contracting data clerks for the Heath Records Information Systems at the ser- vice delivery points with clear targets 3. Ineffective coordination between the vertical programmes and with the county governments leads to missed opportunities The assessment revealed challenges in coordination. Development partner supported programmes op- erate independently at the implementation level even in areas when synergy and complementarity can be obtained. There were uncoordinated and ad hoc supportive supervision visits across different pro- grammes, as seen in Figure 1, that rarely responded to the needs of the service delivery and health workers and were not systematically documented. Often times, the national programmes would go directly to the health facility and communities bypassing the county. Lack of ineffective coordination in the actual imple- mentation of service delivery also limits the programmes coverage. KENYA FIGURE 1: ILLUSTRATIVE SUPPORTIVE SUPERVISION VISITS TO A MODEL HEALTH CENTRE JULY – DECEMBER 2018 Supervisor Category Supervision Areas Supervision Team MMC NASCOP – M&E, CBO; SD-CASCO National Nutrition Sub County: Nutrition, HRIO, KANCO CCC/TB Sub County: MOH, HIV Comm, TLC, County HRIO, IP, PH County FP/RH Sub County: Pharmacist, RH Coordinator, PHN, HRIO IP Sub County PMTCT Sub County: SCO, CCO, NASCOP HIV/TB (Peer SS) Sub County: MCH, Pharm, Pharmacist, FP Intercounty Peer SS Immunization GPI Sub County: PHN, HRIO, RH Coordinator, MLC Implementing Partners CIP TB/DGA NLTB PSBI/IMCI Sub County: CO, County PMTCT SC: Pharm, MLS, CO, HRIO, IP IMPLICATIONS POLICY OPTIONS • Ad hoc and unplanned supervisory visits create unnecessary workload on health facilities • Costly and inefficient visits when supervisory visit does not cover all service delivery areas • Align development partner Supportive Supervision framework to fit county specific needs. National and county governments should develop a harmonized supervision framework that aligns activities of Ministry of Health programmes and departments and development partners • Strengthen the capacity of the County Health Departments (CHD) sup- portive supervision systems personnel on operational guidelines and use of tools • Consolidate county supportive supervision data, findings and recom- mendations to inform performance improvement across the counties 4. Fragmented supply chain leading to unnecessary costs and complexities across the health system Uncoordinated and fragmented procurement mechanisms exist across the programmes, largely due to all of the different funding streams. While the Kenya Medical Supply Agency (KEMSA) remains the only state corporation mandated to procure, store and distribute medical supplies for public health pro- grammes on behalf of the government, it is not able to honour all requests. Additionally, there are parallel supply chain systems across the health programmes analysed. Sometimes the purchasing of a necessary devise is not coordinated with the procurement of services to maintain the devise. There is also a lack of clear policy for commodity redistribution or an awareness of its existence. KENYA IMPLICATIONS POLICY OPTIONS • Weak coordination leads to huge quantities of products, over- stock, expiration and waste • Unsynchronized purchase of complementary inputs is a gross inefficiency, which adversely affects coverage • Strengthen the institutional mechanism responsible for coordinat- ing comprehensive forecasting and quantification, as well as budg- eting for health products and technology (HPT) at national and county level • Need for clear guidelines on redistribution of excess and/or near-expiring drugs between facilities and counties to provide a harmonized framework for commodity exchange and redistribution 5. Programme-based human resources for health management leads to duplicative roles, sub-optimal staff performance and utilization, and over reliance on contracted staff The human resources for health (HRH) in these five programmes were found to do similar work, yet they had different terms of service. Some can be contracted by the donor, others by the local government and some at the national level. Furthermore, key programme staff can sometimes only be deployed in areas restricted to their operations, while there is more flexibility for government staff. IMPLICATIONS POLICY OPTIONS • Uncoordinated recruitment and deployment of staff by partners to support disease control efforts • Some partner recruited staff are not recognized in the gov- ernment scheme of service, making their transition to the civil service a challenge • Donors support counties’ HRH interventions in an uncoor- dinated way, such as trainings in the same region, leading to high absenteeism and repeated/duplicative trainings targeting similar capacities • Dependence on contracted staff for programme implemen- tation, especially for staff in the HIV and TB programmes (threat to integration & sustainability) • Government and development partners need to regularly and jointly develop HRH needs and jointly recruit the staff based on needs • Implement workplace capacity build- ing initiatives guided by county-based Training Needs Assessments to keep staff within their workstations • Transition planning for recruited HRH as part of recruitment that is guided by long term staffing needs 6. Disjointed service delivery, which leads to missed opportunities for access Disjointed service delivery leads to poor health seeking behaviours, a lack of gatekeeping and referral system and inability to foster complementarity across the health sector. These duplications and overlaps of services adversely affect hospital operations. KENYA IMPLICATIONS POLICY OPTIONS • Missed opportunities to align services leads to adverse health outcomes and increased loss to follow-up • Lower quality care at higher level facilities due to overcrowding and lack of staff due to lack of gatekeeping and referral system • Difficult to allocate resources and plan infrastructure • Initiate discussions at national and county level on how to integrate health programme interventions into govern- ment programming • Strengthen the primary health care system to ensure there are necessary linkages across the health system so that patients follow the prescribed pathway • Strengthen county health department’s capacities to develop, implement and monitor performance FIGURE 2: PATHWAY FOR HIV+ MOTHER Way Forward Based on the cross programmatic efficiency analysis, this policy brief provides policy options that the government of Kenya could consider to address the identified system misalignments and duplications so as to make the health system more efficient in achieving objectives. These actions will be necessary in achieving sustainable scale-up as the country looks towards transition. This policy brief was based on a report authored by Wasunna Owino, with support from Brendan Kwesiga, Estella Waiguru, and Isabella Maina. It was prepared by Brendan Kwesiga and Alexandra Earle. Financial support is gratefully acknowledged from The Global Fund Kenya: cross-programmatic efficiency analysis. Policy brief (Health financing case study, no. 26) ISBN 978-92-4-006654-0 (electronic version) ISBN 978-92-4-006655-7 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. KENYA Comprehensive Core Clinic Unit (CCC) OUTPATIENT DEPARTMENT Triage MO, CO, Nurse, Mid- wife, Records Officer Post Natal Family Planning Child Health Delivery EmoC Entry (Routine) Self Referral HIV Lab Routine Laboratory (Sub County) MNH Results Self Referral Referral Non HIV Text Screening for TB, Cervical Cancer Referral for specialized care Suspected HIV HIV Care