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Slide 1 - GIZ Health Sector Programme in Kenya

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					         Joint Mission on
       Harmonizing Support
  to Reproductive Health in Kenya

Preliminary Results and Recommendations
            Nairobi, 03-03-2011



            Joint Mission on Harmonizing Support to
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                        RH in Kenya 2011
          Overview of mission
Commissioning partners:
DANIDA, DFID, GDC, USAID
Together with MOPHS, MOMS, BMGF
Duration: from 13th February to 4th March, 2011
Field visits to:
Nyanza, Western, Eastern, Coast Provinces
Nairobi: Korogocho, Dondera, Stahere slums

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                            RH in Kenya 2011
        Overview of presentation
1.   Distribution of Commissioning DPs
2.   Overview of Financing
3.   Appraisal of Thematic Areas and Framework
4.   Ways of Working (“Modalities”)
5.   Health System re. RH (Supply Side)
6.   Demand Side Interventions
7.   Complementary Health Service Provision
8.   Adolescent SRH and SRH-R
9.   Next Steps
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                              RH in Kenya 2011
1. Distribution of
Commissioning DPs




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               RH in Kenya 2011
          Incidences of Overall Poverty (%)
           2005/2006 versus DP Presence
    To be inserted

                                           73.9%
                          50.9%
  52.2%

          49%                                                       KENYA POVERTY LINE=46%
                                                                    ABOVE POVERTY LINE
                                                                    BELOW POVERTY LINE

                    51%                                             DFID
47.6%                                                               BMGF
                                                                    GIZ
                                                                    KFW
                                    69.7%
                                                                    DANIDA
            21.3%
                                                                    USAID
                                                                    Sources: WMS series
                          Joint Mission on Harmonizing Support to   1992,1994 and 1997;KIBHS
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                                      RH in Kenya 2011              2005/06
        Skilled Birth Attendance (%) - 2008/09
                  versus DP Presence
      To be inserted

                                                                    Kenya: 44%
                          43%
                                                                        Greater than national average

           34%                             32%                          Less than national average

                                                                        DFID
 26%
                                                                        BMGF

                   74%,                                                 GTZ

                                                                        KFW
46%
                                                                        DANIDA

                                    46%                                 USAID
             89%
                                                                        Source;KDHS

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                                      RH in Kenya 2011
2. Overview of Financing




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                   RH in Kenya 2011
         Examples of
GoK and DPHK reporting of spend
     on Reproductive Health




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                      RH in Kenya 2011
      Ministries’ Reporting on Reproductive Health
              (Printed Estimates for FY 2010- 2013)
                           Approved Estimates (Kshs Millions)
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%

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                                            RH in Kenya 2011
DPHK Reporting on Reproductive Health
 AOP6 PLANNED INPUTS
 (2010-11)
                                RH                          RH         MCH            MCH        nutrition
              USD($)    commodities      condoms          O&M     commodities         O&M           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
                                                    on Harmonizing Support to $11,907,727
                                      Joint Mission$21,097,504   $35,053,500                 $17,264,216     $104,366,763
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                                                  RH in Kenya 2011
            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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                               RH in Kenya 2011
             Finances for Health & RH

Kenya
Total Resources for Health                      Estimated Resources for RH
in US$ mio

GoK                   550                                      25
DPs                   600                                     104
Households            275                                      60
TOTAL               1,425                                     190


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                                RH in Kenya 2011
         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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                            RH in Kenya 2011
Health Financing- Allocation of Resources (1)
DP Resources 2009/10                           WHO for RH
                                               Recommendations
Procurement        42%                         Drugs & supplies 48%
Service Delivery   55%                         Staff salaries   22%
Infrastructure      3%

Support Systems      2%                        System dev.                25%
                                               (incl infrastructure, training)




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                               RH in Kenya 2011
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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                              RH in Kenya 2011
            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)


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                            RH in Kenya 2011
              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.

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                              RH in Kenya 2011
3. Appraisal of Thematic Areas
       and Framework




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                     RH in Kenya 2011
           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
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                            RH in Kenya 2011
           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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                            RH in Kenya 2011
          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
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                          RH in Kenya 2011
     Policy / Community Strategy
• Concerns about cost effectiveness, opportunity cost
  to train more CHWs
• Concerns about SRH impact
Recommendations:
• 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
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                              RH in Kenya 2011
4. Ways of Working
    (“Modalities”)




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                RH in Kenya 2011
     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.
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                            RH in Kenya 2011
      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
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                           RH in Kenya 2011
 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.


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                            RH in Kenya 2011
 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.

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                            RH in Kenya 2011
 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.
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                            RH in Kenya 2011
 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.

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                            RH in Kenya 2011
 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


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                           RH in Kenya 2011
          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
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                            RH in Kenya 2011
5. Health System re. RH services
           (Supply Side)




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                      RH in Kenya 2011
     Leadership and Governance (1)
Insufficient leadership and governance for RH
Recommendations:
• 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
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                             RH in Kenya 2011
   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
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                              RH in Kenya 2011
Human Resources for Health (HRH) (1)
HRH - Maldistribution urban / rural
Recommendations:
• 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
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                           RH in Kenya 2011
 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).
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                              RH in Kenya 2011
      High Impact Interventions
Low coverage of High Impact Interventions
Recommendations:
• 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
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                            RH in Kenya 2011
     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
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                           RH in Kenya 2011
     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


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                           RH in Kenya 2011
    Low utilization of RH services
High unmet need for FP methods
Recommendations:
• 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
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                            RH in Kenya 2011
6. Demand Side Interventions




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                    RH in Kenya 2011
      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


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                              RH in Kenya 2011
     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



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                           RH in Kenya 2011
    Low utilization of RH services
High unmet need for FP methods
Recommendations:
• 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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                           RH in Kenya 2011
     7. Complementary
    Health Service Provision
(“Total Market approach”, PPP”)




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                    RH in Kenya 2011
 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 Plan
                Joint Mission on Harmonizing Support to
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                            RH in Kenya 2011
 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



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                             RH in Kenya 2011
8. Adolescent SRH
        and
       SRH-R



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               RH in Kenya 2011
          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
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                            RH in Kenya 2011
            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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                               RH in Kenya 2011
  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



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                            RH in Kenya 2011
9. Next Steps




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            RH in Kenya 2011
          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
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                             RH in Kenya 2011
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 Communication
                Joint Mission on Harmonizing Support to
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                            RH in Kenya 2011
          Thank you
for your attention and support!

         Luise Lehmann,
 Kawaye Kamanga, Dhimn Nzoya,
Marilyn McDonagh, Rachel Phillipson
          Joint Mission on Harmonizing Support to
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                      RH in Kenya 2011

				
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