Evaluations of OVC Interventions Overview

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					         Futures Group’s USAID /Health Policy Initiative

                           Report on

FORUM ON POVERTY AND ACCESS TO HEALTH SERVICES IN KENYA


                 WEDNESDAY, JUNE 20, 2007
                                                     TABLE OF CONTENTS

ABBREVIATIONS AND ACRONYMS........................................................................................... 3
ACKNOWLEDGEMENTS ................................................................................................................ 4
EXECUTIVE SUMMARY ................................................................................................................. 5
1.0       BACKGROUND AND CONTEXT....................................................................................... 6
   1.1        OPENING REMARKS ............................................................................................................. 7
   1.2        KEYNOTE ADDRESS ............................................................................................................. 7
2.0       PRESENTATIONS ................................................................................................................ 7
   2.1 POVERTY DYNAMICS IN KENYA –GEOGRAPHIC DIMENSIONS OF WELL-BEING IN KENYA BY. 8
   MR. GODFREY NDENG’E, CENTRAL BUREAU OF STATISTICS)....................................................... 8
   2.2   TARGETING THE POOR AND VULNERABLE GROUPS: EXPERIENCES OF MOH RESOURCE
   ALLOCATION CRITERIA BY DR. NZOYA MUNGUTI ........................................................................... 9
   2.3   OUTPUT BASED APPROACH (OBA) BY MR. FRANCIS KUNDU (NCAPD) ....................... 12
   2.4   WAIVERS AND EXEMPTIONS IN PUBLIC HOSPITALS IN KENYA BY DR. SAM MUNGA
   (MOH)14
   2.5   NHIF REIMBURSEMENTS TO PUBLIC HOSPITALS BY DR. SAM WERE (MOH) ................. 16
3.0       EMERGING ISSUES .......................................................................................................... 17
4.0       GAPS TO BE ADDDRESSED IN THE NEXT ROUND OFDISCUSSIONS .............. 18
   4.1        CRITICAL GAPS ................................................................................................................... 19
   4.2        AGENDA FOR NEXT ROUND OF DISCUSSIONS .................................................................... 19
5.0       CONCLUSION ..................................................................................................................... 19
ANNEXES......................................................................................................................................... 19
   ANNEX I: MEETING TIMETABLE ..................................................................................................... 19
   ANNEX II: LIST OF PARTICIPANTS .................................................................................................. 21




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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
ABBREVIATIONS AND ACRONYMS


AIDS                       -         Acquired Immunodeficiency Syndrome
CBS                        -         Central Bureau of Statistics
CDF                                  Constituency Development Fund
CMR                        -         Child Mortality Rate
FP                         -         Family Planning
FY                         -         Financial Year
HIV                        -         Human Immunodeficiency Virus
HPI                        -         Health Policy Initiative
IMR                        -         Infant Mortality Rate
KDHS                       -         Kenya Demographic Health Survey
MMR                        -         Maternal Mortality Rate
MOH                        -         Ministry of Health
NCAPD                      -         National Coordinating Agency for Population and Development
NHIF                       -         National Hospital Insurance Fund
NHSSP                      -         National Health Sector Strategic Plan
OBA                        -         Output Based Approach
PPA                                  Participatory Poverty Adjustment
RAC                        -         Resource Allocation Criteria
TB                         -         Tuberculosis
USAID                      -         United States Agency for International Development




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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
ACKNOWLEDGEMENTS

The USAID Health Policy Initiative (USAID-HPI) and the Ministry of Health (MOH) would
like to acknowledge with gratitude the input from all the presenters. The information shared
on some of the tools being implemented to enable the poor to access quality health
services, is invaluable and will contribute to the finalization of the Health Care Financing
Strategy.


June 2007




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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
Executive Summary

The Government of Kenya (GOK), through the Ministry of Health (MOH), has established a
Health Financing Task Force with participants from all stakeholders including development
partners, implementing partners, representatives from the civil society and the Ministry of
Finance. The Task Force was set up to provide leadership in the development of a long-
term fiscally sustainable, equitable and efficient approach to financing health services in
the country and to determine the appropriate interim actions that are required to move the
current system to the longer-term vision. As part of this process, a Working Group has
been set up to provide recommendations on how to include the income poor and
vulnerable groups into the strategy.

It is against this background that the Working Group on Poverty and Access to Health
Care services held a consultative meeting with key stakeholders in order to enhance
understanding of poverty dynamics in Kenya, exchange technical information on pro-poor
strategies that are being implemented by different partners in the country and make
suggestions on effective strategies that need to be incorporated into the strategy.

At the meeting, five presentations were made. The Central Bureau of Statistics (CBS)
made a presentation on poverty dynamics in Kenya, the Ministry of Health shared
experiences from the Resource Allocation Criteria (RAC) and the National Coordinating
Agency for Population ad Development (NCAPD) made a presentation on the Output
Based Approach (OBA), strategy for targeting resources for Reproductive Health services
to the poor. The Ministry of Health made a presentation on the waivers and exemptions in
public hospitals in Kenya and the National Hospital reimbursements to public hospitals to
mitigate against the adverse impacts of cost sharing.

A number of gaps were identified that could constitute the agenda for the next round of
consultations. These include the need to assess the impact of the models on improving the
health status of the poor and other vulnerable groups; more discussions on the RAC that
will lead to a review and sensitivity analysis; more attention to the use of the mapping for
additional studies on poverty and access to health services; technical and allocation
efficiency of funds targeting the poor and other vulnerable groups i.e. direct financing of
health facilities; desk review of existing situation on the status of poverty and access to
health to determine the status, the gaps, where to go to enhance access and strategies to
improve the services including the gender dimension; payment of service providers to
avoid corruptive practices; and access for marginalized groups-pastoral communities in the
arid and semi-arid lands.

The agenda for next round of discussions should include the role of the Ministry of Health
in addressing the poor and other vulnerable groups, alternative financing mechanisms and
experiences from the faith-based organizations and the private sector.

In conclusion, the workshop was a success in the sharing of experiences of the tools that
have been used in providing health services to the poor and vulnerable, the challenges
faced and the lessons learnt. It was clear from the deliberations that there are difficulties in
identifying the poor and vulnerable for provision of health services and that it is important

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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
to decide what really is best for the poor-to provide health services or work towards
ameliorating their poverty in line with Vision 2030.




1.0      BACKGROUND AND CONTEXT

The Government of Kenya (GOK), through the Ministry of Health (MOH), has established a
Health Financing Task Force with participants from all stakeholders including development
partners, implementing partners, representatives from the civil society and the Ministry of
Finance. The Task Force was set up to provide leadership in the development of a long-
term fiscally sustainable, equitable and efficient approach to financing health services in
the country and to determine the appropriate interim actions that are required to move the
current system to the longer-term vision. As part of this process, a Working Group has

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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
been set up to provide recommendations on how to include the income poor and
vulnerable groups into the strategy.

It is against this background that the Working Group on Poverty and Access to Health
Care services held a consultative meeting with key stakeholders in order to enhance
understanding of poverty dynamics in Kenya, exchange technical information on pro-poor
strategies that are being implemented by different partners in the country and make
suggestions on effective strategies that need to be incorporated into the strategy.

1.1 Opening Remarks

 At the start of the workshop, Dr. Wasunna Owino of the Health Policy Initiative expressed
appreciation to the participants for creating time to attend the workshop and reiterated the
importance of contributing actively as the contributions made will inform the Health Care
Financing Strategy before it is finalized and disseminated in December 2007. The
objective of the workshop was to provide inputs into the Health care Financing Strategy
with a focus pf poverty ad acce3ss to health services. This is the first round of
consultations and it is expected that stakeholders identify gaps that could form the agenda
for future discussions.

1.2 Keynote Address

In his key note address, Dr. Wasunna Owino of the Health Policy Initiative (HPI) focused
on two issues-why all people should be interested in targeting resources for health and the
process of implementing a targeting strategy.

Given that public funding and resources are limited, it is important to employ a targeting
strategy in the use of the resources. The targeting strategy must be accompanied by a
vibrant private sector, as the public sector cannot provide all the necessary funding and
resources. In addition, targeting requires changes on the distribution of staff, training and
re-training of service providers. Targeting resources can make program user-friendly and
assist in focusing on the poor. While the government may resists targeting so as not to
contradict the goal of “health for all,” there are serious consequences of non-targeting.
These include-less subsidies being utilized by the poorest, the commercial sector losing its
client-base and inefficient use of limited resources.

For efficient and effective implementation of a targeting strategy, the relevant policy
makers and program planners have to be involved at all stages of the process. This calls
for dialogue and advocacy. Citing two principal approaches of implementing a targeting
strategy as using characteristics to identify people to be targeted and individual targeting,
Dr. Owino also observed that eligibility based on characteristics is easier to use. He
concluded that targeting is an essential strategy and the barriers can be overcome through
commitment.

2.0      PRESENTATIONS

It is worth noting that poor people have the poorest health indicators because they have
fewer resources to access health care. These resources are not necessarily financial but
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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
may also include people’s life styles that may not be conducive to healthy living. Findings
from a study conducted in China and replicated in Vietnam on strategies that people use to
finance health care, found that people are willing to pay whatever is needed to provide
quality health care including selling what they own such as land and cows to obtain funds
as well as finding employment alternatives.

2.1 Poverty Dynamics in Kenya –Geographic dimensions of well-being in Kenya by
    Mr. Godfrey Ndeng’e, Central Bureau of Statistics)

The presenter began by giving stating that in order fro the Ministry of Health to target
health needs for the poor, it is crucial to know where the poor are. Defining poverty as
being of two broad types- money metric poverty and non-monetary indicators of poverty,
the presenter described the money metric indicators to include food, non-food, overall
poverty and hardcore poverty and the non-monetary indicators include malnutrition, water,
sanitation, infant mortality ratio (IMR), child mortality ratio (CMR), access issues, disease
burden and orphan-hood. Noting that different communities in Kenya define poverty in
diverse ways depending on their lifestyles and economic ways of life, the presenter
intimated that one of the lessons learnt is that studies on poverty are likely to yield
conflicting results leading to a difficulty in generalizing and in knowing exactly who target
as being poor. Given that lack of basic amenities such as clean water also leads to
diseases, it is difficult to get a consolidated definition of poverty.

Noting that the current national poverty level is 46%, the presenter observed that poverty
levels have been increasing in three provinces- Coast, Northeastern and Nyanza. In other
provinces, household surveys have shown that poverty is declining. What is not clear is the
explanation for the differences. The presenter also described hardcore poverty as the
situation where some people cannot afford the food basket if they forgo the non-food
basket. For example, when a family has to choose between taking a child to hospital and
missing food. The participants were informed that hardcore poverty in Kenya has
significantly reduced from 34% in 1974 to a paltry 18% in 2007.

The presenter used maps to describe where the poor are located in Kenya. The presenter
used poverty maps, which categorized the poor across provinces, within districts and much
smaller areas such as divisions, locations and sub-locations. Detailed poverty maps are
important in showing the geographical differences in poverty incidences. The maps also
assist in understanding the relationships between poverty and health indicators such as
HIV and AIDS, malnutrition, child immunization, safe drinking water, mean distance
between homes and health facilities, malaria and TB. The detailed poverty maps also
show that 60% of the rural poor can be found in 35% of the 422 divisions in the country.

Results from a detailed study on poverty estimates based on a consumption welfare
indicator with information collected at the division level (422 rural) and location level (2,070
rural and 496 urban) show a headcount index (percentage of people falling below poverty
line, defined as Ksh. 1,239/person/month, or $16.50 for rural areas and Ksh.
2,648/person/month in urban areas, or $35). The poverty gap was defined as the
difference between actual levels of consumption and what people would need to get up to
the poverty threshold.

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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
The presenter concluded that the poor are generally the people in households with large
families and that across all categories, the poorest are those with very little or no formal
education. Noting that education is key to eradication of poverty, the presenter observed
that there are variations in geographical areas such that a person with secondary
education in a place like Ganze in Coast province may be poorer that a person with only
primary school education in Central province.

Discussion

In the discussion that followed, participants wished to know: (a) whether the issues of
conflicts and the resulting displacements were taken into consideration when determining
the poverty levels and what impact these factors have had on poverty; (b) what analysis
has been done to show why some provinces have improved or not; (c) whether the issue
of land demarcation, particularly in the Coast Province could be a factor that influences
poverty; and d) what options have been given to the different sectors for improving access
to services that target the poor.

In response, the presenter indicated that the conflict variable has not been used in the
quantitative analysis due to the time constraints but it is possible to do specialized studies
that include conflicts and displacements as a variable. The presenter responded that the
Central Bureau of Statistics is undertaking a study on determinants of poverty in which
they will analyze other fiscal variables and determine which variables contribute to poverty,
the most. The report will be ready in September 2007. A participatory poverty adjustment
(PPA) study was undertaken in the Coast Province and took land ownership into
consideration as a variable. The results have been documented into a report.

With regard to the options available for sectors to improve access to services, the poverty
maps
 Have been used to apportion the constituency development fund (CDF) resources. The
poverty maps have also shown that some people are food-poor and hence the need to get
close to the people and get information directly. The main challenge is that some leaders
have been known to abuse the system and get the resources intended for the poor.




2.2 Targeting the poor and vulnerable groups: Experiences of MOH Resource
    Allocation Criteria by Dr. Nzoya Munguti

In his preliminary remarks, the presenter observed that prior to the 2001/2002 financial
year, the MOH resource allocation process was not sufficiently responsive to local health
needs because resources for health services were allocated to districts on an incremental
(historical) basis without due consideration to varied health needs of districts. The practice
tended to give more resources to the already endowed districts at the expense of the poor
ones. Hence the need to develop an objective, efficient, equitable and transparent criteria
for allocating resources to districts in line with National Polices. The process was
consultative, where selected providers were consulted on the appropriate proxy indicators
for district health needs. The resource allocation criteria (RAC) was developed in the
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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
2001/2002 fiscal year to guide resource allocation practices within the MOH. The RAC tool
was set to:

    o Promote equitable distribution of resources for primary health care facilities;
    o Improve transparency in resource allocation; and
    o Enhance efficiency in resource allocation practices.



The table below indicated the variables and weights assigned to RAC:

       Variables                     Weight1                                 Rationale
Infrastructure (MOH)                  0.15             o In 2001/2002 MOH was facing budgetary
                                                         constraints.
                                                       o MOH was not putting up new facilities
                                                       o MOH opted to equip, renovate and deploy
                                                         staff.
Under Fives                             0.20           o Constitute about 70% of population structure in
                                                         every district.
                                                       o Largest consumers of health care services i.e.
                                                         prevalence of illness = 28%
                                                       o Considered vulnerable groups.
HIV/AIDS Cases                          0.05           o Occupy 50% of Beds in MOH hospitals
                                                       o ALOS is longer than for other conditions in
                                                         hospitals
                                                       o Only opportunistic infections are managed at
                                                         lower level facilities
Poverty levels                          0.30           o ERS focus on poverty eradication
                                                       o Poverty impoverishes the poor
                                                       o The poor fall sick more frequently
                                                       o Unable to pay for health services
                                                       o Increase the demand for waivers and
                                                         exemptions and therefore revenue loss to
                                                         facilities
                                                       o Need to ensure they have access to health
                                                         services
Females in the RH                       0.20           o Constitute 24% of the population
group (15-49)                                          o Largest consumers of health services
                                                       o Considered Vulnerable groups
Area (sq.km)                            0.10           o Transport costs/fuel for delivering/collecting
                                                         drugs and other pharmaceuticals at
                                                         depots/facilities
                                                       o Monitoring and evaluation




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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
It was envisaged that the RAC should not be applied 100% because this would create
huge disruptions in facility operations and would affect service delivery, and the 100%
approach would go against existing agreements between stakeholders and development
partners. It was agreed to implement the RAC in phases as a way of minimizing
disruptions and gaining acceptance amongst stakeholders.

A schedule was developed such that in 2001/2002 only ten percent (10%) was applied to
RAC, twenty percent (20%) in 2002/2003 and forty percent (40%) in 2003/2004. By the
fiscal year 2006/7, RAC had been applied one hundred percent.

Impact of the RAC

It is clear from the information presented that applying RAC has made resources allocation
more equitable. For example, Migori district, with a poverty level of 58% received an
allocation of 0.1% before RAC and the allocation rose to 1.5^ on application of RAC.

A number of limitations in the implementation of the RAC have been noted: These are:

   o Revenues generated by facilities were not taken into account in the weighting
      process, a factor that tended to promote inequalities
   o The inability to itemize the budget
   o The fact that the formula was only applied to existing resources and cannot be used
      to determine the resource requirements for districts/facilities
   o The fact that a majority of the variables are population based- making districts with
      high population to have a higher share of the existing resources (does not translate
      into needs)
   o That RAC is only applied to the operations and maintenance budget
Despite the limitations and perceived weaknesses, RAC, has promoted the transparency
and promoted equitable distribution of resources according to identified needs.

Discussion

In the discussion that followed, participants wished to know: (a) why only 15% was for
infrastructure; (b) whether RAC will focus on facilities in health centers and dispensaries
and wealth creation; (c) whether RAC includes other community interventions such as
home based care (HBC) and curative and preventive measures; and (d) why the stepwise
approach was used in the implementation of RAC;

In response, the presenter said that initially the focus of the MOH was not to put up
infrastructure and that the implementation of RAC in phases was intended to address a
political dimension.
The MOH had to have a starting point where resources were taken from some districts and
given to other needy districts. It has not been able to address all the concerns and
reaching nomadic populations will be reviewed and consultations held with relevant
stakeholders.

Several suggestions were made about RAC

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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
        There is a need to revise the methodology and unpack the weights further. For
         example, the variable, Under 5’s can be discussed in terms of the infant mortality
         rate (IMR) and also the HIV and AIDS prevalence rates. It important to take the
         differences into account.
        RAC is a step in the right direction in the allocation of resources for health and
         should be cascaded down to the grassroots especially because locations have
         unique differences
        If RAC is focusing more on preventive services, then it is important to allocate more
         resources for the facilities
        In order to make a difference for the poor, it is important to use the variable to set
         priorities and use the health data available
        The lessons learned so far in RAC should be used to review the process with a view
         to making it more equitable
        There is a need to create a forum specifically to discuss the RAC especially
         because the criteria set in 2001 need to be reviewed in line with new developments
         and to review the influence of politicians in resources allocation

2.3 Output Based Approach (OBA) by Mr. Francis Kundu (NCAPD)

The presenter began by giving a status of some of the millennium development goals
(MDGs) for Kenya. Currently, maternal mortality is high at 414 deaths per 100,000 live
births; infant and child mortalities stand at 77 and 115 per 1,000 live births respectively;
poverty level is at 47% thus quality health services are out of the reach for the poor; and
skilled attendance at delivery is 42%.

The presenter defined the Output Based Approach (OBA) project as a strategy for
targeting resources for reproductive health services for the poor. OBA is a joint venture
between the Government of Kenya and the Federal Republic of Germany through KfW
Bankengruppe. The main objective of the OBA project is to provide quality reproductive
health care services-safe motherhood, family planning and gender violence-trough a
voucher system to economically disadvantaged people. The project’s target population is
121,620 rural and 19,036 urban poor women between the ages of 15 – 49 years. Currently
the project covers three rural districts and two urban slums. The objective of this project is
to provide improved access to quality reproductive health and family planning services
through a voucher system to economically disadvantaged people living in Kisumu, Kitui
and Kiambu districts as well as Viwandani and Korogocho slums in Nairobi where the
project will be piloted for a period of 3 years. In addition, the project will cover the cost of
providing gender based violence recovery services to the same target group.

The project has three types of vouchers namely; Safe Motherhood, Family Planning and
Gender Violence. The vouchers are distributed by non-governmental organizations
(NGOs), community based organizations (CBOs), and faith based organizations (FBOs)
operating in the project areas. Currently, there are 72 CBOs and NGOs distributing the
vouchers. A client who is eligible to benefit from the project services is required to
purchase a voucher for the desired service at a subsidized cost. The Safe Motherhood
voucher costs Ksh. 200, while the Family Planning voucher is Ksh. 100 and the Gender
Violence is free.

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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
Due to the fact that only the poor and average are eligible for vouchers, a poverty-grading
tool is currently in use. The tool was adapted locally from a tool used in Asia by Marie
Stopes. The tool is simple enough for use at the community level and each site defines its
poverty indicators. The poverty tool grades clients on the following; housing, access to
health services, waters sources and sanitation, cooking fuel, daily income, number of
meals per day, security, garbage disposal and rent/land ownership. Each criteria has a
scale of one to three. The following are the poverty grades:
   o Poor:            8 – 13 points;
   o Average:         14 – 16 points; and
   o Better off:      17 – 24 points.

Challenges

The presenter highlighted the challenges of the project as the project system having been
vulnerable to cases of leakage, fraud and abuse. Examples are; overpricing of vouchers;
targeting the wrong group; targeting clients already admitted; and false claims. These
cases of fraud/abuse of the project system have been addressed by: proper vetting and
training of voucher distributors; random checks by field officers; collaboration with service
providers and public; thorough scrutiny of claims; and disqualification of errant distributors
and providers.

Lessons learnt

The lessons learnt from the project include:
   o Skilled attendance at delivery for the poor has improved;
   o Vouchers dignify the poor by providing them with better choices;
   o Competition between service providers has enhanced the quality of services;
   o Fraud/abuse needs close and continuous supervision to keep it under control;
      andEfficiency in claims processing maintains the confidence of providers

Way forward

    o    Increase uptake of long term FP methods & GBVR services
    o    Accredit more service providers
    o    Undertake a mid-term review in 2007
    o    Draw up a plan to phase the project into MOH
    o    Publish scientific papers

Discussion

In the discussion that followed, participants wished to know: (a) why Kiambu has moved
faster than the other areas; (b) the suggested options for reducing the administration costs;
(c) what control measures have been put in place to reduce the reimbursements for
Caesarian section deliveries; (c) whether the MOH should develop a package of care and
free services and pay for it through taxes at the higher levels; (d) whether it is possible to
identify specifically who is poor and who is vulnerable and refer to the services as
:”subsidized” rather than free; and (e) whether NCAPD has explored the possibility of using
retired skilled and traditional birth attendants (TBAs) as a way of reducing the C-sections.
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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
In response, the presenter indicated that there is no precise answer as why there are
differences between Kiambu and Kisumu but he cited easy access to health facilities,
higher education levels and higher population figures in Kiambu as being some of the
plausible explanations for the differences. More details, he said, would be highlighted in
the results of the evaluation. In terms of high administration costs, the presenter intimated
that NCAPD is reviewing the costs as well as the costs of setting up the structures for
efficient implementation of the OBA. The NCAPD is analyzing the reimbursements and
watching the trend on C-sections while trying out the use of retired skilled birth attendants
in Kisumu.

2.4 Waivers and Exemptions in public hospitals in Kenya by Dr. Sam Munga (MOH)

The presenter began by alluding to the importance of a healthy population in promoting
economic development and the fact that the existing high disease burden in Kenya
constraints economic growth. The presenter informed the participants that the Kenyan
government has prioritized heath in the Economic Recovery Strategy (ERS) (2003-2007)
and attainment of Vision 2030 and developed a new National Health Sector Strategic Plan
(NHSSP), whose theme is “Reversing the Trend”. The vision of the NHSSP is the creation
of an efficient, high quality health care system that is accessible, equitable and affordable
for every Kenyan and the policy objectives are to increase financial resources for health
and increase equitable access.
The presenter observed that cost –sharing in the health sector was introduced for the first
time in 1989 and later suspended in 1990/1991. It was re-introduced in 1992 and has been
operationalised in all health facilities since 1992. The waiver and exemptions system as
described by the presenters is a government-implemented two-step discretionary relieve
from payment of services based on a financial hardship at a particular point in time. It is
not automatic and patients and their relatives apply for the facility. Judgment to grant the
waiver/exemption is made by the management of the health facility. The waivers are
granted based on key variables that include:
a history and observation of the socio-economic status (SES) of the patient and his/her
relatives; means of transport; alcohol and cigarette consumption; type of clothing; and
occupation;

Exemptions are an automatic excuse from payment based on meeting certain specific
conditions – of public health importance (high social benefit) and focuses on vulnerable
groups who include: children under 5 years of age; prisoners, destitute and people under
police custody; maternal and child health services; and referrals.

The waivers and exemptions are administered by medical social workers, health
administration officers (HAO) and nursing officers using a checklist tool and observations
of the outpatients and inpatients. A waivers and exemptions committee based within the
government hospitals and health facilities then approves the recommendations. The
implications for the waivers and exemptions systems as highlighted by the presenters are
the loss of revenue for the facilities at the facility level and loss of revenue for the
government at the national level. This is due to the fact that waivers reduce revenue
collections from user fees, which are the main source of income for many facilities as
government allocations have dwindled over time.
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Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
Challenges
  o Resistance and, negative attitude by staff;
  o Existence of ‘free riders’ because of abuse;
  o Cumbersome/expensive administration procedures;
  o Outpatient poses a bigger challenge;
  o Difficulty to implement a uniform system, nationally;
  o Data gaps, actual loss in revenue not known; and
  o Limited Awareness by Patients.

Recommendations
  o Pooled fund to compensate hospitals for the loss;
  o Empowerment of Facility Managers on Implementation;
  o Reinforce the System, particularly exemptions based public health importance,
     conditions with high social benefits;
  o Change of provider attitude; and
  o Review policy on the 75% revenue retention at the facility

Discussion

After the main presentation, a participant shared real-life experiences in the use of the
waiver and exemption system. She observed that the variable on clothing may not give a
true picture of the poverty level because some people buy “mitumba” and can be very
smart. The main challenges include:

        The variable to be used for rural areas should be different from those used in urban
         areas because urban poverty is defined differently from rural poverty.
        When a person cannot pay the fees at the Kenyatta National Hospital, they are
         return to the District Hospital
        Political statements tend to influence the system and some people approach the
         politicians for waivers and exemptions
        The need to enhance home-based care and provide education that when doctors
         want patients discharged, they are not being sent home to die, they are being sent
         home to receive care form their loved ones.
        The difficulties in tracing relatives of patients especially when a patient needs to be
         discharged to create space for a new patient.
        A shortage of the number of social workers-currently there are 33 social workers in
         77 hospitals

    Recommended next steps

        The need for new guidelines for the social workers given that needs vary according
         to the hospitals-Migori hospital is different from Mbagathi hospital in Nairobi
        The need to decide which of the opportunistic infections should be covered because
         making malaria, HIV and TB free takes a heavy toll on hospitals
        The need for clear guidelines and education on NHIF and how it works
        The need to involve the local administrators in identifying people because people,
         especially in Nairobi, relocate often when rent increases
                                                                                             15
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
        The need to alert politicians about the weight of the statements they make with
         regards to the waivers-in some hospitals, a number of people have refused to pay
         for services citing statements made by the are member of parliament
        Creation of a kitty to balance the waivers

The participants wished to know the extent to which the 10/20policy is being implemented
in Kenya and reiterated the need to articulate the difference between a health insurance
for those who can afford and a health insurance for the poor. It was observed that the
mixing the two health insurance schemes usually causes confusion in parliament.

In response, the presenter observed that the 10/20 policy is being implemented and the
main challenge is that there is a lot of wastage on the money being used on the poor
primarily due to a lack of setting priorities. The presenter observed that the national
Hospital Insurance Fund (NHIF) takes care of its members and the health facilities should
lobby for additional funds from the treasury.


2.5 NHIF Reimbursements to public hospitals by Dr. Sam Were (MOH)

The presenter shared experiences from the strategy on NHIF reimbursements to public
hospitals aimed at mitigating against adverse impacts of cost sharing as implemented at
the Busia Hospital. Noting that the National Health Sector Strategic Plan, clearly sets
access to health care a priority, the presenter noted that health utilization is highest for the
richest 20% of the population. And hence the need to develop a strategy that ensures the
poor have access to health. The strategy on NHIF reimbursements is based on the
rationale that user-fees promote exclusion of the poor in access to health services and
hence it is aimed at protecting the poor and increasing their access to quality health
services. The main challenge is, “who takes up the loss when hospital fees are waived?”

The Busia Hospital Study as a Social Health Insurance (SHI) -like study that has been
tested under the name of “Health Equity Funds” (HEF) in Cambodia. The model introduces
a third party payer mechanism and the provider is paid for the services provided to
selected poor patients. The ultimate objectives of the model are to improve access to
quality hospital care for the poorest and prevent poor households from “catastrophic health
care expenditures” that drive households to poverty. Opportunities include the existence of
an operational hospital waiver and a committed hospital management system. The
methodology includes multi-stage cluster sampling design classified in terms of rural, peri-
urban and urban and 1074 households were sampled. The characteristics studied included
households, mothers and children. Results showed that 52.9% of the extremely poor
households had no access to productive assets, 25.9% had no source of income, 20.2%
had no livestock and 19.3% had no farming land.

The process works by identifying the patients who need assistance while aiming at
minimizing resources used towards non-poor patients and at the same time ensuring that
poor people are not excluded (inclusion and exclusion errors). Payments are made to the
health service providers for the services rendered to the target group.

A few design issues have been identified. These include:
                                                                                             16
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
         The need to define the point of identification of the poor-household or hospital level
          and establishing a cut-off point as it relates to well laid out criteria
         The need to decide on a package of services to be given to the poor and the cost of
          such services in a hospital setting should form the basis for the reimbursement rate
          to be used by the third party payer for both out patient and in patient services
         The need to address the management concerns revolving around the provider and
          the client as well as the provider and the third party payer

The presenter mentioned that different options for identifying the poor have been provided
through the African Population and Health research Centre (APHRC) using elaborate
characteristics for identifying the poor and making decisions on the eligible patients based
on the resources available. The Institute of Tropical Medicine (ITM) of Belgium is in site in
Busia to assist in the implementation. Information on costing and adequacy of resources
remain a challenge in the implementation. In terms of the suggested next steps, the
presenter said that there is a need to share the information with stakeholders and a forum
should be convened at the earliest opportunity.

Discussion

In the discussion that followed, participants wished to know: (a) the status of the national
health insurance bill that was passed by parliament in 2003; (b) why the Busia district
hospital was selected for the project; (c) the reasons why only 9.7% of the population
continue to consume 88% of the resources in health.

In response, the presenter said that Busia District Hospital was selected on the basis of
experience in targeting the poor to mitigate effects of HIV and AIDS and that the
structures were already in place. In addition, the presence of MSF working at the hospital
made the operation easier.

3.0       EMERGING ISSUES

      The presenters shared various practices and models in place at the community facility
      levels. During the presentations and the discussions that followed, a number of issues
      emerged.

      (a) Difficulties in identifying the poor people that should be targeted for services-
          it was clear from the presentations that definitions of poverty differ across
          communities and that there is a need to emphasize the importance of clarity in
          defining the benefits and the beneficiaries, as well as the possibility of using certain
          key variables that constitute criteria for implementation while addressing the various
          challenges in the implementation. There is a need to focus on the conditions of
          public health and the process of social benefit.

      (b) For effective and efficient implementation-there is a need for well-established
         and elaborate structures and cost implications for services provision.

                                                                                               17
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
      (c) Creation of demand-creation of awareness about the services available for the
          poor and vulnerable as away of creating demand even for goods used by the
          vulnerable.

      (d) Involvement of communities-there is a need to increase the involvement of the
          community to strengthen monitoring and supervision of the services provision and
          reduce and ultimately eliminate the incidences of abuse or manipulation of the
          system whereby the politically connected and the rich benefit at the expense of the
          poor and the vulnerable.

      (e) Sustainability-the sustainability of existing models poses a challenge particularly
          on the withdrawal of support by development partners.

      (f) Pooled fund-there is a need for negotiations between the government, the
          development partners, the private sector and the National Hospital Insurance Fund
          to set up a fund to be used in targeting resources. Close collaboration and
          coordination of all partners is crucial for efficient implementation.

      (g) Added costs-there is a need to assess and quantify the added costs in the
          administration of the “free” or “subsidized” health services for the poor. The
          challenge is to balance the costs for administering the service and the costs of the
          service.

      (h) Provider/client attitudes- some of the providers need to be trained so as to
          change their non-supportive attitudes in reaching the poor. There is a need for
          incentives to motivate the service providers as a way of making them support the
          systems. There is a need to increase the general awareness among clients of
          services they are entitled to and the quality of such services.

      (i) Strengthening access-there is a need to strengthen access as a key component of
          health services provision through a well thought out and formulated communication
          strategy that includes the use of retired health providers.

      (j) Development of a national index-there is a need to review the tools and develop a
          national index that could be tailored to individual needs.

      (k) Evidence-based data-for policy advocacy on access to health services for the poor
          and vulnerable, there is a need for continued use of evidence-based data.

      (l) Payments- in- kind-there is a need to assess whether payment for health services
          using what people have such as cows, goats, maize i.e. payment-in-kind can be
          integrated into the health service provision.


4.0      GAPS TO BE ADDDRESSED IN THE NEXT ROUND OFDISCUSSIONS

A number of gaps were identified that could constitute the agenda for the next round of
consultations.
                                                                                           18
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
4.1 Critical gaps
     There is a need to assess the impact of the models on improving the health status
       of the poor and other vulnerable groups
     More discussions on the RAC that will lead to a review and sensitivity analysis.
     More attention to the use of the mapping for additional studies on poverty and
       access to health services
     Technical and allocation efficiency of funds targeting the poor and other vulnerable
       groups i.e. direct financing of health facilities.
     Desk review of existing situation on the status of poverty and access to health to
       determine the status, the gaps, where to go to enhance access and strategies to
       improve the services including the gender dimension.
     Payment of service providers to avoid corruptive practices.
     Access for marginalized groups-pastoral communities in the arid and semi-arid
       lands,

4.2 Agenda for next round of discussions
     The role of the Ministry of Health in addressing the poor and other vulnerable
      groups.
     Alternative financing mechanisms
     Experiences from the faith-based organizations and the private sector

5.0      CONCLUSION

In conclusion, the workshop was a success in the sharing of experiences of the tools that
have been used in providing health services to the poor and vulnerable, the challenges
faced and the lessons learnt. It was clear from the deliberations that there are difficulties in
identifying the poor and vulnerable for provision of health services and that it is important
to decide what really is best for the poor-to provide health services or work towards
ameliorating their poverty in line with Vision 2030. In his closing remarks, Dr. Wasunna
Owino mentioned that the next round of consultations will focus on specific themes drawn
from the issues emerging from the discussions. Dr. Owino thanked all participants for
actively contributing to the discussions and the presenters for sharing their experiences.

ANNEXES

Annex I: Meeting Timetable
          FORUM ON POVERTY AND ACCESS TO HEALTH SERVICES IN
                                  KENYA
                               PANAFRIC HOTEL
                            Wednesday, June 20, 2007
                           8:30 a.m. – 2:20 p.m.
        Time                      Activity           Chair
8:30 – 9:00         Arrival and Registration

9:00 – 9:15                    Welcoming Remarks
                               (MOH/S.N. Muchiri)
                                                                                             19
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
9:15 – 9:35                    Climate Setting
                               (USAID/HPI – Wasunna Owino)
Session One                                                               Adam Lagerstedt
9:35 – 10:00                   Poverty dynamics in Kenya –
                               (Central Bureau of Statistics –
                               Ndenge)
10:00 – 10:15                  Targeting vulnerable groups:
                               Experiences of MOH resource
                               allocation criteria
                               (MOH/Nzoya.D.M)
10:15 – 10:45                  Discussions
10:45 – 11:00                                      TEA / COFFEE BREAK
Session Two                                                        Stephen N. Muchiri
11:00 – 11:20                  Output Based Approach (OBA) as
                               a strategy of targeting resources
                               for Reproductive Health Services
                               to the Poor (NCPD) – Francis
                               Kundu
11:20 – 11:50                  - Waivers and exemptions in public
                               hospitals in Kenya
                               - Under the table payments for
                               Family Planning Services (Sam
                               Munga/ Wasunna Owino)
11:50 – 12:10                  NHIF Reimbursements to public
                               hospitals to mitigate against the
                               adverse impacts of cost sharing
                               (Sam Were – MOH/HSRS)
12:10 – 12:55                  Discussions
12:55 – 1:25                   Plenary
1:25 – 1:40                    Conclusions & Way Forward
                               (Chair, MOH/S.N. Muchiri)
1:40 – 2:20                                           LUNCH BREAK




                                                                                            20
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
Annex II: List of participants

       STAKEHOLDERS CONSULTATIVE FORUM ON POVERTY AND ACCESS TO HEALTH CARE IN KENYA
                                            AT PANAFRIC HOTEL, JUNE 20TH, 2007
                                                    PARTICIPANTS LIST


NO NAME               ORGANIZATION               TITLE                    TELEPHONE E-MAIL

1    Urbanus Kioko The Nairobi University        Lecturer, school of      0720-209100    Urbanuskioko@uonbi.ac.ke
                                                 economics
2    Gideon Muga      APDK                       Ass. National Director   0733-660518,   apdkknat@africaonline.co.ke
                                                                          4451523/4/5
3    Joseph K.        MoPND                      Economist                252299 ext.    jnjogu@treasury.go.ke
     Njagi                                                                33336
4    Henry            Kenya Tenants Welfare      Programme Coordinator    0728-249829    Honderinya2006@yahoo.com
     Nyamweya         Union
5    Francisco Zita   Health Policy Initiative   Country Director -       2716760/1      fzita@constellagroup.com
                                                 Mozambique
6    Geodfrey         Kenya National Buraeu      Principal Economist      0722-517308    gkndenge@cbs.go.ke
     Ndeng’e          of Statistics
7    Geofrey          MoH                        Economist/Statistician   0721-854492    gn_kimani@yahoo.com
     Kimani
8    Richard Olewe    Marie Stopes Kenya         Projects Manager         0724-537068    olewericgk@yahoo.co.uk
9    Wasunna          Health Policy Initiative   Deputy Country           2723951/2      wowino@policy.co.ke
     Owino                                       Director
10   Roselyn          Mbagathi District          Social Worker            0722-673660    rmkabana@yahoo.com
     Okumu            Hospital
11   Grace Wanjiku    Nazareth Hospital          Department In-charge     066-50700      nazcom@wananchi.com
     Njiru                                       (Maternity)
12   Violet Asante    Family Support Institute   Program Coordinator      4440005        admin@fasi.or.ke
13   David            Nazareth Hospital          Account Assistant        066-50700      nazcom@wananchi.com
     Mong’are
NO NAME                       ORGANIZATION                       TITLE                    TELEPHONE E-MAIL

14      Samuel                AMREF                              Programme Manager        6994256         samo@amrefke.org
        Ong’ayo
15      Amyn                  Agha Khan Health                   Director                 041-            Amyn.lakhani@msa.akhskenya.org
        Lakhani               Service - K                                                 2226950/0736-
                                                                                          394840
16      Maria Kamau   Agha Khan Health                           MIS Specialist           0733-832323     mkamau.lakhani@msa.akhskenya.org
                      Service - K
17      Matiko Chacha LICASU - K                                 Executive Director       0722-417999     Licasukenya@yahoo.com
18      Melvin        Kenya Dental                               Secretary                                www.kenyadentalassociation.com
        D’Lima        Association
19      Gabriel       KANCO                                      Capacity Building        2717664/2715008 kanco@kanco.org
        Muswali                                                  Manager
20      Kennedy       GOAL Kenya (GAOL                           Project Manager          2727480/        kokango@goalkenya.org
        Okang’o       mobile clinic)                                                      0722316961
21      Mette Kjaer   AMREF                                      Country Director         6994223         mettek@amref.org
22      Macharia      KFW (German Financial                      Programme Officer        3872122         macharia@kfw.co.ke
        Cynthia       Cooperation)
23      Ambrose       UAP insurance                              Medical Operations       2850720         anyangau@uapkenya.com
        Nyang’au                                                 Manager
24      Bill Omamo    ICRC                                       Head of Protocol         2723963         Nairobi.nai@icrc.org
        Jnr
25      James Burure  LICASU                                     Coordinator              0722-417999     licasukenya@yahoo.com
26      Elizabeth     GTZ/CREAW                                  Human Rights Officer     0720-815370     humanrights@gtzkenyahealth.com
        Kang’atta
27      Adam          World Bank                                 Snr. Health Specialist   3226473         alagerstedt@worldbank.org
        Lagerstedt
28      Safari Ngowa  MAP International                          Community Health         2729497         sngowa@map.org
                                                                 Coord.
29      Nzoya                 MOH                                Health Economist         0722-701970     Plan_mnzoya@health.go.ke
        Munguti
30      Teddy                 MoH                                Economist Intern         0721-612295

                                                                                                                                           22
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
NO NAME                       ORGANIZATION                       TITLE                     TELEPHONE E-MAIL

        Mugendi
        Sekere
31      Angelica              World Friends                      Programme Coordinator     0727 737372        angilak@libero.it
        Alhaique
32      Dr. Florence          CRETA Consultants Ltd              Consultant                0722488880         florencenyamu@yahoo.com
        Nyamu
33      Charles               MILDMAY International Consultant                             0722-747806        Comondi2003@yahoo.com
        Omondi
34      Burkard               German Development                 Snr. Advisor              0723-303459        Burlard.koemm@gtz.de
        Koemm                 Cooperation (GTZ)
35      Sam Munga             MOH                                Head, DHCF                0722-636888        hcf@health.go.ke
36      Bedan                 USAID-K                            HMS Specialist            8622000            bgichanga@usaid.gov
        Gichanga
37      Kate Campbell         UNICEF health, KCO                 Volunteer                 0720-720571        katejcampbell@yahoo.com
38      Peter Ruttu           NHIF                               Accountant                273255 ext. 3103   pruttu@nhif.or.ke
39      Salim Kassim          Health Policy Initiative           Accounts clerk            2716760/1          skassim@policy.or.ke
40      Wilson                Population Council                 Programme Officer         2713480/0733-      wliambila@pcnairobi.org
        Liambila                                                                           542384
41      Gerald Oyugi          MSF-Spain                          Ass. Medical              0722-908874        Msfe_medicoassist@yahoo.com
                                                                 Coordinator
42      Chris Rakuom          MoH                                Chief Nursing Officer    2717077             cprakuom@yahoo.com
43      Francis               Health Policy Initiative           Strategic Information/M 2716760/1            fkangwana@policy.or.ke
        Kangwana                                                 & E Specialist
44      Nancy                 Health Policy Initiative           Administrative Assistant 2716760/1           nombega@policy.or.ke
        Ombega
45      Francis Kundu  NCAPD                                     Population Officer        2711711            fkundu@ncapd.ke.org
46      Eunice Kigen   Ministry of                               Finance Officer           252299             euniceyego@yahoo.co.uk
                       Finacne00000
47      Samuel Were    MoH                                       Dep. Head, HSRS           0723-482015        smlwere@yahoo.com
48      Margaret Gitau NASCOP                                    Prog. Coordinator – FP-   0722-271182        gitau@aidskenya.org
                                                                 UCT Integration

                                                                                                                                            23
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007
NO NAME                       ORGANIZATION                       TITLE                    TELEPHONE E-MAIL

49      Peter                 HENNET/GTZ                         Advisor                  0722-698242      myarango@yahoo.com
        Nyarang’o
50      Maureen               Org. for Health                    Programme Officer        0720550560       Ohers01@yahoo.com
        Owiye                 Education & Research
                              Services (OHERS)
51      M. McDonagh           UNICEF                             Chief of Health Sector                    mmcdonagh@unicef.org
52      Ephantus              WEMIHS                             Project Coordinator      067-22992        mjogu@wemihs.org
        Karua
53      Nellie                OHERS                              Executive Director       0722-            Ohers01@yahoo.com
        Luchemo                                                                           375354/6762524




                                                                                                                                  24
Forum on Poverty and Access to Health Services in Kenya – June 20, 2007

				
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