Family Planning in. Kenya: An Annual review of National and County Family Planning Budgets for the Year 2014/15

Transcription

1 Family Planning in Kenya: An Annual review of National and County Family Planning Budgets for the Year 2014/15

2 Family Planning in Kenya: An Annual review of National and County Family Planning Budgets for the Year 2014/15

3 1 Family Planning in Kenya: Published by: DSW (Deutsche Stiftung Weltbevoelkerung) Hatheru road, Hatheru Court (Lavington) P.O. BOX Nairobi, Kenya Tell / Mobile / Internet: Author: Peter Ngethe Ngure Cover photo credit: DSW Kenya Layout and design: Copyright: DSW (Deutsche Stiftung Weltbevoelkerung) All forms of reproductions, adoptation and translations through mechanical, or electronic means should acknowledge DSW (Deutsche Stiftung Weltbevoelkerung) as the source Disclaimer: All data is accurate as of July 2014

4 An Annual review of National and County Family Planning Budgets for the Year 2014/15 2 Contents impressium 1 LIST OF ABBREVIATIONS & ACRONYMS 3 Introduction 4 Key informant interviews at County level for FP policy/budget data collection 5 County Budget Findings 6 Kilifi and West Pokot county Budget 6 Health Budgets 7 Kilifi findings 7 Facility Assessments in Kilifi 8 Commodity availability at facilities in Kilifi 9 WEST POKOT FINDINGS 9 Facility Assessment 9 Commodity availability at facilities 12 Challenges at the counties 12 Key informant at national level for policy/budget data collection 13 National Level Analysis 14 Policy review and alignment with Budget 15 Conclusions and Recommendations 16 Success/outcome stories for each County 16 DSW gets its space in the county budget Economic Forum 16 Kaloleni residents get their space in budget-making process (Kilifi County) 17 Jitokeze Wamama Wa Africa: Tailoring polytechnic reviews its curriculum to teach family planning to its students in West Pokot County 18

5 3 Family Planning in Kenya: LIST OF ABBREVIATIONS & ACRONYMS AOP CPR CSOs DRH DSW FP GoK HIV ICPD IEA KDHS M&E MCH MDG MOHs NCPD NGOs RH SRHR USAID WHO Annual Operational Plans Contraceptive Prevalence Rate Civil Society Organizations Department of Reproductive Health Deutsche Stiftung Weltbevolkerung Family Planning Government of Kenya Human Immunodeficiency Virus International Conference on Population and Development Institute of Economic Affairs Kenya Demographic and Household Survey Monitoring and Evaluation Maternal and Child Health Millennium Development Goal Ministry of Health National Council for Population and Development Non Governmental Organizations Reproductive Health Sexual and Reproductive Health Rights United States Agency for International Development World Health Organization

6 An Annual review of National and County Family Planning Budgets for the Year 2014/15 4 Introduction Each year, under its Euro-leverage project, DSW Kenya conducts an annual review of Health and family planning national and sub-national budgets in the implementing counties. Through the budget review process, DSW, its CSO partners and the public are able to track their national and county governments budgets and spending and help in holding leaders accountable for their promises and pledges. In the Financial Year 2013/14, DSW Kenya undertook in-depth budget analyses of the Health and family planning national budget and those of West Pokot and Kilifi Counties. The findings and budget amounts of that year act as baselines to verify any changes in the national, health and county budgets - more so budgets on reproductive health (RH) and family planning (FP), for subsequent years. In the area of policies, Kenya is undergoing numerous changes to ensure alignment with the 2010 Constitution of Kenya. Although these policies and guidelines are to be developed at the national level, their implementation is squarely at the county level. In the year under review, DSW Kenya has made major progress in advocating for increases in funding to address the unmet need for FP. The budget study presentations and dissemination carried out with 3,000 Kenyans including the Minister of Health and the Director of Reproductive and Maternal Health led to a government commitment to increase FP resources. This was reflected in the 2014/15 budget where the allocation is 900 million KSH up from 600 million KSH in 2013/14. Under Objective 6, civic education sessions continued with two huge community awareness events being held during the (IWD) International Women s Day in March and the World Contraception Day in September. Following community requests for scrapping of FP fees in the local facility during the IWD, the county leadership of West Pokot County saw to it that this was implemented in the 2014/15 budget. Another barrier to access identified in Year One was in adequate human resources to provide services to women. As per the 2014/15 budget, West Pokot will hire 72 more nurses to improve service delivery.

7 5 Family Planning in Kenya: Key informant interviews at County level for FP policy/budget data collection Key Informant Interviews were held in both Kilifi and West Pokot. In Kilifi, the team met with the County Public Service Commission and the County Director of Health. In West Pokot County, the team met with the County Public Service Commission, County RH coordinator, the County Director of Health and the County Minister of Health.

8 An Annual review of National and County Family Planning Budgets for the Year 2014/15 6 County Budget Findings Kilifi and West Pokot county Budget The Kilifi County Budget Estimates for the FY 2014/15 amounted to 8.43 billion KSH comprising of 4.75 billion KSH (54.4%) for recurrent expenditure and 3.69 billion KSH (45.6%) for development expenditure. The budget is to be financed by the national equitable share of 6.34 billion KSH (75.1%), local revenue sources of 1 billion KSH (11.9%) and 1.1 billion KSH (13%) as projected cash balance from FY 2013/14. This provides for an increment of 1.7 billion KSH. The West Pokot County Budget Estimates for the FY 2014/15 amounted to 4.24 billion KSH comprising of 2.39 billion KSH (56.5%) for recurrent expenditure and 1.85 billion KSH (43.5%) for development expenditure. The budget is to be financed by the national equitable share of 3.67 billion KSH (86.6%), million KSH (0.2%) from DANIDA grant to Health, local revenue sources of million KSH (2.3 %) and million KSH (10.7%) as projected cash balance from FY 2013/14. - This provides for an increment of 663 million KSH. Table 1 County Total Budget 2013/14 Total Budget 2014/15 West Pokot 3,037,074, billion Kilifi 5,820,419, billion

9 7 Family Planning in Kenya: Health Budgets The health service docket in Kilifi County has been allocated the highest amount at 1.4 billion KSH, including 1.1 billion KSH for recurrent expenditure and 309 million KSH for projects. This is an increment from last year s Budget which was billion KSH for health with KSH catering for recurrent expenditure. In West Pokot, the health docket was allocated 922,500,000 KSH in 2014/15, which is an increment from 708,382,978 KSH allocated in the 2013/14 financial year. Table 2 County Health Budget 2013/14 Health Budget 2014/15 RH/FP Budget 2013/14 RH/FP Budget 2014/15 West Pokot 708,382, ,500, , 425, ,000,000 Kilifi 1,275,424,467 1,440,000, ,408, ,755,000 KILIFI FINDINGS During the year, Kilifi County government was busy conducting a human resource for health review and audit which has now been concluded. The review shows huge gaps in human resource, and especially a shortage of nurses at the Mariakani Sub-County Hospital, as well as the Rabai and Vipingo Health Centers. This is being addressed through incorporation of the Economic Stimulus Package Nurses (ESP) to the county register. However, since their remuneration was at the national level, the issue or remuneration has not yet been finalised making it difficult to begin service delivery. DSW also held key informant discussions and advocacy meetings with the Kilifi County Ministry of Health through its Director of Health. This has led to the development of the Kilifi Fiscal Strategy Paper which places family planning baselines as at 45% of women of reproductive age receiving family planning. The projection for the next five years is to ensure that this reaches 80%. The county has also identified cancer screening as key for women of reproductive age, a service set to begin with emphasis on screening for cervical cancer. The current baseline is at 50% and the county has placed its projection to 70% through the fiscal period.

10 An Annual review of National and County Family Planning Budgets for the Year 2014/15 8 Facility Assessments in Kilifi At the facility level, it was clear that the hospitals followed the laid-out plan in having the hospital management committee (composed of the Public Health Officer, the In -Charge, a few nurses and community members) involved in developing the budget for the hospital for the year. This is a change from the year 2013/14 financial year where the community did not have the opportunity to interrogate their issues within the budget. However, the budget hearings only covered development expenditure with no discussions on recurrent expenditure or remuneration of staff. Table 3 No Staff cadres Available by tier Required numbers Total gaps Vipingo Rabai Community Vipingo Rabai Community All levels Clinical Officers (specialists) Medical officers Nursing professionals Midwifery professionals Nursing associate professionals (ESP) Community health workers 7 Community Health Workers The Facility In-Charge at each of the centers was keen to provide reassurance that the relevant services were being provided to women who sought them. However, the demand was overwhelming, especially in the evening when only one caretaker nurse is on duty to manage the entire facility - including the maternity section. All the nurses hired here have had to learn professional midwifery given that this forms a necessary portion of their work at the centres.

11 9 Family Planning in Kenya: Commodity availability at facilities in Kilifi Through distribution from the national office, commodities for FP are available at Kilifi County facilities. The plan of borrowing from near facilities is working well in Rabai where they can get commodities from Mariakani Sub-District Hospital when their stocks are depleted. The challenge identified during the facility assessment relates to procurement of commodities; hospital staff, including In-Charges have not undergone any financial management training to enable them to prepare budgets, or commodity quantification trainings to ensure that they are able to project properly on their resources. WEST POKOT FINDINGS In West Pokot County, during the year, there were a number of changes especially in the preparation, dissemination and identification of issues to be budgeted for. The county Ministry of Health, through the County Assembly Health Committee, developed a schedule for circulation in all the community centers for the respective communities to discuss budget issues and requirements. These discussions contributed to the county prioritising the recruitment of more human resources for health as the key issue to unlocking its health problems. Facility Assessment In 2013/14, DSW noted that out of the 93 facilities in West Pokot, only about 54 were functional with about 20 facilities only operating periodically when there were outreaches. The study noted that there was gross inadequacy of staff with some specialties missing completely. The operational facilities had inadequate infrastructure such as stores for supplies and delivery rooms. Waste disposal methods in the county were also unreliable. The table 4 highlights the gaps identified.

12 An Annual review of National and County Family Planning Budgets for the Year 2014/15 10 Table 4 No Staff cadres No. available No. / 10,000 persons County 1 Medical officers specialists Medical officers Health Records & Information Officers Clinical Officers (specialists) Clinical Officers (general) Nursing staff (KRCHNs) Nursing staff (KECHN) Community Health Workers

13 11 Family Planning in Kenya: Available by tier Required numbers Total gaps Hospitals Primary care Community Hospitals Primary care Community All levels This was followed by intense advocacy throughout the year. In the 2014/15 budget and strategic framework for the West Pokot Ministry of Health, the county allocated 300 million for development of the health sector which includes reopening of 24 health facilities and recruitment of 72 additional health workers. This is key to family planning as these services are now available closer to women in these localities. After engaging with DSW and participating in a presentation of the project s study findings, the County Director of Health was convinced of the need to increase human resource. To this end, in FY2014/15, the county is planning to recruit 72 additional health workers. This is in addition to opening up 20 health centers that had earlier been closed due to lack of staff, among other challenges.

14 An Annual review of National and County Family Planning Budgets for the Year 2014/15 12 Commodity availability at facilities On the availability of commodities at facilities, the assessment of four facilities indicated an increased uptake of since June 2014 when the fees for Progestin Only Injectables contraceptives were waived. The following table provides an overview of the uptake: Table 5 Facility Month/method offered March April May June Kanyarkwat Health Center Sigor Sub-district Hospital Progestin Only Injectables contraceptives Progestin Only Injectables contraceptives Combined Oral Contraception Pills However, the current challenge at West Pokot is lack of Jadelles at the facilities which however is being addressed after EL linked the County RH coordinator with Bayer pharmaceuticals representatives. Challenges at the counties Human resource for health remains the biggest problem in providing FP services for women at the county levels. In Kilifi County, the three facilities visited were all inadequately staffed while those in West Pokot have only 50% of the required staffing as indicated in table No. 5 above* The county health management teams lack of capacity for quantification was also noted, an issue which DSW raised during discussions. However, training and standards-setting are the preserve of the national government and thus DSW, Jhpiego, USAID, FCI, among other partners escalated the issue to them. It is worth noting that until the roles and responsibilities regarding family planning commodities and human resource funds are clearly marked out, it will be difficult to quantify allocation for FP and health as a whole.

15 13 Family Planning in Kenya: Key informant at national level for policy/budget data collection DSW Kenya was able to meet the Director of Reproductive and Maternal Health, Dr. Kigen and present to him the FP study findings. Dr. Kigen was keen to engage particularly on the issue of the development of FP strategies for counties, which would also create an opportunity to measure the rates of increase in family planning support and funding. During the year, DSW also met with officials of the National Council for Population and Development and engage with them in the NCPD county meetings which are aimed at sensitizing county governments on the issue of budgeting for family planning and population management.

16 An Annual review of National and County Family Planning Budgets for the Year 2014/15 14 National Level Analysis The budgetary allocation to the health sector in FY 2014/15 was 47.4 billion KSH or 2.6% of the total budget an increase compared to 36.2 billion KSH allocated in FY 2013/14. The allocation comprised of 26.1 billion KSH (55.0%) for recurrent expenditure and 21.3 billion KSH (45.0%) for development expenditure. The FY 2014/15 combined Budget Estimates for the County Governments for ten devolved sectors amounted to billion KSH. The Health had the highest budget allocation at 20.9% i.e billion (county government budget implementation review report for 2014/15 half year). This the total budget for the health sector allocated from the national government to the counties is billion shillings or 6.5% of the total national Budget. The Department Reproductive and Maternal Health has now received support to conduct training of County Health Management Teams, and to train record officers on how to measure FP in their facilities for reporting to the national government. The presentation of data collected from the assessments played a pivotal role in making the case for the national government to increase its FP funding. From the study, the Director of the Department also noted that there had been no funds increment for 3 years. Now, in stark contrast, 900 million KSH has been allocated to FP for 2014/15, mainly for commodities. This is an increase of 300 million KSH from the 2013/14allocation. Following various discussions and engagements with DSW Kenya and other partners, the National Ministry of Health, through its Department of Reproductive, Maternal Health (DRMH), has been able to secure funding to conduct procurement, monitoring and quantification training for County Management Committee members. Table 6 Kenya Total National Budget (Trillion KSH) Total Health Budget(Billion KSH) Total RMCH Budget (Billion KSH) Total FP Budget 2013/14 1, ( ) ,000, /15 1, ,000,000

17 15 Family Planning in Kenya: The National Budget increased minimally in the year 2014/15 mainly due to increment in funding for counties and for security in the country. In the health sector, the total increment in the FY2014/15 was billion KSH 28.7 billion KSH has been allocated to the health sector with a focus on national hospitals (47%), universal maternal healthcare (14%) and health sector equipment financing (10%). Although Kenya still lags behind in achieving the 2001 Abuja Declaration and Abuja + 12 in which African governments committed to allocate 15% of their total budget to public health by 2015, Kenya s current budget allocation to health is 6.5% up from 4.2% in the FY 2013/14. The Ministry of Health is expected to focus on scaling up policy interventions aimed at enhancing the accessibility of affordable health care services. Priority areas include scaling up the provision of free maternal health care at a cost of 4 billion KSH and increasing access to primary health care in public health centres and dispensaries. The long-term objective will be to introduce free primary healthcare; and equip all public health facilities at an estimated total cost of 45 billion KSH over a period of 10 years. Budgetary allocations for the sector increased from 57.6 billion KSH in FY 2011/12 to 87.8 billion KSH in FY 2012/13. The total expenditure of the National Government for the Ministry of Health in FY 2014/15 is 28.7 billion KSH reflecting a 2.9 billion KSH cut compared to FY 2013/14 allocation. This allocation does not include devolved health services expenditure. In FY 2014/15, the Ministry of Health will focus on scaling up policy interventions aimed at enhancing accessibility to affordable health care services. Priority areas will be scaling up free maternal health care and increasing access to primary health care in public health centres and dispensaries at a cost of 4.7 billion KSH. This is a commendable effort by the Government and is in sync with the global health agenda. The success of this program is dependent on the availability and adequate supply of health workers among others. Policy review and alignment with Budget The 2013/14study indicated that although Kenya is a signatory to many national and international treaties, there is no clear budget alignment. However, continuous advocacy bringing about tangible change as evidenced by the 2014/15 budget. Budget allocations to the health sector are in line with the Kenya Health Policy and improving access to health care services in informal settlements is a commendable effort by the Government. The Ministry will also focus on training and building the capacity of its workforce in areas of skill deficit and for efficient and excellent service delivery in the public health sector. NB: Unfortunately, the 2014/15 PBB does not provide a summary of national government expenditure by economic classification, but provides this for each Ministry, Department and Agency (MDA) or Vote. While it is possible to calculate the summary, it would be quite a laborious task given that the accessible PBB Budget Estimates are not in machine-readable format. Notably, these figures are not expected to be very different from the 2013/14 estimates.

18 An Annual review of National and County Family Planning Budgets for the Year 2014/15 16 Conclusions and Recommendations The 2014 annual review with the district and national leadership was carried out well and in time to meet the deadline. Most of the data was collected continuously during the implementation of the annual work plan, thus helping to maintain continued engagement with leaders of the relevant counties, which is key for the success of DSW advocacy. However, resource limitations have limited the impact of this continuous engagement. In Kilifi, the success has been the availability of other projects to support EL in its work. Indeed, being invited to provide support to the review of the county s EPI and annual plan is in itself a success for DSW. DSW is supporting the county government of Kilifi to ensure that their indicators for success in the Ministry of Health have improved CPR. It is worth noting that until the roles and responsibilities regarding family planning commodities and human resource funds are clearly marked out, it will be difficult to quantify allocation for FP and health as a whole. Allocation and absorption of resources allocated by the national government to the counties has greatly improved since the FY2013/14. Availability of information is now easier and clear allocation of resources can be traced. The RH and family planning budge lines however have yet to get a permanent space in the counties budget as the tussle on commodities is still ongoing between the National government Department of Maternal and child health, the Kenya Medical Supplies Authority (KEMSA) and the county governments, Success/outcome stories for each county DSW gets its space in the county budget Economic Forum In 2013, DSW carried out district assessment of family planning budget in West Pokot County. The findings from the study indicated that there was little budgetary support for FP and human resources for health in the county. This made women in the county to incur some costs to meet their contraceptive needs. Indeed, the costs for contraceptives were quite high and women were not able to sustain their purchase of the commodities. DSW presented the findings of last year s (2013/14) budget study to the Chairman of the West Pokot County assembly and health committee, and also delivered the community s budget asks which included increasing the health budget from 23% to 30% and including a dedicated budget line for FP. The chairman was impressed by the presentation and provided DSW with the current County budget guidelines to disseminate to the communities as they await public participation on county budget. The chairman also indicated that although there will be no specific budget line labeled

19 17 Family Planning in Kenya: FP in the new budget, the RH budget will cover FP commodities and on-the-job training of providers on youth-friendly services and FP. He also committed to ensure that the funds set aside for recruitment of nurses are duly utilised. DSW further highlighted the challenges posed by charges levied on the provisions of contraceptives commodities where Pills go for 50 shillings, DEPO for 50 shillings, insertions for 200 shillings and tubal ligation and vasectomy at 1000 shillings. The Chairperson of the Health Committee committed to ensure that the charges were all dropped except for vasectomy and tubal ligation which are surgical procedures and require special expertise. This waiver has now been confirmed. Kaloleni residents get their space in budget-making process (Kilifi County) In late April 2014, DSW through its Euro-leverage project mobilised community members to attend the Kilifi County budget hearing where the government officials arrived to the forum four hours late. The community refused to allow them to speak until they could highlight the reason for their lateness, provide the previous financial year s (2013/14) budget allocation and expenditure, and the proposed development budget for 2014/15. The budget officers were unable to present the previous year s expenditure which was key to the community since they needed to know how their health budget which was 16% of the total budget had been spent. The community sent the officers away and developed a memorandum to the county assembly. Having participated in the meeting, DSW took up the opportunity to organise training on budget tracking for the community and build capacity on the issues to look out for in the 2014/15 budget. Topics included increasing the health budget, RH commodities costs, matching figures to actual work and monitoring budget implementation. The session was conducted jointly by DSW, Kaloleni Women Group and Shangwaya Youth Assembly and facilitated by EL Coast Champion, Wilson Amani. Following the consultation, participants agreed that during the week of the 9th to14th May 2014, members of the county assembly would visit Kaloleni to listen to the community s grievances and get community inputs on the budget. During the resulting meeting, Euroleverage project Champion, Mr. Amani presented the community s position paper, which was taken up by the County Budget Chair. The County Assembly organised community hearings from 1st July 2014 to present the 2013/14 expenditure and present specific budget lines on RH for the community to review. This is a huge success as communities have only been receiving projections on the budget with no real effort at accountability of family planning budgets in Kilifi County by the responsible parties. This is also key to informing 2014/15 year s frugal/ prudent expenditure especially when the leaders realise that the community is keen to see how well their money has been spent.

20 An Annual review of National and County Family Planning Budgets for the Year 2014/15 18 Jitokeze Wamama Wa Africa: Tailoring polytechnic reviews its curriculum to teach family planning to its students in West Pokot County DSW conducted civic education session with civil society organisations during the celebration of the International Women s day, in West Pokot. Jitokeze Wa mama wa Africa, a women training center for tailoring, requested DSW for training on FP and how to incorporate it in their curriculum. Through its West Pokot office, DSW organized an FP training session which equipped Jitokezeto to develop a new curriculum in May, which incorporates monthly FP discussions. The Reproductive Health Coordinator for West Pokot Sub County conducted the first session aimed at enlightening students on family planning and using their platform of tailoring shops to disseminate family planning information to clients visiting the center. The students requested for Information Education and Communication (IEC) materials to disseminate from their shops, as well as commodities such as condoms for distribution. However, clients in need of long-term methods are referred to the Reproductive Health Coordinator for further referral to the Kapenguria County Hospital.

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