Tracking spending on health to improve equity – Kenyan case Thomas Maina 24/04/2012

Health care financing policy and strategy in Kenya Important decisions made by the government over the past decade with regard to HCF The strategies include: – Decision to introduce user fees in 1989 – Shift in focus from curative to preventive health care (HSSP II and KHPF) – Reform NHIF to enhance the benefit package and improve access to health care – Setting up a SHI scheme a flagship project of the Vision 2030 to improve equity in health care financing – Scale up Output Based Approach to improve access to health care by the disadvantaged – Development of a care financing policy

History of NHA in Kenya Kenya has implemented four rounds of NHA between 1997/98 and 2009/10 The first round of NHA undertaken in 1998 and used data for FY 1994/95 Financed by Danida and USAID through Partnership for Health Reform HH contribution estimated using Welfare Monitoring Survey of 1994 Key findings: – THE – Kshs. 31 billion ($US 560 million) – HH contributed bulk of the THE (53%)

Sources of funding health care -1994/95

Second round of NHA-2001/02 Conducted in 2003 using data for FY 2001/02 Financed by SIDA, USAID through Partnership for Health (ABT) and NHIF A HIV/AIDS sub-analysis also undertaken A Household Health Expenditure and Utilization undertaken to estimate HHs contribution Key findings: – THE – Kshs. 47 billion (US$598 million) – Again HHs contributed bulk of THE (51%) – Public providers consumed 60% of the THE – HIV/AIDS sub account – THE hiv – Kshs. 8.2 billion (US$103 million with donors contributing 51%,HH 26% and Govt 21%

Sources of funding -2001/02 –General Health and HIV/AIDS

Percent distribution of public outpatient services

Third round of NHA Undertaken in 2007 and used data for FY 2005/06 HIV/AIDS and RH sub-accounts Financial and technical support by USAID through Health system 20/20 HH survey also undertaken to estimate HH contributio n Key findings: – THE- Kshs. 71 billion (US$964 million) – HHs contributed 36% ( reduction of 15% from 2001/02) – THEhiv – Kshs 19 billion (US$256 million) – Donors financed 70%,HHs 23% and Govt 7% – THE RH - Kshs. 9 billion (US$119 million –HHs 38%,Govt 35% and donors 24%

Sources of funding – 2001/02,2005/06 and 2009/10

Fourth round of NHA Conducted in 2010 using data for 2009/0 HIV/AIDS,RH,TB, Malaria and Child health sub-accounts Financial and technical support from USAID through HS20/20, financial support also from WHO and World Bank Key findings: – THE – Kshs billion (US$1,620 million) – Further reduction of HHs contribution from 36% in 2005/06 to 28.5% in 2009/10 – Doubling of donor support to 35% – THE HIV – Kshs. 30 billion – Donors 51%, private sector 28% and Govt 21% – THE RH –Public and private major contributors (40% and 38% respectively – THE Malaria- 52% came from private sector including HH

Cont fourth round of NHA – THE TB – Donors contributed 39% – THE CH – Donors contributed 44%

Use of NHA by the government to inform policy – address equity and access issues Evidence Results of 1997/98 and 2001/02 provided evidence on HH spending on health (over 50%) The NHA of 1997/98 and 2001/02 also provided evidence that the rich benefit more from public spending on health – hospitals while the poor benefit more from – lower level health services Government response HCF became a topical issue in many forums – Taskforce on HCF – SHI and OBA flagship projects of Vision 2030 MoH lobbied for more resources from MoF – 30% increase in 2003/04

Cont use of NHA by the government to inform policy – address equity and access issues Measures to reduce OOP: – 10/20 policy (2004) – 50% increase in outpatient visits – HHES of 2003 reported stock outs leading to reduced access to health care – procurement of a 3 month kit of EMMS in lower level facilities leading to increased utilization – User fees accounted for 30% of O&M in health facilities – piloting of HFF in Coast and NE and scaling up of the same in all provinces (HSSF) – Mobilized donors to hire nurses for the lower level All the above measures led to a reduction of OOP from 51% in 2001/02 to 30% in 2009/10

Conclusion Evidence provided by the several rounds of NHA impacted on policy process – pro-poor policies The need to institutionalize NHA to continue providing evidence on HCF on regular and timely basis Institutionalization efforts so far: – Msc in Health economics course – to increase the pool of graduates with knowledge on NHA – Standardized donors/NGO reporting tool – plans to computerize – Simplified NGOs tool – Piggy backing HH spending on health on regular surveys – KAIS in 2007 and 2012 – NHA as part of the PS performance contract to increase demand