Human Resource in Health and UHCKisumu County Health Sector, Kenya

Dr. Elizabeth OgajaMinister of Health Services & Promotion of Health Investments, Kisumu County, Kenya9th Oct 2015Health Sector Development Partners Stakeholders Forum

OUTLINE1. Health Reform in Kenya

2. Health in Kisumu County

3. Policies and Strategies for HRH

4. Opportunities and Challenges

5. Conclusion

HEALTH REFORM IN KENYA

Health Reform in Kenya

Health Policy and Constitution Vision 2030

•To create a globally competitive and prosperous nation with a high quality of life by 2030

Kenya Constitution 2010

•Introduces a devolved system of government which would enhance access to quality services by all Kenyans

Kenya Health Policy 2012 – 2030

•Seeks to make the realization of the right to health by all Kenyans a reality as defined under Art 43. of the Constitution

HEALTH SYSTEMS – ref. WHO

1. Human Resource for Health2. Service Delivery3. Health care financing4. Infrastructure5. Essential Health Products and Technologies6. Health Management Information System7. Leadership Management and Governance

Patient Focused Healthcare

HEALTH FACILITY

PreventionInvestigationsDiagnostics;Treatment

Equipment

Medicines

Medical Supplies

Constitution of Kenya: Article 43. (1) (a) Every person has the right—to the highest attainable standard of health…

Community Strategy = Community Health Services

Community Strategy = Community Health Services

Devolution of Health Sector, 2013• National Ministry of Health

Steers implementation of national policies and development of standards for service delivery

CURRENT STATUS• 47 new County Ministries of Health

Administrative authorities• Fiscal authorities in health service delivery

HEALTH IN KISUMU COUNTY

Health Reform in Kenya

Kisumu County

Population Over 1 million (national 43 million)

Poverty rate47% (national 45.9%)

HRH Training Centres in Kisumu County

Maseno University•School of Medicine

Uzima Medical College •School of Medicine and School of Nursing Great Lakes University Kenya University•School of Community Health•School of Public Health

Kisumu Medical Training Colleges (3 campuses)•Annual output of 300 trained health workers•Diploma in Community Health Nursing, Clinical Medicine, Medical Laboratory Sciences

Some thoughts on HRM Policy • National Policy on HRH has been finalized and launched – how are we as

counties undertaking the customization and implementation?• Must move away from 1 person HF management structures• Ideally a primary health facility should have a minimum of 12-14 staff

depending on work load:1. Clinical Officer 2. Nursing Officer 3. Pharm. Tech4. Lab Tech5. Public Health Officer6. Admin. Officer7. Nutritionist

Need at least 2 per cadre – more if the workload demandsNeed to plan for the application of the WHO Workload Indicator of staffing needs methodologies

Poor Health Coverage

Health Indicators

Kisumu County Health Sector (2013) ,data.world bank.org (2014), quandl.com (2014)

Indicators Kisumu County

Kenya Germany

Life expectancy at birth in years 61 61 81

Under-5 mortality rate per 1000 live births 105 73 4

Maternal mortality ratio per 100,000 live births

600 488 7

Births attended by skilled health personnel 60% 43.8% 98.6%

Malaria prevalence 37% n.a. n.a.

HIV adult prevalence 17% 6.2% 0.1%

Possible obstacles to UHC

Financial, Geographic and Therapeutic Barriers

•Little risk-pooling

•High out of pocket payments

•Insufficient quantity and quality of health care services

•Geographically hard to reach

•Mismanagement of resources

•Demotivated staff

•Understaffed health facilities

Chuma & Okungu (2011), Flessa (2013), World Bank (2014)

HRH Statistics Cadre Per 100,000

Kisumu, 2012(MOH, 2013)

Kenya, 2012(MOH, 2013)

WHO minimum recommendation

Nurses 73 (54% of WHO recommendation)

49 (36% of WHO recommendation)

135

Doctors 10 (28% of WHO recommendation)

7 (19% of WHO recommendation

36

Laboratory Technicians

6 7

Pharmacy Technicians 1 1

Public Health Officers 10 4

Kenya Ministry of Health (2013), Kiambati et al. (2013

Kisumu County HRH Kisumu County HRH

Total Comments

Salaries covered by County Government

1,600 (84%) • All cadres, including administration

• 16% of total county health budget

• One third employed at regional referral hospital

Salariescovered by partners

300 (16%) • Clinical and medical health care & records staff.

• Partners funded by PEPFAR

• More than ½ of the contracts will end in 2016;

renewal only if donor funding continues.

• Distributed throughout all 6 sub-counties and at

all health facility tier levels.

Total 1,900 (100%)

Health Financing in KisumuTypes Comments

County Government • 33% of total county government annual budget.• One third for regional referral hospital. • Includes free public Primary Health Care services.

Free maternity care services

Endorsed by the government in 2013 to sink high MMR.

Fee for services At 3rd and 4th tier level public health facilities

Out-of-pocket payments

Nation-wide: 77% (World Bank, 2014)

Partner support • 16% of county HRH. • Capacity building and commodities of health facilities

(these are often not reported to county)

Health Financing in Kisumu (cont.)

Types Comments

National Hospital Health Insurance (NHIF)

Primary provider for health insurance in Kenya. Covers inpatient care. Compulsory for employed personnel. Low coverage.

Community-Based Health Insurance (CBHI)

STIPA (NGO) 4,700 beneficiaries in Kisumu County. Targets low-income and informal sector.

Other NGOs providing CBHI include KMET and Changa Muka.

Output-based Aid Vouchers for Safe Motherhood Services. Target: economic- disadvantaged women. KfW and BMZ funded

Social Franchising Insurance (premium payments) for outpatient, maternity and referral services in private sector. Pilot phase in 2 counties, including Kisumu. Target: 6,200 low-income earners. KMET (NGO) and PharmAccess. Funded by Dutch Government.

POLICIES AND STRATERGY /HRH

Health Reform in Kenya

Framework for policy direction

Kenya Health Policy 2012-30

Kisumu County Strategy Plan 2013-2017

Orientation Area

Intervention Area Milestones

Health workforce

Recruitment and secondment of staff from national government

Develop norms and standards of staffingYearly recruitment of staff

CHW allowances 2544 CHWs (approx. 1 million USD p.a.)

Personnel emoluments Review salaries and allowances upwards

Pre-service training Initiate sponsorships/scholarships with 5-year bonding

In-service training Enrol staff on trainings, CPD

Staff motivation Conduct staff satisfaction survey, Operational Research

OPPORTUNTIES AND CHALLENGES

Health Reform in Kenya

Opportunities Kenya’s Health Policy 2012-30•Emphasises every Kenyan’s right to health•HRH is identified as policy orientation

Decentralised County Health Sector •Potential to fully utilize resources efficiently and effectively

Kisumu Strategic Plan •Recognizes the need of attracting, obtaining and maintaining HRC•Determination to invest in CHWs and strengthen PHC

PPP -Universities contribute to research in health -Partners are taking lead in UHC initiatives (e.g. MSH launching UHC program)

Governance of Health Sector at the Policy Level

• National Ministry of Health:– Department for HRH Management & Development

• County Governments– Council of Governors

• Committee on Human Resources• Committee on Health and Biotechnology

– Council of County Health Ministers• HRH• EHPT• Health care Financing• Inter-county relations• ICT in Health and Health Informatics• PPP in Health• Health Research and Quality Assurance

– Inter-county HRH Forum

INTRA-COUNTY GOVERNANCE STRUCTURES

• County Executive for Health Services• County Health Management Coordinating

Committee• Sub-county Health Management Teams• Ward Health Managent Teams?• Facility Health Mangement Teams

COUNTY HEALTH MANAGEMENT COORDINATING TEAMS

• Will depend on the way the Health department is structured in each County

• Must reflect the functions as tranferred by:– The Constitution (including Sch 4 as well as the

Transition Authority Gazette Notice no. 139)• Governance structure – developed with

assistance of organizational reform experts

COUNTY HEALTH MANAGEMENT COORDINATING COMITTEE

• CEC • CHIEF OFFICERS• DIRECTORS

– Preventive Promotive Healthcare– Community Health Services– Referral Health Services– Curative Health Services

• MEDICAL SUPERINTENDANTS/ FACILITY MANAGERS– Service Delivery Teams

• Medicines and Therapeutics Committee• Nursing Services• Surgical Services• Paediatric Services• Maternal Health Services• Adolescent Health Serivces• Patient Support Services

Structures for County Government

NEED TO GET IT RIGHT FROM THE BEGINNING

.Pass and enact legislation,

.Vet and approve appointments of county public offices,

.Approve budget and expenditure of county government

County-Sub-county-Ward-City-Municipality

Enabling Legislation

Regulations & Enforcement Oversight

Policy formulation

-Harmonization of different levels of Staff-Skills & Competencies-Deployment& secondment-Terms & conditions of service-Remuneration-HR Audit, Head count

-National Capacity Building Programme-Capacity Building Transformation Initiative-Skills, Audit-Learning-Professional competenciesfor Government

HR, Financial Management-Procurement-Performance Management-Strategic Planning, ICT-Asset Management-Budget, ISD-Risk Management

County Offices-Equipment-County Assembly chambers;-Vehicles, etc.-Accommodation-Assets

COUNTY ASSEMBLY

Pass and enact legislation,Vet and approve appointments of

county public offices,Approve budget and expenditure

of county government

STRUCTURE

CountySub-countyWardVillage (in the Constitution – yet to

be formalized in some counties)City (some counties)Municipality

POLICY, LEGAL & REGULATORY ENVIRONMENT

Enabling LegislationRegulations& Enforcement Oversight Policy formulation

STAFFING

Harmonization of different levels of Staff

Skills & CompetenciesDeployment& secondmentTerms & conditions of serviceRemunerationHR Audit, Head count

CAPACITY BUILDING

National Capacity Building Programme

Capacity Building Transformation Initiative

Skills, AuditLearningProfessional competencies for Government

SYSTEMS, PROCESSES AND PROCEDURES

HR, Financial ManagementProcurementPerformance ManagementStrategic Planning, ICTAsset ManagementBudget, ISDRisk Management

INFRASTRUCTURE

County OfficesEquipmentCounty Assembly chambers;Vehicles, etc.AccommodationAssets

THE COUNTY PROGRAMS BASED ON FOURTH SCHEDULE OF THE CONSTITUTION OF KENYA 2010

The county programs based on fourth schedule of the Constitution

of Kenya 2010 (Continued…)

Sample

THE COUNTY ASSEMBLY MODEL SUPPORTING STRUCTURES INCLUDE;COUNTY ASSEMBLY BOARD, COUNTRY ASSEMBLY BOARD SECRETARIAT, OFFICE OF

THE COUNTY ASSEMBLY CLERK AND DEPARTMENTAL/ DIVISIONAL STRUCTURES

THERE SHALL BE ESTABLISHED AT THE LEVEL OF EACH SUB-COUNTY THE OFFICE OF THE SUB-COUNTY ADMINISTRATOR.

Subject to subsection (3) of the County Government Act, the functions and provision of services of each county government shall be decentralized to—

•The urban areas and cities within the county established in accordance with the Urban Areas and Cities Act (No. 13 of 2011);

•The sub-counties equivalent to the constituencies within the county established under Article 89 of the Constitution;

•The Wards within the county established under Article 89 of the Constitution and section 26; and

•Such number of village units in each county as may be determined by the county assembly of the respective county and such other or further units as a county government may determine.

IF THE CONSTITUENCY OR PART OF A CONSTITUENCY FALLS UNDER URBAN AREAS OR CITIES, THAT CONSTITUENCY OR PART OF THE CONSTITUENCY,

SHALL BE CONSIDERED AS FALLING UNDER SUBSECTION (1)(A) OF THE COUNTY GOVERNMENT ACT.

The Urban Areas and Cities Act, provides for classification, governance and management of urban areas and cities to provide for the criteria of establishing urban areas to provide for principle of governance and participation of residents and for connected purposes.

An urban area can be classified as a city under this Act if the urban area satisfies the criteria set in Section 5 of the Urban Areas and Cities Act.

Under Section 27 of the Urban Areas and Cities Act, a city county shall be governed and managed in the same manner as a county government.

UNDER THE FIRST SCHEDULE OF THE URBAN AREAS AND CITIES ACT – CLASSIFICATION OF CITIES AND TOWNS BY SERVICES THE SERVICES TO DELIVERED BY A MUNICIPALITY

IS LARGELY THE SAME IN THE CITY WITH MINOR VARIATIONS.

The functions performed by the board of a city or municipality

under Urban Areas and Cities Act shall, in the case of a town, be

performed by a Town committee appointed by the county governor

and approved by the county assembly.

COUNTY EXECUTIVE COMMITTEE WILL BE CRITICAL IN ENSURING MANAGEMENT AND COORDINATION OF THE FUNCTIONS OF THE COUNTY ADMINISTRATION AND ITS

DEPARTMENTS .…

Example

HUMAN RESOURCE MANAGEMENT

• Gauge the actual numbers scientifically– WHO Methodology – Work Indicator of Staffing Needs– Facility-based calculation– Based on workload and available work days per cadre– Facility numbers – aggregate to sub-county and

county level– Human resource budget – calculate based on current

schemes of services (including approved allowances)– Capacity Building on the use of the WISN

methodology is required

CHALLENGES for HRH •Critical shortages in HRH nation and countywide – address this by using a professional method of estimating numbers

•Regeneration of Health Workforce: Outflow higher than inflow – need to professionalize human resources management with highly qualified HRM and HRD managers embedded within the County Ministries of Health

•Discontinuation of partner support will have critical outcome on health coverage (16% of HRH supported by partners) – The Government has no option but to rationalize and invest in HRH for UHC

•Young leaders in health sector with little experience in management: •Addressed by proper preparation for service:

–Orientation–Management Training–Professional Development–Mentorship

•One third of Kisumu County’s health budget is allocated to regional referral hospital. This creates bottlenecks in Primary Health Care and HRH regeneration

CHALLENGES FOR HRH

National Government• Are the HRH at the NG

properly capacitated for their role as policy formulators:– How many formally trained in

policy formulation and analysis– How many formally trained in

M & E especially for policy development and strategic planning

– How many formally trained in the development of standards of health service delivery

County GovernmentPrimary responsibility is implementing health policies, strategies and guidelines– Training needs assessment

must be done – to cater for the role given by the Constitution

– Require training in programme based budgetting, strategic planning

– Training in Health Systems Management

– Management training for coordination of health services

– Communication strategy

CONCLUSION

Health Reform in Kenya

Towards UHC and sustainable HRHNational MOH

•To develop comprehensive evidence-based policy framework to address critical shortage of HRH (e.g. Innovated Human Resource Solutions/ IHRS)

•To develop Service Charters (SOPs, Quality Management, Benchmarks)

•To provide affected counties with sufficient conditional grand for regional referral hospitals

County MOHs

•To take an active role in coordination of PPP towards UHC

•To strengthen resource mobilisation

•To invest in Primary Health Care and in HRH

•To build capacity of health managers so that they may plan resources effectively, efficiently and equitably

TOWARDS UHC AND SUSTAINABLE HRH

• Investment pillars for UHC– Human Resources for Health– Infrastructure– Essential Health Products and Technologies– Health Financing

Thank you for your attention!

ReferencesChuma & Okungu (2012) ‘Viewing the Kenyan health system through an equity lens: implications for universal coverage’, International Journal for Equity in Health.

Dunne (2013) ‘Tackling the Challenges of Human Resources for Health (HRC) Strengthening in Kenya’, Global Health Fellows .

Health Rights Advocacy Forum/ HERAF (20120 ‘The health service commission – They

Kenya Ministry of Health (2013) Kisumu County Health at a glance (www.healthpolicyproject.com).

Kfw (2012) ‘Vouchers for reproductive health care services in Kenya and Uganda’.

Kiambati et al. (2013) ‘Understanding the labour market of human resources for health in Kenya’, WHO Working Paper.

Koon (2013) ‘The road to universal health coverage in Kenya’, London School of Hygiene and Tropical Medicine.

KPMG (2013) ‘Devolution of Healthcare Services in Kenya’/ Lessons learnt from other countries’.

Flessa (2013) ‘Kenya’s Road to Universal Health Coverage –The Roles of the Public and Private Sector’, Universitaet Greifswald

WHO (2014 ) Out-of-pocket health expenditure data (who.int)

WHO (2010) Global Atlas of Health Work Force (who.int)