By Shifting the Paradigm, Kenya's County Health Sectors See Gains
This post was originally published on Medium.
Sarah Esinven—the director of planning, monitoring, and evaluation in Kenya’s Turkana County— remembers what it was like in 2013, when federal agencies began devolving authority to county governments. Most were unprepared. “I had 22 different budget categories… and we didn’t know how to cost or estimate,” she recalled. “We would just allocate two million here and three million there, without really knowing.”
That year, Kenya’s federal government mandated that counties begin using program-based budgeting (PBB)—a method of budgeting that links budgets to health outcomes, directing resources to the most impactful programs.
But two years into Kenya’s devolution, most counties—including Turkana—didn’t know how to put PBB into practice, leaving gaps in budget allocation and advocacy efforts. What was missing was a way to quickly bring county management teams up to speed on PBB. To do this, tools needed to be developed to help these teams implement and become effective stewards of county resources, bolstering their ability to pass along critical knowledge to their successors.
Supporting Kenya’s Journey to Self-Reliance
Enter USAID’s Health Policy Project (HPP), which struck a collaboration between government entities and other key stakeholders to develop a new PBB manual and template for the county health sector. The manual allowed county health management teams to establish specific categories for priority health areas such as HIV, family planning, malaria, tuberculosis, and maternal, newborn, and child health. Through training and mentoring, county health teams were encouraged to adapt the template to reflect specific priorities and given tools and guidance on how to influence the budget approval process and advocate for their communities.
As HPP concluded and its successor project—Health Policy Plus (HP+)—ramped up, this work to strengthen county planning and budgeting continued. HP+ and the Kenya School of Government picked up where HPP left off, using the PBB curriculum to train county health management teams, organize trainings, and provide hands-on mentoring and coaching. The school, a lead partner in the budget reform effort, is tasked with orienting senior public officials to government policies and procedures, including PBB. As Andrew Rori, the Kenya School of Government’s deputy director, commented, “HP+ brought a different approach… emphasizing stakeholder engagement.” “HP+ took a county-by-county approach instead of grouping counties,” he explained. “This meant that we could tailor each [budget] to address county-unique problems, making them more relevant.”
A Deep Dive
For nine select “deep-dive” counties in Kenya, the project went a step further, working with county teams to track how budgeted funds were spent and determine whether spending had the intended impacts on health outcomes. HP+ also worked with county health management teams to identify ways to be more efficient in spending—revealing bottlenecks and gaps in areas such as supply chain and procurement processes and human resources—and developing roadmaps for how to address these gaps and strengthen local health systems. With HP+’s support, counties such as Nyeri and Mombasa are beginning to see positive changes in their local health systems:
Success and Savings in Nyeri
Before HP+’s involvement, Nyeri County spent a significant portion of its health budget on staff salaries. Working alongside HP+ and USAID’s Capacity Project, the Nyeri County health management team was able to forecast the retirement of about 280 staff, eliminate redundancies, and adopt more economical hiring mechanisms. Dr. Nelson Mwangi Muriu, Director of Health Services in Nyeri County, noted, “We set a small target to save KSh100,000 [just under US$1,000] last year and ended up saving about KSh500,000! We can use the funds [saved] as a supplementary budget and reallocate for something else.” Dr. Muriu also noted that after implementing PBB, the county has been able to increase its health budget by over 20 percent, from about KSh2.2 billion in FY2015/16 to about KSh2.9 billion in FY2017/18.
A Doubling of Health Funds in Mombasa
In Mombasa County, the health management team used their new PBB knowledge and skills to incrementally increase their health budget each year, from 12 percent of the total county budget in FY2014/15 to 27 percent in FY2017/18. As a result of those increases and other strategic shifts in health financing, the county has drastically reduced out-of-pocket costs, from 41 percent of total health expenditure in FY2014/15 to 34 percent in FY2016/17.
Nyeri and Mombasa aren’t the only counties beginning to see change. In just two years (2016/17 to 2018/19), HP+’s nine deep-dive counties collectively increased their health budgets by 15 billion Kenyan shillings [over US$140 million]—a 30 percent jump. Even more significantly, the additional funds are being spent on procuring essential medicines and other supplies, ensuring that people can access the medicines and care that they need without putting their families’ financial health at risk.
Now, armed with the skills to carry out PBB and expenditure review work on their own, these county health teams are taking a hopeful look toward their futures—as well as those of their neighbors. Elsewhere, across Kenya, health teams continue to struggle to effectively budget and spend health resources. In response, county health teams from HP+’s deep-dive counties are mobilizing to share what they’ve learned with their colleagues—a county-to-county effort to help improve health spending and outcomes nationwide.
For Esinven, the seeds of change in Turkana have been sown. In place of the 22 budget categories that used to exist, “Now,” she explained, “I have three…[and] now we know how to cost correctly.” “The advocacy training has helped us defend our activities,” she added, “and we have been able to increase our health budgets each year.”