The Ministry of Finance allocated 5.6% of the national budget (Kshs. 41.5 billion) to the ministries responsible for health services in Kenya in the 2010/2011 financial year. This budgetary allocation is insufficient considering the enormous health challenges in Kenya such as HIV/AIDS and malaria, an acute shortage of qualified health workers, poorly remunerated health personnel, shortage of drugs and medical supplies in public health institutions and unaffordable health services. Even with these limited resources allocated to the critical sector of health, corruption remains rampant impeding access to quality, equitable and effective health services. Corruption in the procurement of health resources, payment systems, pharmaceutical supply chain and embezzlement of user- fee revenues are the consequences of institutional, legislative and policy risks within the health sector in Kenya.
It is against this backdrop that Transparency International-Kenya conducted a study on integrity in the health sector in Kenya. “The study unpacks critical issues related to corruption and health that all stakeholders should address to safeguard the right to ‘the highest attainable standard’ of healthcare services as required by the Constitution of Kenya,” said TI-Kenya Executive Director, Samuel Kimeu during the launch of the ‘Kenya Health Sector Integrity Study Report’.
The study used both quantitative and qualitative data collection techniques including key informant interviews with stakeholders, focus group discussions, integrity monitoring tools and assessment reports’ reviews, and other existing literature/reports/studies. In all the areas sampled, interviews were conducted with health workers, key informants (Ministry of Health staff, department heads, medical superintendents, hospital administrators and hospital board members among others), exiting clients, other stakeholders and community members. Eighty two healthcare workers and 258 clients were among those interviewed. The assessment was conducted in national, provincial, district and rural/community health facilities in Nairobi, Eldoret, Kisumu, Kakamega, and Mombasa. Others areas covered were: Nyamira, Bokoli, Kabuchai, Kilifi, Ganze, Kabarnet, Marigat and Nyamusi.
- Acute shortage of medicines and other essential supplies in public hospitals: Several patients sampled accused nurses and other medical personnel of hoarding the drugs and secretly supplying them to private pharmacies, where some patients were directed after missing the drugs in the hospital chemists. Many patients are unable to afford the extra charges demanded by hospital staff to source for drugs elsewhere.
- Poor accountability mechanisms: In various institutions sampled, it was noted that revenue collected is not receipted. Sometimes, the amount paid by patients is not what is indicated on the hospitals’ price lists.
- Cases of conflict of interest are affecting the quality of health services: This was evident among government doctors or senior staff that consult for many health institutions especially those stationed in cities and major towns.
- High levels of corruption at various levels in the sector especially in the procurement of drugs and medical supplies: The Kenya Medical Supplies Agency (KEMSA) lacks the institutional capacity, autonomy, financial and human resource capacity to perform this critical function efficiently and effectively since it works under the influence of the senior ministry staff or politicians. Also cited were the slow procurement processes by KEMSA and the ministries of health, lengthy ministerial consultations (between the ministries of finance and health), inflated tenders and budget limitations.
- Delays in service delivery: In some institutions, patients/ clients waited for long hours before receiving medical attention.
- HIV/AIDS financial and other resources are not reaching the target groups: Most of the finances are used in administration and staff capacity building, leaving little for the beneficiaries
- Favouritism in employment: Recruitment and promotion processes in the health sector are plagued by corruption, nepotism and tribalism, influenced by politicians and other interested parties.
- Lack of coordination and turf wars between the Ministry of Public Health and the Ministry of Medical Services: Conflicts over duplicated and overlapping functions between the two health ministries pose the greatest challenge in the implementation of policies, for instance the HIV Treatment, Care and Support policy.
- Insufficient dissemination of information: The health ministries are unable to fund the dissemination of existing information including free medical services and policies to the provinces, districts, and communities, therefore some citizens are charged for free services due to ignorance.
- Poor management of grants and resources: This is largely due to the limited capacity of the health ministries and implementing partners. Lack of proper documentation, reporting and communication among the Government departments and implementing partners has further eroded accountability in grant and resource management.
- Laxity by regulatory bodies/councils: Inefficiency in the enforcement of laws, guidelines and standards that govern the quality of healthcare services has led to an escalation of training institutions that are not accredited and which offer sub-standard training thus compromising the quality of health services. Many laboratories, chemists and clinics operating in Kenya do not meet the required legal standards and regulatory requirements thus endangering the lives of many Kenyans.
- Weak sanctions: The sanctions for noncompliance with the existing laws, standards and regulations are inadequate and not sufficiently deterrent to potential offenders. This encourages contravention of the laws since the penal consequences are not stiff and there is a high probability of evading punishment due to corruption within the enforcement machinery.
- Poor accountability for the Global Fund: The Country Coordinating Mechanism (CCM) for the Global Fund (GF) is not a legal entity that is recognised within the Kenya Government system. Accountability for the GF is therefore questionable since there are no clear mechanisms of monitoring expenditure.
- Capacity building: The ministries of health should develop national or regional centres of excellence to provide training on essential management and professional skills.
- Human Resources: Strengthen the Human Resources Management System for the ministries of health and ensure fair distribution of medical staff in the country and provide incentives (financial/salary increase, training opportunities after a stipulated period of service, promotion, and improving the working environment) to staff working in hardship areas.
- Participation and partnerships: Civil society and citizen participation in governance issues in the sector was weak or absent in most of the sampled areas therefore support is required in the formation or strengthening of existing health sector networks, professional associations/boards/councils, advocacy and “watchdog” groups (including consumer protection bodies) through the establishment of organisational development grant programmes, which may be either donor funded or financed by a combination of donors, the government and civil society.
- Strengthen the capacity of Facility Management Boards: The government should work towards strengthening the capacity of the boards to make them fully responsible for ensuring that the recommended and approved facility actions are implemented efficiently and within the defined principles. The membership of the boards should be reviewed to ensure broad inclusion and participation of all stakeholders taking into account education levels, professionalism, gender balance, broad representation and at-risk communities
- Procurement: The procurement procedure and law should be reviewed to make it more responsive especially with regard to the procurement of drugs. KEMSA should be given autonomy to curb interference by high ranking health officials and political interests.
- Global Fund: A programme evaluation covering governance, participation, leadership, systems and structures of the Global Fund in Kenya should be conducted. The lessons and experiences learnt will be documented, shared and will inform subsequent management of GF in the country.
- Donor coordination and reporting on governance: The establishment or strengthening of sector donor coordination committees should be considered. Mechanisms to establish a more harmonised system of channelling funds towards strengthening healthcare delivery should also be developed.
- Funding for regulatory agencies: The regulatory bodies require support to identify funding sources and ensure proper enforcement of safety and quality standards as an integral aspect of promoting quality healthcare.
- Harmonisation of legislation pertaining to healthcare: All laws and policies that affect the health sector should be reviewed and harmonised into one regulatory regime that clearly spells out the duties, functions and roles of each body/department to avoid overlapping and duplication of functions so as to ensure efficiency and coordination in the sector.
- Awareness creation: Ensure proper implementation of laws and policies related to the health sector through awareness creation and capacity development of all the stakeholders, including the citizenry, on the provisions of these frameworks.
“The recommendations will serve as a basis for an action plan to improve governance in the health sector and provide a foundation for empowering the citizens to increasingly and persistently demand for better services in this critical sector, “ said Mr Kimeu. “Through our Citizen Demand Programme, TI-Kenya will craft various advocacy interventions to pursue these recommendations and other improvement plans by other stakeholders.”
Improving governance of the health sector will re- inject revenues hence improving the quality of healthcare and life, especially that of poor and marginalised communities who are less able to afford bribes or higher payments for subsidised or free health services.
The challenges faced in enhancing good governance in the health sector are immense: and can only be tackled by collaborative action involving the government, private sector, civil society, development partners and citizens. This kind of action will be critical in enhancing Kenya’s chances of meeting three Millennium Development Goals related to health: reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases.
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