2014年-世界发展银行全球_Laying_the_Foundation_for_a_Robust_Health_Care_System_in_Kenya___Kenya_Public_Expenditure_Review_64页_5mb

Summary of Laying The Foundation For A Robust Health Care System In Kenya

Core Content

This document, titled Laying The Foundation For A Robust Health Care System In Kenya, presents a comprehensive review of Kenya's health care system, focusing on equity, efficiency, and effectiveness in the context of devolution. It outlines key challenges and opportunities for improving the health system and offers policy recommendations to address them.

Main Points and Key Information

1. Health System Overview

• Kenya has devolved health services to county governments, aiming to improve equity in access.
• The health system is structured across six levels of care, with Level 1 and 2 facilities mainly focused on primary health care (dispensaries, health centers, community facilities).
• Level 4 and 5 facilities (secondary and tertiary) are the main drivers of curative expenditure, accounting for about a third of total public health expenditure.
• The public sector dominates Level 6 (tertiary) facilities, with 78% of beds in Level 5 provided by the government.
• Spatial disparities exist in health infrastructure distribution, with high concentration in Northern Corridor and population-dense areas, while remote counties rely on non-governmental organizations (NGOs) and faith-based organizations (FBOs).

2. Health Outcomes and Disease Burden

• Kenya has seen significant improvements in child mortality and immunization rates over the past decade.
• Infant and under-five mortality declined by nearly a third between 2003 and 2008.
• HIV prevalence among adults dropped from 7.2% in 2007 to 5.7% in 2012.
• Lower respiratory infections showed the largest reduction in disease burden (21% decrease from 1990 to 2010).
• Non-Communicable Diseases (NCDs) now account for 50–70% of all hospital admissions and up to 50% of inpatient mortality.
• By 2027, it is projected that NCDs will surpass communicable diseases as the main cause of mortality, even without injuries.

3. Health Expenditure Trends

• Total health expenditure per capita increased from US$32.4 in 2001/02 to US$50 in 2011/12.
• Out-of-pocket (OOP) payments account for over a third of total health expenditure, making it inequitable and inefficient.
• Public health expenditure has stagnated, remaining low compared to regional and global standards.
• Public health spending accounts for about 1.2% of GDP and 25% of total health spending.
• Donor funding contributes about a third of total health expenditure, but much of it is off-budget and disease-specific, limiting strategic health system strengthening.

4. Efficiency and Inefficiency in the Health System

• Macro-level efficiency is low, with Kenya ranked among weak performers in infant and maternal mortality (Figure 4.3).
• Allocative efficiency is poor, with heavy reliance on curative services and insufficient investment in preventive care.
• Technical efficiency varies by level of care and provider type, with private and FBO providers generally more efficient than public ones.
• Absenteeism among health professionals is a major source of inefficiency, with doctors (38%), clinical officers (36%), and nurses (30%) having the highest rates.
• Drug shortages and delays in disbursement further hinder the system's efficiency.

5. Equity in Health Spending

• There is a strong correlation between poverty and health expenditure per capita, indicating inequities in access to health services.
• County-level disparities are significant, with Wajir having only 12% skilled delivery assistance compared to Nyeri at 94%.
• Preventive care and primary health care remain underfunded, despite the government’s efforts to increase their share.

6. Devolution Opportunities and Challenges

• Devolution presents a unique opportunity to address historical inequities and system inefficiencies.
• County governments now control two-thirds of the health sector budget, but public expenditure on health declined in 2013/14.
• Effective resource sharing (e.g., networked hospitals) is encouraged over new investments in infrastructure.
• The Sri Lanka model is highlighted as a successful case study, achieving remarkable health outcomes with cost-effective strategies, including community-based midwives and tax-funded public health systems.

7. Policy Recommendations

• Increase public funding, particularly for primary health care.
• Reduce reliance on OOP payments and promote pre-payment mechanisms such as health insurance.
• Mainstream donor support and ensure it aligns with local priorities.
• Create incentives for health staff to improve attendance and performance.
• Equip health facilities with adequate essential medicines and supplies.
• Adopt cost-effective preventive care interventions to enhance service delivery and health outcomes.

Conclusion

The document emphasizes that devolution is a key mechanism to improve equity and efficiency in Kenya’s health system. While improvements in health outcomes have been made, systemic inefficiencies and inequities persist. The Sri Lanka model offers valuable insights for improving health delivery, and policy reforms are necessary to ensure financial sustainability, equitable access, and efficient service delivery.