Public Expenditure Tracking Survey

1. Public Expenditure Tracking Survey MINISTRY OF MEDICAL SERVICES AND MINISTRY OF PUBLIC HEALTH AND SANITATION Findings of 2009

2. INTRODUCTION • GOK has reiterated the importance of financial management as a key area within the broader sectoral reforms, • Several interventions have been undertaken to financial challenges facing the public health sector • These include: • a Rapid Results Initiative on public financial management (PFM), • removal of several redundant stages of the central level approval and • authorisation process prior to distribution of notification of AIEs to the operational level budget holders, • issuing of cheques to accompany the AIEs from July 2006, and • development of a Position Paper supporting direct financing of rural health facilities

3. Introduction • Despite increase in budgetary allocations, the increase has not been reflected in significant improvements in health indicators. • This raises the concern whether increased budget translates into better performance of the health sector and • more importantly, whether the resources are utilized in an effective and efficient manner 

4. Introduction... • PETS was expected to provide fundamental information on: • challenges and gaps in resource allocation and • disbursement of funds to the intended recipients. • Overall aim is to identify challenges to the financial flows in order to help evaluate the efficiency and effectiveness of public expenditures, particularly for the rural health facilities.

5. Study Objectives • To collect centrally sourced secondary data to produce a rapid estimate of all resources allocated to the health sector in the FY 2009. • To track the flow of resources from the Headquarters to the Provincial and District Health/Medical Officers to health facilities. • To obtain, track and analyse the flow of medical and non-medical drugs (tracer drugs) from the HQs and Divisions within the ministries to public health facilities included in the sample; • Identify challenges in the flow of the tracer drugs from the HQs to the sampled health facilities;

6. Objectives cont……. • To produce, for this subset of districts, a detailed breakdown of resource use by facility type and programme activity. • To identify the disbursement profile of district resources and to document any problems or obstacles district face in fully accessing and utilising approved budgets. • To identify current practices in and criteria for sub-district resource allocation and to discern from interviews with facility in-charges the major challenges they face in dealing with competing resource claims. • To classify the clients of district services by relevant beneficiary groupings and to assess the degree to which government services are reaching their intended target groups (i.e. the relative shares received by the poorest and most disadvantaged, and those with priority health needs such as women and children).

7. Study focus: Expenditure Tracking • National information • On-budget resources: Information from returns at Ministry of Finance, and the Ministries in Health Administration • Off-budget resources: Information sampled from representative donors • Multilateral sample: UNICEF, UNFPA • Bilateral sample: USG, DfID • Commodities: MEDS and KEMSA • Field information • Provincial level • All 8 provinces to be involved (health management, and treasury) • All level 5 public facilities to be visited • District level • 2 Districts per province, based on (1) those that benefited from above SOURCES of resources, and (2) reflect diversity and variety of district attributes • All level 4 facilities – public and mission ; four public and 1 mission level 3 ; and 8 public and 2 mission level 2 facilities to be visited • District management visited too

8. AIEs for Provincial General Hospitals O&M Expenses v/s Budget Allocations in FY 2008/09

9. Comparison of DAB Estimates and Actual spending based on AIEs

10. Number of days from raising AIE to receipt by Medical Superintend at PGH in each quarter, FY2008/09

11. Days remaining in the FY in the 4th Quarter

12. Financial Flows from MOH to District Hospitals • Percentage of original printed estimates that were devolved ranged from a low of 6% to 198%. • Quarterly allocations in most of the hospitals were lower than the imputed quarterly allocation. • Kiambu DH-the MS received AIEs amounting to Kshs 12.409 million compared to DAB devolved amount of Kshs 17.084 million.

13. AIEs for District hospitals O&M expenses in FY2008/09

14. Timeliness of Flows • On average an AIE took 33 days to be processed up to the point of arriving at the beneficiary facility, • Overall, the duration ranged from 3 to 89 days. • In the 1st quarter, the duration ranged from 14 to 89 days, while in the 2nd and 3rd quarters it varied from 3 to 61 days and 5 to 65 days respectively. • On average, it took around 35, 22, 31 and 44 days in the 1st, 2nd, 3rd and 4th quarters for the AIEs to be processed at the MOH headquarters and receipt by the MS.

15. Delays in AIE processing from MOH HQs to DH, FY2008/09

16. Flows from MOH to Rural health services (sub-vote 113) Completeness of transfers • AIEs in most of the DMOs exceeded the estimated budget allocations. • For instance, the proportion of AIEs as a percentage of the original printed devolved estimates for Nyandarua was 119%. • Overall, devolved estimates ranges between 21% in Kisii to 119% in Nyandarua.

17. AIEs for DMOHs under R11 113 335, FY2008/09 (Kshs)

18. Timeliness of Transfers from MOH to DMOH Delays in AIE Process from MOH Headquarters to DMOH, FY2008/09

19. Reasons for delays in receiving AIEs

20. Absorption of GOK Funds

21. Stock outs of key commodities (tracer drugs) Duration of stock-outs of medicines and supplies in RHF, FY2008/09

22. Duration of stock-outs of Vaccines, FY2008/09

23. Duration of stock-outs of contraceptives, FY2008/09

24. Duration of stock-outs of non-medical supplies, FY2008/09

25. Frequency of receiving medical and non-medical supplies from DMOH in 2008/09 FY • Majority of RHF (91) receive vaccines on a monthly basis, • While 86, 79, 20 and 83 RHF reported receiving drugs, contraceptives, vaccines and non-pharmaceuticals on a quarterly basis.

26. Frequency of receiving medical and non-medical supplies from DMOH in 2008/09 FY

27. Challenges faced by health facilities

28. Recommendation • Need to design a system of tracking the flow of funds at all levels of the public health care system from the source through the intermediary institutions to the service providers, especially the rural health facilities. • Need for speeding up the implementation of the health financing reform-Direct Facility Funding (DFF) especially that related to direct transfer of funds to public health facilities including health centres and dispensaries. • Ministries to ensure that information on DAB allocations is available for all the public health facilities including the rural health facilities.

29. Recommendation… • MOH & KEMSA should design a standard format for reporting information on medical drugs and non-medical supplies distributed and received by the facility in-charges • Technical divisions/programmes such as DRH and KEPI should routinely provide estimates of the quantity and ideally the value of expected commodity flows to each district and hospital.

30. Recommendation… • Documentation of NHIF funding through reimbursements and the corresponding amount of reimbursements per facility per quarter. • If the MOH decides to institutionalise future PETS, it will be important to design a mechanism of reporting specific financing sources of financing by the health facilities. • The reporting mechanism designed should have a separate instrument for NHIF reimbursements and donor funding in order to ensure that all sources of funding are captured. • This should include actual reimbursements, dates of receipt of funds etc.

31. Institutionalization of PETS • Routine production and use of PETS to inform health policy • Institutionalization initiatives • Development of standardized tools • PETS and PERs undertaken as part of the PFM

32. Thank you