Sessional paper no 6 of 2012 on the Kenya health policy 2012-2030.pdf

Ministry of Ministry of Publk Medical Services Health and Sanitation I I I Sessional Paper Noe 6 of 2012 on the , Kenya Health Policy I 2012-2030 I I I I I I I I Sessional Paper No. 6 of 2012 on...

Ministry of Ministry of Publk Medical Services Health and Sanitation I I I Sessional Paper Noe 6 of 2012 on the , Kenya Health Policy I 2012-2030 I I I I I I I I Sessional Paper No. 6 of 2012 on the Kenya Health Policy I I 2012 - 2030 Ill II CONTENTS I Acronyms Foreword ii iii I PART 1: BACKGROUND Chapter 1: Introduction iv 1 I 1.1 Health Policy and the National Development Agenda 1.2 Health Policy and the Constitution of Kenya 2010 1 1 I 1.3 National, Regional and Global Health Challenges 1 1.4 The Sessional Paper Development Process 2 Chapter 2: Situation Analysis 3 2.1 Overall Health Profile 3 2.2 Progress in Overall Health Status 4 2.3 Health Investments 6 I 2.4 Progress in Implementation of Planned Interventions 6 2.5 Overall Performance in Country Commitments 10 Ii PART 2: POI.ICY DIRECTIONS 11 Chapter 3: Policy Framework 12 I Chapter 4: Policy Goal and Objectives 15 4.1 Policy Goal 15 4.2 Policy Objectives 15 Chapter 5: Policy Guiding Principles, and Orientations 19 5.1 Policy Principles 19 5.2 Policy Orientations 19 PART 3: POLICY IMPLEMENTATION 27 Chapter 6: Implementation Framework 28 6.1 Stakeholder Roles 28 6.2 Institutional Framework 29 Chapter 7: Monitoring and Evaluation 32 7.1 Monitoring and Evaluation Framework 32 7.2 Progress indicators 33 Chapter 8: Conclusion 34 Glossary of terms 35 I I Sessional Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 ACRONYMS cso Civil Society Organization DALY Disability Adjusted Life Years I ESP Economic Stimulus Program FBO Faith Based Organization I GDI Gender Development Index GDP Gross Domestic Product GOK Government of Kenya HMIS Health Management Information System HRH Human Resources for Health ICT Information Communication Technology IEC Information Education Communication KEMSA Kenya Medical Supplies Agency KHPF Kenya Health Policy Framework I MDGs Millennium Development Goals MOMS Ministry of Medical Services I MOPHS Ministry of Public Health and Sanitation NACC National AIDS Control Council NCD Non Communicable Disease NGO Non Governmental Organization SACCO Savings and Co-operative Organization SAGA Semi-Autonomous Government Agencies SWAp Sector-Wide Approach TB Tuberculosis WHO World Health Organization ii I. Sessional Paper No. 6 of 2012 on the l{enya Health Policy 2012 - 2030 FOREWORD The Sessional Paper No. 6 of 2012 on the Kenya Health Policy, 2012 - 2030 gives directions to ensure significant improvement in overall health status in Kenya in line with the country's long term development agenda, Vision 2030, the Constitution of Kenya 2010 and global commitments. It demonstrates the health sector's commitment, under government stewardship, to ensuring that the Country attains the highest possible standards of health, in a manner responsive to the needs of the population. This Sessional Paper is designed to be comprehensive, balanced and coherent and focuses on the two key obligations of health: contribution to economic development as envisioned in the Vision 2030; and realization of fundamental human rights as enshrined in the Constitution of Kenya 2010. It focuses on ensuring equity, people centeredness and participatory approach, efficiency, multisectoral approach and social accountability in delivery of health care services. The Sessional Paper focuses on six Policy objectives, and seven Policy orientations to attain the overall government's goals in health. It takes into account the functional responsibilities between the two levels of government (county and national) with respective accountability, reporting and management lines. It proposes a comprehensive and innovative approach to harness and synergize health services delivery at all levels by engaging all actors, signaling a radical departure from past approaches in addressing the health agenda. This is demonstrated by the policy directions outlined in the Sessional Paper, particularly the right to the highest attainable standard of health. There is therefore an urgent need to raise awareness and ensure the necessary ownership of the Sessional Paper's Policy imperatives by the various stakeholders and implementing partners. The Sessional Paper was developed through a participatory process involving all stakeholders in health including government ministries/agencies, development partners (multisectoral and bilateral) and implementing partners (Faith based, private sector and civil society). It is our sincere hope that all the actors in health in Kenya will rally around these policy directions elaborated in the Session al Paper to ensure that we all steer the country towards the desired health status. Hon. Beth Mugo, EGH MP Minister of Medical Services Minister of Public Health and Sanitation I ii I ll r ' I I Sessio11al Paper No. 6 of 2012 011 the Kenya Health Policy 2012 - 2030 I - CHAPTER 1: INTRODUCTION I 1.1 Health Policy and the National Development Agenda Kenya has over the years taken important steps aimed at laying a firm foundation to overcome the I development obstacles and improve socio-economic status of her citizens including health. Some of the steps include the development of Kenya Health Policy Framework (KHPF 1994-2010), launching of Vision 2030, enactment of the Constitution 2010, and fast tracking of actions to achieve the Millennium I Development Goals (MDGs) by 2015. The implementation of KHPF 1994-2010 has led to significant improvement of health indicators such as I infectious diseases and child health. The emerging trend of non-communicable diseases is however a threat to the gains made so far. This Sessional Paper No. 6 of 2012 on the Kenya Health Policy provides the long term intent of government towards attaining its health goals. The Sessional Paper aims to consolidate I the gains attained so far, while guiding achievement of further health gains in an equitable, responsive and efficient manner. It is envisioned that the ongoing government reforms, together with anticipated sustained economic growth, will facilitate the achievement of the health goals. Vision 2030 details the long-term national development agenda- aiming to transform Kenya into a globally competitive and prosperous industrialized middle income country by 2030. Health is one of the components of delivering the Vision's Social Pillar given the key role it plays in maintaining a healthy and skilled workforce necessary to drive the economy. To realize this ambitious goal, the health sector defined priority reforms as well as flagship projects and programs. These include: restructuring of the sector's I leadership and governance mechanisms; improving procurement and availability of essential medicines and medical supplies; modernizing health information systems; accelerating health facility infrastructure development to improve access; developing human resource for health, developing equitable financing I mechanisms and establishing a social health insurance scheme. This Policy aims to implement the priority health reforms envisaged in Vision 2030, with a view to ensure a healthy workforce capable of contributing towards the country's development agenda. I 1.2 Health Policy and the Constitution of Kenya 2010 I , The Constitution of Kenya 2010 provides an overarching conducive legal framework for ensuring a more comprehensive and people driven health services delivery. It also seeks to ensure that a rights-based approach to health is adopted and applied in the delivery of health services. The Constitution provides that every person has the right to the highest attainable standard of health. It further outlines that a person shall not be denied emergency medical treatment and that the State shall provide appropriate social security to persons who are unable to support themselves and their dependants. The Constitution I introduces a devolved system of government which would enhance access to services by all Kenyans, especially those in rural and hard to reach areas. The Constitution also singles out health care for specific groups such as children and persons living with disabilities, as a key area of focus in health services delivery. The underlying determinants of the right to health, such as adequate housing, food, clean safe water, social security and education, are also guaranteed in the Constitution. The Sessional Paper on the Kenya Health Policy therefore seeks to make the realization of the right to health by all Kenyans a reality. 1.3 National, Regional and Global Health Challenges I Globalization, political instability and the emerging regional and national macroeconomic challenges triggered by the global economic downturn, together with climate change, have adversely impacted on health. In addition, the increased cross-border movements of goods, services and people as well I as international rules and institutions have had a considerable influence on national health risks and priorities. To respond to these challenges, a number of regional and global initiatives, focusing on health, have been undertaken, including major reforms within the United Nations and international and regional 1  Sessional Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 declarations and commitments. This Sessional Paper on the Health Policy has been developed at a time when the global development efforts towards attainment of MDGs are coming to a close while other global initiatives such as those targeting non communicable diseases, social determinants of health, managing emerging and re-emerging health threats, are gaining momentum. Further, there are emerging global efforts and commitments on Aid Effectiveness that focus on aligning donor support to country policies and strategies and priorities and using country systems in implementation for purposes of ownership (these include Rome 2003, Paris 2005, Accra 2008, and Busan 2011). This Sessional Paper on the Health Policy is therefore aligned to these unfolding global events. 1.4 The Sessional Paper Development Process The Sessional Paper on the Health Policy was developed through an evidence-based and consultative process that was undertaken over a period of two years. Under the stewardship of the government, an extensive consultation process with stakeholders (government ministries/agencies development partners -multilateral and bilateral- and implementing partners -faith based, private sector, and civil society) was undertaken in order to gain consensus on divergent views. First, a comprehensive and critical analysis of the status, trends and achievement of health goals in the country and secondly the contribution of the previous policy framework and the sector actions towards achieving the health goals was undertaken. The outputs from these processes are available, as background information, to this Sessional Paperl,2 These informed the definition and development of this Sessional Paper's Policy's objectives and Policy orientations. 1 Government of Kenya, 2010. Health Situation trends and distribution, 1994- 2010, and projections to 2030. 2 Government of Kenya, 2010. Review of the Kenya Health Policy Framework, 1994 - 2010. 2 I Sessional Paper No. 6 of 2012 011 the Kenya Health Policy 2012 - 2030 I - CHAPTER 2: SITUATION ANALYSIS I A comprehensive review of the 1994 - 2010 Kenya Health Policy framework was undertaken with a view to attain a deeper understanding of the challenges affecting the health sector, existing opportunities and define the necessary interventions. I This chapter highlights the progress made in the overall health of the country. To help in understanding the health patterns, it summarizes the situation regarding progress in (a) overall health status; (b) investment I made in health and (c) Implementation of planned interventions. Based on these, the chapter paints a picture of future trends in disease burden in the country up to 2030. 2.1 Overall Health Profile Life expectancy (LE) at birth in Kenya reduced to a low of 45.2 years during the 1994-2010 policy period, but was estimated to have risen up to 60 years by 2009'- a trend that was reflected across all age groups. However, stagnation/ worsening of the health situation was seen across all ages as demonstrated by poor performance of various health indicators as shown in the figure below. By the end of the last policy period, however, some evidence of improvements for specific age cohorts was emerging, particularly for adult, infant and child mortality. Recent trends in Health Impact 140 700 I =..c: t:: 120 600 :.a 100 500 i- 0 0 0 _,-........ 80 400 0:: 2 60 300 z o::' 2 40 200 o::' 2U') :::, 20 100 0 0 1993 1998 2003 2008 -UMR -!MR NMR ' --MMR I Source: Respective Demograp 1c an Nevertheless, geographic and sex specific differences in health indicators among different age groups across the country persist. In addition, the country still faces a significant burden due to all disease domains - communicable conditions, non communicable conditions, and injuries/ violence. I iii 3 WHO 2010 World Health Statistics 3  Sessional Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 Leading causes of deaths, and disabilities in Kenya Causes of death Causes of DALY's % total % total Rank Disease or injury Rank Disease or injury deaths DALYs 1 HIV/AIDS 29.3 1 HIV/AIDS 24.2 Conditions arising during perinatal Conditions arising during 2 9.0 2 10.7 period perinatal period 3 Lower respiratory infections 8.1 3 Malaria 7.2 4 Tuberculosis 6.3 4 Lower respiratory infections 7.1 5 Diarrhoeal diseases 6.0 5 Diarrhoeal diseases 6.0 6 Malaria 5.8 6 Tuberculosis 4.8 7 Cerebrovascular disease 3.3 7 Road traffic accidents 2.0 8 lschemic heart disease 2.8 8 Congenital anomalies 1.7 9 Road traffic accidents 1.9 9 Violence 1.6 10 Violence 1.6 10 Unipolar depressive disorders 1.5 (Source: GOK 2010. Review of the Kenya Health Policy Framework, 1994 - 2010) DALY's = Disability Adjusted Life Years - Time lost due to incapacity arising from if/ health This trend in health status has mainly been as a result of a number of contextual factors. The population growth rate has remained high (2.4% annual growth rate), with a high young and dependent population that is increasingly urbanized. Although the period under review showed improvements in GDP and reduction in population living in absolute poverty, especially in urban areas, absolute poverty levels still remained very high {46%). Literacy levels remained good at 78.1%, though inequities in age and geographical distribution persist. Gender disparities too were significant, though showed improvements particularly after 2003, a reflection of better opportunities for women. However, disparities between regions persist, with the GDI ranging from 0.628 (Central region) to 0.401 (North Eastern region). Finally, security concerns still persist in some areas of the country, making it difficult for communities to access and use existing services. Gender based crimes also continue to be reported in urban areas, particularly in the informal settlements. 2.2 Progress in Overall Health Status 2.2.1 Status of key health indicators Many interventions have been introduced in the health sector to improve key health indicators- such as maternal and child health, HIV/AIDS and Tuberculosis (TB), Malaria, emerging threat of Non Communicable Diseases among others- and address age-specific health needs. During the period under review, interventions were undertaken aimed at improving maternal and child health indicators, albeit with mixed results. Coverage of critical interventions relating to maternal health stagnated or reduced, with improvements only seen with use of modern contraceptives (33% - 46%). On the other hand, child health interventions showed improvements in coverage during this period. However, reports indicate that ill health amongst children remains high, with no indications of improvement. Specific interventions were also introduced to address the high burden due to specific diseases such as HIV/AIDS, Tuberculosis (TB) and Malaria. Notably, HIV/AIDS control showed progress with evidence of reducing incidence, prevalence and mortality. However, differences in coverage with regards to age, sex, and geographical location persist. Coverage regarding critical interventions for HIV prevention and management significantly improved during the previous policy period. Although TB control was challenged by the HIV epidemic, it also showed improvements, with key indicators such as Case Notification, Case Detection, and Treatment Successes all showing improvements. However, the emergence of drug resistant TB since 2005, particularly in males, is a key challenge. There was also evidence of reduction in malaria related mortality since coverage of effective interventions, such as Insecticide Treated Nets {ITN); Intermittent Prophylaxis Treatment; (IPTp) and Inside Residual Spraying (IRS), was scaled up. Although high coverage of interventions addressing Neglected Tropical Diseases has been achieved, they still exi.st among 4  Sessio11ai Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 different populations in the country. Non communicable conditions represent an increasingly significant burden of ill health and death in the I country and include cardiovascular diseases, cancers, respiratory diseases, digestive diseases, psychiatric conditions, congenital anomalies, amongst others. They represented 50 - 70% of all hospital admissions during the previous policy period and up to half of all inpatient mortality. There is no evidence of I reductions in these trends. Finally, injuries and violence were high, mainly affecting the productive and young population, with mortality levels arising from this increasing over the years. I 2.2.2 Risk factors to health Risk factors to health in Kenya include unsafe sex', suboptimal breastfeeding, alcohol and tobacco use, obesity and physical inactivity, amongst others. I Evidence points to improvements in unsafe sexual practices, with people increasingly embracing safe sex practices. This is attributed to steady improvements in knowledge and attitudes of communities regarding I sexually transmitted infections and conditions. Breastfeeding practices have also changed, with exclusive breastfeeding for up to five (5) months showing significant improvements. Tobacco use remains high, particularly among productive populations in urban areas and among males. Evidence shows that one in five males between 18-29 years and one in two males between 40-49 years are using tobacco products. The same pattern is seen in the use of alcohol products, especially the impure alcohol products mainly found in the rural areas. Cases of alcohol poisoning continued to be reported during the previous policy I period, with over 2% of all deaths in the country being attributed to alcohol use. Obesity appears to be on the rise, with an increasing population of Kenyans being overweight. It is estimated that 25% of all persons in Kenya are overweight or obese, with the prevalence being highest among women in their mid to late I 40s and in urban areas. Leading risk factors and contribution to mortality and morbidity (WHO 2009) Mortality (deaths) Burden (DALYs) % total % total Rank Risk factor deaths Rank Risk factor DALYs 1 Unsafe sex 29.7% Unsafe sex 25.2% 2 Unsafe water, sanitation, and hygiene 5.3% 2 Unsafe water, sanitation, and hygiene 5.3% 3 Suboptimal breast feeding 4.1% 3 Childhood and maternal underweight 4.8% 4 Childhood and maternal underweight 3.5% 4 Suboptimal breast feeding 4.3% 5 Indoor air pollution 3.2% 5 High blood pressure 3.1% 6 Alcohol use 2.6% 6 Alcohol use 2.3% 7 Vitamin A deficiency 2.1% 7 Vitamin A deficiency 2.1% 8 High blood glucose 1.8% 8 Zinc deficiency 1.8% 9 High blood pressure 1.6% 9 Iron deficiency 1.2% 1O Zinc deficiency 1.6% 10 Lack of contraception 1.2% I 2.2.3 Other determimmts of health Other health determinants include nutrition, maternal education, safe water, adequate sanitation, proper housing, among others. Maternal education has a strong correlation with child's health and survival. Improvements in maternal education have been noted over the years, with the number of women with no education reducing, while those with secondary or higher education increasing. Progress towards child nutrition has shown stagnating trends. Even though there have been improvements in acute nutrition deficiencies, such as underweight indicators in children under five (5), not much improvement is seen in prevalence of more chronic under nutrition variables, such as stunting and wasting. Additionally, undernourished children, both acute and chronic, are seen more in urban compared to rural areas in the country. The nutrition status of women has also shown stagnating patterns, with up to 1%, and 12% of adult women being stunted and having 4 Unsafe sex leads to many conditions affecting Health, such as HIV, reproductive tract cancers I conditions and other Sexually Transmitted Infections, unwanted pregnancies, psychosocial conditions, amongst others. 5  Sessional Paper No. 6 of2012 on the Kenya Health Policy 2012 - 2030 unacceptably low body mass index (BMI) respectively. Under-nutrition is higher amongst women aged 15 - 19 years and in rural areas of the country. Obesity is higher in urban areas, currently affecting half of all women in Nairobi. There were improvements in availability of safe water sources and sanitation facilities particularly in rural areas. This however remains inequitable, with rural areas and some regions such as arid and semi arid areas still having poor services. Housing conditions have been improving, with a notable increase in households using permanent roofing, while households using earth floors reducing. The proportion of population in active employment has stagnated/ reduced, with an associated increase in the proportion of inactive population. Finally, there has been a continued increase in urban population primarily driven by migration from rural to urban areas of those aged 20- 34 years, both male and female. This increase is fueling an increase in urban informal settlements in the country, with their associated health risks. 2.3 Health Investments Overall health system expenditure has significantly increased in nominal terms, from 17 US$ per capita, to an estimated 40US$ per capita during the Overall Health Expenditure trends 9.00%. " ~. -- - -- ~----- --------·-··-.---- 45 period under review. This increase was 8.00% 8.00% 40 primarily driven by increases ingovernment 35 and donor resources, with proportion of 6.00% 30 household expenditures reducing as a 5.()0% 25 proportion of the total expenditures. 4.00% 20 However, there was no real increase in 3.00% 15 health system resources, with health 2.00% 10 1.00% expenditures as a proportion of GDP, 0.00% and public expenditures as a proportion 2001/02 2005/06 2009/10 of general government expenditures ffliimilllTHE as a% of nominal GDP Government health expenditure as a% of total Govermental expenditure remaining stagnant during the period. ~THE percapita{US$) Additionally, health expenditures exhibited movement towards fairness in financing for health, with contribution to total expenditures increasing by amount of wealth. Out of pocket spending was also highest in the better off provinces of the country. Financial risk protection also steadily increased to an estimated over 17% of the total population having some form of financial risk protection by the end of the policy period. Evidence from the National Health Accounts, 2010 demonstrated improvements in allocative efficiencies, with more services being provided using the same amounts of resources in real terms. However, resources are increasingly being directed to management functions as opposed to service delivery. Looking at actual expenditures, limited real improvements in human resources for health and infrastructure were noted during the previous policy period. While the actual numbers of these investments were improving, the numbers per person were stagnating/ reducing. This is a reflection of the stagnation of real resources for health. Improvements in real terms are only notable in the last two (2) years of the policy period (2009 and 2010). 2.4 Progress in Implementation of Planned Interventions The previous policy framework planned interventions in seven policy imperatives, plus a comprehensive reform agenda. Progress against planned interventions is mixed, as detailed below. 2.4.1 Ensure equitable allocation ofgovernment resources to reduce disparities in health status A comprehensive bottom up planning process was instituted in the 2nd halfofthe policy period. However, other systemic issues, such as actual capacity to implement priorities, affected the prioritization process. 6  Sessional !'aper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 As such, interventions chosen did not necessarily lead to equitable access to essential curative as well as preventive services. Additionally, the poor information on resources available made it difficult to link I the micro-economic framework with the epidemiological information for a rational planning framework. No criterion was established for geographic allocation of resources. Nevertheless, a standard resource allocation criterion for district hospitals and rural health facilities (health centers and dispensaries) was in use, though only for operations and maintenance. The norms and standards for health delivery I which includes human resource; equipment and infrastructure norms, were in place though lacked in operationalization. Allocation for essential medicines and supplies based on facility type for lower level I facilities was in place for most of the policy period. Experience with a pull system, with special drawing rights, was built in some provinces/regions in the country, with good results. 2.4.2 Increase cost effectiveness cost efficiency of resource ail'ocation use I Burden of disease and cost effectiveness were not comprehensively utilized in determining priority interventions. Prioritization was based not just on cost effectiveness, but also on feasibility of I implementation, the system's capacity for implementation, and availability of resources to facilitate implementation. Data from the health management information system (HMIS) was used to determine the disease burden during the policy period. While norms and standards defining the appropriate mix of personnel and operations and maintenance inputs at all levels were in place, these were not utilized to ensure cost efficiency. Additionally, the Health Sector was not able to define and use unit costs for service delivery. I 2.4.3 Continue to ma11age population growth Reproductive health services program interventions were strengthened across the country, with improvements in availability and range of modern contraceptives that increased the scope of choice for users. I Maternal education efforts improved, with advocacy efforts contributing to improvements in services Trends in overall contraceptive use rate among married women delivery, such as in family planning and its positive impact in family health. Information, education and communication (IEC) materials 46 and processes were developed throughout the 39 39 policy period, facilitating dissemination of the 33 27 family planning messages. Community 17 involvement in the advocacy and distribution was a key emphasis of the strategies, leading 7 to increased access, availability and uptake of the commodities. This resulted in a drop in the 1978 1984 1989 1993 1998 2003 2008-09 fertility rates in most regions of the country for Data from the first frve sources omit several nolhem districts, while the 2003 and 2008-09 KOHS 11·. I surveys represent the entire country. some time before stagnating. Efforts to raise awareness on sexual and reproductive health amongst the youth were promoted, with a strategy available to roll out youth friendly services in health facilities. This aimed at managing unwanted teenage pregnancies. 2.4.4 Enhance the regulat01y role ofgovernment in all aspects ofhealt/i care provision Measures were put in place to devolve management decision making to provinces and districts and leave central level in charge of policy functions, though their impact was limited due to lack of a legal I framework and weak management capacity in the devolved units. The passing of the new Constitution in 2010 finally embedded this in law. The Public Health Act is however not attuned to the stewardship role of government in the current health delivery environment. Notably, the national level and sub-national level regulatory boards were strengthened to improve their capacity to deliver. Gradual decentralization of the management and control of resources to lower level institutions was initiated through the Health Sector Services Fund. 7  Sessional Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 Z.4.5 Create an enabling environment for increased private sector and community involvement in health services provision and finance With the formalization of the Kenya Health SWAp process in 2006, a framework for sector coordination and partnership was established. Necessary instruments were defined based on Memoranda of Understanding to guide this dialogue and collaboration. In addition, service provision by non state actors has been facilitated by government, including through provision of public health commodities and medical supplies and tax exemptions for donations in some of the facilities and secondment of very critical staff in specific cases especially for underserved areas. However, the key beneficiaries of these have primarily been the faith based health services providers, and not the private for profit services providers. Collaboration with private for profit actors, and traditional practitioners is still weak. Government has also began facilitating provision of health promotion and targeted disease prevention/ curative services through community based initiatives as defined in the 2007 Comprehensive Community Health Strategy. Z.4.6 Increase and diversify per capita financial flows to the health sector The sector was not able to expand the budgetary allocations, in real terms, to health. However, the sector came up with strategies to influence resource allocation which included development and costing of sector plans, and active participation in resource allocation discussions. Nominal increases in allocations were achieved, particularly since 2006, and accelerated with the Economic Stimulus Package (ESP) in 2009. These increases are nominal, not real, and Public Health expenditure trends represent a shift in total sector financing away from government and households, towards donors. There was also a relative increase in finances for preventive and promotive health care, as a proportion of recurrent versus development expenditures (see the figure above). The result of this weak sector financing means that the opportunity cost of new programs was high -with common programs having less financing. Similarly, a relative shift 2002 2003 2004 2005 2006 2007 2008 2009 of resources towards preventive / promotive ii@@ffi Recurrent(Ksh. millions) ii!Jffi1l!l1 Development(Ksh. millions) services implied less investment in real terms Recurrent[%) Development(%) for medical care. Nevertheless, the financing of health services has increasingly become progressive. The National Hospital Insurance Fund has been transformed into a state corporation mainly aimed at improving effectiveness and efficiency in health financing. It has expanded its benefit package to include more clinical services, preventive and promotive services. Provision of insurance services has also expanded, with increased numbers of firms and persons covered. This has however remained limited to urban areas. In addition, the 10/20 Policy on cost sharing was introduced in 2004, reducing contributions of users of facilities to a token amount in dispensaries and health centers. Further, exemptions for user fees for some specific health services was introduced, including treatment of children less than 5 years, maternity services in dispensaries and health centers, TB treatment in public health facilities, and immunization services. Although this has significantly improved financial access to services, it has greatly reduced amounts of resources mobilized through user fees. Community based health financing initiatives have not effectively been applied in the country in spite of the existence of a relatively strong community based Savings and Cooperative Organization (SACCO) that would have acted as a backbone for community based insurance initiatives. Z.4.7 Implementation of the reform agenda A number of reform initiatives were undertaken albeit with mixed results: 8  Sessional Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 i. The capacity of the Ministry of Health was strengthened particularly in planning and monitoring, though limitations remain in other areas such as leadership/ management; ii. An essential package for health has been available with each strategic plan, though its application to guide service delivery priorities has been limited; I iii. Innovative service delivery strategies have been applied, such as mobile clinics, outreaches, or community based services, though their application has been limited to some areas and programs; iv. Sub-national management functions have been strengthened to allow them to better facilitate and supervise service delivery, though this mandate has been exercised differently in the various provinces/ regions, and districts; v. New statutes, laws, and policies guiding different aspects of the health sector have been introduced, though done in an uncoordinated manner and no update of existing laws undertaken; vi. The sector has made some efforts to develop a health financing strategy to guide its resource rationalization, and mobilization approaches; vii. Human resource component is being strengthened through redistribution; increase in numbers and review of management structures, although challenges still remain in terms of investments; application of norms and standards, as well as motivation of existing staff. The sector does not also have an infrastructure investment plan to guide the distribution and improvement of health infrastructure, leading to low investments for both new and existing infrastructure. viii. Coordination of HIV/AIDS infection and other STls control is being undertaken through a semi autonomous institution - the National AIDS Control Council (NACC) - managed through a different line ministry from the ministry responsible for health. However, financing of this approach, together with integrating the response into the overall health agenda, remains challenging; ix. While an explicit National Drug Policy was in place, its implementation was slow and only a fraction of the steps set out were realized. Some of the notable achievements include improvement in commodity management, particularly, harmonization of centralized procurement, warehousing and distribution mechanisms through Kenya Medical Supplies Agency (KEMSA). An Essential Medicines List has been available, though adherence to its use has been poor. Attempts to introduce a demand driven procurement system were instituted, with evidence of better availability of required commodities in public health facilities; x. Health Management and Information System architecture has continued to improve information completeness. However, information collected still remains limited to a few conditions, with completeness and quality weaknesses. Additionally, information analysis, dissemination and use is not well entrenched in the sector. Use of information sources beyond routine health management information remains weak; xi. Cost containment and cost control strategies have not been wholly applied in the sector. Cost information is missing, and expenditure review data and recommendations are not applied. Contracting strategies for health services by providers were not employed as a means of cost control; xii. Amount and scope of systems, clinical and biomedical research being carried out has increased, with a number of operational decisions effected. There is however little collaboration amongst different research institutions, and poor linkage between research and policy; xiii. The decentralization of the central level Ministry of Health in line with devolution of its functions to the provinces/regions and districts hasn't happened yet. The central level has instead expanded significantly, as more programs are established, necessitating more program management units. 9 I.  Sessional Paper No. 6 of2012 on the Kenya Health Policy 2012 - 2030 2.5 Overall Performance in Country Commitments From the situation analysis, it is evident that progress towards attaining the overall health goals depicted mixed results. Notably, progress towards key commitments the country has made is still slow. The country is not on track to attain the commitments relating to health related Millennium Development Goals', with no progress noted towards MDG's 5 (improve maternal health), and limited progress towards MDG's 1 (eradicate extreme poverty and hunger), 4 (reduce child mortality rates) and 6 (combat HIV, malaria, and other diseases). The lack of progress towards MDG 5 is also reflected in the limited progress towards attaining the obligations in the African Union Maputo Plan of Action', which aimed to reduce poverty levels with an uncompromising evidence based approach to achieving the MDG's. Regarding investment in health, there have been limited increases in financing. Although the Paris Declaration on Aid Effectiveness' was prioritized, the implementation of the principles remained poor. In addition, limited progress has been made towards the implementation of commitments of the Abuja Declaration, in which countries committed to spend at least 15% of their public expenditures on Health. 5 United Nations Millennium Summit, 2000 6 African Union Commission, 2006. Plan of Action on Sexual and Reproductive Health and Rights (Maputo Plan of Action) 7 DECO, 2005. Paris Declaration on Aid Effectiveness 10  I I I I ,I '"' I I I I I I I I , I ~~  Sessional Paper No. 6 of 2012 on the Kenya Health Policy 2012 - 2030 CHAPTER 3: POLICY FRAMEWORK Emerging trends point to the fact that non communicable conditions and injuries/ violence related conditions will increasingly, in the foreseeable future, be the leading contributors to high burden of disease in the country, although the role of communicable diseases will remain significant. This implies that future country policies will be faced with a high disease burden arising from all the three conditions. Current total annual mortality is estimated at approximately 420,000 persons, out of which 270,000 (64%), 110,000 (26%) and 40,000 (10%) are due to communicable, non communicable, and injury conditions respectively. As interventions to address communicable conditions reach maturity and attain sustained universal coverage, projections show that there will be reductions in this category of disease burden, although these reductions will be slow due to the high populations facilitating communicable disease transmission. Future projections indicate that if the current policy directions and interventions' are sustained, the overall mortality will reduce by only 14% {360,000 persons) annually by 2030. The contribution by disease domain would however be different, with communicable, non communicable, and injuries conditions contributing 140,000 (39%), 170,000 (47%), and 60,000 (14%) respectively. This represents a 48% reduction in absolute deaths due to communicable conditions, but a 55% increase in deaths due to non communicable conditions, and a 25% increase in deaths due to injuries/ violence as shown in the figure below. Health projections: 2011- 2030 By disease domain by disease condition 300,000 70,000,000 100,000 60,000,000 +HIV/AIDS 2S0,000 50,000,000 ] 80,000 ""100,000 +Malaria 1 I ] lS0,000 40,000,000 ~ :;; £ 60,000 ◄-Tuberculosis ~ 30,000,000 {:!. ~ 40,000 100,000 10,000,000 ""'~·Cancers 20,000 50,000 10,000,m)O 0 , ·f}·· Cerebrovascular disease 2010 2015 2020 2025 2030 ~ lschaemic heart disease I-+- Commun~ l>le --;-- Non--Com,n,ak.ab[e -