Health Sector Strategic and Investment Plan (KHSSP) July 2013-June 2017: The Second Medium Term Plan for Health

Objectives

Kenya’s Health Sector Strategic and Investment Plan is the second medium-term health plan supporting Kenya Vision 2030, the 2010 Constitution and the Kenya Health Policy 2012–2030. Its vision is a globally competitive, healthy and productive nation, while its mission is to build a progressive, responsive, sustainable, technologically driven, evidence-based and client-centred health system that advances the highest attainable standard of health for all Kenyans.[1][2][3]The overall policy goal is equitable, affordable, quality and responsive health and related services, with universal coverage of critical services as the principal health-services objective.[4]

• Accelerate health impact by reducing neonatal and maternal deaths by at least half, reducing time spent in ill health by at least 25%, and improving client satisfaction by at least 50%.[2][5]
• Eliminate communicable conditions, halt and reverse the rising burden of non-communicable conditions, reduce violence and injuries, provide affordable and responsive essential healthcare, minimise exposure to health risks, and strengthen collaboration with health-related sectors through a Health in all Policies approach.[3]
• Prioritise maternal and newborn health, the Kenya Essential Package for Health, equity for rural, poor, informal-settlement, marginalised and other at-risk populations, and action on contextual determinants of health.[2][6]
• Address non-communicable conditions including mental health conditions, diabetes mellitus, cardiovascular diseases, chronic obstructive airway conditions, sickle cell disorders and cancers.[7][8]
• Reduce major health risks, including unsafe sexual practices, harmful alcohol use, tobacco and other addictive substances, physical inactivity, unhealthy diets, unsafe water and sanitation, raised blood glucose and raised blood pressure.[9][10]
• Improve access, coverage and quality of Kenya Essential Package for Health services, including a target of at least 90% physical access, stronger referral capacity, lower pre-payment burdens and improved patient experience.[9]

Implementation

Implementation combines a devolved national and county health system, a tiered Kenya Essential Package for Health service model, investment across seven health-system areas, and coordinated action by public, non-state and external actors.[2][11][12]National government provides policy, legislation, standards, technical oversight, resource mobilisation and national referral functions, while counties coordinate service delivery, planning, procurement, contracting, social health insurance and county workplans.[13][14]

• Deliver services through community, primary-care, county and national tiers, with interventions organised by population cohort and level of care.[11][15]
• Extend the full service package to congregate settings, at-risk groups, northern counties, informal settlements and other hard-to-reach areas through upgraded dispensaries, functional model health centres, mobile services and county referral systems.[16][9]
• Strengthen community health provision towards one functional community unit per 5,000 people, with a national target of 8,000 functional units, alongside outreach, supervision, facility management, clinical governance and disaster preparedness.[17][18]
• Expand the workforce by applying minimum staffing norms, mapping human resources, developing county workforce plans, securing recruitment funding, improving equitable deployment, retention, appraisal, leadership and training capacity.[19][20]
• Invest in infrastructure, equipment, transport, communications and information and communication technology according to minimum norms, prioritising underserved areas and coordinating facilities with workforce and commodity investments.[21][22]
• Strengthen health products and technologies through harmonised regulation, the Kenya Medical Supplies Authority, supplier accreditation, demand-driven supply systems, facility inventory management, local production, research, generic prescribing and price guidance.[23][24][25]
• Improve quality through service charters, client-satisfaction surveys, patient-safety measures, accreditation, the Kenya Quality Model for Health, facilitative supervision and strengthened referral services.[26]
• Use financing mechanisms that combine taxation, out-of-pocket payments, external sources, social or private insurance, pooling and strategic purchasing, while seeking resource adequacy, efficiency, equity and lower direct payments.[27][28]
• Institutionalise annual national and county health accounts, costing, updated resource-allocation criteria, community pre-financing and output-based financing in hard-to-reach areas.[29][30]
• Coordinate partners through a sector Code of Conduct, Joint Financing Agreement, Health Sector Coordinating Committee, Joint Inter-Agency Coordinating Committee, technical groups and county stakeholder forums.[31][32][33]
• Operate management and accountability structures through national senior management, County Health Management Teams, sub-county teams, primary-care teams, hospital boards, facility committees and community health committees.[34][35][36][37]
• Strengthen the Health Information System through common data architecture, interoperable databases, the District Health Information Software 2, electronic medical records, vital registration, disease surveillance, surveys, research and a Health Observatory.[38][39][40][41]
• Monitor progress through baseline, mid-term and end-term targets, routine reporting, quarterly performance reviews, annual workplan reports, annual state-of-health reporting, joint annual reviews, a mid-term review and an end-term review.[42][43][44][5]

Monitoring & Evaluation

The monitoring and evaluation framework combines common data architecture, routine information, vital registration, surveillance, surveys, research, performance reviews and public reporting to improve technical accountability and evidence-based decision-making across national and county health services.[45][38][40]

• Establish a common data architecture, strengthen generation, validation, analysis, dissemination and use of health information, and improve data sharing across counties, programmes and semi-autonomous government agencies.[45][40][41]
• Use baseline, mid-term and end-term targets, principally for 2012, 2015 and 2017, to track health impact, outcomes, service coverage, quality and investment outputs.[42][46]
• Monitor non-communicable conditions through indicators including adult body mass index, cervical-cancer screening, mental-health outpatient cases, high-blood-pressure outpatient cases and cancer admissions.[47][48][42]
• Track wider performance through indicators for injuries and violence, maternal and child health, risk factors, service access and quality, workforce, infrastructure, medicines and community services.[49][50][26][51]
• Undertake annual Health Accounts, benefit-incidence analysis, household-expenditure surveys, expenditure tracking and reviews, value-for-money assessments and sector-wide efficiency reviews to assess financial performance and equity.[29][30]
• Conduct quarterly performance reviews through health management teams and stakeholder forums, and use annual work-plan reports, county reports and joint reviews to agree and follow up actions.[43][44]
• Produce an annual state of health report consolidating multi-source statistics and performance against strategic objectives, alongside public fact sheets and dissemination through reports, websites, broadcast media, newsletters and other channels.[43]
• Use the joint annual review to assess the preceding financial year, determine actions and spending plans, and inform the following year’s planning and budget process.[5]
• Conduct mid-term and end-term evaluations across input and process, output, outcome and impact indicators; the mid-term review also serves as the Millennium Development Goals evaluation.[5]

Important system weaknesses include fragmented and non-interoperable databases, incomplete reporting from non-state facilities, irregular validation and auditing of routine data, delayed vital-registration verification, limited comprehensive analysis, and weak links between research findings and decisions.[38][52]Monitoring arrangements are more explicit than formal sanctions: the supplied material does not specify a consolidated accountability-enforcement mechanism, detailed surveillance methodology or universal reporting calendar beyond the stated annual, quarterly and other review processes.[53][54]

Costing & Financing

The financing strategy seeks universal access to the Kenya Essential Package for Health through adequate, efficient and equitable resource use, expanded service and population coverage, and reduced direct payments for care.[27][28]Financing sources include taxation, out-of-pocket payments, external assistance and social or private health insurance, using pooling, purchasing, direct provision and contracting mechanisms.[27]

• Institutionalise annual national and county Health Accounts, finalise the Health Financing and Social Protection Strategy, introduce costing for financing decisions and expand community-based pre-financing mechanisms.[29]
• Update resource-allocation criteria across all resources and financing sources, restructure direct financing to reflect county functions and scale up output-based financing in hard-to-reach areas.[30]
• Reduce inequitable financing by directing comparable priority to preventive and promotive care, and by preferentially allocating resources to hard-to-reach areas and vulnerable populations.[55][56]
• Address a reported funding gap for essential medicines and medical supplies, establish dedicated maintenance budget lines for infrastructure, equipment and transport, and prepare realistic five-year costing for data handling, storage and ownership policy.[57][4]
• Mobilise and rationalise resources for health products and technologies, including priority research, through a financing strategy.[24][25]
• Align annual workplans with available budgets and use annual reviews to translate performance findings into future spending plans.[58][5]

In 2009/10, total health expenditure was approximately 5.4% of gross domestic product, or US dollars 42.2 per capita, while government health expenditure was 4.6% of general government expenditure.[27]Public sources, including external support and health insurance, financed 63.3% of total health expenditure; private sources financed 36.7%, predominantly through point-of-service out-of-pocket payments.[27]Government health expenditure had remained between 4% and 7% of total government expenditure, below the 15% Abuja Declaration target and the 12% Economic Recovery Strategy target.[27]The material identifies inadequate and incomplete funding information, including donor and private expenditure, but does not provide a consolidated programme budget, quantified overall financing gap, costing methodology or economic assumptions.[28]