Decentralizing Kenyas health management system: an evaluation. January 2009. Based on further analysis of the 2004 Kenya Service Provision Assessment Survey.

Kenyas Ministry of Health (MOH) commitment to address the inherent constraints in the health sector has included deliberate decentralization efforts aimed at strengthening the effective implementation of activities at the district level and fostering closer coordination and collaboration amongst the line ministries donors organizations and other stakeholders. Among these efforts local District Health Management Boards (DHMBs) and District Health Management Teams (DHMTs) gradually assumed responsibilities for the operation of the facilities under their jurisdiction through a single line grant annual work plans and procurement plans. To assess the current effectiveness of the district health management systems in meeting their responsibilities we analyze data from a special District Health Management module of the 2004 Kenya Service Provision Assessment Survey to discern the degree to which the DHMTs and DHMBs meet norms and standards in the areas of governance and management human resource development and management commodity management infrastructure development health care financing budgeting and management and performance monitoring. Notably data on DHMTs and DHMBs were missing for 20 percent of the districts. This level of nonresponse has the potential to weaken the validity of the findings particularly when the excluded DHMTs are in provinces with some of the worst health indicators in the country. Their exclusion was due to difficult terrain and insecure environment both of which imply that the right of the population to health care services is compromised. The results of this descriptive analysis indicate that although most of the DHMTs hold meetings frequently the unavailability of the guidelines on the functioning of the DHMTs made it difficult to determine compliance of DHMTs with any existing norms and standards. The survey missed the opportunity to assess the activities and achievements of the HFMCs and HCMTs which are important for decentralization. Although most of the DHMTs had documented plans for improving reproductive health less than a quarter reported implementing their plans on time. Lack of funds and transport were the most cited reasons for failure by DHMTs to meet their supervision targets despite the near universal existence of documented supervision plans. In terms of support of human resources continuing professional development is an accepted norm in the districts but there is urgent need to strengthen and expand the scope of updates to serving staff through the establishment of district health training committees and regular monitoring of their activities. An assessment of available infrastructure indicated that repair and maintenance units existed in most districts with nearly all of the districts contracted with the provincial workshop for repair and maintenance work. Communication facilities between most district hospitals and close to three quarters of the health centers with referral facilities under government management had capacity to communicate easily by telephone or two-way radio with a referral facility to arrange transport during emergencies. The situation was much better for NGO/mission-run facilities. Regarding financing issues despite existence of both recurrent and development funds funding for medicines equipment and maintaining buildings was inadequate for most districts. Sources for funding for district health services included central government funding supplemented by local government revolving funds and other sources. Increased annual budgetary allocations to the agreed 15 percent to ministries of health in agreement with the Abuja accord may increase financial resources required for medicines equipment and maintenance of buildings.