1. Joint Mission on Harmonizing Support to RH in Kenya 2011 1 1 Joint Mission on Harmonizing Support to Reproductive Health in Kenya Preliminary Results and Recommendations Nairobi, 03-03-2011

2. Overview of mission Commissioning partners: DANIDA, DFID, GDC, USAID Together with MOPHS, MOMS, BMGF Duration: from 13 th February to 4 th March, 2011 Field visits to: Nyanza, Western, Eastern, Coast Provinces Nairobi: Korogocho, Dondera, Stahere slums Joint Mission on Harmonizing Support to RH in Kenya 2011 2

3. Overview of presentation 1.Distribution of Commissioning DPs 2.Overview of Financing 3.Appraisal of Thematic Areas and Framework 4.Ways of Working (Modalities) 5.Health System re. RH (Supply Side) 6.Demand Side Interventions 7.Complementary Health Service Provision 8.Adolescent SRH and SRH-R 9.Next Steps Joint Mission on Harmonizing Support to RH in Kenya 2011 3

4. 1.Distribution of Commissioning DPs Joint Mission on Harmonizing Support to RH in Kenya 2011 4

5. Incidences of Overall Poverty (%) 2005/2006 versus DP Presence To be inserted Joint Mission on Harmonizing Support to RH in Kenya 2011 5

6. Skilled Birth Attendance (%) - 2008/09 versus DP Presence To be inserted Joint Mission on Harmonizing Support to RH in Kenya 2011 6

7. 2.Overview of Financing Joint Mission on Harmonizing Support to RH in Kenya 2011 7

8. Examples of GoK and DPHK reporting of spend on Reproductive Health Joint Mission on Harmonizing Support to RH in Kenya 2011 8

9. Ministries Reporting on Reproductive Health (Printed Estimates for FY 2010- 2013) Joint Mission on Harmonizing Support to RH in Kenya 2011 9

10. DPHK Reporting on Reproductive Health Joint Mission on Harmonizing Support to RH in Kenya 2011 10 AOP6 PLANNED INPUTS (2010-11) USD($) RH commoditiescondoms RH O&M MCH commodities MCH O&M nutrition O&MTOTAL AFDB $0 CLINTON $0 DANIDA $0 DFID$6,043,976 $397,630 $6,441,606 EU $1,400,727 FRANCE $0 GAVI $35,053,500$532,000 GTZ$5,599,840 $4,619,868 $10,219,708 KFW $0 ITALY $0 JICA $183,506 UNAIDS $0 UNFPA$1,000,000 $1,429,500 $2,429,500 UNICEF $1,300,000 $6,300,000$5,739,738$13,339,738 USG $12,670,000 $3,675,000 $16,345,000 WFP $11,241,728 WHO $497,000 $282,750$779,750 WORLD BANK $6,400,000 TOTAL$12,643,816$6,400,000$21,097,504$35,053,500$11,907,727$17,264,216$104,366,763

11. Finances for Health & RH Two costed strategies – Average is $215 million National Road Map for MNH and Child Survival Strategy (2008): $50 and $380 million per year respectively. WHO cost estimate per head for scaling up maternal health of $1.40, implying an additional cost for Kenya of $60 million. Joint Mission on Harmonizing Support to RH in Kenya 2011 11

12. Finances for Health & RH Kenya Total Resources for Health Estimated Resources for RH in US$ mio GoK 550 25 DPs 600104 Households 275 60 TOTAL1,425190 Joint Mission on Harmonizing Support to RH in Kenya 2011 12

13. Finances for Health & RH Could have sufficient resources for RH. The single largest cost component in both strategies is CHWs: $20m in the Road Map, $90 million in the Child Survival Strategy. Out-of pocket expenditure on (reproductive) health: private sector and demand side approaches have potential. BUT – Additional RH components (e.g. ASRH, gender violence) and will raise total cost. Joint Mission on Harmonizing Support to RH in Kenya 2011 13

14. Health Financing- Allocation of Resources (1) DP Resources 2009/10WHO for RH Recommendations Procurement 42%Drugs & supplies 48% Service Delivery 55% Staff salaries 22% Infrastructure 3% Support Systems 2%System dev. 25% (incl infrastructure, training) Joint Mission on Harmonizing Support to RH in Kenya 2011 14

15. Health Financing- Allocation of Resources (2) DPs spending about the right amount for commodities Too little being spent on systems development (and infrastructure) DP vertical spending - overwhelmingly on HIV/AIDS. PETS – over 50% leakage Recommendation: Resources looking adequate – the task for RH is to allocate resources more effectively. Joint Mission on Harmonizing Support to RH in Kenya 2011 15

16. Health Financing 2009 Health Financing Strategy has stalled – KNHIF proving difficult to tackle and progress v slow. Recommendation: Plan B carry on with demonstrating alternatives that work on the ground with well designed pilots: social insurance (HAKI) Joint Mission on Harmonizing Support to RH in Kenya 2011 16

17. Health Financing Vouchers / OBA scheme puts RH purchasing power into women hands and is effective and popular with women and service providers. High admin costs should be reduced if scaling up; International evidence that voucher schemes costly and unsustainable. Dont seek to transfer costs to GoK, instead use OBA to direct DP resources to give more women decent, subsidised, urgently needed RH services. Joint Mission on Harmonizing Support to RH in Kenya 2011 17

18. 3. Appraisal of Thematic Areas and Framework Joint Mission on Harmonizing Support to RH in Kenya 2011 18

19. Joint Mission on Harmonizing Support to RH in Kenya 2011 19 Joint Mission on Harmonizing Support to RH in Kenya 2011 19 Technical Appraisal In mapping donor support the policies and strategies to identify gaps and areas for support we looked at DPs current support to RH against : Vision 2030 NHSP 2 RH Strategy MNH Road map AOP funding

20. Technical Appraisal Policy environment: Numerous policies and strategies (65 strategies in RH Strategy); Good information on unit costs; Insufficient analysis of cost-effectiveness; But no document prioritising support to RH - leading to a fragmented approaches and inefficient use of available resources. Joint Mission on Harmonizing Support to RH in Kenya 2011 20

21. Joint Mission on Harmonizing Support to RH in Kenya 2011 21 Joint Mission on Harmonizing Support to RH in Kenya 2011 21 Technical Appraisal We found clustering of support around SMNH and FP seemingly much less support for adolescent sexual and reproductive health (ASRH), gender and sexual and reproductive rights (SRH-R). Recommendation: More should go to ASRH and SRH-R

22. Policy / Community Strategy Concerns about cost effectiveness, opportunity cost to train more CHWs Concerns about SRH impact Recommendations: Immediate: Get a common understanding about the revised Community Strategy, its evidence base and cost implications (also in view of RH B.P.) Medium-term: Support if and where feasible, provide training and tools Joint Mission on Harmonizing Support to RH in Kenya 2011 22

23. 4.Ways of Working (Modalities) Joint Mission on Harmonizing Support to RH in Kenya 2011 23

24. Joint Mission on Harmonizing Support to RH in Kenya 2011 24 Joint Mission on Harmonizing Support to RH in Kenya 2011 24 Immediate Recommendations DPs provide TA to DRH to develop a strategic RH costed business plan to reduce MNM – - covering public and non-state actors – - showing what is needed, - where and how it should be delivered - prioritised and highlighting gaps. Agree on one TA plan reflecting all TA required. Agree on one RH commodity plan.

25. Why an RH Business Plan? Technical Efficiency; It will help ensure more efficient use of available resources; Can be used to mobilise resources with DPs and MOH and MOF; Used by DRH to lead, coordinate and review support to RH; DPs should report funding against main themes in the BP – transparent tracking of resources. Joint Mission on Harmonizing Support to RH in Kenya 2011 25

26. Ways of Working DPs with MOH (1) More adherence to Paris Declaration and Code of Conduct. Support the SWAp process, at minimum by joint planning around existing funding baskets: HR, EMMS, HSSF Joint annual review of RH by all partners – feeding into annual Health Summit and SWAp. Joint Mission on Harmonizing Support to RH in Kenya 2011 26

27. Ways of Working DPs with MOH (2) Use a core set of indicators to measure and monitor RH. Support the TA RH plan with a pooled fund (managed independently) – at minimum joint TA RH plan Pool support for RH commodities to EMMS – minimum one plan reflecting all support to RH commodities. Joint Mission on Harmonizing Support to RH in Kenya 2011 27

28. Ways of Working DPs with MOH (3) Report funding against agreed areas of RH. Harmonize approach to per diems in RH. Ensure that IPs work with the districts and AOP process – include in MOU with IP. Provide TA (Health Systems Adviser) to DRH – maternal mortality is a systems failure, will ensure strategic planning and linkages to the SWAp process. Joint Mission on Harmonizing Support to RH in Kenya 2011 28

29. Joint Mission on Harmonizing Support to RH in Kenya 2011 29 Joint Mission on Harmonizing Support to RH in Kenya 2011 29 Ways of Working DPs with MOH (4) DRH – needs to be more strategic and tell DPs what is required and where – less advocacy more action. RH – ICC should play a more strategic role using the RH Business Plan to assess performance against the plan, funding and agreed priorities. RH - ICC commodities should be stopped and quantification covered by procurement ICC.

30. Ways of Working DPs with MOH (5) Districts – ensure effective stakeholder coordination Define principles of engagement at district level – should be developed into a binding code of conduct Provide TA to support this process in districts Joint Mission on Harmonizing Support to RH in Kenya 2011 30

31. Operational research Knowledge management OR – fragmented as often driven from outside country (global funding). Lack of proactive knowledge management Recommendations: Use RH ICC to decide on priority OR – relate to RH B.P. RH - support to establish focal point (TA) for knowledge management Joint Mission on Harmonizing Support to RH in Kenya 2011 31

32. 5.Health System re. RH services (Supply Side) Joint Mission on Harmonizing Support to RH in Kenya 2011 32

33. Leadership and Governance (1) Insufficient leadership and governance for RH Recommendations: Upgrade management skills Match person-to-post to ensure leadership Streamline data management to support planning at all levels Include total market approach (e.g. PPP) Comprehensive policies and guidelines to guide Counties Joint Mission on Harmonizing Support to RH in Kenya 2011 33

34. Leadership and Governance (2) Health Sector Policy – A broad participation in the revision process and ensure RH needs are sufficiently addressed Devolution process to Counties – Immediate: Provide TA to MOPHS in the planning of devolution – Support professional advocacy campaign on RH – Medium-term: Support devolution process in RH – Support MOPHS to provide TA to Counties in their planning and implementation stage Joint Mission on Harmonizing Support to RH in Kenya 2011 34

35. Human Resources for Health (HRH) (1) HRH - Maldistribution urban / rural Recommendations: MOH – Agree on redistribution plan and incentives, money and non monetary Inform further HRH planning about implications of devolution to Counties DPs - Support incentives through HRH pooled fund Joint Mission on Harmonizing Support to RH in Kenya 2011 35

36. Human Resources for Health (HRH) (2) Skilled Birth attendance (SBA) not available at lower levels. i.e. dispensaries, Health Centres Recommendations: Immediate: Increase training on safe delivery at levels 1 to 3 using centres of good practice and existing training modules (funded through TA pot) Medium Term: DPs to support recruitment of additional nurses through HR pot (after redistribution). Joint Mission on Harmonizing Support to RH in Kenya 2011 36

37. High Impact Interventions Low coverage of High Impact Interventions Recommendations: Integrate into RH B.P. - Focus on agreed RH outcomes Immediate: DP/IPs to prioritize support to the Acceleration Plan Address issues of access, equity, quality and sustainability Joint Mission on Harmonizing Support to RH in Kenya 2011 37

38. Low utilization of RH services at HF – level 1-3 (1) Stock-outs, erratic delivery of FP / RH commodities to HF, no consumables, poor environment - cause of informal user fees Recommendations Supply Side Interventions: Review division of labour between RH coordinator and pharmacist Integrate all RH/FP commodities into the supply chain management system Joint Mission on Harmonizing Support to RH in Kenya 2011 38

39. Low utilization of RH services at HF – level 1-3 (2) Recommendations Supply Side Interventions: Support RH commodities through EMMS earmarked pot. Develop mechanisms to cover costs for consumables, auxiliary staff (e.g. HSSF) Scale up infrastructure improvements to dispensaries for safe deliveries Joint Mission on Harmonizing Support to RH in Kenya 2011 39

40. Low utilization of RH services High unmet need for FP methods Recommendations: Immediate: Assure the availability of complete range of contraceptives in HF Train staff in IUCD and implant insertion Scale-up promotion of LAPM and services Include FP into combined RH OBA voucher Integration of FP into VCT and PMTCT Joint Mission on Harmonizing Support to RH in Kenya 2011 40

41. 6.Demand Side Interventions Joint Mission on Harmonizing Support to RH in Kenya 2011 41

42. Low utilization of RH services at HF – level 1-3 (1) Demand side interventions for RH to reduce barriers to RH services: Address counterproductive practices and fears (BCC and practical solutions at HF) Engage womens groups and male involvement Create and maintain Community Fund to cover transport or user fees Community partnering with local transport industry Joint Mission on Harmonizing Support to RH in Kenya 2011 42

43. Low utilization of RH services Recommendations: Organize knowledge sharing of good practices from the different regions Medium-term: Support further piloting and implementation of pre-payment (e.g. voucher) and health insurance schemes Joint Mission on Harmonizing Support to RH in Kenya 2011 43

44. Low utilization of RH services High unmet need for FP methods Recommendations: Disseminate messages addressing particular reservations about FP Address particular needs of adolescents Continue to support special promotion of under-utilized FP methods (e.g. LAPM) Support targeted communication campaigns Joint Mission on Harmonizing Support to RH in Kenya 2011 44

45. 7.Complementary Health Service Provision (Total Market approach, PPP) Joint Mission on Harmonizing Support to RH in Kenya 2011 45

46. Total market approach and PPP (1) Missed opportunities to use complementary services for different population groups, involving public and non-state actors (NGO, FBO and private sectors) in achieving Health MDGs Recommendations: Immediate: DPs continue to advocate for PPP Medium-term: Include non-state actors in RH Business Plan Joint Mission on Harmonizing Support to RH in Kenya 2011 46

47. Total market approach and PPP (2) Continue to support social franchising and OBA scheme with non-state service providers Pilot sub-contracting integrated RH services to FBOs in underserved areas (performance based) Continue to establish PPPs with companies Joint Mission on Harmonizing Support to RH in Kenya 2011 47

48. 8.Adolescent SRH and SRH-R Joint Mission on Harmonizing Support to RH in Kenya 2011 48

49. Adolescent SRHR (1) Teenage pregnancies – important part of MMR Recommendations: Give high priority to comprehensive RH in in- school and out-of-school programmes Assure that RH and SRH-R aspects of existing curricula are covered in actual teaching Partner with youth associations to address teenage RH and income needs Joint Mission on Harmonizing Support to RH in Kenya 2011 49

50. Adolescent SRHR (2) Bias of health service providers against adolescents and unmarried youth Recommendations: Train health staff to be responsive to youth needs without prejudice (youth lens) Increase set-up of Youth-friendly RH Services in HFs and in (e.g.) youth centres Support YFS in non-health settings (e.g. schools – MOE, youth empowerment centres - MOYAS Joint Mission on Harmonizing Support to RH in Kenya 2011 50

51. SRH-R - Gender-Based Violence High level of gender-based domestic and sexual violence Recommendations: Immediate: Coordinated response among all actors Utilize Technical Working Group on GBV Joint Mission on Harmonizing Support to RH in Kenya 2011 51

52. 9. Next Steps Joint Mission on Harmonizing Support to RH in Kenya 2011 52

53. Priorities on Demand and supply side interventions Assure availability and quality of obstetric care at Level 1 to 3 and referrals through complementary providers Assure availability of diverse options for family planning Assure demand side measures for decision- making, financial and geographic accessibility Assure comprehensive RH information and services for adolescents in and out-of-school Joint Mission on Harmonizing Support to RH in Kenya 2011 53

54. Next Steps towards DP harmonization Develop RH Strategic Costed Business Plan Complete Gaps Analysis of DP Contributions Harmonize Interventions through Stakeholder Code of Conduct at National and District Level Create TA Pooling Mechanism Provide TA to devolution process re. RH Rationalize RH Supply Chain Management Create High Visibility of RH through Advocacy and Targetted Communication Joint Mission on Harmonizing Support to RH in Kenya 2011 54

55. Thank you for your attention and support! Luise Lehmann, Kawaye Kamanga, Dhimn Nzoya, Marilyn McDonagh, Rachel Phillipson Joint Mission on Harmonizing Support to RH in Kenya 2011 55