Health spending still low despite years of devolution


Is your governor taking you for a sick ride? Maybe

Only about a third of funds allocated to counties for development in the sector was spent in the last fiscal year

Kenya is a good way off from meeting the pledge it made more than 15 years ago to spend 15 per cent of its budget on health, a Nation Newsplex review of county and national governments budgets shows.

Health constituted eight per cent of the combined national and county budget allocations in the 2016/17 fiscal year, which is about half of the country’s longstanding commitment, amounting to Sh172.5 billion.

It was also the same share as the previous year and one percentage point higher than in the 2014/15 financial year.

A third of the money allocated to health in the recurrent budget and two-thirds of the funds earmarked for development was not spent.

The proportions are consistent with what the government allocated to health before it was devolved. The percentage of the budget allocated to health in the final fiscal year before the introduction of the devolved system of government was also eight per cent.

When it comes to the actual spending, the shortfall is worse partly due to the challenges county governments are facing in implementing their budgets.

The analysis, based on the Controller of Budget’s reports, finds that the total public expenditure on health was five per cent of the overall spending by the two levels of government in 2016/17 or about Sh110 billion, a drop from six and seven per cent in the two previous years respectively.

Six countries

In 2001, officials from African Union member countries met in Abuja, Nigeria and pledged to set a target of at least 15 per cent of their annual national budgets to improve health.

Most countries are yet to achieve the target.

According to the AU Commission, six countries have met the benchmark. They are Burkina Faso, Niger, Rwanda, Botswana, Malawi and Zambia.

However, the World Health Organisation says only Rwanda and South Africa have done so.

Health, along with agriculture and water, are some of the key services that were devolved to from the national government.

Data from the World Bank indicates that the public sector makes up about two-thirds of health spending in Kenya while public health expenditure as a share of Gross Domestic Product is about 3.5 per cent.

One in four shillings allocated by devolved governments goes to health. But even though most counties earmarked a sizeable share of their budgets to health in the last three financial years, their efforts were undermined by the low national government allocations of just two per cent of its overall budget to the sector during the 2014/15 to 2016/17 financial years.

The nurses’ strike ended on November 2 after 151 days while the doctors’ lasted 100 days by the time it was called off in mid-March.

In the last two financial years, health made up three per cent of the total national government spending, a fall by almost half from the 2013/14 fiscal year, the first budget under the devolved system of government.

At the county level, the combined allocations to health by devolved units was 21 per cent in the financial year 2014/15, which improved two points to 24 per cent in the following two financial years.

But when it comes to county expenditures, the proportion spent on health last year was 17 per cent or one in every six shillings used by counties. This was an eight percentage drop from the previous year. In the 2014/15 year, counties spent 22 per cent on health.

But even as the share of budget apportioned to and spent on health by counties is significant, the sector has been dogged by strikes and lack of basic equipment in public hospitals. The consequences have been dire.

The nurses’ strike ended on November 2 after 151 days while the doctors’ lasted 100 days by the time it was called off in mid-March.

During the strikes, the number of women who died in childbirth in public hospitals doubled nationally in the first half of 2017 to 857, compared to 413 in the first half of 2016, revealed an earlier Newsplexanalysis of service data recorded daily in the Kenya Health Information System.

Kenya is not only struggling to pay its health workers but also dealing with shortages.

There are 108 doctors and nurses per 100,000 people, about half of the World Health Organisation recommended rate, according to the Economic Survey 2016.

Unspent funds

Moreover, health allocations and spending among counties are not uniform, varying widely from region to region.

In the last fiscal year, slightly over half (56 per cent) of the Sh95.1 billion allocated to health by the devolved governments was spent, with the recurrent budget 62 per cent while the development absorption rate was 37 per cent.

This means a third of the money allocated to health in the recurrent budget and two-thirds of the funds earmarked for development was not spent.

It was expected that the absorption rate would improve as the financial systems and governance capacity of county governments matured but the analysis reveals this is not happening.

In the 2014/15 fiscal year, the overall health funds absorption rate was 82 per cent.

The following year, it improved by two points to 84 per cent before plummeting by 28 per cent in the last financial year.

In the 2014/15 financial year, 59 per cent of the development budget was used up. The following year, it inched up to 62 per cent before diving to 37 per cent last year, a worrying reality.

The Council of Governors has repeatedly blamed the poor absorption of funds, especially those allocated to development, on delayed disbursement from the central government.

The other factor hindering spending is late submission of financial reports by county treasuries, which affects timely preparation of budget implementation reports.

Integrated Financial Management Information System connectivity challenges slow down the approval of procurement requests and payments to suppliers.

In the last financial year, two counties — Machakos (17 per cent) and Lamu (48 per cent) — spent less than 50 per cent of the money it allocated to health.

In contrast, Kakamega (103 per cent) and Mombasa (104 per cent) exceeded their allocations.

In the same financial year, 11 counties allocated about a third and more of their budget to health while 18 spent the same proportions on the sector.

Embu, Baringo and Nakuru earmarked 36 per cent of their budget to health, the largest share.

But Baringo spent 38 per cent of its total budget on health, the second highest share, while the other two counties spent one percentage point less.

Nyeri used up a bigger share of its budget (40 per cent) on health than any other county despite allocating a third of its budget to the docket.

Two counties — Turkana (14 per cent) and Laikipia (11 per cent) — earmarked less than 15 per cent of their budgets to health.

But while the latter spent only eight per cent of its expenditure on health, the former used 17 per cent.

Machakos, at six per cent, spent the least on health even though it assigned 28 per cent of its budget to the docket.

In the previous fiscal year (2015/16) the same number of counties allocated about a third of their budgets to health. The top three allocations were by Embu (36 per cent), Kiambu (35 per cent) and Nyeri (35 per cent).

In that year, only three counties allocated less than 15 per cent of their budgets to health: Turkana (10 per cent), Laikipia (11 per cent) and Mandera (14 per cent).

In terms of spending, at least 11 counties spent about a third of their budgets on health. Nyeri spent a bigger share (41 per cent) of its budget on health, followed by Nakuru and Embu at 40 per cent each.

Best indicators

In the 2014/15 fiscal year, seven, allocated about a third or more of their budgets to health.

Nyeri earmarked the largest share (39 per cent) and almost half of its total spending (44 per cent) went to the sector. Nakuru was in second place with 40 per cent.

Nyeri, which topped in the percentage of its budget spent on health for the three years under review, already had some of the best health indicators in the country even before devolution.
More children were delivered in hospital (96 per cent) in Nyeri in 2012 than any other county, according to data from the Ministry of Health.

It also had the least percentage of underweight children under five (eight per cent) and the third least share of stunted under-fives at 21 per cent.

During the same year the county had 15 doctors per 100,000 people, a rate only second to Nairobi, which had 22 doctors per 100,000 people.

Regarding nurses, it ranked third with 103 per 100,000 people. The county was placed ninth in the rate of clinical officers, with 11 per 100,000 people.

At the bottom in the 2014/15 fiscal year, seven counties allocated less than 15 per cent of their budgets to health.
They were Laikipia (eight per cent), Taita-Taveta and Migori (10 per cent), Narok and Kajiado (11 per cent), Kirinyaga (12 per cent) and Mandera (13 per cent).

On the share of total spending assigned to health, the seven counties, along with Turkana, whose health spending made up 11 per cent of total expenditure, and West Pokot (13 per cent) spent less than 15 per cent of their budgets on health.