<TITLE: Governing "Good Governance" in Developing Countries
ACADEMIC DOMAIN: economics and administration
DISCIPLINE: management studies
EVENT TYPE: conference presentation
FILE ID: CPRE05J
NOTES: continuation of and continued in CDIS050, session also includes presentations CPRE05G/I, partly poor sound quality

RECORDING DURATION: 29 min 15 sec

RECORDING DATE: 11.11.2004

NUMBER OF PARTICIPANTS: unknown

NUMBER OF SPEAKERS: 2

S3: NATIVE-SPEAKER STATUS: Nepali; ACADEMIC ROLE: senior staff; GENDER: male; AGE: 31-50

S17: NATIVE-SPEAKER STATUS: Kikuyu (Kenya); ACADEMIC ROLE: senior staff; GENDER: male; AGE: 31-50>


<S3> presenting a paper on health care policy develop- administration in postcolonial kenya and challenges for the future please okay </S3>
<S17> well good afternoon everyone and er , i hope i will be able to to speak loudly enough so that you can hear me erm well i'll this is the s- the er topic of my presentation today i'll be discussing basically that's the title of the paper that i have written here and er there this is the summary of what i generally want to to discuss so i'll , talk a little bit about the intro- introduce the er the the topic there and then i'll talk about this development of the health care policy in postcolonial kenya i'll i'll use that er powerpoint and i'll also use this er er slide pro- projector so erm , if i would begin and and talk about er some of those key points there with regard to the development of health care policy in kenya er generally the world health organisation has identified er in 2000 they filed a report er to have across the world involving the developed and developing countries it can identify (xx) generations of health reforms or health (transformations) so you have (especially) er from the 50s and 60s (xx) er the development of a a hospital system er in kenya we're looking at the centralisation of the health care system kenya obtained independence in 1963 so a fast-evolving plan for er general development of of the country identified er disease poverty and and illiteracy as the key points for this for nation building so there was a point about erm transferring or reforming the health care at that time in at 65 you generally (xx) needed to pay to get to a hospital so in 60 in 65 the first policy was to create a er , erm a system where health will be accessible freely so that you don't have to pay anything at all in the hospital or or the health-centre and then after that time health was administered by the municipal (xx) across the country so the ministry of health decided to centralise health er the health system and so all administration came under the government central government and and by that they tried to er increase the availability of health care and that meant that they they started to construct er an expansion of er primary health care facilities er especially in the er from the s- 60 65 to the end of the 70s a lot of er health centres er organised according to health district were were established and of course at that time you had an expanding population at the same time so you have improved health standards and then you have an expansion of the health s- of the health system and in (xx) way the free health policy that existed at that time obviously was overwhelmed because you have increased population increased standard of living and also increased er health indicators so in that that way the health system was (xx) to the second level of the plan actually identified a new to introduce user fees for the health system and also at that time er there were also an idea to er , to have a preventive (birth) policy actually a preventive (birth) policy er was stated in the first development plan of 60 (xx) to 70 and however that preventive policy did not materialise until much later er wha- what happened was that they started to to organise a family health policy er to try to decrease the this er rate of population growth as also er part of health er health development policy at that time er and then also there was a need to because of the the the fact that the the health care system that was being developed was that was seemed to be overwhelmed and a lot of people were still using traditional er health practitioners so the minister and the government at that time tried to to integrate traditional health practitioners into the health normal health system that was not an isolated er issue er it was also part of the world health organisation policy especially from the (xx) of the mid-70s er there was a a a global er conference of the world health organisation and and and it came up with a a document for the traditional practitioners as as primary health care workers and so the the policy was (xx) this policy especially for the developing countries to create integrate the traditional health practitioners into the normal normal health system er however what has happened and what happens especially with a with policy development normally (xx) i mean other developing countries in the in the region in sub-saharan region is non-elected government would create a competent policy but the implementation would take place a little bit (xx) so there's always a delay with the policy statement the policy formulation and the implementation of it and especially you have a policy that is developed and then it takes a while before you have it make it into a legislation and then before that you begin to implement it so all these all these er these aspect for the preventive health care for example as a policy itself has not been mati- has not (been really) researched to a great extent until now er in present time and it's still process of making the policy clear in the institutions that are needed for that er for example with relation to traditional health er health care er it is only now that the government has actually drafted a a bill when in fact already in the 70s a unit within the ministry of health for integrated traditional health practitioners was established but there was obviously opposition in the formal or modern health medicine and traditional medicine and so the (law) has been there and yet still the implementation or utilisation for traditional health and traditionalists er is about 23 per cent in recent times so it's actually been increasing and now the government has come up with the so-called traditional health practitioner's bill er in 2003 and then erm , er one of the other er issue that was that er came to be taken as as as an aspect that needed to be developed was health insurance so you have a health insurance system a statutory system that was er crafted in in 1965 er it was 66 rather the so-called the national hospital insurance fund and that is a contributory fund so that er all those people in formal employment a percentage nearly two per cent of their income is submitted to the fund and then the fund covers hospitalisation (xx) time of hospitalisation basically it covers your bed cost when you're admitted in a hospital now that's the system which in place today but that system has changed somewhat in 1998 it er it it early 1992 when the government actually introduced the user fee policy which was already anticipated 10 years earlier then at that time the health insurance system er this national health insurance fund was only used and utilised for (xx) private health care providers because there was a free health care policy but in 1992 there was an additional user fee policy that is cost-sharing in hospitals that meant also the government hospitals and and the fee then in the er the system for the health insurance system was restructured so that also the government hospital can be (reimbursed from) that system and in 1998 there was a further restructuring of this statutory insurance system er to autonomise it so it became autonomised so you have in the 1960s you have a er development and expansion of the health care system you have improved health indicators in the eight in the 70s and in 1980s and then you have the mid-1980s and all to the end of that decade and then in the 1990s you have a (xx) plus severe structural development crisis and and then you have then an advance of of health indicators that have been achieved in the in the mid-1990s so you you're seeing these er health (xx) erm i can give you some er statistics for that but this trend is not in a good (xx) it is generally the case in all these sub-saharan african countries so this trend of er developing health system er expanding health infrastructure in the 60s and 70s and then the (xx) of socio-economic prices in the mid-80s and generally er (xx) referred to the 80s as the lost decade in in africa erm the this er health promotion or so-called evolution or what i would say the evolution and development of the health system you cannot oppose that kind of a trend so you have and then in the 1990s you have serious reforms that are implemented you have the user fee policy in 1992 the user fee policy was put into place in 1989 of course er you're looking at a further global er or larger influences the er new movement of movement of liberalism had taken the place of old in the restructuring of a welfare state (system especially) in the UK and in the US as well and then you have these so-called structural adjustment policies that er they tried to push er in the states and reduce government expenditure so at that time there's a lot of pressure from the world bank IMF to to free to liberalise the health system as such and also to introduce these user fees not only in health policy but also in higher education as well and the health the implementation for the health was already in 1989 but (xx) government abandoned it nine months later because of severe opposition from the parliament but still it was it still had a coming in 1992 again and then it has been continuing on at our time so the user fees and then the decentralisation you have in the early 1980s you had er the a large er governmental post-governmental decentralisation system or infra- er framework that was practised (xx) the district through er focus for rural development and that created possibility for health management at the district level so health management became er more district-based and that's in 1992 and then we have in 1994 er kenya the kenya health er policy framework that is on-going and has er serious er er suggestions for how health care should be developed and after that time (xx) and then we have a national social health insurance er fund which tries to reform the previous er erm health insurance system i'll talk about those a little bit later er but i would like to mention er two things here i would like to talk about the health care system and situational analysis for the health care system and health care financing and then i'll talk about some of the challenges that i can see now how do you manage this <PREPARING POWERPOINT, P:40> i would just like to mention that this here what you're seeing is the is how the health care system is organised in the country er you have there at the top the ministry of health erm this structure is a very recent structure so that these structures actually are crafted and agreed upon by all the health care providers in the country so this here this is how the system should be organised this is what is existing today but the decentralisation that i mentioned earlier er from early 1980s and that was agreed and and more more fundamentally imp- implemented in the 1990s from 1992 has not been achieved to the extent that it it's meant to be achieved so generally you have a ministry of health and then you have er you have a provincial health administration in place and then you have the district health administration and then you have down below the health centre teams and then you have the dispensary in in most developing countries you have the lower level it is a lower tier of health infrastructure you have either dispensary or health centre it's the same also in finland and then you go on a little bit higher you go to a hospital and then you go to a er this sort of a regional level hospital system and then you go to the national hospital that's the teaching hospital at the top at the er end er a ministry of health there so and then you have different teams or management teams er at the district level here you have . this is the most important body for health administration in kenya it's called the district health management board so this board administers and manages er the decision-making it also makes the district health plans for that district the district may have er you know it may have 70 health centres it may have a number of hospitals but normally a district has one or two hospitals and then everything else is either a hospital er i mean a health centre or a dispensary which are the lower level now you have only in-patient er health care is i- at the health centre minimal in-patient for them and the dispensary it's much much low lower you only have er out-patients to take care so the district health management er this is the centre for health for the decentralisation that is being crafted today today however the implementation for the decentralisation has only been implemented in 14 (xx) districts in kenya you have 71 of them so by the time they reach that goal and remember the decentralisation started in 1982 so it's a very long time and they haven't even reached the er a full decentralisation the decentralisation that is existing now does not include financial decision-making for example so and i mentioned also the the these all the er all the health institutions the dispensary the health centre and the hospital they collect user fees and er these user fees are supposed to be used for further development of the health care within that district so 75 per cent of the collection of the revenue collected in any health centre or dispensary is used for that to devel- further develop that particular health centre so they're collecting (xx) er retain 75 per cent and then 25 per cent goes to the district the body here and then the district decides to use that funding for health prevention and health promotion and so it's a fairly interesting system but er as i mentioned it's changing er quite a bit <P:07> and i would like to to talk a bit about the er , the health distribution the distribution of health care in the country by different subsectors and different er hospital or or health er infrastructure there er institutions so you have as you can see the government runs about 51 per cent of the entire health system er the NGOs the non-governmental organisations offer it 20 per cent and then you have the private sector the business sector that offers the rest 29 per cent er but as you can see there the dispensary system the dispensary the erm (xx) so in the 1960s and 70s the government evolved a lot of these primary health care facilities the dispensaries and the health centres so that's that's the distribution of the er , of the er of the country's health system . i should just mention before i remove this that er in kenyan health policy framework that i'll talk a little bit about later on talks about er transferring greater responsibility for curative services to the private and NGO sector system but you can see the way it's distributed there their level of interest for these two types of organisational sectors er can also be an indicator of how in fact they can absorb greater responsibility for curative er system and as well for the other sector , now here i have some three er figures here that i'll just mention briefly health care financing this is the present and this is the future so the present there indicates that er the source of financing for health care in kenya is very much er individual or household-based okay so out of pocket er expenditure as you can see here out of pocket expenditure is very high at 53 point one per cent and then the (xx) this is the er the insurance system the institutionary insurance system that i mentioned earlier that was developed in 1966 so that system has er a little bit less as well and then you have private funds and also NGOs so that's the present this chart here indicates the expenditures er the ministry of health has two expenditure budgets it has two budgets it has current expenditure for paying salaries and things like that and then it has a development budget for for building new facilities and you can see the manner in which it has developed with regard to the er development of the primary health care system so the primary health care system has had increased funding especially then from the the er the late 1980s and that is very much in line with the world health organisation the alma-ata declaration in 1978 for er developing primary health care for all by the year 2000 so there were these international policies shaping the health care development in the country er the future here is that er , future here is that er , this is the proposed pre-paid er national social insurance system so whereby everyone will have pre-paid into the insurance system er for their health care the present system is you go to the hospital you you you pay and then you get treated or you get treated and you pay er and the the new system is you will have pre-paid before if you look you you see the er the the , the sources of financing change so er of course it'll mean that all those who today pay the out of out of pocket expenditure is very high er normally health health indication or indication for health expenditure also provides good analysis for poverty levels and there is a clear connection between health levels of health and poverty and so the idea is that the course of the the er the er analysis of the cost for health in kenya is too high and it perpetrates poverty so it's tied to poverty so if you reduce the health expenditure for household then you are you are able to to create opportunities for greater economic er prosperity or to remove them out of the poverty so this new system is attempting to do just that so you would have the insurance system er that is then funded largely here the 12 per cent er the 12 (xx) the 29 per cent that would be paid for by formal sector er employees and employers and then you have the government funding which is from tax expenditure then it's also quite high and then so the new system would rely very little on donor finance which is a plus and i call for that <P:07> so i'll just put a o- er one more or two more er overheads here and then conclude <PREPARING OVERHEAD PROJECTOR, P:37> okay so i mentioned the er the , kenya health policy framework the health policy framework that was crafted in 1994 tried to shape how the future of health care will be er with with er with regard to to decentralisation further decentralisation of the public system and then the sh- the idea of shifting these responsibilities of curative services to the private sector and NGOs and also how to manage the health care financing from the the er institutionary national er hospital insurance fund to the er social insurance fund and not to get confused with that i'll just talk briefly about this er this er the social insurance health fund but this is the vision so the vision for health care policy today is to provide quality health care that is acceptable and affordable and that is accessible for all so how do you achieve that , well the government is trying to achieve that through this national social health insurance fund and as i mentioned it will transform the existing system where you pay as you use er the health centre or hospital and so on and so forth to a pre-paid insurance system that means that every individual resident today father mother and child will contribute as well the e- the existing national health insurance based system that was set in 1963 or 66 rather er today it means that only one person contributes per household so the head of the household contributes for this and then it covers everyone else in the family so that system covers about 30 per cent of the of the population today , but as we saw the out of pocket expenditure for health is far much higher so that that existing institutionary er system is very low and therefore does not cover all the larger er needs for health er financing in the country so the new system would mean that even children will er contribute as well any resident person in the country if you're staying there on a residential basis er even as a foreigner and not don't have a citizenship and that system was crafted there with er ideas from places like germany austria and also er malaysia and so they they borrowed ideas from there some challenges now we've had er for the challenge the key challenge today for implementing this er health this er social insurance fund is opposition from the private sector and trade unions er the private sector of course they oppose to the system because with this would be a monopoly insurer and presently there are a few two or three private insur- insuring companies and they they cover a pretty small percentage of peo- about 200,000 people only (xx) of those wealthy people they are opposed to this monopoly insurance system but it is not only because of the the fact that it might eliminate most private insurances insurances but also that those operating the private hospital hospitals today are worried about the kind of er management and negotiations for reimbursements for what kind of cost how and how much will (xx) this system insure you will be reimbursed if you go to (xx) because this will er this system you as any individual resident will be able to access health from anywhere from a private hospital a government hospital NGO hospital from a traditional health practitioner but how do you create a system for actually to enumerate and (xx) to the goals and then reimbursing them so that's our major problem the enumeration of contributors you see poverty in kenya is 56 per cent so that's very high those people who are poor cannot be able to pay for themselves for this system the government will pay for them through the tax-based er through tax collection that is okay but how do you get to enumerate all those people many of them don't have registration cards they don't have (xx) they really don't have any way of registering you know over 60 per cent of the population of of the country so that's one of the big challenges and then high levels of poverty of course poverty is not a standard it's not a erm people get in and out of poverty er seasonally so how do you you have to create a system for sustaining those levels and so the the challenge is not merely a (xx) it's enormous er today the er the the parliamentarians are discussing how to actually find a solution to to have a consensus on this system er i'll end there because of the time </S17>
