DOMESTIC RESOURCE MOBILIZATION FOR HEALTH: NATIONAL HEALTH FINANCING DIALOGUE FOR IMPLEMENTATION OF THE HEALTH SECTOR DOMESTIC FINANCING SUSTAINABILITY PLAN [caption id="attachment_5411" align="aligncenter" width="931"] The NACC CEO Dr. Nduku Kilonzo (In white top) and participants following keenly on discussions during the National Health Financing Dialogue for implementation of the Health Sector Domestic Financing Sustainability Plan that was held in Nairobi, Crown Plaza Hotel[/caption] The National AIDS Control Council (NACC) together with Global Fund – Kenya Coordinating Mechanism (GF-KCM) held a Policy Dialogue meeting early October 2018 in Crown Plaza Hotel, Nairobi to deliberate on the need for Domestic Resource Mobilization for Health geared towards building a Health Sector Domestic Financing Sustainability Plan. The Government of Kenya has been heavily reliant on donor funding for Health programs for over ten years. For example, external financing towards HIV accounted for 73% of resources, 37% of TB spending and 12% of malaria spending in 2015. External funding from the US Government and from the Global Fund are expected to be substantial between 2018 – 2020 for the three diseases with external funding being roughly 1.2 times the Ministry of Health’s budget. There are many challenges confronting the health sector in the area of financing and that is the reason the policy dialogue has become even more critical in light of escalated costs related to the provision of health services, the unpredictability of resource flows and the significant changes in the way external assistance is being financed and distributed in the health sector. The National Health Financing Dialogue highlighted more critical issues in health care service delivery with a focus on efficiency and value for money as well as strengthening the country’s need for a the sustainable health financing mechanism. This is coming at a time when His Excellency the President of the Republic of Kenya has set a target of attaining 100% Universal Health Coverage(UHC)  over the next five years. This is in keeping with every Kenya’s right to quality and affordable health care, including reproductive and emergency health services as enshrined in the Constitution. In addition, the recently enacted Health Act 2017 mandates the Government of Kenya to ensure progressive financial access to UHC. There is a clear recognition and increasing conversation about the need to diversify and expand the sources of domestic funding to ensure sustainable financing of the health sector and reduce dependence on development partners.  In 2014, the Kenyan economy was rebased and reclassified as a Lower Middle Income Country. The rebasing of the Kenyan economy means that Kenya should significantly increase resources for health from domestic sources, procure essential health related commodities at market prices and will no longer be eligible for World Bank IDA concessional loans. Notably, domestic funding for the HIV, TB and malaria programs have been progressively increasing. The government is strongly committed to increasing its contribution to the health sector including the three disease programs over the 2018-2021 implementation phase as well. The increasing focus on universal health coverage through improved domestic financing for health is articulated through the ‘Second Medium Term Plan of Kenya, Vision 2030’, ‘Kenya Health Policy, 2014–2030’, and ‘Kenya Health Sector Strategic And Investment Plan (KHSSP) July 2014 – June 2018’.  It is also worth noting that the Kenya 2030 vision provides for increase of the Government expenditure on health from 8% in 2016 to 12% by 2017/18. This was expected to greatly narrow the funding gaps. Kenya’s disease responses face three key long-term transition challenges. The first is replacing donor funding, a second is closing the resource gap even when external resources are available in the health sector and a third is ensuring the efficient delivery of health services. To address these challenges and ensure that disease responses are financed, the following key recommendations were proposed:

1. Integrating sustainability and transition issues into routine health financing discussions between the Ministry of Health and the National Treasury official at the national and county levels.
2. Specifying the national and county roles with respect to program activities that will be transitioned the short, medium and long term.
3. Ensuring efficiency is a central focus in the sustainability and transition planning for the three diseases.
4. Ensuring the health financing functions are aligned with public financial management and analysed at the program level.
5. Ensure all government stakeholders adopt ‘urgent incrementalism’ in ensuring step-wise annual progress on which aspects of programs will be transitioned to the government of Kenya for funding. A forecast could be developed for a 10 year period.

This Policy dialogue interrogated these recommendations further with the aim of developing and finalizing a road map for implementation of the country’s domestic financing sustainability plan for health. The discussions focused on increasing domestic financing for health and reflected on the advocacy plan for the same. This will help in forming consensus on government health financing priorities and next steps to ensuring robust funding is available to meet not only the programmatic gaps for the AIDS, TB and Malaria programs but the entire health sector programmes. security and medicare The deliberations also pointed at the need to provide a platform for which the key Kenya stakeholders including government, civil society, NGOs as well as partners to discuss and showcase mechanisms to increase domestic resources for health in the effort to achieve Kenya’s goals towards universal health coverage and also develop the Transition roadmap for implementation of the country’s domestic financing sustainability plan for health. The dialogue successfully brought key stakeholders of public sector financing and health financing, the Ministries of Health, Finance and Planning, Members of Parliament, civil society partners, development and other technical partners and if you want to more of this Check out doctorpaydayloans.co.uk. Click the links below to read the Policy Issue papers on:

1. Co-financing Commitments and Strategy: The HIV, TB and Malaria Replacement Challenge
2. UHC Delivery for Kenya
3. Unlocking Investors’ Potential in the delivery of UHC in Kenya

[caption id="attachment_5311" align="aligncenter" width="1018"] Governor Ferdinand Waititu (in a checked shirt) hosted a team of representatives from Georgetown University Medical Center – A Center for Global Health and Quality led by Prof. Mark Dybul, a Co-Chair of Center for Global Health and Quality at Georgetown University and National AIDS Control Council team led by the CEO Dr. Nduku Kilonzo (middle) at the county’s headquarters.[/caption] The National AIDS Control Council in partnership with the Georgetown University Medical Center – A Center for Global Health and Quality is piloting a Business Process for Impact (BPI) model that will scale up HIV and Universal Health Care (UHC) results through a Human Centered Design (HDC) approach.  BPI will focus on supporting the coordination of youth led HIV programmers to promote good health choices and uptake of health services among Kenya’s Adolescents and Young People (AYP) in Kiambu and Homabay counties for two years. During the inception visits to the two counties that took place from 8^th to 10^th August, 2018 by the Georgetown University Medical Center representatives together with National AIDS Control Council team led by NACC CEO Dr. Nduku Kilonzo, the leadership of these counties showed support for the Business Process for Impact. In Kiambu County, Governor Fedinand Waititu together with the presentation of the key county health management representatives cited alcoholism as one of the key socio dynamic issue that contribute to increase of new HIV infections among AYPs, an issue that the county is struggling with and cited the Business Process for Impact is an initiative that will bring along various stakeholders in reversing the trend of increase of new HIV infections among the AYPs in the county. Also in Homabay County, deputy Governor Hamilton Orata welcomed the process as he cited that previously, a lot of money and resources have been poured in the county for HIV response related activities with no tangible results and the county continues to struggle with increase of new HIV infections, a challenge he attributed to lack of framework of monitoring the activities of various programmers on the ground and he sees the BPI process as the only way that will bring on board various stakeholders in a systematic way and monitor their activities in order to boost results in HIV response. [caption id="attachment_5307" align="aligncenter" width="1127"] Prof. Mark Dybul (left), a Co-Chair of Center for Global Health and Quality at Georgetown University making a point on the Business Process for Impact model to the representatives of the county health management team led by deputy governor Hamilton Orata (center) in the presence of the NACC CEO Dr. Nduku Kilonzo (2nd left) during the inception visit in Homabay County.[/caption] BPI will see data driven decision making in all levels of health system, promoting innovation and develop systematic linkage of Communities of Practice (CoPs), creating energetic and empowered layers in both private and public sector from the grassroots level that will inform the top county management in making decisions that will promote community prevention and care delivery in HIV that will eventually heighten the attainment of the Universal Health Care. According to Prof. Mark Dybul, a Co-Chair of Center for Global Health and Quality at Georgetown University, Kenya has tremendously achieved in various innovations and the BPI approach will go a long way in bridging the gap to building mechanisms that will capture such innovations through coordination, information sharing and make use of the available data that will build accountability mechanisms and reporting in HIV response specifically among the AYPs. During the courtesy call to Homabay County government, the National AIDS Control Council CEO, Dr. Nduku Kilonzo reiterated the benefits of the model in HIV response in the counties saying that “it will not only coordinate external partners but also bring coordination within communities and strengthen communication across different level of government – a two-way communication between communities and the governance leadership”. Drawing from effectiveness in networking Communities of Practice (CoPs) in healthcare, BPI will identify and develop formal networks from various professional disciples and existing service delivery structures such as Comprehensive Care Clinics that provides comprehensive care where people living with HIV and AIDS go for holistic care and management, creating a two-way flow of data and information. During the pilot phase, the CoPs who have focus on HIV programming for the Adolescents and Young People (AYP) will be drawn from various stakeholders including community based organizations, community health workers, groups and networks of persons living with HIV or young people, non-government organizations and health providers including nurses and public health officers, either in their various homogenous groups or as mixed groups. The BPI will use the Human Centered Design (HCD) in developing the CoPs in the counties.  HCD is a concept that is gaining momentum globally as it seeks to accelerate the development of locally effective solutions as seen in international health and development projects such as family planning and comprehensive sanitation systems.  Currently, in Kenya, the use of HCD methods in public health remains minimal yet its broader application of HCD to CoPs of providers and policymakers has yielded important results globally. The use of HCD to enhance the use of data that will boost development and adoption of locally relevant innovations for health in the two counties and a model that is expected to be applied in other counties in Kenya. Currently, NACC has made available Kenya HIV situation room in all counties and is accessible to county leadership and programmers. The Kenya HIV situation room facilitates tracking of key HIV indicators at national and county levels and is also configured to mine data from key monitoring and evaluation systems in Kenya such as DHIS and other public and private sector systems.  BPI will leverage on the system to help find solutions, communicate action and seek innovative ways to ensure that there is consistent action towards results in HIV response among the AYPs, through networking and providing opportunities that will drive systematic change and accelerate better health outcomes that will eventually promote UHC. During the inception visit in Kiambu and Homabay counties the NACC team was led by CEO Dr. Nduku Kilonzo and the Georgetown University Medical Center was presented by Prof. Mark Dybul, a Co-Chair of Center for Global Health and Quality at Georgetown University, Prof. Susan Kim and Stephen Kretschmer, an expert consultant on Human Centered Design.  The visits also included Mbagathi Hospital Comprehensive care clinic and the AHF Center of Comprehensive Care Clinic in Nairobi’s Eastleigh, located east of the capital’s central business center and WOFAK – an NGO that is in the forefront in fighting HIV and AIDS in Homabay and finally paid the courtesy call to the Homabay County Commissioners office.

NACC calls for inclusion of HIV in the NHIF to attain Universal Health Care Talks on modalities of implementing Universal Health Coverage have gained momentum, so has the National AIDS Control Council similarly embarked on a process of ensuring HIV and AIDS is included in the Universal Health Coverage. The Council has constituted a multi sectoral coordination team to aid in voicing the need to have HIV and AIDS condition included in the National Health Insurance Fund (NHIF) in an effort towards attaining Universal Health Coverage. Currently health care related to HIV and AIDS is partly absorbed from the opportunistic infection perspective given that ARV are publicly provided by the government. However, the full and direct HIV and AIDS spectrum of treatment is not included due to high cost of retroviral therapy largely supported by donor funds. The Ministry of Health has already put in place a Rapid Results Initiative (RRI) to fast track the implementation of Universal Health Coverage which is one of the pillars of the Governments Big Four Agenda. Others pillars being Housing, Manufacturing, and Food Security. Anchored on Four Pillars the National AIDS Control Council coordination and reporting model seeks to guide the realization of Universal Health Care with the Inclusion of HIV and AIDS as well as People Living with HIV in the essential benefits package. Through the model, a replica of a similar coordination structure by the Ministry of Health, The NACC will be reporting to the Ministry in a well laid down mechanism up to the Presidency. The four committees namely communication, service delivery, HIV Financing and legal teams are critical in this process. The composition of the team includes representation drawn from the private sector, civil society, development partners and the community of People Living with HIV. [caption id="attachment_5172" align="alignleft" width="515"] Proposed Coordination structure and reporting mechanism Why leverage on HIV for Universal Health Care.[/caption]   The fight against HIV and AIDS like many other conditions is essential in the ongoing talks on the implementation of Universal Health Care. Cushioning People Living with HIV from expensive life-long anti-retroviral treatment certainly is critical in the realization of this Agenda. At the Centre of Universal Health Coverage is the issue of affordability. Thus Universal Health Coverage means people have access to health services required, not necessarily free but without suffering financial problems. It’s on this premise that the National AIDS Control Council is spearheading the inclusion of HIV response in the attainment of Universal Health Coverage through three pronged proposal under the rallying call of ‘Leaving no one behind’ in this important course.

1. Attaining Universal Health Coverage requires that People Living with HIV and AIDS are also included in the Social Health Insurance Scheme under the Social Protection theme.

Kenya has 1.6 Million People Living with HIV. This constituency cannot be left behind in the Universal Health Coverage reach. Today, HIV and AIDS accounts for 29% of annual deaths in the country. Besides, it contributes to 15% of the country’s disease burden. Thus including HIV Testing and Prevention services as well as Anti-retroviral therapy in the Universal Health Coverage essential package is important. This is envisaged to increase the contribution to the social health insurance as it will encourage more people to enroll through the National Health Insurance Fund.

2. Leveraging anti-retroviral therapy funding through the National Health Insurance to cover resources gaps and significantly accelerate achievements targets.

There’s a gap of approximately 280 USD per capita between essential Total Health Expenditure (THE) and the projected needs for ensuring 80% of the population has access to an essential benefit package for health. According to the Kenya National AIDS Spending Assessment 2017, there’s need to channel Ksh 47.02 Billion through a support mechanism to contribute to the risk pool of the national insurance scheme which is needed to support pooling of resources for Anti-Retroviral Therapy(ART). This essentially will bridge the funding gap, increase efficiency in money flows with reduced fragmentation and better link inputs with outcomes.

3. Attaining Universal Health Coverage demands that the rising epidemic of Non-Communicable Diseases (NCDs) is controlled.

Non-communicable diseases are on the rise contributing to 50% of all adult hospital admissions and 40% of adult deaths. Over the last decade their contribution to overall mortality has increased by more than 60% while that of HIV has decreased by the same amount. Kenya’s significant progress has been through a multi-sectoral approach. Therefore the most effective and efficient way for the Ministry of Health to invest in the integration of Non Communicable Diseases (NCDs) prevention in to HIV and AIDS. The integration should be geared towards optimal utilization of the existing HIV prevention infrastructure and modalities. This will promote better health and control escalation of Non Communicable Diseases associated costs to the national health insurance scheme.