Kenya in 2013 formally decentralized a series of governance responsibilities to its 47 counties, including the provision of health care. But while the original goal of devolution was to improve efficiency in service delivery and permit greater ownership and engagement at the local level, in the health sector this has not translated as well as anticipated. Rather, devolution has caused major interruptions in the supply chain and in the collection of data against health indicators which could suggest an impact on the programs paid for with Global Fund grants.
In 2014, this translated into a major stockout of first-line TB drugs at county level. Without clear directives from the Ministry of Health, the county governors used the funds that would have been spent on these drugs for other things. After exhausting the national reserve, Kenya was forced to make an emergency request for a loan of drugs from Malawi, and had to ask the Global Drug Facility for assistance to procure the equivalent of a year’s supply – worth some $8 million.
According to John Ochero, portfolio manager at the Global Fund for Kenya, a series of measures have been taken to ensure this problem does not reoccur.
“For Global Fund grant funds, procurement will continue being done centrally as it was before – i.e. through the appointed Procurement entity / agent (KEMSA) so there will be no adverse effect,” he told Aidspan. “Implementation of the other areas (HSS, etc.) will follow the same principle: working through the MoH and the health departments of the counties directly without the funds flowing through the county accounts. So we have no risks anticipated in the short run.”
His optimism, however, is not shared by everyone.
“If devolution has an impact on the health system as a whole, it also has an impact on the Global Fund programs,” said Nelson Otuoma, executive director of the Nephak network of people living with HIV, which is a civil society representative on the Kenyan CCM.
To see whether Otuoma’s concerns were well-founded, the KCM carried out a series of field visits in May and June, which included stops in the western counties of Homa Bay and Vihiga. The oversight committee produced a report, a copy of which was shared confidentially with Aidspan, that noted stockouts in a number of the 16 facilities visited.
The report noted that “stockouts of anti-malaria drugs were glaring; in the two counties there was [also] inadequate supply of nutritional supplements and Isoniazid,” a first-line TB drug.
While procurement for anti-malarials is the purview of the central government, county governments must handle any additional stock needs to respond to epidemics or stockouts. The KCM’s report, in noting the stock management challenges, recommended a new strategy to engage with county governments to ensure that capacity and management deficits do not preclude them from engaging in wider discussions about strategic stock management.
Stock management is not just strategic, as the western counties know too well: it’s also sometimes the difference between life and death. More than 40 people died in a malaria epidemic between April and July in Kakamega, just north of Vihiga. Low stock levels in the health centers and public hospitals were blamed for the entirely preventable deaths, according to Evelyn Kibuchi, who leads the Kenya NGO consortium, Kanco.
“The resources are there,” she lamented. “These deaths could have been avoided.”
In the joint HIV/TB concept note submitted by Kenya in early 2015, the need to reinforce pharmacy capacity at the county level, specifically in terms of procurement, was also flagged. Around $180,000 of grant funds will be allocated to improve training in supply chain management to improve the understanding of needs and thus plan better for contingencies and outbreaks. Pharmacies will, going forward, also be invited to quarterly planning meetings to share information on drug stocks, both in terms of needs but also to share some of the challenges they are confronting.
Delays and gaps in monitoring and evaluation of programs
The KCM report also highlighted problems in data collection, monitoring and evaluation. Data collected by community volunteers was “not comprehensively captured in DHIS,” the report found.
Bernard Langat, head of the Global Fund program at the Finance Ministry (the Global Fund PR) also flagged this as a particularly critical issue.
“The biggest problem is the delay in reporting, and incomplete data” related primarily to stock usage, he told Aidspan. “If you don’t know what you consume it’s difficult to give a supply based in reality on the ground. You have to use historical data which doesn’t show the reality.”
The problem, according to Peter Messoh, a finance officer in the Health Ministry, is the failure by a number of counties to even create their own M&E departments. Even in those counties with an M&E department, reporting is ongoing – but at a glacial pace.
“And this has an impact on the results reported by the government to the Global Fund,” he said.