A Senior Management Course for Health

Managers in Kenya

2nd EDITION July 2014

MODULE 1: Understanding foundations of the health

system in Kenya

Unit 1.4: Organization of the healthcare system and health services

Purpose

•This unit discusses the administrative structures of the health system and organization of health services in Kenya.

•It also explores the concepts of health sector reform and regulation of the health system.

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Objectives

•By the end of this unit, the participant should be able to:

•Describe how health services and systems are organised in general and in Kenya in particular.

•Describe the governance, management and coordination structures operating at all levels of health system in Kenya.

•Explain the roles and functions of these structures at different levels of health system in Kenya.

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OverviewThis unit will cover the following topics:

•Health systems organisation: general and in Kenya.

•Governance, management and coordination structures: national and county levels.

•Roles and functions of these structures at various levels of the health care system.

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Overview (Cont’d)

•National health policy framework: process and evolution.

•Health sector reforms: components and characteristics.

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Session 1.3.1

Health Systems Structures and Organisation

Organisation of Health Systems

•Health systems are organised into different forms in different countries.

•Health systems are organised based on government administrative levels.

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Organisation of Health Services in Kenya

The KHSSP III 2012 – 2017 defines the Kenya Essential Package for Health (KEPH) as consisting of the following cost-effective health services organised by:

•Type (4): promotive, preventive, curative & rehabilitative;

•Target group (cohorts – 5+1):

–Pregnancy and the new born (up to 28 days), early childhood (29 days – 59 months), late childhood and youth (5 – 19 years), adulthood (20 – 59 years), elderly (60 years and over), cross cutting interventions (all cohorts).

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Organisation of Health Services in Kenya (Cont’d)

Tiers or Levels (4):

– Tier 1: Community level;

– Tier 2: Primary Care level

– Tier 3: County level

– Tier 4: National level.

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Organisation of Health Services Delivery Illustrated

• Highly specialised health care, for area / region of specialisation

• Training and research services on issues of national importance

• Comprehensive in-patient diagnostic, medical, surgical and rehabilitative care, including reproductive health services

• Specialised outpatient services• Facilitate, and manage referrals from lower levels, and

other referrals• With other County Referral Facilities, form the County

Referral System

• Disease prevention and health promotion services• Basic outpatient diagnostic, medical surgical &

rehabilitative services • Inpatient services for emergency clients awaiting referral,

clients for observation, and normal delivery services• Facilitate referral of clients from communities, and to

referral facilities

• Facilitate individuals, households and communities adopt appropriate healthy behaviours

• Provide agreed health services• Recognise signs and symptoms of conditions requiring

referral,• Facilitate community diagnosis, management &referral.

COUNTY REFERRAL FACILITIES

NATIONAL REFERRAL FACILITIES

Referral services

Referral services

Referral services

PRIMARY CARE FACILITIES

LEVELS DESCRIPTION FOCUS

COMMUNITY UNITS

All district, sub-district hospitals, including NGO / private, form network of County Referral Services in a county

All PGH’s, and National ReferralsAre general, regional, or discipline specialists

All dispensaries, health centres, clinics, maternity homesCatchment area: 30,000 persons

No physical facilities

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Health Systems Structures

Health systems comprise of:

•Governance structures;

•Management structures;

•Coordination/partnership structures.

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Structures in Kenya’s Health SystemCoordinatio

n

Government of Kenya, KHSSP, 2012 - 2017

JOINT INTER AGENCY COORDINATING COMMITTEE

HEALTH SECTOR COORDINATING COMMITTEE

COUNTY HEALTH STAKEHOLDERS FORUM

SUB COUNTY HEALTH STAKEHOLDERS FORUM

COMMUNITY HEALTH COMMITTEE

Technical Working Groups & their ICCs

COUNTY EXECUTIVE COMMITTEE

COUNTY DEPARTMENT FOR HEALTH

County Hospital Board

Primary Care Facility Management Committee

NATIONAL MINISTRY OF HEALTH

COUNTY HEALTH MANAGEMENT TEAM

County Hospital Management Team

SUB COUNTY HEALTH MANAGEMENT TEAM

Primary Care Facility

Management Team

COMMUNITY UNIT

Governance Stewardship

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Activity 1.3.1.1 Brainstorming (15 minutes)

Participants work in pairs to brainstorm on the following:

– What is governance?

– Describe two examples of experience of governance in your health institution - one good

and one bad.

Sample a few pairs of participants to share definitions and

experiences in plenary.COPY TO TLA 1.3.4

Session 1.3.2

Governance Structures in Health System Management

Governance Structures

Definition of Governance:

•Governance entails processes, mechanisms and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations (Omosa et al 2006).

•It is the process through which elements in society wield power and authority and influence and enact policies and decisions concerning public life and economic and social development (Governance working group 1996).

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Governance Simplified is……TAPE

Tran

spar

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:

mak

e av

aila

ble

or

mor

e wid

ely

know

n

Accountability:

required or expected

to justify actions or

decisionsEquity: the quality

of being fair and

impartial Pro

bity: t

he qualit

y

of being h

onest and

mora

lly u

pright

T.A.P.E.

Definitions: Oxford English Dictionary 17

Governance Structures (Cont’d)

•The governance structures of the health system are created to provide an oversight role to the management structures.

•They are supposed to provide voice to the citizens to ensure that people’s rights of access to quality health care are respected.

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Objectives of Governance and Management Structures

•Improved voice and accountability: through ensuring that their issues and aspirations are being raised, and incorporated into the priorities for the health sector.

•Political stability and lack of violence: through ensuring that actions of the health managers are appropriately articulated to the population.

•Government effectiveness: through appraising performance of stewardship functions exercised by the management levels by participating in, and approving annual work plans and reports of performance.

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Objectives of Governance and Management Structures (Cont’d)

•Regulatory quality: through ensuring that expected regulatory functions are carried out to the benefit of the population.

•Rule of law: through ensuring that legal framework is adhered to, in all actions of the sector.

•Control of corruption: through monitoring of implementation of health activities.

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Governance Structures for the Health System in Kenya

•At the national level, the governance structure for the health system is the Parliamentary Committee on Health.

The committee members are yet to be configured in the new government structure

•At the county level, a health (or social) committee shall be set up, to provide overall governance for health in the county.

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Session 1.3.3

Management Structures in Health System

Management

Management Structures

•The sector stewardship and management framework relates to how the government, through the Ministry of Health, shall organise itself to coordinate and lead the delivery of the defined health package.

•Management structures exist from national to community levels.

•National level structures exist at all levels of the Ministry of Health

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Organisational Structure of National Health Services

CABINET SECRETARY FOR HEALTH

PRINCIPAL SECRETARY FOR HEALTH

DIRECTOR GENERAL FOR

HEALTH

Semi Autonomous Government Agencies

Resource Centre

Disaster Management

Directorate for Health

Promotion and Disease

Prevention

Directorate for Health Curative

and Rehabilitation

Directorate for Sector Planning and Governance

Directorate for Administration

National Hospitals

Child HealthReferral Services

Health Planning

Financial Mgt.

KEMSA

KEMRI

Reference Labs

NHIF

PPS

NBTS

NACC

Disease Control

Animal Health

Nutrition

Health Promotion & Community

Care

Environment and Hygiene

Control

NCD & Injury Control

Pharmaceutical

Laboratory

Clinical Services

Nursing Services

Quality Assurance

Reproductive Health

Sector Coordination

Health Information

Sector Governance

HR Management

Infrastructure Mgt.

Procurement

Supply Chain Mgt.

Logistics Mgt.

Internal Audit

HR Administration

AccountsSEN

IOR

MA

NA

GEM

EN

T

TO

P M

AN

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National Level Management Functions

•National planning and policy formulation;

•Enforcement of standards;

•Ensuring commodity security;

•Performance monitoring;

•Capacity strengthening;

•Resource mobilisation;

•Operational and other research;

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National Level Management Functions (Cont’d)

•Monitor quality and standards of performance of the national and county governments in the provision of health services;

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Management Structures at County Level

•The Constitution of Kenya 2010 has assigned the larger portion of delivery of health services to the Counties with exception of National Referral Services.

•Governance units at County level include:

₋ County department responsible for health;

₋ Hospital boards;

₋ Primary care management committees;

₋ Community health committees.

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Organizational Structure of County Health Services

Resource Centre

Disaster Management

Directorate for Health Promotion

and Disease Prevention

Directorate for Curative and

Rehabilitation

Directorate for Planning and Governance

Directorate for Administration

Child Health Referral Services Health Planning Financial Mgt.

Disease Control

Animal Health

Nutrition

Health Promotion & Community Care

Environment and Hygiene Control

NCD & Injury Control

Pharmaceutical

Laboratory

Clinical Services

Nursing Services

Quality Assurance

Reproductive Health

Sector Coordination

Health Information

Sector Governance

HR Management

Infrastructure Mgt.

Procurement

Supply Chain Mgt.

Logistics Mgt.

Internal Audit

HR Administration

Accounts

COUNTY DIRECTOR FOR HEALTH

Sub County Health Management Teams

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County Level Management Functions

• Delivering county health services;

• Licensing and accrediting non state health service providers (HSPs);

• Financing of county level health services;

• Maintaining, enhancing and regulating asset development and HSPs operations;

• Approving county special partnership agreements (SPAs) for county HSPs;

• In collaboration with national government, gazette regulations for community managed health supplies to be implemented at county level;

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County Management Functions (Cont’d)

•Planning, investment and asset ownership function of public health facilities;

•Developing an investment plan to enable fulfillment of the highest attainable right to health and document, annually, progress on fulfillment as required by the Constitution;

•Asset financing and ownership;

•Channeling public and other funds to develop health facilities.

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Technical Management of Health at County

This comprises of:

•Office of the County Executive officer of Health;

•Office of Head - Health department;

•Other offices that shall be approved within the county by the governor in consultation with the county assembly.

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County Technical Management Functions

•Strategic and operational planning, supportive supervision, monitoring and review of health service delivery in the County;

•Coordinate delivery of health services in the County;

•Provide a linkage with County Executive officer, Head of health department and other actors to facilitate health sector dialogue at the County;

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County Technical Management Functions (Cont’d)

•Provide leadership and stewardship for overall health management in the County, through building linkages with, and putting in place influencing strategies for health related sector’s in the County, such as education, roads, gender, nutrition, etc.;

•Mobilise resources for County health services;

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Facility Management StructuresHospital Management Teams (HMTs) exist in all types of hospitals. In general, the membership is made up of the heads of the following departments:

•Nursing;

•Medical;

•Surgery;

•Obstetrics and Gynaecology;

•Pharmacy;

•Laboratory; and

•Administration. 34

Facility Management Functions

• Preparation of hospital work plans, e.g., annual operation plans;

• Ensuring equitable distribution of resources within the facility, e.g., supplies, staff within the departments;

• Ensure that quality services are offered to the clients in the hospital;

• Ensure that proper records and information are maintained;

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Facility Management Functions (Cont’d)

•Proper financial management, e.g., ensuring proper budgeting and utilisation of funds such as the Facility Improvement Fund (FIF);

•Commodities and supplies management;

•Infrastructure and equipment management;

•Emergency preparedness and timely response;

•Human resource management and development.

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Management Structures at Primary Care Facilities

•The management teams at the primary care facilities are composed of an officer in-charge ,a clinical officer, nurse, public health officer.

•The link person between the level 2 and 3 facilities and the community is the Community Health Extension Worker (CHEW).

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Management Structures at the Community Level

•At community level, there are no formal management structures. Management is provided by the County, while the health facilities provide the supervisory function.

•The link person between the facilities and the community is the Community Health Extension worker (CHEW).

•CHEWs are supported by CHWs/ CHVs

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Understanding the Structure and Functions of the Health System in

Devolution

National County

Kenyatta National Hospital (KNH)

County referral Health Services

Moi Teaching and Referral Hospital (MT&RH)

Sub-county Health Services

Kenya Medical Training College (KMTC)

Environmental Health Services

Kenya Medical Supplies Agency (KEMSA)

Communicable Disease Control

National Hospital Insurance Fund (NHIF)

Nutrition

National Quality Control Laboratory (NQCL)

Family Planning Maternal and Child Health

National Blood Transfusion Services

Health Education

Exclusive Functions of National and County Departments of Health

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Exclusive Functions of National and County Departments of Health (Cont’d)

National Functions County

Pharmacy and Poisons Board Health Informative System

National Public Health Laboratory Food Control Administrative Services

Government Chemist Vector Borne Disease Control

Radiation Protection Board Communicable Disease Control and Management

Kenya Medical Research Institute (KEMRI)

County Administration and Planning

Mathari Mental Hospital Primary Health Services

Spinal injury Hospital Rural Health Training and Demonstration Centre

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National County

Resource mobilisation Resource mobilisation

Quarantine administration Quarantine administration

Disaster preparedness Disaster preparedness

Emergencies/outbreaks Emergencies/outbreaks

Partnerships (Public and Private) including intergovernmental relations

Partnerships (Public and Private) including intergovernmental relations

Planning and budgeting Planning and budgeting

Legislation Legislation

Concurrent Functions

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National CountyMonitoring and Evaluation Monitoring and EvaluationDisease prevention & control (policy & coordination)

Disease prevention & control

Procurement of health products and technologies

Procurement of health products and technologies

Health Information systems

Health information systems

Health financing (Policy & regulation)

Health financing (implementation)

HRH management and development

HRH management and development

Concurrent Functions (Cont’d)

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Residual functions

Regulation of Health Products & Technologies

Regulation, setting norms and standards

Regulation of Health Professionals & Services (Boards & Councils)

Port health services

International health relations and diplomacy

International Health Regulations (IHR)

Regulation of medical training (tertiary & middle level)Health Research

Food Safety Policy & Regulation

Regulation of the Veterinary profession ????

Residual Functions (National level)

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• The transfer of assigned functions will take place

over time.

• The 6th Schedule of the Constitution provides for a

3 year period of transfer of functions.

• Function assignment and transfer is not a one-time

exercise, but rather an ongoing policy dialogue.

Implementation of Devolved Functions

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•Transition period means the period between commencement of the Transition Act (2012) and three years after the first elections under the Constitution (county assemblies in place)

•Two phases:

1. Phase One: the period between commencement of the Act and the date of the first elections under the Constitution

2. Phase Two: the period between the date of the first elections and three years after the elections

Transition Period

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• HR mapping;

• Development of KHSSP/MTP;

• Development of norms and standards;

• Development of KEPH;

• Development of capacity building packages-induction manual, change management strategy, county health systems etc.;

• Development of county health facts sheet;

• Inventory of assets and liabilities;

Ongoing Devolution Processes in the Health Sector

Dialogue amongst Council of Governors, CIC, TA, CRA, Treasury and the Health Sector on the following salient issues in delivery of the right to health under devolved systems:

1. Procuring and managing essential health products and technologies;

2. Management of Cross-County Hospital Services; 3. Ensuring maintenance of standards in

procurement and administration of special health commodities for public health programmes;

4. Management of the Health Sector Services Fund.

Ongoing Devolution Processes in the Health Sector (Cont’d)

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• High level committee on devolution (Function Assignment and Competency Team)

– established in October 2012 by the Ministry of Health with clear TORs to spearhead the devolution process in the Sector by addressing priority actions to ensure smooth transition.

• TWG on devolution

– formed to operationalise the Terms of Reference and to drive the technical work of the Function Assignment and Competency Team.

Progress So Far in Devolution

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Session 1.3.4

Coordination/Partnership Structures in Health System Management

Coordination/Partnership Structures

•Partnership means voluntary joint action or decision-making in a harmonious and supportive way, for a common goal and outcome.

•It involves all players or stakeholders who, through their actions, will influence health services delivery.

•In the health sector, partnership is guided by an overall instrument, the Code of Conduct, which defines roles and obligations of different sector actors towards attaining its overall goal and objectives. 51

Coordination/Partnership Structures (Cont’d)

•The health sector partnership in Kenya is guided by the Kenya Health Sector-Wide Approach (KHSWAp) introduced in 2005.

•The SWAp principles reflect those set out in the Paris Declaration on Aid Effectiveness, built around country ownership, alignment, harmonisation, managing for results, and mutual accountability.

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Coordination/Partnership Structures (Cont’d)

•It is based on having the sector working around:

– One planning framework;

– One budgeting framework;

– One Monitoring framework.

•Partnership structures are necessary as they provide opportunity for stakeholders to share experiences, expertise and lessons learnt.

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Partnership Structures in the Health Sector

• Fostering partnerships in improving health and delivering services is critical to the successful achievement of the objectives of the health sector.

• The health sector has put in place a multi-layered sector coordination framework that consists of the following structures:

₋ Joint Interagency Coordinating Committee (JICC);

₋ Health Sector Coordinating Committee (HSCC);

₋ Health Sector Steering Committee (HSSC);

₋ Interagency Coordinating Committees (ICCs, for technical issues);

₋ County Stakeholder Forums (CHSF). 54

National Level Coordination Framework

Development Partnership Forum (DPF)

Development Partners Consultative Group (DCG)

Development Partnership Forum (DPF)

Service Delivery

Aid Effectiveness GroupSector Working Groups (SWGs)

Joint Inter Agency Coordinating Committee

Health Sector Coordinating Committee

Steering Committee

Sector Technical CommitteesInter Agency Coordinating

CommitteesHuman Resource for

Health

Health Infrastructure

Health Information

Health Leadership

Health Financing

Health Products

Inter Agency Coordinating Committees

Inter Agency Coordinating Committees

Inter Agency Coordinating Committees

Inter Agency Coordinating Committees

Inter Agency Coordinating Committees

Inter Agency Coordinating Committees

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Sector Coordinating Framework

Joint Inter Agency Coordinating Committee (JICC)

Health Sector Coordinating Committee (HSCC)

County Health Stakeholders Forum

Health Sector Steering Committee Secretariat

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Functions of Joint Inter-Agency Coordinating Committee

•Provides leadership for overall sector policy direction;

•Approves the Kenya Health Sector Policy and Strategic Plans;

•Undertakes advocacy for the health sector;

•Leads resource mobilisation efforts for the health sector.

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Functions of ICCs

•Support management of key action points as

identified by the HSSC;

•Facilitate formation of working groups or task

forces as required to address key issues and tasks;

•Coordinate with and oversee work of appointed

working groups and task forces.

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59

Membership of ICCs

• Government of Kenya, represented by head of department responsible for the area of the ICC;

• Representative of HSCC steering committee secretariat;

• Heads of related divisions in the responsible department;

• Technical advisors nominated by government;

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Membership of ICCs (Cont’d)

• Development partners, represented by partners supporting the areas of the ICC;

• Technical advisors nominated by development partners;

• Implementing partners, represented by partners supporting the areas of the ICC;

• Technical advisors nominated by implementing partners.

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County Stakeholder Forums

•The County Health Stakeholder Forums (CHSF) provide the oversight role in the provision of the health services at the County level.

•The County Governor provides the chair for the Forum.

•The members of the Forum are drawn from relevant government departments and implementing partners, including faith-based and non-government organisations.

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County Stakeholder Forums

•The County Health Stakeholder Forums (CHSF) provide the oversight role in the provision of the health services at the County level.

•The County Governor provides the chair for the Forum.

•The members of the Forum are drawn from relevant government departments and implementing partners, including faith-based and non-government organisations.

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Functions of County Stakeholder Forums

•Foster collaboration among the health sector stakeholders by providing a platform for discussion and dialogue on health-related issues;

•Review and approve the respective annual plans to ensure that there is harmonisation among health sector stakeholders.

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