Mapping Report on Decentralized Government Funding available for Health in Kenya and

Organizations involved in Monitoring

May 2011

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Table of Contents

TABLE OF CONTENTS .......................................................................................................................................... 2 LIST OF TABLES................................................................................................................................................... 3 LIST OF FIGURES ................................................................................................................................................. 3 ACKNOWLEDGMENT............................................................................................................................................ 5 LIST OF ABBREVIATIONS ..................................................................................................................................... 6 EXECUTIVE SUMMARY ........................................................................................................................................ 8 CHAPTER ONE ................................................................................................................................................... 10 INTRODUCTION AND METHODOLOGY................................................................................................................ 10 1.0 INTRODUCTION ............................................................................................................................................ 10 1.1 PURPOSE OF THE MAPPING ........................................................................................................................... 11 1.2 APPROACH AND METHODOLOGY................................................................................................................. 12 1.3 DATA COLLECTION METHODS..................................................................................................................... 12 CHAPTER TWO .................................................................................................................................................. 13 LEGAL FRAMEWORK FOR DECENTRALIZED HEALTH FUNDS IN KENYA ............................................................ 13 2.0 INTRODUCTION ............................................................................................................................................ 13 CHAPTER THREE ............................................................................................................................................... 16 MANAGEMENT AND IMPLEMENTATION OF DECENTRALIZED HEALTH FUNDS ................................................... 16 3.1 DIRECT DECENTRALIZED HEALTH FUNDS ................................................................................................... 16 3.1.1.0 HEALTH SECTOR SERVICES FUND (HSSF)............................................................................................. 16 3.1.1.1 HSSF MANAGEMENT ............................................................................................................................ 16 3.1.1.2 DETERMINING FUNDS TO BE ALLOCATED TO DISPENSARIES AND HEALTH CENTRES............................. 18 3.1.1.3 FLOW OF FUNDS .................................................................................................................................... 19 3.1.1.4 REPORTING............................................................................................................................................ 19 3.1.1.5 ACCOUNTABILITY IN THE MANAGEMENT OF FACILITIES ....................................................................... 20 3.1.2 HOSPITAL MANAGEMENT SERVICES FUND (HMSF)................................................................................. 21 3.1.2.1 IMPLEMENTATION OF THE HMSF .......................................................................................................... 21 3.1.2.2 HMSF MANAGEMENT STRUCTURE AND RESPONSIBILITIES .................................................................. 21 3.1.2.3 CRITERIA FOR RESOURCE ALLOCATION ................................................................................................ 24 3.1.3 THE HIV AND AIDS FUND ....................................................................................................................... 25 3.1.3.1 KENYA HIV AND AIDS DISASTER RESPONSE PROJECT (KHADREP) .................................................. 25 3.1.3.2 TOTAL WAR AGAINST AIDS.................................................................................................................. 25 3.1.3.3 DISBURSEMENT PROCEDURES AND REPORTING..................................................................................... 28 3.1.3.4 GRANTS AWARDS.................................................................................................................................. 28 3.2.0 INDIRECT DECENTRALIZED FUNDS ........................................................................................................... 33 3.2.1.1 CONSTITUENCY DEVELOPMENT FUND (CDF)........................................................................................ 33 3.2.1.2 CDF SUPPORT TO HEALTH SECTOR....................................................................................................... 35 3.2.1.3 THE CDF HEALTH SECTOR PROJECTS CHALLENGES ............................................................................. 35 3.2.2 LOCAL AUTHORITIES TRANSFER FUND (LATF) ....................................................................................... 36 3.2.2.1 LATF STRUCTURE AND ALLOCATION CRITERIA ................................................................................... 36 3.2.2.2 LOCAL AUTHORITY EXPENDITURE ON HEALTH PROJECTS .................................................................... 37 3.3.3. ECONOMIC STIMULUS PACKAGE (ESP) ................................................................................................... 38 CHAPTER FOUR ................................................................................................................................................. 40 MONITORING OF DECENTRALIZED FUNDS TO ENSURE ACCOUNTABILITY......................................................... 40 4.0 INTRODUCTION ............................................................................................................................................ 40 4.1 GOVERNMENTAL PERCEPTION ON MONITORING OF DECENTRALIZED HEALTH FUNDS ............................... 40 4.2 ORGANIZATIONS INVOLVED IN MONITORING ............................................................................................... 41 4.3 SNAP SHOT OF ORGANIZATIONS MONITORING DECENTRALIZED FUNDS ..................................................... 41 4.4 CHALLENGES IN MONITORING AND EVALUATION OF DEVOLVED HEALTH FUNDS......................................... 47 CHAPTER FIVE................................................................................................................................................... 49 CONCLUSION AND RECOMMENDATIONS............................................................................................................ 49 5.0 CONCLUSION ............................................................................................................................................... 49 5.2 RECOMMENDATIONS ................................................................................................................................... 52 ANNEX 1: SAMPLE LIST OF HEALTH CENTRE THAT RECEIVED HSSF................................................................. 54 ANNEX 2: THE EVALUATION PROCESS AND EVALUATION CRITERIA................................................................. 55 ANNEX 3: SAMPLE OF HEALTH FACILITIES SUPPORTED BY CDF IN FY 2009-2010 .......................................... 58 ANNEX 4: LIST OF HEALTH PROJECT FUNDED OR PLANNED TO BE BY LATF IN FY 2009/2010........................ 60

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List of Tables Table 1: Health Centers and Dispensaries Criteria for Resource Allocation ………………..18 Table 2: Hospital Criteria for Resource Allocation ………………………………………….24 Table 3: How the additional funding to TOWA is broken ………………………..................26 Table 4: Essential commodities supported by TOW……… ………………………………..27 Table 5: Timelines in Receiving and Awarding of Proposals ……………………………….29 Table 6: Actual Capital Expenditure Distribution by Project Type FY 2008 – 09 ………….37 Table 7: Allocations under ESP 2009/2010 and 2010/2011 ……………………..................38 List of Figures Figure 1: Flow of HSSF Funds ………………………………………………………19 Figure 2: HSSF Reporting Process ……………………………………………………….20 Figure 3: Proposal Flow for Civil Society/Private Sector Organizations/Research Institutions ………………………………………………………………………………………..30 Figure 4: Financial Mechanism and Flow of Funds under the TOWA Project ……………..31

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Mapping Report on Decentralized Government Funding available for Health in Kenya and Organizations involved in Monitoring

@ May 2011

For enquiries, kindly contact:

Health Rights Advocacy Forum (HERAF) Muthangari Road off Gitanga Road, Valley Arcade

P.O. Box 100667, 00101 Nairobi, Kenya.

Tel: +254-20-3861482/3 Fax: +254-20-3861483

Email: info@heraf.or.ke Website: www.heraf.or.ke

Disclaimer: The views expressed in this report under no circumstances should they be regarded as reflecting the position of Open Society Initiative for Eastern Africa (OSIEA)

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Acknowledgment Health Rights Advocacy Forum (HERAF) wishes to acknowledge contributions from institutions and individuals who contributed significantly to successful completion of this study. First and foremost we are grateful to Open Society Initiative for Eastern Africa (OSIEA) in collaboration with the Public Health Watch project (PHW) of the Open Society Foundation’s Public Health Program for their financial support without which this study could not have been carried out. We owe great gratitude to HERAF staff and the research assistants (David Nderitu and James Mugo) for their tireless efforts towards making sure that this study was a success. Special thanks go to Paul Kuria and Winfred Lichuma who provided useful technical support that ranged from the study design to critiquing the report. We are equally grateful for useful comments that OSIEA technical staff provided to improve the quality of this report. We say a big thank you! Finally, we wish to thank all government officials, devolved funds committee members, civil society organisations and all persons who in either one or another way participated and contributed to the successful completion of this study. Your expertise, resources, and guidance have been invaluable.

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List of Abbreviations

AOP Annual Operational Plan

CACC Constituency AIDS Control Committee

CBK Central Bank of Kenya

CBO Community Based Organisation

CDC Centre for Disease Control

CDF Constituency Development Fund

CfP Call for Proposals

CSO Civil Society Organisation

DFID Department for International Development

DMOH District Medical Officer of Health

DMST District Medical Services Team

DTC District Technical Committee

ESP Economic Stimulus Package

FBO Faith Based Organisation

FMA Financial Management Agency

GJLOS Governance, Justice, Law and Order

GOK Government of Kenya

H/DMC Health Center/ Dispensary Management Committee

HERAF Health Rights Advocacy Forum

HMC Hospital Management Committee

HMSF Hospital Management Services Fund

HSSF Health Sector Services Fund

ICC Inter-Agency Coordination Committee

IDA International Development Agreement

JAPR Joint HIV&AIDS Programme Review

KHADREP Kenya HIV and AIDS Disaster Response Project

KHPF Kenya Health Policy Framework

KNASP Kenya National AIDS Strategic Plan

KNHSSP Kenya National Health Sector Strategic Plan

LA Local Authorities

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LATF Local Authority Transfer Fund

MAP Multi-Country AIDS Programme

MOF Ministry of Finance

MOH Ministry of Health

MOMS Ministry of Medical Services

MOPHS Ministry of Public Health and Sanitation

MP Member of Parliament

MTEF Medium-Term Expenditure Frameworks

NACC National Aids Control Council

NCCK National Council of Churches of Kenya

NGO Non Governmental Organisation

NHSC National Health Services Committee

NHSSP National Health Sector Strategic Plan

NRB Nairobi

OP Office of President

OSF Open Society Foundation

OSIEA Open Society Initiative for Eastern Africa

PDPHS Provincial Director of Public Health and Sanitation

PHMC Provincial Health Management Committee PHMT Provincial Hospital Management Team PHW Public Health Watch Project QIP Quarterly Implementation Plans

TOWA Total War against AIDS

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Executive Summary The past two Public Expenditure Tracking Surveys1;2 estimated that only about 44 percent of the budgetary allocation by the government (including commodities) reach level 2 (dispensaries) and level 3 (health centres). To overcome this challenge, the government has embarked on institutional reforms within the health sector in order to improve the country’s health care delivery systems. One of the reforms introduced is the adoption of “devolution” approach that allocates funds and responsibilities for delivery of health care to dispensaries, health centres and hospitals3. The process of instituting the health financing reforms has however, been confronted by a number of challenges. These include poor understanding of the devolved health sector funds and lack of committed or incapacitated champions to monitor the funds. It is on this background that, Open Society Initiative for Eastern Africa (OSIEA) in collaboration with the Public Health Watch Project (PHW) of the Open Society Foundation’s Public Health Program, commissioned a study to map decentralized funds available for health services in Kenya and document the organizations engaged in monitoring the utilization and accountability of these funds. This is with the aim to equip civil society groups, particularly those representing marginalized and underrepresented communities, with the tools, information, arguments and capacities to hold governments and national leaders accountable to uphold international standards and policies in health. It emerged from the study that Kenya health sector has been guided by Kenya Health Policy Framework, (KHPF) 1994 – 2010. This was implemented through the Implementation Plan covering the period between 1995 and 1998 and two successive 5 - Year National Health Sector Strategic Plans (NHSSP). The first NHSSP covered the period 1999 to 2004 and the second (NHSSP II), 2005 to 2010. KHPF identified decentralization as one of the areas that needed reform in the period between 1994 and 2010. In this regard a national policy concerning decentralization in the health sector was to be prepared, adopted and implemented. In addition to decentralization, KPHF identified reforms in health care financing as urgent. The gazette notice of the Health Management Fund (HMF)4 was issued in 2007 to enable channeling of funds directly to health facilities (dispensaries, health centres and hospitals). After the contentious 2007 national election and the formation of Grand Coalition Government the then Ministry of Health was split in two namely the Ministry of Public Health and Sanitation and Ministry of Medical Services. As a result the legal notice had to be revised to accommodate the split. Hence HMF was split into the Health Sector Services Fund (HSSF) and the Hospital Management Services Fund (HMSF). HSSF is a direct transfer of funds to dispensaries (level 2) and health centres (level3) while HMSF is a direct financing to level district (level 4) hospitals and Provincial General (level 5) hospitals. The health sector has also benefited from the HIV and AIDS fund. The National

1 Government of Kenya, (2009) MOH Public Expenditure Tracking Survey 2008; Nairobi: Government Printer 2 Government of Kenya, (2009) Kenya Household health Expenditure and Utilisation Survey Report 2007; Nairobi: Government Printer 3 Government of Kenya (2008) Ministry of Health Medium Term Plan 2008 – 2012; Nairobi: Government Printer 4 Government of Kenya (2007) Government Financial Management (Health Management Fund) Regulations, Legal Notice No. 123; Nairobi: Government Printer

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Aids Control Council (NACC) disburses HIV and AIDS funds through Calls for Proposals (CfP). The other devolved funds that have benefited the health sector include the Constituency Development Fund (CDF), Local Authority Transfer Fund (LATIF) and Economic Stimulus Package (ESP). These three funds have provided mechanisms for increasing access to health services for all including the poor. New constructions were fuelled by the availability of the Constituency Development Fund (CDF). The ESP that was channeled through the Ministry of Public Health and Sanitation5 was also a boost to the health sector. The study established that the monitoring of health sector decentralized funds is urgently required. Indeed such monitoring is recognized as the missing link in the government efforts in establishing and improving the management of decentralized funds. Many of the health management committee members representing communities are handpicked may have little knowledge on how the funds should be managed hence the need to establish a strong oversight institutions. There was however sentiments that citizen groups involved in monitoring decentralized funds should avoid misreporting. “…you citizen groups are at times lead by malice and misinformation in your monitoring efforts, exaggerating figures …” The citizen groups that were identified for their involvement in monitoring decentralized funds can collectively be termed as the Civil Society. This encompasses a wide range of organizations which are not under the control of governments and which are not for profit. They include: Non Governmental Organizations (NGOs), Community Based Organizations (CBOs), Faith Based Organizations (FBOs), Residents Associations and Professional Associations among others. To these organizations, the concept of accountability for decentralized funds involves tracking and reporting on allocation, disbursement and utilization of the decentralized funds. This dimension of accountability deals with compliance with laws, rules, and regulations regarding financial control and management of each fund.

5 Health Action International Kenya (2009) East African Health Budgets 2010/2011: An Analysis on Financing for Essential Medicines; Nairobi: HAI, Africa

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Chapter One

Introduction and Methodology

1.0 Introduction The Health Sector is one of the key components addressing equity and socio-economic agenda of the Economic Recovery Strategy for Wealth and Employment Creation (ERS) and the social pillar of the Kenya Vision 20306. Good health is expected to play an important role in boosting economic growth, poverty reduction and the realisation of social goals. However, accessibility, availability affordability and quality of health services are critical issues for the poor. According to the Kenya Household Expenditure and Utilization Survey Report of 20077, 38% of the people failed to seek health care in 2007 when in need cited lack of money as reason for such failure. Also, the Kenya Household Health Expenditure and Utilization Survey Report 20078 and the National Health Accounts (NHA)9 for fiscal year 2001/2002 showed that Kenyan households were financing over half of all health expenditures. Ill-health therefore, contributes to, and perpetuates, poverty as ill health costs runs down people’s paltry resources. In a measure aimed at reducing the costs of health on households (out-of-pocket expenditure) the Government of Kenya in 2004 abolished user fees at all public dispensaries and health centres. The only fee patients pay at these levels is Kshs 10 (US $.125) and Kshs 20 (US $.25) respectively for the card. However through Facility Management Committees some facilities have adjusted the payable fees upwards depending on the services sought. At hospital level, the government retained a cost-sharing policy where patients are expected to pay part of the cost for their treatment. A fee waiver system was introduced to cater for the poor. However, the waiver system has not worked well. It is faced by numerous challenges including a rigid bureaucracy, corruption, lack of transparency and accountability. As a result, the very poor remain by and large, shut out of public health facilities. The government has further faced challenges in ensuring available health sector funds reach the intended beneficiaries. The past two Public Expenditure Tracking Surveys10;11 revealed a wide disparity between the funding allocated to rural health facilities and the amount reaching the intended beneficiaries. The Public Expenditure Tracking Surveys estimated that only about 44 percent of funds (including commodities) reach the lower level facilities (dispensaries and health centers). This was as a result of several factors such as delays in 6 Government of Kenya (2008) Ministry of Health Medium Term Plan 2008 – 2012. Nairobi: Government Printer 7 Government of Kenya, (2009) Kenya Household Expenditure and Utilization Survey Report 2007; Ministry of Medical Services and Ministry of Public Health and Sanitation; Nairobi: Government Printer 8 Government of Kenya, (2009), Kenya Household Expenditure and Utilization Survey Report 2007: Ministry of Medical Services and Ministry of Public Health and Sanitation: Nairobi: Government Printer 9 Government of Kenya, (2005) Kenya National Health Accounts 2002: Estimated Expenditure on General Health and HIV/AIDS Care: Nairobi: Government Printer 10 Government of Kenya, (2009) MOH Public Expenditure Tracking Survey 2008: Nairobi: Government Printer 11 Government of Kenya, (2009) Kenya Household health Expenditure and Utilisation Survey Report 2007; Nairobi: Government Printer

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disbursing funds due to failure by the facility to provide accounts to district treasury on time, delays at the then Ministry of Health (MOH) headquarter, shortfalls in quarterly allocations, liquidity problems at MOH and failure to comply with government accounting procedures. The delays in disbursing funds to respective facilities may also be attributed to delays in release of funds at the Ministry of Finance or at the MOH headquarters. According to the Survey12 facility in-charges have very little knowledge about what public resources that have been budgeted and how much should be due to them. The situation is compounded further by the wide variation between the resource flows at the DMOH and at the rural facilities. Actually, dispensaries and health centres receive a large proportion, if not all, of their allocations in the form of in-kind materials. This disconnects between the funds allocated and what is received at the facility level makes it difficult to accurately determine the financial flows between the DMOH and the facilities (dispensaries/health centres). To overcome some of these challenges stakeholders have been calling on the government to accelerate budgetary reforms especially the direct facility funding to rural health facilities in order to allow such facilities to receive their funds directly from MOH Headquarters. In response to this call, the government has embarked on institutional reforms within the health sector in order to improve the country’s health care delivery systems. One of the reforms introduced is the adoption of “devolution” approach that allocates funds and responsibilities for delivery of health care to dispensaries, health centres and hospitals13. This is expected to enable citizens to participate in decision-making processes including taking charge of their health needs and thereby contributing to improved quality, accountability and transparency in the management of the funds. Unfortunately, in implementing the health financing reforms, a number of challenges have been encountered. These include poor understanding of the devolved health sector funds and lack of committed or incapacitated champions to monitor the funds. It is on this background that, Open Society Initiative for Eastern Africa (OSIEA) in collaboration with the Public Health Watch Project (PHW) of the Open Society Foundation’s Public Health Program, commissioned a study to map decentralized funds available for health services in Kenya and document the organizations engaged in monitoring the utilization and accountability of these funds. The main aim of the mapping study is to equip civil society groups, particularly those representing marginalized and underrepresented communities, with the tools, information, arguments and capacities to hold governments and national leaders accountable to uphold international standards and policies in health. 1.1 Purpose of the mapping Main Objective To identify all the decentralized government funding available for health in Kenya and the organizations involved in monitoring them with the aim of developing a strategy to involve and empower communities in monitoring the utilization of the decentralized funds towards delivering high quality health care services for all Kenyans.

12 GOK, (2009) MOH Public Expenditure Tracking Survey 2008 Nairobi: Government Printer 13 Government of Kenya (2008) Ministry of Health Medium Term Plan 2008 – 2012 Nairobi: Government Printer

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Specific objectives of the mapping 1) To map existing decentralized health funds, including those funds not directly earmarked

for health, but that can be used for health services. 2) To map organizations that are doing accountability work related to health funds,

including those that do non-health related monitoring, but may be interested in doing so 1.2 Approach and Methodology In accordance with the terms of reference provided and in order to obtain the information required to identify decentralized government funding available for health in Kenya it was necessary to obtain data from different sources, including budget allocations, public expenditure reviews and discussions with key informants in government, civil society and private sector organizations. The study comprised budget analysis through scrutiny of national budget documents, Medium-Term Expenditure Frameworks (MTEFs), expenditure records and interviews (face-to-face or telephone) with key informants in government. 1.3 Data Collection Methods Gathering of data involved the use of a variety of methods. The three key methods used to collect data are as follows: Record Reviews This involved compilation of laws and policies guiding decentralised funds in Kenya, reports about the fund from government, development partners, civil society organisations and other stakeholders. Some of the reports reviewed included Constituency Development Fund (CDF) reports, Annual Reports for Local Authority Transfer Fund (LATF) and Public Expenditure Surveys and reports. Documentary Analysis This was mainly used to obtain information on available decentralized funds in Kenya, legal frameworks under which the Funds are established guidelines and manuals detailing the management and governance of such funds. Field interviews This was used to obtain information on personal/organizational experiences with the decentralized funds from a sample of diverse stakeholders. Such interviews were conducted with Ministry of Finance, Ministry of Planning and Vision 2030, Ministry of Public Health and Sanitation, Ministry of Medical Services, National AIDS Control Council (NACC) and the Ministry of Local Government and Local Authorities. Other interviews were held with civil society organizations dealing with decentralized funds.

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Chapter Two

Legal Framework for Decentralized Health Funds in Kenya

2.0 Introduction The Kenyan health sector has been guided by Kenya Health Policy Framework, (KHPF) 1994 – 201014. Its strategic theme was ‘Investing in health’ and overall goal ‘to promote and Improve the health of all Kenyans through deliberate restructuring of the health sector to make all health services more effective, accessible and affordable’. The KPHF was implemented through the Implementation Plan covering the period between 1995 and 1998 and two successive 5 - Year National Health Sector Strategic Plans (NHSSP). The first NHSSP covered the period 1999 to 200415 and the second (NHSSP II), 2005 to 201016. KHPF identified decentralization as one of the areas that needed reform in the period between 1994 and 2010. In this regard a national policy concerning decentralization in the health sector was to be prepared, adopted and implemented. This implied delegation of power and transfer of responsibility for planning, management, resource allocation and decision making from central level to the grassroots institutions (health facilities). However, to date, no legislative framework to support the health sector decentralization was developed. In addition to decentralization, KPHF identified health care financing as one area that needed urgent attention and reform. During the development of the national policy some of the longer term options which were under consideration included provision of direct funds from the Government to districts. Under these arrangements district level planners and managers would have the option of restructuring health services in a manner that best suited both local circumstances and the levels of resources. These also included resources allocated and those local funds they could raise from cost sharing and other local initiatives. Unfortunately, direct funds could not be implemented without a clear structure that had legal backing. The Constitution of Kenya governs all public expenditures and provides that all revenues or other monies raised or received for the purposes of government of Kenya are paid into and form a Consolidated Fund from which no withdrawal can be made. The law nonetheless provides for withdrawals (establishment of a fund) through an Act of Parliament and/or through a government policy. To establish the decentralized fund for the health sector, the government opted for the second option, came up with a policy by issuing a gazette notice of the Health Management Fund (HMF) in 200717. After the contentious 2007 national election, Grand Coalition Government was formed necessitating the split of the MoH into Ministry of Public Health and Sanitation (MOPHS) and Ministry of Medical Services (MOMS). MOPHS core function is to provide primary 14 Government of Kenya (1994) Ministry of Health: Kenya’s Health Policy Framework 1994 – 2010. Nairobi: Government Printer 15 Government of Kenya (1999) The National Health Sector Strategic Plan 1999 – 2004. Nairobi. Government Printer 16 Government of Kenya (2005) Reversing the Trends – The Second National Health Sector Strategic Plan of Kenya (NSSP II) 2005 - 2010. Ministry of Health, Nairobi. Government Printer 17 Government of Kenya (2007) Government Financial Management (Health Management Fund) Regulations, Legal Notice No. 123

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health care services at the community, dispensary and health centres levels18. MOMS on the other hand is responsible of medical services, with core mandate of ‘...ensuring that essential medical care is made available as needed, when needed and in appropriate amounts’19. With these developments the legal notice had to be revised to accommodate the two Ministries. This led to establishment of two decentralized funds, HSSF to benefit community units, dispensaries and health centres and the HMSF to benefit hospitals in level 4 and 5. Health Sector Services Fund (HSSF) The HSSF on one hand was established through a ministerial policy contained in Legal Notice No. 401 (amended in 200920) as an innovative direct transfer of funds to dispensaries and health centres. According to the legal notice, the funds are sourced from the Government, grants or donations from development partners, cost-sharing revenue and from any income generated from the activities of the fund itself. The fund is currently located in the MOPHS and is supposed to finance activities of all the public dispensaries and health centres. That is, providing resources for implementing each facility's Annual Operational Plan (AOP) to address preventive, promotive and curative services at levels one (community), two (dispensary), and three (health centre). The first disbursement of HSSF took place on 28th October 2010 when the government disbursed Ksh 143 million to 590 health centres across the country21. However, dispensaries are yet to get their share of the fund. According to HSSF secretariat some health centres that did not receive the fund have not met the funding criteria which include having a management committee that is fully trained to handle the fund. Annex 1 provides a sample of Health Centers that received the funds. Hospital Management Services Fund (HMSF) The HMSF on the other hand was established through a Legal Notice 155 of 200922 to provide direct financing to level 4 (District) and 5 (Provincial General) hospitals. The legal Notice has also allowed the fund to finance level 4 and 5 hospital’s Annual Operational Plans derived from the National Health Sector Strategic Plan (NHSSP II) 2008 – 2012 and MOMS Strategic Plans23. The fund is currently located at MOMS. The HIV and AIDS Fund The health sector has also benefited from the HIV and AIDS fund. The Fund is established by a Presidential Order in Legal Notice No. 170 of the State Corporations Act24. Alongside mobilising resources, the 1999 Legal Notice included the provision of grants to implementing

18 Government of Kenya (2008) Ministry of Public Health and Sanitation; Strategic Plan 2008 – 2012; Nairobi: Government Printer 19 Government of Kenya (2008) Ministry of Medical Services; Strategic Plan 2008 - 2012; Nairobi: Government Printer 20 Government of Kenya (2009) Government Financial Management (Health Sector Services Fund) (Amendment) Regulations, Legal Notice No. 79; Nairobi: Government Printer 21 Head Health Sector Services Fund Secretariat , Ministry of Public Health and Sanitation 22 Government of Kenya (2009) Government Financial Management (Hospital Management Services) Regulations, Legal Notice No. 155; Nairobi: Government Printer 23 Ministry of Medical Services; Hospital Management Services Fund: Guidelines on Financial Management for Levels 4 and 5 Hospitals, July 2010; Nairobi: Government Printer 24 Government of Kenya (2009), the State Corporations Act, 1999 Order 1, National Aids Control Council; Nairobi: Government Printer

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agencies as a mandated function. This grant has popularly been referred to as the Community AIDS Fund. The HIV and AIDS Funds are sourced by the government in form of a credit from World Bank and donations from development partners. So far the country has had two credits from the World Bank implemented under the projects namely Kenya HIV and AIDS Disaster Response Project (KHADREP) from 2000 to 2005 and Total War against AIDS (TOWA). Indirect Funds to Health Sector The other devolved funds that have benefited the health sector include the Constituency Development Fund (CDF) and Local Authority Transfer Fund (LATIF). The two funds have provided mechanisms for increasing access to health services for all including the poor. Constituency Development Fund (CDF) The Constituency Development Fund (CDF) was established in 2003 through the CDF Act No. 1125. The Act was amended through the CDF (Amendment) Act, 200726. The Act provided that there shall be paid into the Fund "an amount of money equal to not less than 2.5 percent of all Government ordinary revenue collected in every financial year; and any monies accruing to or received by the national committee from any other source". Local Authority Transfer Fund (LATIF) On its part, the Local Authorities Transfer Fund (LATF) came into effect in June 1999 under the Local Authorities Transfer Fund (LATF) Act (No. 8 of 1998)27 which came into effect on 10th June 1999. The Act established a central-local revenue transfer mechanism to facilitate the disbursement of funds to local authorities “to supplement the financing of the services and facilities they are required to provide under the Local Government Act”. The LATF Regulations28

were issued in September 1999 by the Minister for Finance covering the appointment of the LATF Advisory Committee members, the criteria for disbursement of funds, and the reporting and record keeping obligations. The Fund receives 5% of the national income tax revenue that is allocated to all Local authorities based on a transparent, equitable and objective formulae whereby at least 6.6% of the total fund is allocated equally among all Local Authorities, 60% is allocated according to the relative population size of the local authorities while 33.4% is shared based on the relative urban population densities. Disbursements are made directly to the Local Authorities to be utilized by them to improve service delivery to the public, to improve financial management and accountability, and to eliminate all outstanding debts by 2009-1029.

25 Government of Kenya (2004) The Constituency Development Fund (CDF) Act (No. 11) of 2004; Nairobi: Government Printer 26 Government of Kenya (2004) The Constituency Development Fund (CDF) (Amendment) Act, 2007 (Act No. 16) 2007; Nairobi: Government Printer 27 Government of Kenya (1998) Local Authorities Transfer Fund (LATF) Act (No. 8 of 1998) 28Government of Kenya (1999) Local Authorities Transfer Fund (LATF) Regulations, Legal Notice No 142 29 Government of Kenya (1999) Local Authorities Transfer Fund (LATF) Regulations, Legal Notice No 11

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Chapter Three

Management and Implementation of Decentralized Health Funds

3.1 Direct Decentralized Health Funds This category of funds is constituted of decentralized funds that are specifically earmarked for the health sub-sector by design at the highest policy level. 3.1.1.0 Health Sector Services Fund (HSSF) The main objective of HSSF is to deliver finances for operations direct to the point of use in the dispensaries and health centers. Prior to this policy, only about 50 per cent of targeted funds could reach these facilities (Level 2 and 3 respectively)30. This was due to several factors including delays at the Ministry of Finance or at the MOH headquarters to release the funds, shortfalls in quarterly allocations, liquidity problems at MOH and failure to comply with government accounting procedures31. 3.1.1.1 HSSF Management The fund is implemented through management committees at the national and respective health facility levels. These consist of National Health Services Committee; Health Centres Management Committees and Dispensary Management Committees. The criteria for the composition of the committee members as well as the procedures for their operations including their functions are provided for under Legal Notice No. 401 (amended in 200932) establishing the fund. The MOPHS has further issued Guidelines33 on the appointments of committee members both at national and facility levels. The National Health Services Committee The National Health Services Committee (NHSC) is mandated to:

a) Approve the work plans prepared by a health facility b) Ensure equitable distribution of resources to health facilities c) Review and approve annual expenditure statements of the health facilities d) Receive returns on cost sharing e) Approval of the planning formats f) Give guidance to the Districts on the approval of the facility plans g) Approve the criteria of allocation h) Confirm the available resources and provide the finance schedule to PDPHS and

DMOHs i) Final approval of the annual operation plans j) Disburse funds to facilities.

30 Hon. (Prof) Peter Anyang’ Nyong’o, Minister for Medical Services, Kenya; Citizen’s Engagement in Health Service Provision in Kenya 31 GOK, (2009) MOH Public Expenditure Tracking Survey 2008. Nairobi: Government Printer 32 Government of Kenya (2009) Government Financial Management (Health Sector Services Fund) (Amendment) Regulations, Legal Notice No. 79; Nairobi: Government Printer 33 GOK (2009) Guidelines on Financial Management for Health Facilities through the Health Sector Services Fund; MPHS

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Role of the Officer Administering the Fund The officer administering the fund is an employee of MOPHs and Secretary to the National Health Services Committees. The officer is required to:- • Supervise and control the administration of the fund • Open and operate a bank account at a bank approved by the Minister for the time being

responsible for finance • Develop a criteria for the allocation of funds for approval by the National Committee • Prepare annual distribution of resources to facilities • Institute prudent measures for the proper utilization for monies deposited in the Fund

using suitable internal controls and appropriate mechanisms for accountability including audit of accounts by internal auditors of the Ministry responsible for matters relating to finance

• Cause to be kept proper books of accounts and records relating to all receipts, payments, assets and liabilities of the Fund and to any other activities and undertakings financed by the Fund

• Prepare, sign and transmit to the Controller and Auditor-General in respect of each financial year and within three months after the end thereof, a statement of account relating to the Fund specifying all contributions to the Fund, and the expenditure incurred from the Fund, and such details as the Treasury may from time to time direct, in accordance with the provisions of the Public Audit Act

• Furnish such additional information as he may be required that is proper and sufficient for the purpose of examination and audit by the Controller and Auditor-General in accordance with the provisions of the Public Audit Act

The Health Centers/Dispensary Management Committees Each committee according to the Legal Notice on HSSF34 should have at least seven and not more than nine members consisting of a representative from the provincial administration in the area of jurisdiction, the person in charge of the health facility who should be the secretary. The District Medical Officer of Health or his representative duly nominated by him/her in writing and the person in charge of the local authority health facilities or the area councilor. These persons constitute the ex-official members of the committee. The other persons provided for by the Legal Notice on HSSF35 include five (5) residents (local citizens) of the area of jurisdiction, appointed by the Minister or any other person authorized by him in writing. Among these 5 local residents, one person should be knowledgeable and experienced in finance and administration while among the remaining four, three should be women. Each member of a committee, apart from the ex-officio, is expected to hold office for a period of three years and shall be eligible for re-appointment for a further term. The chairman of the committee should be appointed from among the members and should not be an ex-officio member. The committee is expected to meet at least four times a year and the quorum for such meetings should be five of all the members including the secretary. The committee shall be responsible to the officer administering the Fund.

34 Government of Kenya (2009) Government Financial Management (Health Sector Services Fund) (Amendment) Regulations, Legal Notice No. 79; Nairobi: Government Printer 35 Ibid

17

The Health centers or dispensary management committee is mandated to: 1) Supervise and control the administration of the funds allocated to the facility 2) Open and operate a bank account at a bank approved by the minister for finance 3) Prepare work plans based on estimated expenditures cause to be kept books of accounts

and records of accounts of the income, expenditure, asserts and liabilities of the facility as prescribed by the officer administering the fund

4) Prepare and submit periodic financial and periodic performance reports as prescribed 5) Cause to be kept a permanent record of all its deliberations

According to the Guidelines on Financial Management for Health Facilities through the Health Sector Services Fund of 200936, annual Work plans and budget should be prepared by each health facility technical team. The health facility technical team is headed by the facility in-charge who is also the secretary to the facility committee and it members includes heads of departments in each facility. Their workplans and budgets are tabled to the health facility committee for approval prior to onwards submission through the DMOH to the National HSSF Committee for approval. Monthly and quarterly financial and services reports are required to be submitted through the DMOH to the National HSSF Committee. 3.1.1.2 Determining Funds to be allocated to Dispensaries and Health Centres Allocations to level 2 and 3 (Dispensaries and Health centers) are equal for all the health facilities. According to HSSF head of Secretariat, beginning 2011/2012 financial year, allocations to dispensaries and health centres will be made based on Facility Annual Operation Plans (AOP). In the processes of developing the AOP each facility should indicate the expected amount of income it hopes to collect from user fees (10/20) during the financial year based on realistic projections of expected user charges. Such estimates should be based on the estimates of the previous year’s collections. HSSF is however is based on the resource allocation criteria (poverty level, population, transport and running costs) as shown in Table 1 below37. Table 1: Health Centers and Dispensaries Criteria for Resource Allocation

Variables Weight Poverty levels 0.3 Physical Access (area) 0.05 Number of children (Under 5) 0.2 Female population 0.2 HIV/AIDS prevalence 0.1 Number of health facilities 0.15 Total 1.00

Source: Position Paper on Flow of Funds to Health Facilities for improvement of Health Service in the district Each facility determines the resource envelop available to it. These are the funds from the user fees (10/20) and HSSF allocation. Having determined their resource envelops each facility then proceeds to develop its AOP. This plan is divided into four (4) Quarterly Implementation Plans (QIPs). The HSSF Secretariat then funds these (QIPs) plans on a quarterly basis. 36 GOK (2009) Ministry of Public Health & Sanitation; Guidelines on Financial Management for Health Facilities through the Health Sector Services Fund 37

18

3.1.1.3 Flow of Funds According to the guidelines the funds should flow from the Treasury to an HSSF Commercial Bank Account operated by the parent Ministry and overseen by the National HSSF Committee. Funds should then be directly sent to Health Facility (respective dispensary/health centre) HSSF Commercial Bank Accounts and FBO Secretariats to finance approved annual work plans as indicated in Figure 1 below. Figure 1: Flow of HSSF Funds

Parliament Treasury

Source: Guidelines on Financial Management for Health Facilities through the Health Sector Services Fund

.1.1.4he technical reports are compiled quarterly by the Officer-In-charge of the facility on behalf

ispensary Management Committee (H/DMC) and forwarded to District

to the National Committee. The Officer in Charge

3 Reporting Tof Health Center/ DMedical Officer of Health (DMOH) for onward transmission to the Fund Administrator with a copy to the Provincial Director of Public Health Sanitation (PDOPHS). Figure 2 below shows the reporting process of HSSF. Financial reports on the other hand are forwarded to the DMOH for examination by MOPHS

ccountant before being forwarded Aprepares and submits financial reports on monthly basis, and should reach the MOPHS Headquarters not later than the tenth day of the following month.

Level 2&3 HSSF Funding

Services

Demand

Services

Demand

Services

Demand

Services

Demand

Other funding Support Commercial Bank HSSF

HSSF National Committee

FBO Secretaries

H/DMC H/DMC H/DMC H/DMC

Communities and HF Outreach persons

19

Figure 2: HSSF Reporting Process

ve

een obtained, used and the financial position of the facility at specific dates. The law nts annually. All facilities should

there is need to ensure that internal audit does not become a bottleneck to the activities of the

Source: Guidelines on Financial Management for Health Facilities through the Health Sector Services Fund The Government conducts periodic internal audit/inspection of facilities as part of internal control to provide assurance that the resources provided have been put to proper use. This should b Source: Guidelines on Financial Management for Health Facilities through the Health Sector Services Fund 3.1.1.5 Accountability in the Management of Facilities The management of health facilities should be accountable to the community and the Government, through the Health Centre/ Dispensary Management Committee, for the proper use of the facilities’ resources. The Officer-in-Charge is required to maintain accountingecords and to prepare financial statements, which show how the facility’s resources har

brequires that the National Audit Office audits public accoutherefore maintain proper records for audit purposes. The Government conducts periodic internal audit/inspection of facilities as part of internal control to provide assurance that the resources provided have been put to proper use. This should be done by internal auditors from the District Treasury who should then submit report to the District Medical Officer of Health (DMOH) for levels 2 and 3 facilities. However,

H/DMC

Services Services

Demand

Services

Demand

H/DMC H/DMC

District MoH Qrtly progress reporting of level 2-3 HF as part of the integrated district health sector plan (AOPs) covering all state & non state facilities

Level 2&3 HSSF Fund reporting

Level 2-3 HF submit qrtly progress reports to the districts MOH for all health services including HSSF Support Demand

Provincial MoPHS Qrtly HSSF progress reporting for level 2-3 HF as part of the integrated district health sector plan (AOPs) covering all state and none state facilities

FBO Secretariat submit qrtly HSSF Progress & financial report

Parliament Other funding Support Treasury

HSSF National Committee

Commercial Bank HSSF

Commercial submits monstatement

H/DMC

Communities and HF Outreach persons

Provincial DPHS

FBO Secretariats

National HSSF Secretariat

HSSF Fund and

District MoH

20

facility. Already some projects supported by decentralized fund such as CDF have stalled due to various audit queries. There is also need to derive mechanisms to ensure that audit queries re responded to and culprit’s punished if need be without hurting the project activities.

o not now their duties and responsibilities making them vulnerable to corrupt practices by senior

and therefore respond adequately to citizen oncerns. The fund is financed from the monies appropriated by Parliament for that purpose,

onies received as user charges (cost-aring) and income generated from the proceeds of the fund

pitals thought their respective secretariats

the financial year 2010/2011 HMSF distributed Kshs 194 million to 267 hospitals in the first

According to the HMSF Guidelines , a lot of emphases have been placed on stronger roles unity members and women

presentatives) to take care of citizen interests in the management of hospitals40. It is hoped

a There are also provisions for joint financial reviews/verification. This should be carried out in consultation with Partners of the fund and the Fund Administrator in order to improve management systems. The guidelines have made it clear that non-compliance with these guidelines constitutes a breach of duty and those responsible shall be liable to disciplinary action under the provisions of the existing laws and regulations. It is also the duty of the government to improve the capacity of the fund managers prior to taking up such responsibilities. Some of the offices managing these funds have not been trained hence dkgovernment officials and development parties. 3.1.2 Hospital Management Services Fund (HMSF) 3.1.2.1 Implementation of the HMSF The implementation of activities through Hospital Management Services Fund (HMSF) started in July 201038. HMSF is meant to provide a framework for better management of finances at the hospital level. The overall objective of this initiative is to give autonomy to hospitals to manage their own responsibilitiescgrants or donations made by development partners, msh The fund is intended to improve the flow of funds to the hospitals to ensure planned activities are implemented as scheduled. The purposes of the fund include to: a) Provide resources for medical supplies, rehabilitation and equipment of hospitals in

Kenya b) Support capacity building in management of hospitals c) Support and empower local communities to take charge of improving their own health d) Provide grants for strengthening of the faith based hos

e) Improve the quality of health care services in the hospitals According to Head, Division of Health Care Financing, Ministry of Medical Services during

quarter and 128 million shillings in 2nd quarter. 3.1.2.2 HMSF Management Structure and Responsibilities

39

for Hospital Management Committees (who includes commre

38 Reversing the trends The Second National ealth SectorH Strategic Plan of Kenya Annual Operational Plan 6,

ly 2010–June 2011 39 Ministry of Medical Services; Hospital Management Services Fund: Guidelines on Financial Management for Levels 4 and 5 Hospitals, July 2010

a

Ju

40 Hon. (Prof) Peter Anyang’ Nyong’o, Minister for Medical Services, Kenya; Citizen’s Engagement in HealthService Provision in Keny

21

that this will promote good governance, accountability and transparency in handling public

l Hospital Services Committee b) The Officer Administering the Fund

The ted by the following MOMS structures: adquarters

c) The District Medical Services Team

TheThi

y the hospital Ensure equitable distribution of resources to hospitals

statements of the hospital

The e composed of 9 members drawing rep e 2 women representatives, 1 rep e ssociation.

t at a bank approved by the Minister for the time being responsible for finance

s of funds for approval by the National Committee

uthorized by him or on his behalf and may impose any reasonable

for monies deposited in the Fund using suitable internal controls and appropriate mechanisms for accountability including audit of accounts by internal auditors of the Ministry responsible for matters relating to finance

funds. The Fund is supposed to be managed by the following structures as per the Legal Notice No. 401 of December 2007 as amended through Legal Notice No. 155 of October 200941.

a) The Nationa

c) The Hospital Management Committees

Committees’ work is supported and supplemena) The HMSF-Secretariat at MOMS Heb) The Provincial Medical Services Team

d) The Hospital Management Team National Hospital Services Committee

s committee is authorized to: • Approve the work plans prepared b•• Review and approve annual expenditure

L gal Notice42 provides that the committee is

res ntation from the MOMS, Ministry of Finance, res ntative of health NGOS network in Kenya and faith based hospital a

The Officer Administering the Fund According to the HMSF Guidelines43 the Officer Administering the Fund is an employee of MOMs and the secretary to NHSC. The officer is expected to:- a) Supervise and control the administration of the fund b) Open and operate a bank accoun

c) Develop a criteria for the allocationd) Prepare annual distribution of resources to hospitals e) If he thinks fit and in consultation with the National Committee, impose conditions on the

use of the expenditure aprohibition, restriction or other requirement concerning such use or expenditure.

f) Institute prudent measures for the proper utilization

41 Government of Kenya (2009) Government Financial Management (Hospital Management Services) Regulations, Legal Notice No. 155 42 Ibid 43 Ministry of Medical Services; Hospital Management Services Fund: Guidelines on Financial Management for Levels 4 and 5 Hospitals, July 2010

22

g) Cause to be kept proper books of accounts and records relating to all receipts, payments, assets and liabilities of the Fund and to any other activities and undertakings financed by the Fund.

h) Prepare, sign and transmit to the Controller and Auditor-General in respect of each financial year and within three months after the end thereof, a statement of account relating to the Fund specifying all contributions to the Fund, and the expenditure incurred from the Fund, and such details as the Treasury may from time to time direct, in

i) se of examination and audit by the Controller and Auditor-General in

TheTheto:

• Cause to be kept basic books of accounts and records of accounts of the income,

• Prepare and submit certified periodic financial and performance reports

The Health Management Committee (PH CCommiprovinc is the Secretary to the committee, representative of Local Aut r ations and 1 represe Management Committees

ould consist of District Commissioner, District Medical Services Officer (DMSO), Person

e Quarterly plementation Plans (QIP) should be derived from the AOP detailing specific outputs to be

mented during that specific quarter inputs, budgets and staff

accordance with the provisions of the Public Audit Act. Furnish such additional information as he may be required that is proper and sufficient for the purpoaccordance with the provisions of the Public Audit Act.

Hospital Management Committees se committees constitute of hospitals and provincial and district levels. They are required

• Supervise and control the administration of the funds allocated to the hospitals • Open and operate a bank account • Prepare work plans based on estimated expenditure

expenditure, assets and liabilities of the facility as prescribed by the officer administering the Fund.

• Cause to be kept permanent records of all its deliberations.

HMSF Legal Notice44 provides that the Provincial M ) is composed of between 7 and 9 members representing the Provincial

ssioner, Provincial Director of Medical Services (PDMS), person in-charge of ial hospital (level 5) who

ho ities, women groups, 2 representatives of Community Based Organizntative from FBOs. The District and Sub-District Hospital

shin-charge of hospital (secretary), Local Authority representative, one person nominated by women groups, one person representing FBOs and 2 persons nominated by recognized Community Based Development Organisations one of whom must be a woman. Hospital’s Officer in Charge The Hospital’s Officer in Charge is expected to co-ordinate and controls the implementation of the Annual Operational Plans (AOPs) and the Quarterly Implementation Plans (QIP). According to the Guidelines45, the Annual Operational Plans operationalises the objectives set out in the National Health Sector Strategic Plan and Ministry of Medical Services Strategic Plan and any other priorities spelt out in the National level. ThImachieved, activities to be impleresponsible for achieving the set targets.

44 Government of Kenya (2009) Government Financial Management (Hospital Management Services) Regulations, Legal Notice No. 155 45 Ministry of Medical Services; Hospital Management Services Fund: Guidelines on Financial Management for Levels 4 and 5 Hospitals, July 2010

23

Each hospital is supposed to open and maintain one HMSF account in a bank approved by the Government. The officer administering the Fund is expected to appoint signatories to the account and for any transaction to be effective there shall be two signatories. Though this is an important guideline to be provided by the Ministry, the Hospital Management Committee (HMCs) should have been empowered to appoint signatories from among its members and

ot handpicked by the officer managing the fund.

ibility is to oversee the implementation of ealth policy, maintenance of standards, quality, coordination, regulation and control of

vincial Medical Officer and the PMST guides,

ead of Accounting Unit at MOMS Headquarters y the HMSF Guidelines47 to check regularly that

s relating to the Fund ecifying all contributions to the Fund and expenditure incurred from the Fund and such

spital Criteria for Resource Allocation Variables Weight

n Provincial Medical Services Team (PMST) The Guidelines46 requires that the PMST which comprises of senior MOMS staff in each province to assist MOMS headquarters in the implementations of all national policies and strategies in the districts of their respective provinces. The PMST provides an intermediary between the ministry and the district. Their responshhealth services. With regard to HMSF the Promonitors and supervises District Medical Services Team (DMST) and hospital managers in the province in the management of HMSF activities. District Medical Services Team (DMST) On its part the District Medical Services Team (DMST) comprising of senior MOMS staffs in each district is required to support, supervise, monitor and control the hospitals planning, budgeting, implementation and reporting to PMST among other roles. HThe Head of Accounting Unit is required ball receipts and payments captured in the ledger are for transactions relating to HMSF only. The officer is also required to prepare and submit to the Controller and Auditor General on behalf of the Officer Administering the Fund a Statement of Accountspdetails as the Treasury may direct from time to time in accordance with provisions of thePublic Audit Act. 3.1.2.3 Criteria for Resource Allocation The Ministry of Medical Services has developed rational resource allocation criteria which is used to disaggregate funds allocated to hospitals as shown in Table 2 below.

Table 2: Ho

Poverty levels 0.20 Bed utilization 0.40 Out Patient Cases 0.20 Accident Prone 0.05 Price Fuel 0.15 Total 1.00

Source: Gui Management for Levels Hospitals, July 2010

delines on Financial 4 and 5

46 Ibid 47 Ministry of Medical Services; Hospital Management Services Fund: Guidelines on Financial Management for Levels 4 and 5 Hospitals, July 2010

24

The variables defined and weights are subject to review from time to time in light of new information becoming available as well as em g issues requiring attention to address

parities between and within provinces or districts (Counties).

.1.3 The HIV and AIDS Fund

.1.3.1 Kenya HIV and AIDS Disaster Response Project (KHADREP) approved the first credit of US $ 50 million through the

ster Response Project (KHADREP). KHADREP elped Kenya to achieve significant progress in the fight against the pandemic, but also

GOs. It closed in

dial action was taken, and following extensive consultations between the enyan Government, the World Bank, and other stakeholders on new organizational

ACC. Some of the remedial actions included restructuring

ent, fiduciary risk management, and onitoring and accountability.

The Committee was structured to have a broad stakeholder embership including senior representatives from Government, civil society, the private

ergindis 3The HIV and AIDS Fund is sourced by the government in form of a credit from World Bank and donations from development partners. 3In December 2000, World BankWorld Bank financed Multi-Country AIDS Programme (MAP)48. In Kenya the programme was known as Kenya HIV and AIDS Disahexperienced mismanagement of some project funds by some officials and NDecember 200549. 3.1.3.2 Total War against AIDS Total War against AIDS (TOWA) was derived from the declaration the President’s 2003 declaration Total War against HIV and AIDS at community level. The new project was approved after remeKstructures and safeguards within Nof NACC to have a community level focus. The Provincial AIDS Control Committees (PACCs) set up in 1999 were replaced with 9 provincial officers to coordinate and supervise activities at regional levels. The original District AIDS Control Committees (DACCs) were replaced with District Technical Committees (DTCs) which coordinate activities at district level and provide technical support to the 210 Constituency AIDS Control Committees (CACCs). The DTC is chaired by the District Commissioner who reports to the Office of the President through the Provincial Commissioners. Following an institutional review in 2004, the NACC Board restructured the Secretariat to renew focus on NACC’s original policy, strategy and coordination mandate. A new team of senior and middle level management staff were recruited. A lot of emphasis has been placed on performance management, financial managemm The measures also included the strengthening of the Inter-Agency Coordinating Committee (ICC) for HIV and AIDS which is the primary forum for deliberating on AIDS policies and strategies, including coordination and review of the National Strategy. The Director of the NACC Secretariat is the chair.msector and development partners. The NACC Board receives progress reports and recommendations for policy action from the ICC.

48 World Bank (April 2007) “Kenya - HIV/AIDS Disaster Response Project, Abstract and Implementation Completion Report” 49 Ibid

25

Financing for the TOWA Project The US $ 80 million credit under TOWA is provided on standard International Development

ssociation (IDA) terms, with a commitment fee of 0.35 percent, a service charge of 0.75 ercent over a 40 year period of maturity which includes a 10-year grace period50. At the onception stage the project was also to receive a grant of US $ 33 Million from DFID while e Kenyan government has contributed US $ 2 Million to meet personnel, office rental and

therefore had a grand total of US $ 115 million51.

e areas through funding for the national malaria rogram.

The mainstreaming is negative (-2%) as shown by Table 3 below. According to ACC at the time when the renegotiation was taking place, the mainstreaming sector had not

Apcth50% of operating costs. TOWA Unfortunately, the DFID grant was not guaranteed forcing the government to seek for additional financing from World Bank. The additional financing for the TOWA Project was approved by the World Bank in December 201052 to scale up the HIV and AIDS prevention and mitigation activities supported by TOWA since March 2008. The amount approved was US$55 million to expand HIV and AIDS interventions throughout the country, and also increase access to bed nets among Kenyans living in malaria-pronp As indicated in Table 3 below, the bulk of the additional funds (42%) should go towards expanding the CfP to channel money and provide capacity building support to CBOs and NGOs working at the constituency and district levels. The Table also shows that 17% of the money will go purchasing more bed nets while 12% will support commodities (Condoms and TB drugs).Nbeen absorbing the funds as envisioned, hence the (-2%) was meant to take into account of the absorption rates of the different budget lines. Table 3: How the additional funding to TOWA is broken

Activity (US$ million) % Additional Call for Proposals (Grants) 23,249.00 42 Bed nets 9,527.00 17 Commodities (Condoms and TB drugs) 6,693.00 12 Strategic Leadership 6,504.00 12 Fiduciary Accountability 4,858.00 9 Mainstreaming (1,014.00) -2 Other Programmatic Expenditure and M&E 5,183.00 9 Total 55,000.00 100.0

Source: NACC: Revised Estimate of Project Costs of the Wo port No: 4-KE53

CompThe p e imp of ya National AIDS Strategic Plan (KNASP) and it consists of two main components.

rld Bank Re 5762

onents of TOWA Project s designed to be an integral part of throject i lementation the Ken

50 World Bank Press Release No:2007/487/AFR 51 World Bank (February 2007) “Total War on HIV and AIDS (TOWA) Project, Project Information Document (PID) Appraisal Stage”

11

it in the amount of SDR 35 million (US$ 55.0 million equivalent) to the republic of (TOWA) Project”, dated November 18, 2010

52National AIDS Control Council (NACC), 2053 NACC: Revised Estimate of Project Costs of the World Bank Report No: 57624-KE “A project paper on a proposed additional credKenya for a Total War Against and HIV and AIDS

26

Component I: Strengthening the NACC’s Governance and Coordination Capacity

continued development of the coordinating

advisory support and strategically prioritize, strengthen and focus

b)

c) Evidence-Based Management: Through this sub component the project will support the

d) apacity Building of Implementing Partners: The aim of this sub-component is to

secand

e

through the Call for Proposals (CfP).

d

1)This component is expected to support the function, the monitoring and evaluation framework of the KNASP III. This is through the following sub-components: a) Strategic Leadership through financing regular reviews, especially the annual Joint HIV

and AIDS Programme Review (JAPR), supporting NACC operations at all levels, building capacity of staff and stakeholders, ensuring social accountability by communicating results and experiences to stakeholders, providing technical assistance for NACC to enable it toprogram targeting and ensuring an efficient operating environment.

Accountability and Verification: The project will finance contracts for Financial Management Agent, Compliance Verification Agent, Performance Auditor, Procurement Monitoring Agent and External Auditors to assist NACC in its verification and accountability functions in the use of the Project resources.

development of the Management Information System (MIS), the continued development of the Monitoring, Evaluation (M&E) and Research System and the Operations Research agenda.

Cstrengthen the capacity of civil society organizations particularly at grass-root level in the use of grant funds through provision of technical and advisory services to enable them to plan, network, coordinate, monitor and report on Subprojects.

2) Component II - Support for programme implementation This component makes financial resources available to civil society, public sector, private

tor, universities and research institutions, focusing on initiatives in line with the KNASP responding to priorities identified by the JAPR.

Th component would include three sub-components, these are: a) Grant Awards: In this sub-component civil society organizations, private sector and

research institutions are supported to implement and manage subprojects for selected initiatives that link with and support the implementation of KNASP and agreed activities in the Joint HIV and JAPR. This is to be achieved

b) Mainstreaming Public Sector Programmes: Through this sub-component grants will be

provided to selected Ministries, Departments and other government agencies to mainstream HIV and AIDS activities in public sector programs.

Procurement of essential commodities: The sub-component will support the purchase anc)distribution of essential commodities for addressing the HIV and AIDS epidemic such as drugs, condoms, bed nets, test kits, reagents and laboratory equipment and supplies. Table 4 below shows the essential commodities supported by TOWA project.

27

Table 4: Essential commodities supported by TOWA Item Amount (US$) Million Condom procurement 10,900 First line TB drugs 3,630 Procurement of bed nets 20,900 CFP to support Malaria Program 2,000 Operating costs to KEMSA 2,570 Total 40,000

The e civil society ed that the fund is mainly cons enyans will have to re k. It is normally assumed that all HIV and AIDS support to the government including the support channeled to community organized groups through the CfP ation could be instrumental in enab ring and calling for accountability from both the gov nefiting from CfP. Indeed the contract that the government

ego nd enters into with the development partners such as the World Bank should be ut in public d

rants to implementing partners (Civil Society, Private Sector, CBOs and NGOs) are each implementing partner through the

P). The Calls are advertised according to the principles in the NACC ommunication Strategy. Constituency AIDS Control Committees (CACCs) and District

established and operates in all the 210 constituencies in Kenya. Each ACC according to Guidelines54 should have a multi-sectoral representation of 18 to 21

society organisations, PLWHIV, key Government Ministries at the

Source: National AIDS Control Council

study found out that that K

(the publ t informic) is nop ctituted of a loan th ay ba

is a grant. Such informling more vigilance in monito

ernment and organizations benp

tiates aomain for discussion.

3.1.3.3 Disbursement Procedures and Reporting The International Development Association (IDA) fund is deposited in a Special Account operated by Treasury. To access these funds NACC has opened TOWA project account in a local commercial Bank to which replenishment is based on quarterly withdrawal applications submitted by NACC. The Government contribution is transferred on a quarterly basis through the Parent Ministry under which NACC falls for purposes of Government Budgeting to the Project Account. Gfinanced under grant agreement between NACC andFinancial Management Agency (FMA). The Public Sector partners also accesses their funds through the FMA. 3.1.3.4 Grants Awards The National Aids Control Council (NACC) disburses HIV and AIDS funds through Calls for Proposals (CfCTechnical Committee (DTCs) invite NGOs, CBOs, FBOs, the Private Sector and Research Institutions to submit proposals based on the CfP and the agreed upon eligibility criteria. CACCS have beenCmembers including civil divisional level and the private sector. The Committee is mandated to review, assess and approve proposals at the constituency level funded through NACC. The Committee is also expected to supervise and monitor the implementation of projects by the funded organizations in their respective constituency. 54

(Ed NACC (2010) Total War Against HIV and Aids (TOWA) Project Operations Manual, November 2010

ition)

28

On its part the composition of DTCs as provided for by the Guidelines55 should be multi-sectoral and all-inclusive with membership drawn from public sector, private sector and civil society. Each District Technical Committee should have 12-18 members and has a term of 5 years. Membership from the private sector and civil society should be based on gender and technical knowledge on HIV and AIDS. The DTC is expected to provide technical support and oversight to CACCs. Templates for proposal development guidelines, proposal evaluation process and criteria, capacity assessment checklist for implementers, application form for CSO have been developed. Proposals are reviewed and awarded by committees at various levels of CACC, DTC and NRC as shown by Table 5 below while Figure 3 below shows the steps that civil society proposals have to under go. Table 5: Timelines in Receiving and Awarding of Proposals Initiative Proposal Value

In US $ Detailed Review and Approval By

Feedback after submission

Funding after approval

Constituency (local) level Up-to 5,000 CACC 4weeks 4 weeks

District level From 5,001 to DTC 4 weeks 4 weeks 25,000 National level 25,001 – 100,000 NCC 4 Weeks 4 weeks

Above 100,000 nk, DFID

NACC in consultation with World Ba 4 Weeks 4 weeks

Source: Total W

ar A ids (TOWA) Project Operations Manual

f pr e in t two stages at the three levels as per the Proposal Annex 2. The first stage is preliminary

en g ere to the defined ligibility criteria bei C audule es. The

second step is te on ls that prelim teria, in eria for the CfP).

olitical and ethnic interests thereby making the process not credible.

funding become available, hence they not always as professional as that of well established ideas

gainst HIV and A

The review o oposals is don at leasEvaluation Process and Criteria as shown inevaluation to sure that the or anizations submitting proposals adh

ng bad listed by NACto assess proposa

e , including notchnical evaluati

due to fr meet the

nt practicinary cri

terms of appropriateness and results committed to (as per crit The process of reviewing the proposals at the three levels (constituency, district and national) however, raises significant issues. The criteria used to establish technical teams for reviewing the proposals is wanting. At times their professional training and competence in handling such a task efficiently is questionable. Some of the team members merely find themselves executing such a task by purely being a civil servant, CACC or DTC members which is not guarantee for competence. In addition, some have vested interests or are easily swayed by p Discussions with stakeholders revealed that most of the proposals are submitted by organizations with low competence in developing credible proposals. These include community based organizations which may have started as women groups, youth support groups and community neighborhood associations among others but later sought registration and Non Governmental Organisation (NGO) in order to fit in the HIV and AIDS funding criteria. Their staff normally operates as volunteers with anticipation of formalization once

civil society organizations. But nonetheless, they are more likely to have good funding 55 Ibid

29

that may never see the light of the day because of their capacity and the rigid funding criteria

very.

in operation. Sometimes they are called upon to have such proposal re-written at a fee in order to succeed. This encourages corruption. The study found out that successful proposals have encountered delays in the disbursement of the funds from the time proposals are submitted, approved and the actual release of the funds. This is despite the TOWA Guidelines stipulating that such awards should take 4 weeks upon conclusion. This is not the case in most times due to inadequate liquidity, logistical challenges and rigid bureaucratic processes that the process follows. As a result projects have delayed to commence and at times implementing organizations are required to adopt a crashing programme in order to meet the deadlines set. Unfortunately this has ended up compromising on the quality of the project deli Figure 3: Proposal Flow for Civil Society/Private Sector Organizations/Research Institutions

Allocations of funds to result areas and levels determined by ICC Advisory committee

Preparation of CFP by AdHoc drafting committee

Recommendation of the CFP by ICC Advisory Committee

Allocated amounts communicated to CACC’s /DTC’s/ National level

CFP for civil society, private sector and research institutions advertised through the print/electronic media and through other channels of communication.

Sub project proposals prepared by civil society/ private sector

CACCs receive and approve up to US$ 5,000

DTCs review and approve US$ 5,001-25,000 Approved proposals

funded by FMA

Ad-hoc National Proposals review committee review and approve proposals at the national level US$ 25,001 30

Proposal coordinating office receives and checklists proposals

Source: Total War Against HIV and Aids (TOWA) Project Operations Manual Figure 4: Financial Mechanism and Flow of Funds under the TOWA Project

63% of credit 32% of credit

OP Development Account 100%

World Bank NBI

= Funding stream

=Accounting stream

IDA- Project credit account-Washington

Special A/C 100%

CBK-Development exchequer 100% Treasury

NACC Project Account 100%

6% of credit

CACC Operating A/C

NGOs /FBOs/ CBOs/ CACC Level proposal up to $5000

CACC

MOHA Pool Fund A/C (OVC)

Ad-hoc committee

CACC

3.33% of credit

DTCs Operating A/C

Sub-Sector project A/C

Programme Technical Audit

NGOs /FBOs/ CBOs/ CACC Level proposal up to $5000

Proposal Coordinating Office

FMA

NGOs /FBOs/ CBOs/ CACC Level proposal up to $5000

NACC Operating Project A/C

Ministerial Sector project

31

Source: Total War Against HIV and Aids (TOWA) Project Operations Manual Civil Society Organizations/Private Sector/Research institutions Funds for NGO/CBO/FBO, the Private Sector and other implementing agents are released through the Financial Management Agency (FMA). The implementing agents are required to spend the funds as per the approved work-plan. The implementing agencies are required to account for the funds to the FMA. The FMA is responsible for reviewing financial reports from institutions under the TOWA FMA Account, consolidating and submitting them to NACC at the end of each quarter. It was evidenced from the study that the fund is supporting several consultancies under the accountability and verification sub-component. These include the FMA which was put in place based on the anticipated volume of sub-projects to be supported and the need for rapid disbursement of the funds. In calling for accountability on how the funds in the project are being utilized, it would be appropriate to do an analysis of volume of funds disbursed through FMA, the cost of disbursing one (1) shilling to implementing organizations and the value the FMA has added to the fund. Such statistics would be instrumental in making decisions on whether to improve the limited capacity within NACC to administer sub-projects directly, revise the terms of reference for the FMA or forgo the FMA altogether. In addition, there are consultancies for external auditor, performance audit, procurement monitoring and the independent compliance verification agent. It would be important for the public to be made aware how much of the Fund (loan) is actually utilized by these consultants, their cost effectiveness and whether they are indeed necessary for the project versus enhancing the capacity of NACC staff to carry out such tasks. Indeed is the TOWA credit for consultants or for poor citizens?

32

3.2.0 Indirect Decentralized Funds This category of funds is constituted of decentralized funds for general development purposes cutting across all the sub-sectors including health. Consequently stakeholders in the health sub-sector can apply for and access money to finance their activities from these funds. 3.2.1.1 Constituency Development Fund (CDF) The CDF supports any project including health that ensures widespread benefit to a cross-section of the citizens of a particular area in the community. The CDF is administered under the Ministry of Planning, National Development and Vision 2030 and is managed through 4 committees 2 of which are at the national level and 2 at the grassroots level established by the CDF Act. These are The CDF Board and Parliamentary Select Committee for the CDF, both at national level. At the local levels there is District project Committee (DPC) and the Constituency Development Committee. The CDF Board This Committee is established under Section 5 (1) of the CDF Act. It draws representation from 4 Government Ministries, national Assembly, 8 persons appointed by the Minister from a list submitted in accordance with sub-section (3) of the CDF Act which mandates the following institutions to make nominations:

• The Kenya Farmers Union • The Institute of Engineers of Kenya • The Kenya National Chamber of Commerce • The NGO Council • The Kenya National Union of Teachers (KNUT) • The Catholic Church • The National Council of Churches of Kenya (NCCK) • The Supreme Council of Kenya Muslims (SUPKEM)

The subsection provides that at least one third of the 8 appointees must be of either women or men. The other person in the committee is the Officer Administering the Fund, who is an ex-official member and secretary to the committee. The national Committee is supposed to make sure that allocation and disbursements of the funds to all constituencies ensure prudence management of the funds, receive and imitate discussions of the annual reports and returns from each constituency. Parliamentary Select Committee for the CDF The Committee is established under Section 27 of the CDF Act. It is established by the National Assembly based on the standing orders and consists of a chairman and not more than 10 other members who are not ministers of the government. The Committee oversees the policy framework of the Fund and implementation of the Act, considers project proposals

the members of parliament approves them and channels them to Clerk of the National ssembly for onwards transmission to Minister of Finance for inclusion in the printed

stimates.

he District Project Committee hese committees are located at district levels to coordinate project activities financed by DF. The memberships of the committee includes all members of parliament from the

espective district, mayors and chairpersons of local authorities within the district,

fromAe TTCr

33

chairpersons of constituency committees, District Commissioner, District Accountant and the istrict Development Officer who is the secretary of the committee.

he District Project Committee is supposed to co-opt heads of departments in which the roject are being implemented as ex-official members. The committee is supposed to ensure at there is no duplication of projects within the constituency and such projects are

DF Committee he CDF Act provides for the election of a team of 15 members from the constituency as

evelopment Committee

the National CDF ommittee, which presents final recommendation to the Finance Minister. The CDF projects

bureaucracies, CDF is channeled directly to local vels and thus provide people at the grassroots the opportunity to make expenditure ecisions that meet their felt needs. This is therefore an opportunity for community members

to influence and tap into this fund in support of health sector projects. A community may request to be given a chance to nominate representatives to represent their interests in any project being undertaken in their region56. Nonetheless, Kituo goes further and observes that the Fund is characterized by undemocratic appointments of the committee members. Such appointments do not allow community participation, instead members of parliament appoint people at their own discretion. Indeed, the CDF Act No. 1157 amended through the CDF Act of 200758 that governs the Fund exhibits a weak legal framework

D Tpthimplemented and managed as provided for by the law. CTguided by the guidelines for the formation of the Constituency D(CDC). The guidelines qualify any resident of the constituency who is honest, of high integrity and literate to serve in the CDC. However, the Act provides for the following categories of persons to sit in the Committee:

• The area M.P • Two Local Authority councilors from the Constituency • One District Officer from the Constituency • Two persons representing Religious Organizations • Two men representatives from the constituency • Two women representatives from the constituency • One youth representative • One person nominated from the civil society (NGOs). • Three other members from the constituency.

This committee operates and manages the funds under the patronage of the Member of Parliament of the respective Constituency. The Committee in each constituency approves CDF project proposals. The approved project list is reviewed by cshould be implemented by the District Project Committee with the assistance of the relevant government departments. All works and services, and payments should be done in accordance with government regulations. Unlike other development funds that filter from the Central Government through larger and more layers of administrative organs and led

56 Kituo Cha Sheria, Decentralized Funds Regime in Kenya: A Guide for Community Participation; Nairobi: Kituo 57 Government of Kenya (2004) The Constituency Development Fund (CDF) (Act No. 11) of 2004; Nairobi: Government Printer 58 Government of Kenya (2004) The Constituency Development Fund (CDF) Amended (Act No. 16) of 2007; Nairobi: Government Printer

34

making it vulnerable to manipulation by the constituency committee under the influence of e Act, confers upon Members of Parliament a fourth

.2.1.2 CDF Support to Health Sector k (KHPF) implementation period (1994 –

. For instance, over 1,000 dispensaries have been onstructed through CDF and efforts are being made to provide staff, drugs and equipment to

nal. Annex 3 shows a sample of health facilities put up through CDF.

acilities constructed with CDF to remain un-ope i personnel to manage them59. Prior to the construction of these fa get communities were not established. As a result som o remain under utilized. Also, due to this poor planning by 2008/09, only about 300 dispensaries out of 1,000 built using CDF were reg r rts are currently underway to recruit additional staff as well as engage with the NGOs faci ie (PPPs) in health.

pa f ions per facility, there were no

luenced by local political interests thereby 61

tituents should the MP CDF framework does not provide for any

capacities of CDF committees are overstretched. It is important to note that the

the sitting member of parliament. Thtripartite function, namely legislative allocation of finance, expenditure of public finance and implementation of legislation – proposed projects. 3During most of the Kenya Health Policy Framewor2010), there was no real increase in new facilities across the country. New constructions gathered pace towards to the end of the policy period, fuelled by the availability of the Constituency Development Fund (CDF). Indeed during this period the health sector had anticipated shift, from construction of facilities to maintenance of existing ones. On the contrast, the sector has been receiving a large proportion of the CDF, given the high priority that communities give to healthcmake them operatio 3.2.1.3 The CDF Health Sector Projects Challenges The poor linkages between the CDF committees and the District Health Management Teams have contributed close to a half of health f

rat onal. This is due to lack of cilities needs and priorities of the tar

e f the facilities even after been commissioned

60iste ed and made fully operational . Nonetheless, effoand private sector on how to put to use these

lit s within the framework of Public, Private Partnerships

A rt rom physical infrastructure norms that define populatguidelines developed, to provide guidance in deciding when a new facility is required, where it should be constructed, and what level of facility it should be. There are also reports that some of these facilities have been built, not necessarily to appropriate designs and standards, r in appropriate locations. They were largely info

contributing to inequitable distribution of such facilities . Citizens’ participation in the management of CDF monies is at the behest of the Member of

arliament (MP). The CDF Act does not provide for recourse to consPfail to hold local consultation forums. Also, theintegration with other development plans such as district development plans and District Annual Operational Plans. Citizen’s participation is very minimal. According to Public Expenditure Review Policy for Prosperity 2010-201262 CDF has some disbursement problems, about 16 percent is not disbursed and a further 14 percent is disbursed but not spent. The execution rates and low project completion rates suggest that there is considerable room for improvement and it is likely that the institutional and management 59 Ministry of Health (2007), NHSSP II Midterm Review report: Reversing the Trends. Republic of Kenya. 60 Institute of Economic Affairs 2009/2010 Budget Guide for Members of Parliament 61 Government of Kenya (2010) Kenya Health Policy Review 1994 – 2010 Synthesis report 62 Public Expenditure Review Policy for Prosperity 2010-2012: Key Highlights on Decentralized Funds

35

CDF secretariat based in Nairobi had put a freeze on several CDF accounts and those constituencies have not accessed the funds subjecting the community to poor services.

mittee comprising of representatives rawn from the private sector, the Ministry of Finance, the Permanent Secretary Ministry of

with the technical support of the Kenya Local Government Reform

l basis on the financial aspects of the Fund. Und lations, the Permanent Secretary is responsible for ensuring that Local Aut r ments which are necessary to ena hese include production of reports to the LA disbursements and other relevant issu ; d database of submitted information. The A the Minister for Finance on the crit a ursement and management of the ves, and all other issues related

t ifically require the Committee to meet

andate to improve policy and management of the 63

expenditures. Local

rder to qualify for LATF, each Council is required to develop a 3-year Local nd

3.2.2 Local Authorities Transfer Fund (LATF) The Fund falls under the responsibility of the Minister for Finance and administered by the Permanent Secretary, Treasury and Ministry of Local Government. The operations of the funds are monitored and guided by LATF Advisory ComdLocal GovernmentProgramme’s secretariat. The Permanent Secretary Local Government is responsible for supervising the administration of the Fund, maintaining the proper books of accounts and other records, and reports to the Controller and Auditor General on an annua

er the LATF reguho ities (LAs) comply with the various submission requireble the LATF funds to be released to the LA. TTF Advisory Committee and to the LAs regarding the es and maintaining records, including a computerise

L TF Advisory Committee is responsible for advisingeri for disbursement, the rules and procedures for the disb

d objectifunds, the funding needs of LAs to support the funhe operation of the Fund. The Regulations specto

quarterly, review the operations and administration of the Fund, and issue an Annual Report by the end of the calendar year following the period to which it relates. In the current organization structure of the fund, the responsibility to govern the management of LATF is vested in the minister for Finance, in consultation with the Minister for Local Government. The split of roles and responsibilities between the two ministries adversely affects the fund and as a result there are proposals to harmonize the role of the two ministries y establishing one LATF board with the mb

fund . 3.2.2.1 LATF Structure and Allocation Criteria The LATF is an unconditional “block grant” to provide Local Authorities with supplementary funds that are combined with own-source revenues to meet the Local Authority’s objectives nd as such is not a categorical grant earmarked for any specific LAa

Authorities have the discretion to allocate the LATF funds and their own source revenues through the annual budgetary process as stipulated in the Local Government Act and related financial regulations. LATF and all other revenues are subject to all general budget and financial management conditions and Local Authorities are accountable for the execution of their budgets, including the use of the LATF monies, according to the guidelines issued under the Local Government Act. In oAuthority Service Delivery Action Plan (LASDAP). The LASDAP details activities aprogrammes meant to deliver new, extended or improved services. It addresses direct service 63 Public Expenditure Review Policy for Prosperity 2010-2012: Key Highlights on Decentralized Funds

36

delivery to citizens focusing on health, education, roads, street lighting, water, sanitation, waste disposal, garbage collection, parks, and recreation and sports facilities. Nonetheless, the LASDAP (local planning process) is weak and without sufficient

volvement of communities/citizens. Failure to involve local citizens in planning negatively lth projects may fail to be identified and prioritized

allocate the quivalent of at least 65% of the LATF service delivery account for capital projects.

Average Project

inaffects projects identification process, heafor such funding. Also, local communities are not well informed on the planning and financing mechanisms so as to lobby for more health related projects from the fund. 3.2.2.2 Local Authority Expenditure on Health Projects In accordance with the LATF regulations, each Local Authority is required to e

64According to GOK the capital expenditure for the financial year 2008/2009 were in areas of Roads, Education, Water and Sanitation and Health among other investments. Table 6: Actual Capital Expenditure Distribution by Project Type FY 2008 – 09

Actual % Distribution Cost

Project Type No Amount (Kshs) No Amount

(Kshs) Kshs

Roads 706 2,153351,791 17% 44% 3,050,073Others 409 508,307,921 10% 10% 1,242,807Education 1,040 496,188,167 26% 10% 477,104Vehicles 128 374,297,282 3% 8% 2,924,198Water & sanitation 581 280,290,147 14% 6% 482,427Public lighting 68 258,871,103 2% 5% 3,806,928Markets 180 219,287,099 4% 4% 1,218,262Health 357 170,578,623 9% 3% 477,811Council premises 140 140,228,285 3% 3% 1,001,631Bus park 107 104,418,264 3% 2% 975,872Equipment 149 80,695,273 4% 2% 541,579Administrative Support 66 41,965,190 2% 1% 635,836Sports/recreation 67 36,425,987 2% 1% 543,671Solid waste 25 12,993,328 1% 0% 519,733Housing 26 12,904,562 1% 0% 496,329Slaughter slabs 18 5,527,277 0% 0% 307,071GRAND TOTAL 4,067 4,896,330,299 100% 100% 1,203,917

ource: LATF Annual Report and Revenue of Local Authority Financial PerformS ance FY 2008 – 09

completed in one year. Regulations should be developed and adhered to reduce the number of alth

The amounts of funds spent in health sector projects in 2007/08 to 2008/2009 financial years amounted to 3% of total LATIF amount spent as indicated in Table above. However there is some concern that the funds available are diluted through the large number of projects which entail small project sizes and means that there are not funds available for them to be

projects to be planned and budgeted for in each financial year. Annex 4 shows a list of he 64 GOK, Local Authorities Transfer Fund )LATF); Annual Report and Revenue of Local Authority Financial Performance FY 2008 - 2009

37

65facilities supported by LATF in 2009/2010 financial year. As reported in GOK recent studies and monitoring visits to LATF projects reveals that the level of physical completion f the projects in many councils is low and the issue of better monitoring and the rewarding

addressed.

enya Tomorrow”. The Fund was targeted at reviving economic rowth at community levels which had taken a downturn in 2008 following a prolonged

ows the 2009/2010 and 2010/2011 for the government funding under ESP through the

t outlook paper the overnment proposed to gradually unwind the temporary monetary and fiscal stimulus

oof completion remains a major issue that should be 3.3.3. Economic Stimulus Package (ESP) The ESP is a short-term fiscal devolution instrument for decentralizing government intervention development resources at community levels. The Fund was established in the 2009/10 Budget under the government sponsorship aimed at “Overcoming Today’s Challenges for a Better Kgdrought, electoral violence, high oil and food prices and spill over effects of the global economic crisis. The health sector benefited from the ESP that was channeled through the Ministry of Public Health and Sanitation66. Among the activities scheduled for implementation in financial year 2009/2011 includes recruitment of nurses (20 nurses per constituency), construction of one model health centre in each of the 210 constituencies, procurement of 5 motor cycles and 20 bicycles per constituency and procurement of drugs and non-pharmaceuticals. Table 7 below shMinistry of Public Health and Sanitation Under the Economic Stimulus Package a total of 3,080 health workers have been employed on contract and deployed to rural areas. The Government intends to increase funds for personnel emoluments, which will be used to absorb these health workers upon expiry of their contracts. Unfortunately according to the 2011/2012 budgegpackage. The implication of this reduction is that some of the proposed projects may not be completed. Table 7: Allocations under ESP 2009/2010 and 2010/2011

Budget item 2009/10 2010/11 Contractual employees 314,999,995 2,071,000,000 Medical Drugs 500,000,000 - Non-Pharmaceuticals 500,000,000 - Construction of buildings 4,000,000,000 1,000,000,000 Purchasing of beddings and linen - 100,000,000 Rent of vehicles - 294,000,000 Refined fuels and lubricants - 60,000,000 Purchase of bicycles & motorcycles - 111,000,000 Totals 5,314,999,995 3,636,000,000

Source: East African Health Budgets 2010/2011: An Analysis on Financing for Essential Medicines

The operationalization of the fund lacked its own independent legal/policy Framework but was instead squeezed mid-way between the district focus for rural development and the 65 GOK, Local Authorities Transfer Fund )LATF); Annual Report and Revenue of Local Authority Financial Performance FY 2008 - 2009

: An Analysis on Financing r Essential Medicines

66 Health Action International Kenya (2009) East African Health Budgets 2010/2011fo

38

constituency focus. Under this “hybrid” implementation approach, the government stated that stimulus projects would be identified and managed through the Constituency Development

und Committees (CDFC) but the funds would be channeled though the respective line

very of quipment, recruitment and deployment of nurses and community health workers.

Fministries. In the health sector, the District Health Implementation Team (DHIT) under the leadership of District Medical Officer of Health (DMOH) is the implementing body. The team is required to identify health facilities to benefit, supervise the works and ascertain delie

39

Chapter Four

Monitoring of Decentralized Funds to Ensure Accountability

iodic audits, and formal law enforcement through

e citizenry monitoring and hope that your report will capture the true picture of

ans are aw he newly operational decentralized health funds. Efforts y organ ke them aware will assist in effective monitoring. D l Management Servic etariat of ials were positive on th se nds. “ ffective ci itoring are highly welcomed, we at this has been the missing piece in our efforts to de ntralize health fund the health m rs representing communities are han have little knowledge on health funds” HMSF national official.

n its part the National AIDS Control Council (NACC) noted that information of all decen the

one of the officers interviewed in NACC.

4.0 Introduction Monitoring of government decentralized funds is instrumental in ensuring that the expected returns from the funds are beneficial for the poor. In order to improve on the process an analysis of the governmental perception on monitoring of decentralized health funds, organizations involved, challenges and obstacles encountered is instrumental in order to design and a programme that would empower them to improve the monitoring and accountability processes. 4.1 Governmental Perception on Monitoring of Decentralized Health Funds The study found out that the government is welcome to organisations interested in monitoring decentralized health funds. Indeed it was evident from the officers interviewed that they recognised monitoring as an important way of ensuring that decentralized funds are implemented according to plans and that the desired results are achieved. This was acknowledged as a major shift from the traditional focus on improving the “supply-side” of governance which was supposedly achieved through political checks and balances, administrative rules and procedures, perState agencies like Courts of Law and the Kenya Police. These “top-down” accountability mechanisms have only received limited success. According to the study, after the 2002 General Elections there has been an increased attention to the “demand side” of good governance. That is, strengthening the voice and capacity of citizens (especially the poor and marginalized) to demand greater accountability and responsiveness from government officers and service providers. “We welcome with both arms crediblthe fund” said an officer with HSSF National Secretariat during the interview. Certainly the government is acknowledging that not many of the Keny

ivil societare of t

by c isations to ma

iscussions with Hospita es Fund Secr fice role of civil society in monitoring health ctor devolved fu …efforts by an evil society to do health funds mon recognize th

ce s. Many of anagement committee membe d picked may

Otralized HIV funds is open to the public for scrutiny. Indeed most of it is posted in

organisation’s website. They were however cautious in urging that citizen groups involved in monitoring to avoid misreporting. “…you citizen groups are at times lead by malice and misinformation in your monitoring efforts, exaggerating figures and misreporting” remarked

The study sought to identify organizations that are involved in improving (supply-side) service delivery and enhancing the ability of citizens to engage (demand-side) with public

40

servants and politicians in a more informed, direct and constructive manner in management of decentralized funds in Kenya. 4.2 Organizations involved in monitoring

he organizations involved in monitoring and accountability can be termed collectively as the

others.

mong the civil society, the concept for accountability for decentralized funds involves acking and reporting on allocation, disbursement and utilization of the decentralized funds. his dimension of accountability deals with compliance with laws, rules, and regulations garding financial control and management of each fund. All decentralized fund in Kenya

re established under a legal or policy framework that the civil society seeks to ensure there is ompliance. They also identify weaknesses within the framework that may be hindering roper implementation of the fund and advocates for review.

he civil society on one hand calls for demonstrations and accountability for performance in ght of agreed-upon performance targets. Such performance focuses on the services, outputs, nd results of implementing decentralized funds. On the other hand the civil society are not nly concerned with how decentralized funds are allocated and spent (as directed by ppropriate accounting standards and following legally mandated procedures) but also how e decentralized funds are targeted for social equity in order to meet the needs of a broad

range of citizens, (the poor and marginalized) rather than benefiting a privileged few. It is however evident that most civil society organizations undertake general monitoring of the fund, for example, the CDF or LATF without specifically zeroing in on the portion of the fund benefiting the health sector. There is also evidence that internal reports, manuals and guidelines among other monitoring tools developed by the civil society are all in general forms and rarely meet the specific needs of each sub-sectors for example, health, education or roads. This is despite overwhelming evidence that a huge portion of these in-direct funds are used to support health initiatives67,68. 4.3 Snap Shot of Organizations Monitoring Decentralized Funds The following section provides a brief snapshot of the organizations that are involved in monitoring and calling for accountability in the management of decentralized funds. They include: National Tax Payers Association (NTA) NTA is a national, independent, non-partisan organization focused on improving the delivery of services and the management of devolved funds for the benefit of all Kenyans. It has eight regional offices, one in each of the eight provinces of Kenya. The orgaisation monitors the CDF, LATF, ESP and rural roads funds.

TCivil Society Organisations. This encompasses a wide range of organizations which are not under the control of governments and which are not for profit. They include: Non Governmental Organizations (NGOs), Community Based Organizations (CBOs), Faith Based Organizations (FBOs), Residents Associations and Professional Associations among AtrTreacp Tliaoath

67 Government of Kenya (2009) Local Authorities Transfer Fund (LATF) Annual Report and Revenue of Local Authority Financial Performance for financial year 2008 - 2009 68 Government of Kenya (2009) Constituency Development Fund (CDF), Projects Status Report for financial year 2009 – 2010

41

Some of the tools that NTA to monitor and demand for accountability include the Citizen’s Report Cards. The organization has ished Citizen’s Report Cards in 49 onstituencies from all provinces in Kenya . On each report card the Association makes

recomme future rojects.

backup to policy makers including members of parliament.

CLARION)

ency

researched and publ69c

ndations to stakeholders responsible on how best to improve current and p

Institute of Economic Affairs (IEA) The Institute of Economic Affairs is a national civic forum that seeks to promote pluralism of ideas through open, active and informed debate on public policy issues. The IEA's mandate is to promote informed debate on key policy issues both economic and political and to propose feasible policy alternatives. The Institute has for example conducted study on CDF to inform on national policy dialogue and reforms in the management of the Fund70. In addition, the

stitute provides researchin Until recently the budgetary process was viewed as the exclusive preserve of legislators and administrators and treated as a technical matter for consideration by experts. Civil society involvement was generally confined to specialized lobby groups representing business and trade associations who possessed the knowledge and power to exercise influence. IEA is one such institution that have been instrumental in strengthening the capacity of civil society organisations to comprehend the budget making processes and expenditure tracking to improve transparency and accountability in use of public funds. Some of the activities that the Institute is involved in range from formulating alternative

udget proposals and submitting these for consideration by Treasury, scrutinizingbgovernment budget priorities from a pro-poor perspective, and mobilising citizens to take part in participatory budget exercises. The Institute has also organised training for citizens and policy makers to increase budget literacy and capacity for engagement. This involves analyzing the impact and implications of budget allocations, demystifying the technical content of the budget, raising awareness about budget-related issues and undertaking public education campaigns to improve budget literacy. The organization also reviews national budgets in order to assess whether allocations match the government’s announced social commitments such as decentralized funds.

entre for Law and Research International (CCLARION is a national membership Non-Governmental Organisation (NGO) founded in 1993 and registered in 1994, to enhance democratic governance through research, advocacy and public education in Kenya, regionally and internationally. CLARION's mission is to promote and enhance constitutionalism, good governance and human rights through systematic generation of knowledge, advocacy and public education.

he organization raises awareness of community members on the CDF, LATF, ConstituTBursary Fund, Road Maintenance Levy Fund and Constituency the Constituency HIV/AIDS Funds, enhances their capacity to engage in participatory planning, monitoring and evaluation. The strategies employed include training, research, community accountability forums, awareness raising and social mobilization.

69 NTA (2010) Citizen’s Constituency Development Fund Report Card for Ganze Constituency, Kilifi District. 70 IEA 2006 Kenya’s Verdict: A Citizens Report Card on Constituency Development Fund (CDF); IEA research Paper Series No. 7

42

Other strategies employed by the organization include development of community action plan to enhance the benefits of the Funds, project reports and handbook as tool for use by ivil society organizatios in monitoring decentralized funds. The booklet is also an awareness

sensitize the public on fiscal decentralization

ISA is a civil society initiative committed towards the achievement of sound policy and

SA develops policy papers, emorandums for Reform, CDF Status Reports, conduct joint civil society organizations

assist ommunity groups and individuals to understand the CDF process and to provide information

of citizens in their monitoring efforts through social udits.

s two communication platforms, TISA website - as the social media sites, the Local evelopment Monitor a quarterly Publication, and participates in radio and TV talk shows.

rstand the CDF process and to provide information nd skills on how to monitor these funds through social auditing73.

craising tool that is used by civil society topolicies. It focuses more on how the public is expected to participate in making decisions on development priorities at Local level71. Through these interventions, communities are able to monitor, evaluate and benefit from such Funds. The Institute for Social Accountability (TISA) Tgood governance in local development in Kenya, to uplift livelihoods of, especially, the poor and marginalized. Her Vision is empowered citizens claiming and enjoying their rights in partnership with effective local governance institutions while her mission is to ensure accountable and impact service delivery by professional and effective local governance institutions in Kenya. Using both qualitative and quantitative methodology TIMsubmissions and coordinates joint studies on decentralized funds. For example under the SPAN umbrella in partnership with Kenya Human Rights Commission (KHRC) TISA coordinated a study on decentralized funds in Kenya, titled ‘Harmonization of Decentralized Development in Kenya: Towards alignment, citizen engagement and accountability’. This includes the production of an advocacy DVD titled ‘The Struggle for Devolution in Kenya’. TISA conducts social audits of decentralized funds and developed a handbook tocand skills on how to monitor these funds through social auditing. Social audit is the process through which all the details of a public scheme are scrutinized by its beneficiaries72. The organization also develops the ‘Local Development Monitor’ a quarterly newsletter that informs the public on the resources available at the local level and opportunities for community involvement. The newsletter is also good at creating an understanding of needed reforms as a way to push for more effective local governance in Kenya. It also covers numerous reports on the experiences a TISA is also known for holding dialogues and engagements sessions with bodies managing pubic funds such as the CDF Board, CDF and Local Authority Parliamentary Committees. TISA runD The driving force behind social auditing is the obligation of duty bearers to take responsibility for use of public resources. TISA has gone a step further and produced the CDF Social Audit Guide – a hand book for communities. The handbook is designed to assist community groups and individuals to undea

71 CLARION (2009) Devolved Funds and Development: A Handbook on Participation.

DF Social Audit Guide: A Handbook for Communities 72 TISA-Shelter Forum-Ufadhili (2010) The Nairobi Social Audit Report. 73 TISA (2009) The C

43

Kituo Cha Sheria Kituo Cha Sheria is human rights NGO whose mission is to empower poor and marginalized people to effectively access justice and realize human and people’s rights through advocacy, networking, lobbying, legal aid, legal education, representation and research.

n decentralized funds among communities, and trains

ouncil f Churches. NCCK is a fellowship of protestant churches and Christian organizations

in the struggle for a new onstitution in Kenya. In the recent past NCCK has been involved in the implementation of

ating awareness on the funds and in informing terventions aimed at enhancing the participation of communities in resource utilization.

udget Monitoring and xpenditure Tracking and had trained staff from KETAM, NEPHAK and KANCO in 2007.

Kituo cha Sheria creates awareness ocommunities on how to monitor decentralized funds. Kituo has developed a guide for interrogating the legal regimes that creates decentralized funds and exploring the room available for the public participation in the implementation of the funds74. National Council of Churches Kenya (NCCK) The National Council of Churches in Kenya, founded in 1918, is the world's largest Coregistered in Kenya. To facilitate the united mission of the Christian church in Kenya, the Council promotes fellowship and ecumenism, nurtures a common understanding of the Christian faith and mission, builds the capacities of the membership and enhances the creation of a just and sustainable society. The Council has been heavily involved in the establishment of growth centers, family life education, finance and media, public law, peace building andcprojects aimed at enhancing accountability in the use of devolved funds in different constituencies around the country. To enable members and other stakeholders monitor the decentralized funds, NCCK has developed Decentralized Funds Manual75. The manual presents decentralized funds in a simple easy to understand language. It expounds on the nature, purposes and structural framework of decentralized funds and also seeks to show communities how they can participate in the management, monitoring and evaluation of each of the decentralized funds in an effort towards good governance and accountability, leading to alleviation of poverty. Indeed the manual is a useful tool for crein Centre for Economics Governance and AIDS in Africa (CEGAA) CEGAA aims to contribute to improved economic governance, fiscal policy and financial management and accountability, with specific attention to improving the response to HIV/AIDS. CEGAA is about 1 year old in doing operational work in Kenya. However, previously the organization had been involved in training in BEThese trainings provided these institutions with the impetus that made the institutions explore opportunities in Budget Monitoring and Expenditure Tracking in Kenya.

4 Kituo Cha Sheria, Decentralised Funds Regime in Kenya: A 7 Guide to Community Participation NCCK (2009) Decentralized Funds Manual: How to participate in the management monitoring and evaluation

of decentralised funds; Nairobi: National Council of Churches of Kenya

75

44

In 2009, CEGAA was involved in training Great Lakes University of Kisumu (GLUK) in Budget Monitoring and Expenditure Tracking. This course provided DMOs, other health practitioners and students of GLUK with understanding of budget – both national and devolved funds; and their role in effective service provision, Monitoring and Evaluation. In the last one year, CEGAA has been involved in carrying out a situational analysis that was gauging the civil society and government’s intervention in Most at Risk Populations

ARPs). CEGAA has also participated in the review of health budget provisions EGAA is also instrumental in sharing of

overnmental Organization (NGO) based at the Coast Province of enya. It was established in 1997 to promote the struggle for human rights with a view to

ccountability of public officials.

on of the fund. This includes development of documentary to empower local ommunities to investigate their local CDF and take on the challenge of holding the officers

his is a national human rights body set up by the government to promote and protect human

s tax payer’s money and oes not belong to the area MP.

Kenya Treatment Access Movement (KETAM) African Treatment

ment, care and support for all

(M(2011/2012) and seeks to influence the budget. Cinformation on the budgeting cycle to relevant government officials, parliamentarians; HIV/AIDS programme managers, civil society representatives, organizations of People Living with HIV/AIDS among other stakeholders. Muslims for Human Rights (MUHURI) MUHURI is a Non GKcontributing towards the national and international struggle to promote and protect the enjoyment of human rights and civil liberties by all. MUHURI seeks to enhance the capacity of coastal communities in Coast province to hold the government and non-state actors accountable. Through its Social Accountability program, the organization empowers communities to monitor public funds so that they can participate in the proper administration and implementation of development projects and demanda Among the funds that the organization has focused on is CDF. In order to bridge the CDF’s accountability gap, MUHURI has been conducting “social audits” a participatory process in which communities monitor publicly financed projects and identify how best to improve project outcomes. Through this process, MUHURI has identified problems and irregularities in the implementation of the CDF in local projects. The organization has engaged the government officers involved, policy makers and committee members in attempt to improve the utilizaticin charge accountable. The organisation is also a member of the Social and Public Accountability Network (SPAN). Kenya National Commission on Human Rights Trights. The Commission also monitors the realization of economic, social and cultural rights through systematically tracking and assessing the government’s performance against set benchmarks and targets. This includes monitoring the usage of decentralized funds such as CDF and documenting the findings in its reports. The Commission also builds the citizens capacity to understand decentralized funds for example; that CDF id

KETAM was founded in 2002 as the Kenya chapter of the broader PanAccess Movement. It advocates for universal access to treat

45

people living with HIV (PLHIV) in Kenya. KETAM aims to advocate and lobby for treatment, especially the use of anti-retroviral (ARVs) medicines for

n and encourage olicy intervention through direct advocacy efforts and media coverage.

ANCO conducts budget tracking for HIV&AIDS, empowers civil society organizations

ga Khan Health Services, Kenya, Community Health Department

nd rogram design development and monitoring. Among the strategies employed is the

making decisions and

rce to counter the pact of HIV/AIDS on their lives and that of their loved ones in Kenya.

d access to treatment, especially the use of

sources to HIV programmes especially drugs and commodities.

increased access topeople living with HIV and AIDS (PLWHAs) and brings together a multidisciplinary group of activists comprised of professionals and experienced HIV treatment advocates from different organizations in Kenya. KETAM conducts budget tracking, to establish the extent to which government resources to HIV drugs and commodities are actually spent in line with stated budget priorities. The Organization analyses reported government expenditures on HIV drugs. As a result KETAM is instrumental in identifying the gaps in HIV drugs or misappropriatiop Kenya AIDS NGO’S Consortium (KANCO) The Kenya AIDS NGOs Consortium (KANCO) is a national membership network of non-governmental organizations (NGOs), community based organizations (CBOs) and faith-based organizations (FBOs) involved in or that have interest in HIV & AIDS and TB activities in Kenya. Kincluding community based organizations to access Constituency HIV fund, advocate for transparency and accountability on how the fund is managed. The organization also mobilizes citizens to demand access to information on government expenditures on HIV and health sectors. AAKHSK’s Community Health Department (CHD) has been operating in Kenya since 1983. It pioneered the establishment of primary health care practice. CHD works in partnership with community-based health and social organisations, non-governmental organisations, and the Ministry of Medical Services and that of Public Health and Sanitation. It provides support from the dispensary level through to the national level. They offer technical assistance and training in key health systems such as dispensary governance, management, financial management and transparency, information systems, ap

76development of handbook for health facility committee members managing funds in health facilities. The tool is instrumental in empowering community members and health care to demand transparency and accountability of decentralized funds including HSSF at health centre and dispensary levels. National Empowerment of People with HIV and AIDS in Kenya (NEPHAK) NEPHAK is a national NGO that unites support groups of People Living with HIV/AIDS (PLWHAs) and individual PLWHAs into a national and formidable foim

The Network advocates and lobbies for increaseanti-retroviral (ARVs) drugs for their members (PLWHAs). They conduct budget analysis and engage in budget making processes to ensure that the government is allocating more re

Aga Khan Health Services, Kenya (2007) Managing a Health Facility: A Handbook for Committee members nd Facility Staff; Nairobi: Macmillan Publishers

76

a

46

The Network is mainly interested with the devolved HIV Constituency Fund. They seek to establish the extent to which the fund is benefiting organizations of PLWHA. They advocate for allocation of more funds into the kitty and seek for more of her members to benefit from

e fund through the Call for Proposals. In order to improve on the transparency and

nizations operating within Kenya, with a ared vision of public accountability and integrity in use of public resources in Kenya. This

anizations operating within Kenya, with a shared

and Democracy (CEPAD), MS Kenya, ocial Economic Rights Foundation (SERF), The Institute for Social Accountability (TISA),

inamwenyuli Youth Group, Poverty Eradication Network EN), Consortium for the Empowerment and Development of Marignaslised Communities

PAN promotes local governance accountability concerns in policy making, to coordinate

(CDF), Local Authority Transfer Fund (LATF), Free rimary Education Fund (FPE), Secondary Schools Education Bursary Fund (SSEBF), Water

AIDS Fund and the Roads Maintenance

anizations involved in monitoring and accountability of ecentralized funds rarely liaise with parent Ministry to get crucial background information

nual plans, monitoring and evaluation

thaccountability of the fund, a member of the network is required by the TOWA Guidelines to sit in each of the Constituency AIDS Control Committees. The Network further mobilizes it members and other stakeholders to demand transparency and accountability in the management of HIV funds in the country. Social and Public Accountability Network (SPAN) SPAN is a national network of Civil Society Orgashis a national network of Civil Society Orgvision of public accountability and integrity in use of public resources in Kenya. Members include Action Aid International Kenya (AAIK), Centre for Enhancing Democracy and Good Governance (CEDGG), Centre for Peace SAbantu for Development, and World Vision Kenya (WVK), Kenya Human Rights Commission (KHRC), Strategies for Northern Development (SND) and Bare Care Centre. The other members include Institute of Participatory Development, IEA, Olosentu Dam Project, MUHURI, Abenengo Esh(P(CEDMAC Kenya), Centre for Human Rights and Community Empowerment, Rural Community Development Agency RCDA-Meru, Ufadhili Trust and Chemchemi Ya Ukweli (CYU) The Institute for Social Accountability is the current host of SPAN secretariat. Sefforts/avoid duplication and to advocate desired changes including accountability in management and governance of decentralized funds. The network’s initiatives aim at bringing in new solutions and sparking national dialogues on the effectiveness of decentralized funds in making sustainable human development a reality. The Network has focused on almost all the decentralized funds in Kenya. These include Constituency Development Fund Pand Sanitation Trust Fund (WSTF), ConstituencyLevy Fund (RMLF). Among the strategies applied include reviewing policies governing decentralized funds and issuing memorandums to the government for considerations and conducting studies aimed at assessing the extent of duplication among the funds in order to seek for suggestions on how the management of the funds can be improved. 4.4 Challenges in monitoring and evaluation of devolved health funds Most of the civil society orgdthat are necessary for the task such as the anframeworks that provides the relevant monitoring indicators. As a result the reports generated by the civil society are not in tendering with the fund plan thereby generating conflicts

47

between the government and civil society. There also negative perceptions from the fund officials that such organization are intruding in the management of the funds thereby denying them crucial details about the fund. The organizations monitoring the decentralized funds are Non Governmental Organizations

GOs), Community Based Organizations (CBOs), Faith Based Organizations (FBOs),

ve, inconsistent and ontradicting report that may not be reliable. In some instances there are incidents where

. For example, it is not clear in most reports

iety organizations are more preoccupied with budget analysis than impact analysis. here is more concentration in monitoring the processes rather than the products (result).

iety is also confronted with unfriendly political climate. This is especially the case ith organizations that promote and call for good governance of such funds as CDF and

(NResidents Associations and Professional Associations among others who most often lack adequate training/capacity to seek for correct information (data), and analyze the bulky data information on the implementation processes of the decentralized funds. They are also faced by inadequate resources including human, capital and money. This leads to poorly organized monitoring exercises mainly reactive thereby generating incomprehensicincorrect data has been recycled in such reportswhether the HIV fund given through NACC is an allocation from government resources, a grant or a loan. Civil socTThis pre-occupation with figures rather than values reduces monitoring and evaluation work into a public popularity contest between the government and civil society around budget expenditures at the expense of value addition. Civil socwLATF. They are alleged to be inciting people against the establishment.

48

Chapter Five

Conclusion and Recommendations

5.0 Conclusion Legal Framework The Constitution of Kenya governs all public expenditures. The Constitution provides that all revenues or other monies raised or received for the purposes of government of Kenya are paid into and form a Consolidated Fund from which no withdrawal can be made unless authorized by the Constitution or by an Act of Parliament. There are two ways that the creation of decentralized funds is anchored in the Constitution namely an Act of Parliament

tor

ations for the health

mittees include

and government policies. Decentralized funds established by Acts of Parliament benefiting the health sector include Constituency Development Fund (CDF) and the Local Authorities Transfer Fund (LATF). However, to date, there is no legislative framework to support the health sector decentralization. In fact the Constituency HIV&AIDS Transfer Fund, the Health SecService Fund (HSSF), Hospital Management Services Fund (HMSF), though earmarked to benefit the health sector directly, they are established through government policies and not a legislative framework. Nonetheless, there sentiments that the multiplicity of policies and Acts of Parliament governing the operations of each of the decentralized funds is contributing to wastage of resources hence the need to harmonize and pull resources in one well structured institution. For example there are feelings that CDF is a duplication of LATF, has no structure and is open to abuse by the politicians. Fortunately, the new constitution, which came into operation in 2010, under the Bill of Rights and Devolved Government introduced many required legislations, particularly in supporting rationalization of service delivery around the decentralization framework. There are proposals on whether this will be achieved through a multiplicity of policies or one structure. Nevertheless, these proposals in the New Constitution have major implicsector hence the need for the civil society among other stakeholders to remain pro-active and inform the upcoming policies and legislation. The policy direction on resource allocation criteria and process should therefore guide how national and county level health facilities should continue to benefit from decentralized funding. HSSF and HMSF The Officer in charge of the facility is required to ensure that the Facility Committees members are provided with relevant health as well as financial information in order to monitor performance of the facility. According to the Guidelines, these comcommunity members and women representatives and are required to take care of citizen interests in the management of fund77. However, this raises the question, whether community members are aware and have the capacity to oversee the implementation of the funds. Most often, the officer in-charge of the facility runs the show while keeping community members

77 Hon. (Prof) Peter Anyang’ Nyong’o, Minister for Medical Services, Kenya; Citizen’s Engagement in Health Service Provision in Kenya

49

in darkness. Also, HSSF and HMSF are new funds that the public is yet to come into terms with. As evidenced by document review and interviews, no civil society organizations has a programme to monitor this fund. Both HSSF and HMSF are facing serious human resources deficiencies at the Health Facilities both in term of work-load and staff orientation towards basic financial management. Increased staffing requirements can only be negotiated with the Directorate of Personnel Management (DPM) and there is currently a halt on the hiring of new staff by all Ministries. The few being employed are meant to replace those that have left due to attrition factors. The process of allocating health sector funds such as HSSF has not taken into account differences in health indicators, health access, and provision costs across country. For example, the government released equal amounts of funds Kshs 243,000 to all health centres across the country. This is an assumption that country is homogenous or the ministry has no ata for planning and resource sharing purposes.

little efforts on the part of the government cluding NACC to inform the masses about the contract that the government negotiates and

has been consumed y consultancies. An analysis of how much of the loan is actually utilized by these onsultants, their cost effectiveness and whether they are indeed necessary for the project ersus enhancing the capacity of NACC as an institution for carrying out such tasks would be

vital. On the same wavelength, it would be appropriate to do an analysis of volume of funds disbursed through Financial Management Agency (FMA), the cost of disbursing one (1) shilling to implementing organizations and the value the FMA has added to the fund. Such statistics would be instrumental in making decisions on whether to improve the limited capacity within NACC to administer sub-projects directly, revise the terms of reference for the FMA or forgo the FMA altogether. A vibrant civil society calling for accountability would also be informed by such statistics. Finally, access to the HIV and AIDS fund depends on the merits of proposed interventions (quality of proposal) though this is negatively affected by levels of literacy and awareness among grassroots organizations. Also, the process (CfP) is characterized by corrupt practices rendering irrelevant some organizations with better chance of succeeding. As a result there is unequal distribution of fund characterized by huge disparities in funds allocation so that some parts of the country receive meager resources compared to others. There is therefore need to enhance equity, transparency and accountability in the funding process. CDF and LATF The health sector has been receiving a large proportion of these funds, given the high priority that communities give to health. New constructions of health facilities took place towards to the end of the Kenya Health Policy Framework (1994 – 2010), courtesy of funds availed by the constituency Development Fund (CDF). In a bid to operationalize some of these facilities,

d The HIV and AIDS Fund In the eyes of the public it is not understood that most of the HIV and AIDS funds channeled through the National AIDS Control Council (NACC) is a loan from the World Bank that the Country will have to repay back. There are inenters into with the development partners such as the World Bank. On the implementation of the Fund (Loan) a huge chunk of the amountbcv

50

the government under the Economic Stimulus Package proposed to employ on contract 20 nurses per constituency and to procur aceuticals.

he construction of new health facilities was however, impacted negatively by lack of guidelines from the gove ty is required, where it should be constructed, and what level of facility it should be. To the contrarily, most of the

ew facilities were determined by political inte ests contributing to inequitable distribution of remained inequitable78.

F are managed through politically driven independent structures. As a

through decentralized funds is pegged on how

embers or are personal gifts from political leaders. Poor monitoring and call for

e drugs and non-pharm T

rnment for use in deciding when a new facili

n rexisting facilities Both CDF and LATresult, there is little or no consultation taking place between the two funds and they are often viewed as competitors rather than partners. The situation is compounded further by inclusion of Economic Stimulus Package (ESP) which has no structures of its own but should ride on CDF and line Ministries structures. Decentralized Health Funds Governance

he achievement of community health needs Twell the community representatives on the various governance committees understand and undertake their respective roles and responsibilities. The appointments to the committee are not participatory and transparent. Indeed most of the committee members are political appointees whose qualifications do not match the tasks as expected. Also, most of the persons appointed into these committees are in many other committees thereby limiting their contribution and participation. Consideration of specialized skills in areas like planning, management and budgeting should be factored into the appointment. In fact many health facilities lack the technical, managerial, and financial skills needed to undertake their new responsibilities. The trainings conducted are not sufficient as they are hurriedly organized and crush managed due to time factor and resources.

onitoring Decentralized Funds MThe decentralized funds guidelines and policies call upon citizens to monitor utilization of decentralized funds at the grassroots levels including at health facility. Health care facilities are also required to develop and publicly display their service charters and organize periodic public briefings aimed at empowering members of the community monitor the quality of service delivery and the utilization of the funds. Government officials and civil society members interviewed felt that lack of professional and technical supervision, has led to poor project quality. This is compounded further by low community participation in monitoring and accountability due to paucity of data and general

formation about the funds. There is also general misconception by community minthat funds are ‘free’ accountability have led to abuse of funds giving a sense of impunity among the perpetrators. Nonetheless, several factors emerged that informs the rationale for civil society participation in monitoring and calling for accountability of decentralized funds. These are as follows: first, citizens have a right to know that there exist centralized funds; second, enhances transparency, credibility and accountability in the way the funds are managed; and third, enhances efficient and fair allocation of the funds (ensuring there is equity and that the poor and marginalized benefits). The other factors that encourage the involvement are

78 Government of Kenya (2010) Kenya Health Policy Review 1994 – 2010 Synthesis report

51

incorporation of the views (consultation) with all stakeholders, to help citizens to identify more with the fund thereby strengthening ownership. The process is also instrumental in creating or strengthening collaborative opportunities in which government, civil society and ther partners can work together (Public Private Partnerships).

engage in while monitoring and calling for accountability in the management of ecentralized funds.

further under the new constitutional ispensation, which has provided for a devolved system of government. These decentralized

gh to make visible differences in access to health care

ecentralized funding should be a creature of the constitution or of some law that specifies

to rationalize each decentralized fund including ddressing existing conflict of interest in which politicians are also public finance managers

wed to accommodate e new developments.

o To achieve the right to health civil society actors must continue to play their watchdog role in promoting transparency and accountability in the management of decentralized funds. However, for this to be achieved effectively there is need for the players (civil society) to avoid unhealthy competition not just for financial resources but also in terms of the activities that theyd Decentralized Funds Allocations Finally, the amount of health funds decentralized to local authorities, districts and constituencies and individual health facilities has in the past five years significantly increased. The funds are scheduled to increasedfunds are substantial enouinfrastructures at community level if they are properly managed. 5.2 Recommendations Designation and consolidation of decentralized units Dthe mode of decentralization, its administration and financing. The legal foundations of Kenya’s decentralized funds need review, since there are instances where the provisions conflict with the Constitution in violating the principle of the separation of powers. Indeed according to Public Expenditure Review Policy for Prosperity 2010-201279 there is need for separation of roles to improve accountability for public funds in the current organizational structure of CDF. The Member of Parliament has a role in appointment of committees that are the executor of funds and as a member of legislature, also the overseer of public funds. The new constitution dispensations has provided legal framework for governing decentralized funds. It is however necessary for the civil society to advocate for development of effective legislations and institutional frameworks aand development officers. Such rationalization would also improve the scope for selecting projects and their management. There are also concerns that although a lot of work has been done to operationalize the HSSF and HMSF there are minimal progress so far in reviewing the Public Health Act to make health facilities accounting units, which would greatly improve the accounting processes80. It is therefore of paramount importance that the public health Act is revieth Harmonization of health sector projects The expansion of networks of health facilities through the CDF, LATF and ESP needs to be in tune with constituency development projections. Such facilities should be integrated 79 Public Expenditure Review Policy for Prosperity 2010-2012: Key Highlights on Decentralized Funds 80 GOK, Kenya Health System Assessment 2010

52

harmoniously, together with other required inputs (especially human resources, drugs, equipment and commodities), to ensure efficient, equitable, effective and sustainable delivery

f health care services. This can however, only be achieved if the CDF, LATF and ESP

IV and AIDS Fund

oan is utilized by consultants including the Financial anagement Agency (FMA), their cost effectiveness and whether they are indeed necessary

f NACC as an institution for carrying out such

schemes that are yet to be known by the ublic. In order to address the problem of ignorance, massive civic education is needed on the

nd HMSF), their governance, management, channels of

spective funds. However, the capacity of ommittee members to manage the fund remains a key barrier. Given the importance of these

oinfrastructures are well coordinated and that the respective health ministry is fully involved in the planning and implementation of the proposed projects. Indeed, the funds can make a significant impact in terms of reversing the trends if their interventions are part of the health sector overall plan and budget.81

HA vigorous campaign should be mounted by both the government and civil society to inform and educate the public about the contract that the government negotiates and enters into with the development partners such as the World Bank. An analysis of how much of the lMfor the project versus enhancing the capacity otasks should be conducted. For the FMA an analysis of volume of funds disbursed through Financial Management Agency (FMA), the cost of disbursing one (1) shilling to implementing organizations and the value the FMA has added to the Fund would also be instrumental in providing data for informing HIV&AIDS Funds to inform monitoring, accountability and other advocacy processes by the civil society. Managerial and Governance Problems Making fund management more transparent would elicit greater interest among the citizenry in participating at all levels of their management. This greater participation by the citizenry goes hand in hand with the need for more public education on what the funds are and how they can be accessed. HSSF and HMSF are newpnature of these two funds (HSSF areporting, monitoring and for accountability. Citizens’ participation Decentralization has created a new managerial layer in which citizen participation has been fore grounded through committees managing reccommittees in governance and management of the funds, much more investment is needed to build their capacity including streamlining the funds management structures. That is, ensure compliance with guidelines/policies governing the fund and the reporting channels including community feedback.

rsing the Trends 81 Government of Kenya (2007) Ministry of Health, NHSSP II Midterm Review report: Reve

53

Annex 1: Sample list of Health Centre that received HSSF MFL CODE

Province Facility District Amount Ksh

10582 Central Kiganjo Hc Nyeri Central 243,000.0010236 Central Gatura Health center Thika E. 243,000.0010462 Central Kangaita H/C Kirinyaga central 243,000.0010545 Central Kiamutugu H/C Kirinyaga E 243,000.0014002 Nyanza Pala ndhiwa 243000.0014011 Nyanza Ramula Ugenya 243000.0013828 Nyanza Muhuru Migori 243000.0013833 Nyanza Diru Homabay 243000.0011748 Coast Maktau Kaloleni 243000.0011262 Coast Rabai Voi 243000.0011264 Coast Buguta Bura 243000.0011282 Coast Bura Bahari 243000.0011383 Coast Chasimba Ganze 243000.0013193 Nairobi Aptc embakasi Embakasi 243000.0012871 Nairobi Baba ndogo Kasarani 243000.0012876 Nairobi Bahati Kamkunji 243000.0012879 Nairobi Dagoreti approved Dagoreti 243000.0013272 North Eastern Almawa Wajir E 243000.0013281 North Eastern Arabia Mandera E 243000.0013290 North Eastern Arbajah Wajir W 243000.0012232 Eastern Kathingu Imenti S 243000.0012283 Eastern Kiarago Iment S 243000.0012287 Eastern Kibugu Embu W 243000.0012530 Eastern Mitaboni Kathiani 243000.0012546 Eastern Mpukoni Maara 243000.00 Source: HSSF Secretariat, Ministry of Public Health and Sanitation Ministry of public Health and Sanitation

54

Annex 2: The Evaluation Process and Evaluation Criteria 1. Evaluation Process The evaluation process will consist of two distinct stages. These are: Stage 1: Preliminary Evaluation Stage

sals will be reviewed against mandatory requirements. These

) Proposal has been submitted to the relevant level (National, DTC and CACC) and office

d and will not proceed to tage 2 of Evaluation.

red to the requirements of the specific TOWA Calls for Proposals.

pplications. Applicants submitting applications for more than one riority must ensure that each is submitted under separate cover. Each application (per

priority) will be scored on an individual basis. Applications will be evaluated in accordance with the selection criteria set forth below. Any award made would be provided to the responsible applicant whose application offers the greatest likelihood of success, value for money, and technical excellence.

During this stage, proporequirements are: a) The Proposal Area is in line with the Areas Advertised for the relevant level of (National,

DTC and CACC). b

as per the set deadline. c) All Relevant Application Forms have been filled as per guidelines. d) All Relevant Attachments have been provided as per guidelines. e) Applicant(s) should not have been bad-listed. f) Applicant(s) should not have pending implementation issues if previously funded under

TOWA Project Rounds of Calls for Proposals. Any proposal not meeting any of these requirements will be rejecteS (ii) Stage 2: Technical Evaluation Stage All Proposals meeting all requirements under Stage 1 above will undergo Technical Evaluation. In carrying out the Technical Evaluation, the Technical Evaluation Criteria set out below will be applied. 2. Technical Evaluation Criteria The criteria will be tailoApplicants should note that these criteria serve to: a) Identify the significant issues which applicants should address in their applications and b) Set the standard against which all applications will be evaluated. Applicants should therefore familiarize themselves fully with the criteria before embarking on proposal development. To facilitate the review of applications, applicants MUST complete the relevant of their ap

55

Section of the Content proposal

Maximum length

Maximum points

d awardeIntroduction History of demonstrated sound programmatic

anagemen quality of prervice, inc meeting goals nd targets; cluding fosts as we reportin f performa uding adherenchedules.

½ page 5 m t practices; oduct or s luding consistency ina cost control, in

ll as in financial orecasting

c g; timelinesso nce, incl e to sc

Justificatio ication on analysis an - Understanding of what exists on the ground - Understan what are the gapimplementa- Understan sting potentiapportunitie

½ page n Justif : Situati 10

ding of s in tion ding of exi l and

o s

Understan hat needs one and what is on the ground, and referencriat m guidelin

ding of w to be d e to the approp e progra es.

Goal Objectives

ves that are specific, measurle, r nd time bound

easurable Results and targets withdicators T Approach:

he technic h will demonsnderstandi riority area to

innovation in proposed implementation, gender consideration and proposed monitoring and evaluation, leading to accomplishing the desired performance objectives and results.

2 pages attainab

Objecti able, 30 ealistic a Clear

M specific in echnical T al approac trate u ng of the p be addressed, an understanding of what exists on the ground and gaps, appropriate linkages,

Delivery methods

A clear implementation plan that is well-conceived: creative, logical, clear sequencing of activities, technically sound, cost-effective, time bound and feasible that contributes to achieving the proposed outcomes.

3 pages 20

56

Section of the Content proposal

Maximum length

Maximum points awarded

Institutional Key Pecapacity

rsonnel: The Applicant will provide highly qualified “Key Personnel” to lead and

re required to: • Propose highly qualified key personnel

implementation of the Applicant’s technical

taff, applicants may propose a staffing

ed based on:

hnical approach and proposed management

lified Senior Management Team with relevant demonstrable expertise and

xperience in

½ page 20

manage the implementation of the project. Specifically, applicants a

positions based on the approach and

proposal. Other Non-Key Personnel: For non-key personnel splan that they believe will be the most efficacious at achieving the project objectives. Proposed non-key personnel will be evaluat• The variety of skill areas and their

appropriateness to fit in the tec

structure; • Qua

experience including ecollaborating effectively with other partners and stakeholders.

Sustainability Demonstrate:

ticipation overnment institutions

½ page 5 • Community par• Working with g• Other sources of funding

Budget explan

Provide a detailed work plan together with a 2 pages 10 ation budget narrative describing how costs have been

calculated including the unit costs of services delivered. A clear work plan that is well-conceived: • creative, logical, technically sound, cost-

effective, and feasible, that contributes to achieving the proposed out

come

57

Annex 3: Samp

l Facilities Supported by CDF in FY 20

Constituency Imp tus

e of Health 09-2010

lementationPlanned Health Projects Budget (Kshs) Sta1) 2,141,057 Complete Construction of Yumbis dispensary 2) 400,000 Complete Completion of Yumbis dispensary 3) 1,800,000 Complete Construction of dispensary at Mansabubu 4) ,800,000 Complete Construction of Galmagala dispensary with

staff quarters 2

5) 2,500,000 Complete Construction of dispensary at Fafi 6) of maternity wing at Bura 2,500,000 Complete Construction 7) 2,20 Co lete Construction of dispensary at H/dera 0,000 mp8) 3,4 C lete Hulugho inpatient ward at Hulugho 00,000 omp9) 2,260,561 Complete Bura District Hospital Staff Housing 10) 3,600,000 Complete Construction of Dispensary at Amuma 11) tering, roofing & fixing 600,000 Complete Amuma Disp- Plas

doors/ windows 12) To commence Kamuthey Disp-

Fafi

1) Kyasioni Dispensary- Purchase of

equipment 1,151,935.80 Complete

2) Katangi Health Centre-Renovation of 500,000 Ongoing Facility

3) 750,000 Complete Construction of Kauthulini Dispensary 4) 500,000 Complete Renovation of Katangi Health Centre 5) 2,103,790 Complete Matuu Hospital- Ward renovation 6) 550,000 Complete Kwa Mwatu Dispensary- Completion of

building 7) 637,220.70 Complete Nthungulu Dispensary- Completion of

buildings, 8) 000 Complete Kwakulu Dispensary- Buildings

construction 500,

9) 315,000 Complete Mamba Dispensary

Yatta

10) Awaiting Funds Ndalani health centre- Tree planting and garbion set-up

1) acabari Dispensary- Staff house repair 200,000 G2) 1,0 C lete Gachuriri dispensary- generator for facility 00,000 omp3) 100,000 Complete Gategi H/Centre- purchase of plastic water

tank 4) 000 complete Kabuguri dispensary- laboratory 500,5) b equip purchase 200,000 Complete Kabuguri dispensary- la6) - disp const 650,000 Complete Kamunyange dispensary7) karaba dispensary- lab renovation 50,000 complete 8) Kiambere health centre-Construction of

drug house (phase 1) 165,000 Not yet. money

not released 9) Kirathe Dispensary- Public /staff toilet

construction fencing 252,510 Not yet. money

not released 10) Kirathe Dispensary- Water tank purchase 47,490 Not yet. money

not released 11) Machang'a dispensary 175,000 Complete 12) Mbondoni disp 250,000 Complete

Gachoka

13) Mbita dispensary- lab eq purchase 250,000 Complete

58

(Kshs) Implementation Status Con ned Health Projects Budget stituency Plan

14) Riakanau dispensary- lab eq purchase 300,000 Complete 15) 1 C lete Rwika dispensary- lab eq purchase 75,000 omp16) 175,000 Co lete Wachoro dispensary- lab eq purchase mp1) 650,000 Completed Kangemi Health Center 2) 23,000,000 Completed with

Ksh19,554,115 Kangemi Maternity

Westland 3) 800,000 Completed with

Ksh 831,572.00 Renovation of Lower Kabete Dispensary

1) Mikequi dispensary

1,760,500 Complete ameni Dispensary- Construction and pping of new

2) ibusu Dispensary- Construction and 1,500,000 Complete Kequipping of new dispensary

3) 00,000 Complete Kau Dispensary- Rehabilitation work 1,04) 00,000 Complete Galili Dispensary- Construction and

equipping of new dispensary 1,8

5) 3,000,000 Ongoing Construction of Semikaro Dispensary 6)

equi3,000,000

Complete Kulesa Dispensary- Construction and

pping of new dispensary 7) Kip

purc1,698,400 Complete ao Dispensary- Construction and

hase of medical equipments

Garsen

8) 0,401.50 Complete Ngao District Hospital- Rehabilitation work

2,19

Source: CDF Project Status

Report 2009/2010 Financial Year

59

Annex 4: List of Health Project Funded or Planned to be by LATF in FY 2009/2010 Province Council oImplemented Projects C st (Kshs)

Kendu Bay 139,Magau Dispensary 800 Mu ouse 25horoni Construction of Doctors H 0,000 Nyanza Ny nstruction 60ando Waganga Dispensary Co 3,528 Bo uction) 62met Kwenikabet Dispensary (Constr 1,877

1) Kapkimbir Dispensary 307,436 2) Ngenybokurio Dispensary 232,380 Kapsab

nsary 14et

3) Kamurguiywa Dispe 0,985 Lit 20ein Kenene Dispensary 0,000 Lo 52dwar Dispensary Nawoitin 2,870 Ke 45iyo Toror Dispensary 0,000 Rift Valley

Kip 27kelion Dispensaries 0,000 Ma 37rakwet Tunyo Dispensary 5,500 Molo 199,Childrens Ward-Molo District Hospital 600 Na a Dispensary kuru Kamar 700,000

Nandi Hills Construction of Health Centers 928,335 Bu on of drugs 5,17ngoma Health including Provisi 0,889

Construction of Malaba Health Center 1,836,498 Construction of Kamuriai Dispensary 1,654,870 Construction of Dispensary-Mugai Ward 436,300 Construction of Dispensary- Chemuche wa 34rd 3,034 Construction of Dispensary-Butali Ward 422,400

Malaba

ary-Mahira Ward 30

Construction of Dispens 2,710 Mu ya) 30mias Lusheya Health Center(Lushea 9,000

Western

Vihiga Construction of health centers 2,408,000 Ch 20uka Dispensaries 3,555 Kangundo Kikuyuni 1,000,000 Ma pensary 15ua Equipping Thuuru Dis 0,000

Riachina Dispensary 1,444,221 Mbeereispensary 2,45

Karaba D 6,327

Me 1ru Marathi Dispensary ,486,113 Me u S nsion of Dispensaries 87,598 r outh ExteNy 4,832,810 ambene HIV&AIDS Mt sary Pha 14ito Andei Rehabilitation of Ivingoni Dispen se 11 9,654 Ru 24nyenjes Kanduri Dispensary 3,500 Th 1,50araka Rehabilitation of Dispensary 0,000

Eastern

Ma pensary 1,00ndera Equipping Khalalio Dis 0,000 Kia ards 80mbu HIV&AIDS Needy Cases Six W 0,000

Kamuchege Dispensary 750,000 Central Ny75

andarua Kihuho Dispensary 0,000

Ny 3,51eri Health Centers 0,250 Olkalou Rurii Health Center 369,555 Central Ru ithurai 1iru Completion of Dispensary G ,862,308 Ma 1lindi Health ,090,882 Coast Mariakani Construction of Dispensary 753,466

Source: LATF Annual Report 2009/2010

60