New report reveals top and bottom counties in health spending

By Paul Wafula

Kenya: Kisii is the top spending county on health per person in the ranking that saw Tharaka Nithi become the least spender among the 47 counties.

A breakdown of the development budgets by the Commission on Revenue Allocation (CRA), County Budgets: 2013-2014 report, shows that Kisii County will spend Sh2,555 on each of its residents to improve their health infrastructure.

This is 10 times more than what the bottom five counties combined plan to spend per person in developing health services in what has seen most counties miss their first opportunity to fix the ailing healthcare system.

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Invest less

It comes at a time when it is becoming clearer that most counties will invest less in healthcare than what the National Government did the previous years before the onset of devolution.

Before devolution, the National Government spending saw Nairobi, Kiambu and Nakuru counties take the lion’s share of the development budget, spending that explains the better health infrastructure in these regions.

To earn the top spot, Kisii will spend Sh3.2 billion, which is about 10 per cent of its entire budget, on its 1.2 million citizens as projected in June 2013.

But CRA notes that Kisii is among a host of other counties, including Mombasa, that are relying on huge unexplained external sources to boost their budgets, a pointer that its generous spending is influenced largely by its muscle in sourcing for health development partners.

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Second and third

Lamu County came in second having set aside Sh1,659 to develop health for each of its citizens, while Isiolo was third with Sh1,484 per person.

The calculations are limited to what counts intend to spend on development expenditure.

Also in the list of the top five spenders are Laikipia and Marsabit counties which plan to spend Sh1,159 and Sh734 per person, taking the fourth and fifth positions respectively.

Three counties from the Western region followed closely in the top 10  big spenders on health per person.

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Busia County was sixth after it set aside Sh734 per person, while Kakamega and Bungoma Counties set aside Sh689 and Sh671 on each of its citizens. Kakamega was seventh followed closely by Bungoma County.

Kakamega and Bungoma counties are also in the top five of the populous counties in Kenya. Busia County is also the only county whose health development expenditure is over 15 per cent of its overall budget.

To complete the list of the top 10 spenders on health are Bomet and Mombasa counties, at position nine and 10 respectively.

Bomet County will spend about Sh654 per person while a resident in Mombasa County will have Sh498 set aside to improve his or her health this financial year.

Some counties that are the least spenders ironically have bigger disease burdens and more pressing health issues.

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It was expected that after devolution, county governments would be best placed to address local challenges, but it appears most counties are yet to fill this given that their spending priorities may not give them the financial headroom to start fixing the healthcare system.

At the bottom, Tharaka Nithi, Nyeri, Homa Bay, Narok and Siaya counties which spend Sh24, Sh32, Sh57, Sh85 and Sh93 respectively. Also in the list of the bottom 10 counties are Siaya (Sh102), Kericho (Sh109), Kajiado (Sh118), Mandera (Sh140) and Nandi (Sh150).

Tharaka Nithi’s total development budget is at Sh1.3 billion.  Agriculture, livestock and water services had Sh312 million, roads, public works, transport and legal affairs took the lion share of Tharaka Nithi’s development budget, receiving Sh911 million.

Public hospital

This has made it the least spenders on health despite having only one major public hospital at Chuka, the other being a church-sponsored institution.

An analysis of the data shows disconnect between what counties plan to spend against their manifestos and strategic plans.

A look at the various county strategic plans and manifestos show that though most counties seem to have appreciated their health challenges, they have begun on a the wrong footing in terms of using hard data and facts to support their expenditure.

Nairobi County, the heart of Kenya’s healthcare system, had huge plans to build more health facilities and pharmacies, create ambulance services, promote primary health care, license and control outlets that sell food to the public, create and improve cemeteries, funeral parlours and cremations and show great leadership in liquor licensing. But it is not among the top 10 health spenders in the country.

It is at position 33, after it allocated only Sh249 to be spent on developing health for each of its 3.4 million people. This is just about 3.5 per cent of its overall budget.

Mombasa County had bigger plans for its health sector. According to its governor’s website, there were plans to have every wards to have a modern health centre that is well equipped and staffed.

Total budget

But the county has allocated Sh498 to be spent on developing health for each of its citizens, bringing its total health development budget to Sh520 million. This is less than 3 per cent of its total budget. Mombasa is ranked position 16 in terms of spending per person in out of the 47 devolved units.

Machakos County, which is emerging as a model county due to its speed in implementing its strategic plans, however, has not allocated money that would roll out its ambitious plan of converting every dispensary in every sub-location to a community hospital to meet World Health Organisation (WHO) standards of a hospital every 5 kilometres.

It also plans to add a few rooms in every health centre for bed wards, maternity, mini-theatre, laboratory and x-ray.

Information on the Machakos County website also gives an insight of their plans to build doctors and nurses quarters to attract health care personnel and give an allocation of Sh300 million to purchase and equip ambulances for every location to ensure that no patient will ever be carried on wheelbarrows to hospitals.

According to the CRA report, Alfred Mutua’s administration allocated Sh420 million was to health development.  This is about 5 per cent of its overall budget. This puts the county at position 24.

Counties are counting on donors to support health services, a factor that partly explains the little allocation to health services despite being ranked as one of the top three priorities in most counties.

The spending per person was calculated using data is contained in a CRA booklet presented to the Inter-Governmental Budget and Economic Council Meeting of August 12, 2013.

The CRA booklet also contains a breakdown of intergovernmental transfers by county, revenue generated at county-level, and expenditure estimates.

“An aggregation of county budgets shows that 69 per cent of revenues will come from National Government transfers while 31 per cent will be generated from own revenue sources,” CRA chairman Micah Cheserem notes in the report.

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health services Commission on Revenue Allocation county governments