Marys Medicine

Education and Health Services in
Data for Results and Accountability Launch edition Service Delivery Indicators: Data for Results and AccountabilityThe Service Delivery Indicators provide a set of metrics for benchmarking service delivery performance in education and health in Africa. The overall objective of the indicators is to gauge the quality of service delivery in primary education and basic health services. The indicators enable governments and citizens to identify gaps and track progress within and across countries over time. It is envisaged that the broad availability, high public awareness and persistent focus on the indicators will mobilize policymakers, citizens, service providers, donors and other stakeholders into action. The ultimate goal is to sharply increase accountability for improved quality of services toward the ultimate end of improving human development outcomes, along the lines originally proposed by World Development Report 2004: Making Services Work for Poor People. The Service Delivery Indicators initiative is an Africa-wide program that collects facility-based data from schools and health facilities every 2-3 years. The perspective it adopts is that of citizens accessing a service. The indicators can thus be viewed as a service delivery report card on education and health care. Complementing other sources that draw on citizens' perceptions to assess performance, the indicators assemble objective and quantitative information from a survey of schools and health facilities. The SDI initiative is a partnership of the World Bank, the African Economic Research Consortium and the African Development Bank to develop and institutionalize a set of robust measures of service delivery. The measurement of these indicators is based on survey instruments underpinned by rigorous research and embraces the latest innovations in measuring provider competence and effort. The survey instruments were piloted in Tanzania and Senegal. Kenya is the first country where the SDI is being rolled out, using a standardized methodology, but with adaptation to each country's context. The countries where implementation is currently happening are: Mozambique, Nigeria, Togo and Uganda. More countries will follow in 2014.
The major funders of the SDI initiative are The William and Flora Hewlett Foundation and the World Bank. Complementary funding for the Kenya SDI was provided by the Canadian International Development Agency (CIDA) and the USAID-funded Health Policy Project. More information on the SDI survey instruments and data, and more generally on the SDI initiative can be found at: and, or by contacting [email protected]. 2013 International Bank for Reconstruction and Development / The World Bank1818 H Street NWWashington DC 20433Telephone: +1 202-473-1000Internet: This work is a product of the Service Delivery Indicators initiative (, and the staff of the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent.
The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.
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Education and Health Services in KENYA
Data for Results and Accountability
Will all Africans share in the continent's rising
Closing the gap between promises, spending
prosperity? Africa is clearly on the move. Headlines
and results depends on what service providers
such as "Africa Rising", "Africa 2.0" and "The sun shines know and what they do: provider behavior is
bright (for Africa)" have been used to highlight Africa's key. Teachers and health providers overcome major
economic prospects with much enthusiasm in obstacles to provide recent years. And within this transformed picture of services in difficult FIGURE 1. Africa is on the Move…
Africa, Kenya's Vision 20301 promises to transform the conditions. They are country into a newly industrializing, middle-income intrinsically motivated country. But the question in Kenya, as indeed in much and often go above of Africa, is how to ensure that the human capital and beyond the call exists to realize the promised economic growth, of duty. But the en-as well as how to ensure that all citizens share in vironment in which newfound national prosperity. The answer lies partly they work, and the in whether people are well educated and healthy institutional incen- enough to gain access to more productive work. tives they face are not always aligned Although Kenya's Vision 2030 highlights with education and
investment in human development, public health sectoral objec-
spending on health and education in Africa has
tives. The 2004 World not guaranteed results. Macro- and microeconomic
Development Report: evidence on the links between education and Making Services Work for Poor People,7 one of the most economic growth is robust.2 And at the household frequently cited reports in this series, highlighted the level it is clear that good health improves the accountability relationships between the various ac- capacity to learn and work, which dramatically tors—policymakers, frontline service providers, and improves income and welfare.3 But what can policy the users of services—as being critical for better do to improve education and health to realize this results in public service delivery. This is because (i) potential? Spending money is one thing—but the Central ministries cannot monitor precisely what the relationship between spending on education and frontline providers do; (ii) The effort provided is high- health, and human development outcomes4 is weak, ly discretionary, i.e. determining how much effort to suggesting gaps in the quality of service delivery (see provide on which patient or student is a judgment Figure 2). This is particularly disconcerting given that governments spend roughly a third of their recurrent budgets on education and health.5 Fundamental to FIGURE 2. Higher Spending on Services Doesn't Necessarily
delivering quality education and health services is the role of frontline service providers—teachers, nurses and doctors. If these providers exert effort and have the right skills, more resources for education and health can indeed have beneficial outcomes.6 Mali
1 Vision 2030 is the country's development program covering the period 2008 to 2030. Launched on 10 June 2008 by President Mwai Kibaki, its objective is to help transform Kenya into a "newly industrializing, middle-income country providing a high quality of life to all its citizens by 2030 in a clean and secure environment." Burkina Faso
2 For the macro evidence see Lucas (1988), Barro (1991), Levine and Renalt (1992), School Completion Rate 20%
Mankiw et al (1992), and Psacharopoulos (1994). Hanushek and Kimko (2000) and most recently Glewwe et al (2012) provide recent reviews of the microeconomic literature on the impact of education on income in developing countries.
3 Spence M. and M. Lewis. (Eds) (2009) Health and Growth. Washington, D.C. World Bank, c2009. , ISBN 9780821376591 Expenditures per Student
4 Filmer, D. and L. H. Pritchett (1999) "The Impact of Public Spending on Health: Does Source: World Development Indicators Money Matter?" Social Science and Medicine, 58: 247‐258.
5 World Development Indicators.
6 Hanushek, E. (2003) "The Failure of Input‐Based Schooling Policies," Economic 7 World Bank. 2003. World Development Report 2004: Making Services Work for Journal, 113(February): F64‐F98.
Poor People. World Bank. Washington, DC.

Service Delivery Indicators for Kenya – Highlights
The Service Delivery Indicators for Kenya are based on surveys of about 600 primary schools and health centers and nearly 5,000 teachers and health providers. They reveal that the country does better on the availability of inputs such as equipment, textbooks, and most types of infrastructure, than it does on provider knowledge and effort, which are relatively weak. Significantly, more investments are needed in "software" than "hardware".
What service providers have to work with
n Kenya public facilities do relatively well on the availability of inputs: 95% of health facilities have access to sanitation, 86% of schools have sufficient light for reading, and the average number of textbooks exceeds Kenya's target of 3 per pupil. The availability of important drugs for mothers remains a challenge: only 58% of tracer drugs for mothers was available in public facilities. What service providers know
n In both education and health, the problem of low provider effort is largely a reflection of poor management of human resources. This is evidenced by the findings that: – Over 29% of public health providers were absent, with the highest absence rate in larger urban health centers. Eighty percent of this absence was approved absence.
– In public and private schools teachers are roughly equally likely to show up at school, but public teachers are 50% less likely to be in class teaching.
n A public school child receives 1 hour 9 minutes less teaching than her private school counterpart. The implication is that for every term, a child in a public school receives 20 days less of teaching time.
What service providers do
n While better than in many other countries, significant gaps in provider knowledge exist among both public and private providers in both sectors. n Only 58% of public health providers could correctly diagnose at least 4 out of 5 very common conditions (like diarrhea with dehydration and malaria with anemia). Public providers followed less than half (44%) of the correct treatment actions needed for management of maternal and neonatal complications. Provider competence was correlated with level of training.
n Just a third (35%) of public school teachers showed mastery of the curriculum they teach. Seniority and years of training among teachers did not correlate with better teacher competence. (For complete results, see Table 1 on page 4) EDUCATION AND HEALTH SERVICES IN KENYA

that needs to be made by each provider;8 and (iii) SDI in Kenya: Implementation
Policymakers and communities have different in- and Scope
formation than do providers; this complicates accountability for quality education and health Survey implementation was preceded by extensive services. These factors make other services, like consultation with Government and key stakehold- ‘commercial services' such as like buying a sand- ers on survey design, sampling and adaptation of wich, fundamentally different from education and survey instruments. Survey implementation took health service provision: if you don't like the sand- place in the latter half of 2012. wich that one seller provides, you just go to another. The survey was implemented Service Delivery
The Service Delivery Indicators (SDI) aim by the Kenya Institute of Pub-
to provide critical information to improve lic Policy Research and Analy-
Indicators provide
accountability for health and education results.
sis (KIPPRA) and Kimetrica with a snapshot of the
Kenya's citizens currently lack the information to quality assurance and oversight hold their government and providers accountable from the World Bank. Fund- state of Kenya's
for education and health services. The SDI provide ing was provided by the World a set of metrics for benchmarking service delivery Bank, the Canadian Internation- education and
performance in education and health in African al Development Agency (CIDA) countries, and have been published for Kenya for and the USAID-funded Health health systems as a
the first time in July 2013. This brief draws from the SDI Kenya Technical Report which contains more whole, and should
detailed information on the survey methodology Information was collected from and results.9 Such information will also enable about 303 primary schools not be viewed
the government to carry out highly targeted (public and private) and 294 narrowly as a
improvements and track their impact over time. health facilities (public and More generally, there is a growing and unprecedent- non-profit private), 2,960 teach- criticism of teachers
ed emphasis on high-quality information about what ers, and 1,856 health providers. works and what does not, and on tracking progress. The surveys provide a represen- or health providers.
This is true from Bono and Bill Gates to the High-Level tative snapshot of the learning Panel of Eminent Persons on the Post-2015 Develop- environment and key resources in both public and ment Agenda. A cross cutting theme in the first report private schools, and the quality of health service de- of this panel10 calls for a data revolution to improve livery and the physical environment within which the quality of statistics and information available to services are delivered in public and private (non- citizens. SDI aims to be a part of that revolution.
profit) health facilities. The SDI indicators—which will soon be standard across several African countries—are grouped into three categories: (i) What providers know (knowledge and ability). Teachers need to have at least a minimum
level of knowledge of the subjects they are teaching and skills to transform their knowledge into meaningful teaching. Similarly, health providers need to be skilled and competent to manage the conditions they are presented with. (ii) What providers do (provider effort). A minimum requirement for service delivery, for example,
is that teachers and health providers are present in the facility and working.
(iii) What providers have to work with (availability of key inputs). These indicators deal with the
service delivery environment, including the availability of teaching and medical equipment and supplies and school and health facility infrastructure.
The annex provides a detailed description of the indicators.
8 The transaction intensive nature of service delivery in health and education makes the cost of the inability to monitor extremely costly.
9 Available at and, or by contacting [email protected].
10 United Nations. 2013. A New Global Partnership: Eradicate Poverty and Transform Economies through Sustainable Development: The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. United Nations, New York.
DATA FOR RESULTS AND ACCOUNTABILITY TABLE 1. Kenya Service Delivery Indicators At-a-Glance
Public Private Rural Urban
Public Private Rural
What providers do (their effort)
Absence from school Absence from facility 20.9% 28.3% 37.6% Time spent teaching What providers know (their ability)
Diagnostic accuracy 74.2% 74.5% 71.1% Minimum knowledge Adherence to clinical 47.6% 41.7% 52.0% Test score on English, Management of maternal / neonatal complications 45.8% 43.4% 48.7% What providers have to work with (availability of inputs)
Drug availability 68.9% 67.2% 63.2% Students per textbook Equipment availability 91.6% 70.5% 87.2% Teaching equipment 85.6% 48.0% 58.1% Summary of the Findings
likely to perform best in the teacher assessments? Teachers who are female, younger, less experienced, What do teachers and health
and on short‐term contracts score better on the assessment. As one would expect, teachers who teach higher grades and have more completed The share of teachers with minimum content years of education score better. Strikingly, there is knowledge is calculated on the basis of a no significant relationship between performance customized teacher test administered to the grade on the teacher assessment and teacher training 4 mathematics and English teachers. The English test and seniority.
results were for teachers teaching English, and the mathematics test results were for teachers teaching Quality in the health sector was assessed12 using mathematics. The test was validated against the two indicators of process (the adherence to Kenyan primary school curriculum.11 In addition to clinical guidelines in five tracer conditions and assessing knowledge of the subjects themselves, the the management of maternal and newborn tests assessed pedagogical knowledge—the ability complications) and an indicator of outcomes of teachers to teach effectively.
(diagnostic accuracy in the five tracer conditions). Three of the tracer conditions were childhood Teachers' knowledge of the subjects they teach was relatively modest, and the pedagogical skills to transform their knowledge into meaningful 12 Clinical vignettes are a widely used teaching method used primarily to measure clinicians (or trainee clinicians) knowledge and clinical reasoning. A vignette teaching was worryingly low. Only a third (35%) of can be designed to measure knowledge about a specific diagnosis or clinical public school teachers scored at least 80% on a test situation at the same time as it measures trainees' skills in performing the tasks necessary to diagnose and care for a patient. According to this methodology, based on the curriculum they teach. Who are most one of the fieldworkers acts as a case study patient and he/she presents to the clinician specific symptoms from a carefully constructed script while another acts as an enumerator. The clinician, who is informed of the case simulation, is asked to proceed as if the fieldworker is a real patient. For each facility, the case simulations are presented to up to ten randomly selected health workers who 11 They were also validated against curricula from 12 other SSA countries ("Teaching conduct outpatient consultations. If there are fewer than ten health workers who Standards and Curriculum Review", prepared as background document for the SDI provide clinical care, all the providers are interviewed. For more information on the by David Johnson, Andrew Cunningham and Rachel Dowling.) methodology, see

conditions (malaria with anemia; acute diarrhea FIGURE 3. Share of Providers who Correctly Diagnosed
with severe dehydration, and pneumonia), and Tracer Conditions
two conditions were adult conditions (pulmonary
tuberculosis and diabetes mellitus). Two other
Share of public providers who could correctly diagnose .
conditions were included: post-partum hemorrhage, the most common cause of maternal death during birth, and neonatal asphyxia, the most common cause of neonatal death during birth. Public providers managed to correctly diagnose less than three quarters (72%) of the tracer conditions. Diagnostic ability scores progressively declined among the three cadre types: doctors, clinical officers and nurses. While diagnostic ability generally appears high, a patient may view these results differently given how basic the tracer conditions are and expect providers to correctly diagnose all five of these cases. Only 58% of public providers were able to correctly diagnose at least four out of the Note: The five tracer conditions are: diarrhea with severe dehydration, malaria with anemia, pneumonia, pulmonary tuberculosis and diabetes.
five tracer conditions (see Figure 3). On measures of process quality, public health providers followed less than half of Kenya's clinical guidelines for these FIGURE 4. Absence from School and Absence from Class
conditions and the most prevalent maternal and neonatal complications. For every 100 teachers .
16 absent
Differences by provider type in quality of education 55 in class and
and health services are often attributed to the notion that the private sector attracts better skilled 27 at school
providers. This is only partially supported by the but not in class
evidence from Kenya. The public-private differences in health provider knowledge and ability were small or not statistically significant. In education, the overall average score on the teacher test was not significantly different. At the same time, however, private sector teachers did score better on the 2 in class, but
assessment of minimum knowledge (40% higher; see Table 1).
What do providers do?
40 minutes in public schools out of a 5 hours and 40 minutes official teaching day.13 Measuring absence rates is difficult—but it is an important measure of what providers do. SDI relies In the public schools, who is most likely to be absent on an unannounced visit to assess the extent of from class? They are teachers with seniority, who absenteeism. In the health survey hospitals were are better educated, more experienced and who excluded because of the complex shift arrangements.
reside in the district where they teach.14 Absence The average absence in schools was relatively low at 16%. While low on average, a fifth of schools 13 To validate the absence data, a complementary measure of effort—the share of classrooms with pupils but no teacher; i.e. orphaned classrooms. This is measured had a school absence rate between 20‐40%, and by inspecting the school premises, counting the number of classrooms with students and recording whether a teacher is present in the classroom or not. for a tenth of schools it is above 40%. But the SDI The share of orphaned classrooms is then calculated by dividing the number of reveal an even bigger concern: teachers who are classrooms with students but no teacher by the total number of classrooms that contained students. In total, about 30% of classrooms were orphaned (almost present at school but absent from class. For every twice as many in public than in private schools). The difference between absence from classroom measured at the teacher level (50%) and orphaned classrooms 100 public school teachers, only 55 teachers were measured at the classroom level (30%) is likely explained by the school adjusting in class teaching and 27 were at school but not in for teacher absence by either cancelling classes or letting students whose teacher is absent join other classes.
the classroom teaching (see Figure 4). This translates 14 This is consistent with analysis in other countries, see Kremer , Chaudhary MN, into an average teaching time of only 2 hours and Rogers FH, Muralidharan K, Hammer J. Teacher absence in India: A Snapshot.
Journal of European economic association 2005; 3(2):658-67.
DATA FOR RESULTS AND ACCOUNTABILITY FIGURE 5. Reasons for Absence in Public Health Facilities
Sick and maternity leave Training and seminar Other approved absence Unapproved absence was also more likely among teachers who teach The outpatient caseload indicator is defined as the higher grades, who were born in the same district number of outpatient visits (recorded in outpatient as the school they are working in and who are on records) in the three months prior to the survey, permanent contracts. Excluding head teachers and divided by the number of days the facility was open principals, a male teacher with a permanent contract during the 3-month period and the number of is 64% more likely to be absent from the classroom health workers who conduct patient consultations. compared to a female teacher with no permanent The term caseload rather than workload is used to contract (33% absent versus 64%). There may be acknowledge the fact that the full workload of a various reasons that underpin absenteeism—some health provider includes work that is not captured sanctioned and some not. But the bottom line is in this measure, such as administrative work. From that excused or unexcused absence has the same the perspective of a patient or a parent coming to result: pupils that are not being taught.
a health facility, caseload is arguably the critically In the health sector, close to a third (29%) of public important measure.
providers was found to be absent. Who were most The data for Kenya shows average caseload per public likely to be absent? Absence was more likely among provider was surprisingly low at 8.7 patients per health providers at urban facilities and in facilities provider per day, and the caseload for half of health with staff in excess of six workers. In urban facilities, providers was less than 7 cases per day. Providers at close to 4 in 10 providers were absent on average. some facilities, however, have higher caseloads. For There was no difference in absence rates among example, the average caseload among the top 20% health cadre-types. busiest public health centers and dispensaries is In any workplace setting, absence may be 22.3 and 15.6 respectively. Comparison to findings sanctioned or not sanctioned. The survey found from other countries provide some context: A recent that the overwhelming share of absence from study in Tanzania reported a caseload of 18.5 patients health facilities (88%) was indeed sanctioned per day.15 absence (see Figure 5). But, from the consumer's For a large share of health providers—especially those perspective, these providers are not available to in moderately sized facilities which account for half deliver services—whether sanctioned or not. It is of the facilities in the country—there are very low possible that absence can be improved by more prudent sanctioning of absence. As with education, caseload levels of about 6.5 patients per provider. this suggests that management improvements and One may ask, why do health staff who are present better oversight of staff can potentially improve the for work, feel that their true workload is higher than availability of staff for service delivery.
these numbers suggest? This is in part because of the relatively high absence rate, causing the burden of Another measure of health provider effort is work to fall on a smaller number of staff than necessary.
patient caseload—usually of concern because a shortage of health workers may cause caseload to 15 Maestad O., G. Torsvik and A. Aakvik. Overworked? The Relationship Between Workload and Health Worker Performance in Rural Tanzania. Health Economics, 29: rise and potentially compromise service quality. EDUCATION AND HEALTH SERVICES IN KENYA TABLE 2. Comparison with Kenyan Norm and other SDI Surveys
Children per classroom Pupil-teacher ratio Students per textbook (for std 4) Availability of teaching resources Grants reaching schools (/pupil) The medical equipment indicator focuses on the availability of minimum equipment expected Unlike measures of teacher and health worker at a facility: a weighing scale (adult, child or ability, the private sector does significantly better infant), a stethoscope, a blood pressure meter on measures of provider effort. Specifically, private and a thermometer at all facilities; and sterilizing school teachers were a third less likely to be absent equipment and a refrigerator at health centers and from the classroom and spend 50% more time in the hospitals. In each case the equipment needed to classroom. Notably, these differences translate into, be observed by the enumerator and assessed as on average, 1 hour and 9 minutes more teaching functioning. It is an important achievement that time per day in private schools. This echoes the refrigeration is available in more than 98% of all findings that 30% of classrooms with children in health centers and hospitals, and in 100% of public public schools were without a teacher, almost twice rural health centers and hospitals. Three quarters as much compared to private schools.
(72%) of public health facilities met the basic Public health providers also underperform equipment requirements. compared to their private counterparts, especially In terms of health facility infrastructure, more than at the level of health centers, where public providers ninety percent (95%) of public facilities had access were 66% more likely to be absent than at private to sanitation and two thirds (68%) had a source of non-profit health centers. electricity. About 75% of public facilities had access to a clean water source. What are the inputs that providers have
to work with?

Drug availability is defined as the number of drugs of which a facility has one or more available, as A few critical inputs for service delivery were a proportion of all the drugs on a list of 26 tracer tracked by SDI. In schools, the following "availability medicines for children and mothers identified by the of teaching resources" assessed were: (i) whether World Health Organization (WHO)16. Enumerators a grade 4 classroom has a functioning blackboard need to observe the drugs and assess that they were and chalk; (ii) the share of students with pens; and unexpired in order to be counted for this purpose. (iii) the share of students with notebooks. An index On average, 78% of tracer drugs for children were was calculated as a simple average of these three available at public facilities.17 Furthermore, the components. Minimum infrastructure resources availability of tracer drugs for mothers at 58% was were assessed as: (i) functioning toilets assessed as relatively low given the national concern about being clean, private, and accessible; and (ii) sufficient maternal mortality and efforts to improve maternal light to read the blackboard from the back of the health outcomes.
classroom. In addition, the student-teacher ratio and students per textbook were assessed. It is commonly reported that rural facilities suffer severe drug shortages compared to their urban The supply of school inputs such as these school counterparts. In Kenya, there was no evidence to infrastructure and teaching equipment indicators, support this. Rural public facilities had 67% of the compares favorably with Kenya's own norms. tracer drugs compared to 63% in urban public Several measures are at or better than the Kenyan benchmark. For example, student-teacher ratio (of 16 WHO (2011). Priority medicines for mothers and children 2012. Geneva World Health 33:1), the number of students per textbook (of 3:1), 17 The 10 tracer drugs for children and 16 tracer drugs for mothers are available from and the availability of teaching equipment compare or Some drugs are not dispensed at the lowest level facilities (dispensaries) and the estimates of drug availability are favorably with the benchmark.
adjusted for level of facility.
DATA FOR RESULTS AND ACCOUNTABILITY facilities. In fact, rural public facilities had 13% more FIGURE 6. Public-Private Differences in
of tracer drugs for children compared to urban public Availability of Key Inputs in Health Facilities
facilities (79% versus 70%). 32% higher
29% higher
in private
in private
There were two areas where the public-private differences were more stark—clean water and electricity. The share of private facilities with a clean water source was 29% greater than public facilities (97% versus 75%). The share of facilities with access to electricity was 32% higher in private facilities driven by lower access to electricity in public Electricity
Clean Water
rural facilities.
Private (non-profit) How do measures of provider effort and
providers were able to correctly diagnose all five of ability relate to the availability of inputs?
the tracer conditions, 13% of providers successfully Poor quality infrastructure is often cited as a adhered to the country's prescribed guidelines for reason for low teacher morale and motivation. the tracer conditions. More optimistically, 62% of One might then expect that better infrastructure providers followed the prescribed treatment actions would be associated with more teacher effort. to manage the two most common maternal and Looking at the SDI data, however, there is neonatal complications, and in the area of inputs, little evidence that better school resources are more than three quarters of public facilities met the correlated with improved teacher effort. minimum equipment requirements.
How does teacher ability and effort
What does this mean for Kenya?
correlate with pupil outcomes?
Almost every report on Kenya's economic prospects Interestingly—and across the board—there calls for improvements in the effectiveness of are fairly strong relationships between student Kenya's education expenditure. Today 10 million knowledge indicators capturing provider effort students are of primary school-going age and that and ability but not with input measures. In cohort will account for half of the next decade's public schools higher absence rates and higher youth bulge. Whether that cohort is educated or not student‐teacher ratio are significantly negatively will determine whether Kenya will experience the correlated with pupil test scores. Time spent education dividend required for Vision 2030, Kenya's teaching and teacher test scores are significantly blueprint for economic and human development. positively correlated with pupil test scores.
Education is one of the single most powerful predictors of social mobility. Quality of education will also determine if the promise of Vision 2030 will The combination of inputs is what
be shared by the third of the population who live on matters—and that raises even more
less than $2 a day.
Kenya has invested heavily in education—today the A unique feature of the Service Delivery Indicator government spends more than any of its neighbors, survey is that it looked at the production of services both as a share of government spending and as at the frontline. Successful service delivery requires a share of GDP. Figure 2 shows the disconnect that all the measures of service delivery need to be between Kenya's spending on education and present at a facility in the same place and at the same learning outcomes. More of the same is not good time. While the average estimates of infrastructure enough. The SDI results point to gaps in teacher availability are relatively positive, the picture is quite knowledge, time spent teaching and absence from bleak when we assess availability of inputs at the classroom that require urgent action.
same time in the same facility—only 49% of facilities Unlike education, government spending on health had clean water and sanitation and electricity. Even is modest in relation to its regional comparators.18 more disconcerting is the finding that not a single health facility had all 10 tracer drugs for children 18 In 2012 government health spending was 8.5% of total government spending, and government health expenditure has remained at a constant 4.8% of GDP or all 16 tracer drugs for mothers. Only 16% of EDUCATION AND HEALTH SERVICES IN KENYA That said, Kenya has made tangible progress results were less positive. Regarding the availability towards the health Millennium Development of drugs, there are some important gaps: only two-Goals. Significant gaps remain—gaps which can thirds of the tracer drugs are available, and some only partly be explained by lack of resources. The gaps remain especially in the availability of tracer room for a budget increase in any sector in the drugs for mothers. The greatest challenge is in the immediate future is potentially constrained by the area of provider effort (evidenced by the provider past and the present: fiscal expansion over the absence data), and provider ability (evidenced past few years needed to bolster the economy19 by the assessments of providers' knowledge and and likely budgetary pressure posed by the new abilities). High provider absence and sub-optimal constitution's county reforms. More than ever provider ability suggest room for improvement in before is it true that quality improvements in the efficiency of spending on human development Kenya's health sector will have to initially come and reflect systemic problems. from productivity and efficiency gains. Further, the success of the health sector in attracting a greater The results should not be viewed narrowly as a budget allocation will be strongly bolstered criticism of teachers or health providers, but as a by demonstrating value for money and the snapshot of the state of the education and health effectiveness of existing health spending.
systems as a whole. Over time, as the impact of reforms is tracked through repeat surveys in each Kenya has made some phenomenal gains in recent country, the indicators will allow for tracking years. For example, the infant mortality rate has fallen of efforts to improve service delivery systems. by 7.6% per year, the fastest rate of decline among Valuable cross-country insights will also emerge 20 countries in the region. Arguably, the next set of as the database grows and more country partners gains will be more challenging—marginal women join the SDI initiative.
and children will become harder (and costlier) to reach, and addressing the performance gaps Final y, improvements in service quality in Kenya identified in the SDI survey at the frontline health can be accelerated through focused investments facilities and service providers will be a critical on reforms to the incentive environments facing determinant of progress.
providers, and in the skills of providers to ensure that inputs and skills come together at the same time and The SDI results found that Kenya does relatively well at the same place. This will be critical to ensure that on the availability of key inputs such as infrastructure, Kenya's gains in human development outcomes teaching and medical equipment, and textbooks. On continue beyond 2015, bringing the country closer measures of provider productivity and efficiency, the to achieving the promises set out in the Vision 2030.
19 Expansionary fiscal policy years have caused the Kenyan government's 2012 budget to be at about 30% of GDP. Kenya' public sector debt has doubled between 2007 and 2012. Debt as a proportion of GDP has now increased by about 4 percentage points from 39% in 2007 to 43% at the end of 2012 but it is still below the policy target of 45%.
DATA FOR RESULTS AND ACCOUNTABILITY Annex 1. The Service Delivery Indicators defined School absence rate
Share of a maximum of 10 During the first announced visit, a maximum of ten teachers are randomly selected from the list of all randomly selected teachers teachers who are on the school roster. The whereabouts of these ten teachers are then verified in the absent from school during second, unannounced, visit. Teachers found anywhere on the school premises are marked as present. an unannounced visit.
Classroom absence rate
Share of teachers who are The indicator is constructed in the same way as School Absence Rate indicator, with the exception present in the classroom out that the numerator now is the number of teachers who are both at school and in the classroom. The of those teachers present denominator is the number of teachers who are present at the school. A small number of teachers are at school during scheduled found teaching outside, and these are marked as present for the purposes of the indicator.
teaching hours as observed during an unannounced visit. Classroom teaching time (also referred to as Time on Task)
Amount of time a teacher This indicator combines data from the Staff Roster Module (used to measure absence rate), the spends teaching during a Classroom Observation Module, and reported teaching hours. The teaching time is adjusted for the time teachers are absent from the classroom, on average, and for the time the teacher remains in classrooms based on classroom observations recorded every minute in a teaching lesson.
A distinction is made between teaching and non-teaching activities based on classroom observation done inside the classroom. Teaching is defined very broadly, including actively interacting with students, correcting or grading student's work, asking questions, testing, using the blackboard or having students working on a specific task, drilling or memorization, and maintaining discipline in class. Non-teaching activities is defined as work that is not related to teaching, including working on private matters, doing nothing and thus leaving students not paying attention, or leaving the classroom altogether.
Minimum knowledge among teachers
Share of teachers with This indicator measures teacher's knowledge and is based mathematics and language tests covering the minimum knowledge primary curriculum administered at the school level to all teachers currently teaching maths and English in grade 4, those who taught English and maths at grade 3 in the previous academic year, and up to 3 randomly selected upper primary maths and English teachers.
Textbooks per student
Number of mathematics and The indicator is measured as the number of mathematics and language books that students use in a grade language books used in a 4 classroom divided by the number of students present in the classroom. The data will be collected as grade 4 classroom divided part of the classroom observation schedule.
by the number of students present in the classroom Unweighted average of the Minimum teaching resources is assigned 0-1 capturing availability of (i) whether a grade 4 classroom has proportion of schools with a functioning blackboard and chalk, (ii) the share of students with pens, and (iii) the share of students the following available: with notebooks, giving equal weight to each of the three components. functioning blackboard Functioning blackboard and chalk: The enumerator assesses if there was a functioning blackboard in the with chalk, pencils and classroom, measured as whether a text written on the blackboard could be read at the front and back of the classroom, and whether there was chalk available to write on the blackboard. Pencils and notebooks: The enumerator counts the number of students with pencils and notebooks, respectively, and by dividing each count by the number of students in the classroom one can then estimate the share of students with pencils and the share of students with notebooks. 10 EDUCATION AND HEALTH SERVICES IN KENYA Unweighted average of Minimum infrastructure resources is assigned 0-1 capturing availability of: (i) functioning toilets the proportion of schools operationalized as being clean, private, and accessible; and (ii) sufficient light to read the blackboard from with the following the back of the classroom. available: functioning Functioning toilets: Whether the toilets were functioning was verified by the enumerators as being electricity and sanitation.
accessible, clean and private (enclosed and with gender separation). Electricity: Functional availability of electricity is assessed by checking whether the light in the classroom works gives minimum light quality. The enumerator places a printout on the board and checks (assisted by a mobile light meter) whether it was possible to read the printout from the back of the classroom given the Caseload per health provider
Number of outpatient visits The number of outpatient visits recorded in outpatient records in the three months prior to the survey, per clinician per day.
divided by the number of days the facility was open during the three month period and the number of health workers who conduct patient consultations (i.e. excluding cadre-types such as public health nurses and out-reach workers). Absence rate
Share of a maximum of 10 Number of health workers that are not off duty who are absent from the facility on an unannounced visit randomly selected providers as a share of ten randomly sampled workers. Health workers doing fieldwork (mainly community and absent from the facility public health workers) were counted as present. The absence indicator was not estimated for hospitals during an unannounced visit.
because of the complex arrangements of off duty, interdepartmental shifts etc.
Adherence to clinical guidelines
Unweighted average of the For each of the following five case study patients: (i) malaria with anemia; (ii) acute diarrhea with severe share of relevant history dehydration; (iii) pneumonia; (iv) pulmonary tuberculosis; and (v) diabetes mellitus.
taking questions, the share History Taking Questions: Assign a score of one if a relevant history taking question is asked. The of relevant examinations number of relevant history taking questions asked by the clinician during consultation is expressed as a percentage of the number of important history questions to be asked based of the guidelines for management of the case (IMIC and Kenya National guidelines).
Relevant Examination Questions: Assign a score of one if a relevant examination question is asked. The number of relevant examination taking questions asked by the clinician during consultation is expressed as a percentage of the total number of relevant examination questions included in the questionnaire.
For each case study patient: Unweighted average of the: relevant history questions asked, and the percentage of physical examination questions asked. The history and examination questions considered are based on the Kenya National Clinical Guidelines and the guidelines for Integrated Management of Childhood Illnesses (IMCI).
Management of maternal and neonatal complications
Share of relevant treatment For each of the following two case study patients: (i) post-partum hemorrhage; and (ii) neonatal actions proposed by the asphyxia. Assign a score of one if a relevant action is proposed. The number of relevant treatment actions proposed by the clinician during consultation is expressed as a percentage of the total number of relevant treatment actions included in the questionnaire.
Average share of correct For each of the following five case study patients: (i) malaria with anemia; (ii) acute diarrhea with severe diagnoses provided in the dehydration; (iii) pneumonia; (iv) pulmonary tuberculosis; (v) diabetes mellitus.
five case studies.
For each case study patient, assign a score of one as correct diagnosis for each case study patient if case is mentioned as diagnosis. Sum the total number of correct diagnoses identified. Divide by the total number of case study patients. Where multiple diagnoses were provided by the clinician, the diagnosis is coded as correct as long as it is mentioned, irrespective of what other alternative diagnoses were given.
DATA FOR RESULTS AND ACCOUNTABILITY Share of basic drugs which Priority medicines for mothers: Assign score of one if facility reports and enumerator confirms/ at the time of the survey observes the facility has the drug available and non-expired on the day of visit for the following were available at the facility medicines: Oxytocin (injectable), misoprostol (cap/tab), sodium chloride (saline solution) (injectable health facilities.
solution), azithromycin (cap/tab or oral liquid), calcium gluconate (injectable), cefixime (cap/tab), magnesium sulfate (injectable), benzathinebenzylpenicillin powder (for injection), ampicillin powder (for injection), betamethasone or dexamethasone (injectable), gentamicin (injectable) nifedipine (cap/tab), metronidazole (injectable), medroxyprogesterone acetate (Depo-Provera) (injectable), iron supplements (cap/tab) and folic acid supplements (cap/tab).
Priority medicines for children: Assign score of one if facility reports and enumerator confirms after observing that the facility has the drug available and non-expired on the day of visit for the following medicines: Amoxicillin (syrup/suspension), oral rehydration salts (ORS sachets), zinc (tablets), ceftriaxone (powder for injection), artemisinin combination therapy (ACT), artusunate (rectal or injectable), benzylpenicillin (powder for injection), vitamin A (capsules)We take out of analysis of the child tracer medicines two medicines (Gentamicin and ampicillin powder) that are included in the mother and in the child tracer medicine list to avoid double counting. The aggregate is adjusted by facility type to accommodate the fact that some drugs are not expected to be available at lower level facilities as outlined in the Kenya Essential Drugs List.
Share of facilities with Medical Equipment aggregate: Assign score of one if enumerator confirms the facility has one or more thermometer, stethoscope functioning of each of the following: thermometers, stethoscopes, sphygmomanometers and a weighing and weighing scale scale (adult or child or infant weighing scale) as defined below. Health centers and first level hospitals refrigerator and sterilization are expected to include two additional pieces of equipment: a refrigerator and sterilization device/ equipment.
Thermometer: Assign score of one if facility reports and enumerator observes facility has one or more functioning thermometers. Stethoscope: Assign score of one if facility reports and enumerator confirms facility has one or more functioning stethoscopes.
Sphygmomanometer: Assign score of one if facility reports and enumerator confirms facility has one or more functioning sphygmomanometers.
Weighing Scale: Assign score of one if facility reports and enumerator confirms facility has one or more functioning Adult, or Child or Infant weighing scale.
Refrigerator: Assign score of one if facility reports and enumerator confirms facility has one or more functioning refrigerator.
Sterilization equipment: Assign score of one if facility reports and enumerator confirms facility has one or more functioning Sterilization device/equipment.
Share of facilities with Infrastructure aggregate: Assign score of one if facility reports and enumerator confirms facility has electricity, clean water and electricity and water and sanitation as defined. Electricity: Assign score of one if facility reports having the electric power grid, a fuel operated generator, a battery operated generator or a solar powered system as their main source of electricity.
Water: Assign score of one if facility reports their main source of water is piped into the facility, piped onto facility grounds or comes from a public tap/standpipe, tubewell/borehole, a protected dug well, a protected spring and harvested rainwater.
Sanitation: Assign score of one if facility reports and enumerator confirms facility has one or more functioning flush toilets with water or VIP latrines, covered pit latrine (with slab) or composting toilet.
12 EDUCATION AND HEALTH SERVICES IN KENYA ReferencesSpence, Michael and Maureen Lewis (eds), Health and Lucas, Robert (1988) "On the Mechanics of Economic Growth. Washington, D.C. World Bank, c2009., ISBN Development," Journal of Monetary Economics, Barro, Robert (1991) "Economic Growth in a Cross- Mankiw, N. Gregory, David Romer and David Weil Section of Countries," Quarterly Journal of Economics, (1992) "A Contribution to the Empirics of Economic 106(2): 407-443.
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in Education: A Global Update," World Development, Glewwe, P., E. Hanushek, S. Humpage and R. Ravina. School Resources and Educational Outcomes in Levine, R. and D. Renalt (1992) "A Sensitivity Analysis Developing Countries: A Review of the Literature of Cross-Country Growth Regressions," American from 1990 to 2010. Center for International Food and Economic Review, 82(4): 942-963.
Agricultural Policy, Working Paper WP12-1 January 2012.
With support from The William and Flora Hewlett Foundation


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Pharmaceutical Regulation in the United States: A Confluence of Influences1 By Reuben A . Guttman2 ©2012 Gr ant & Eisenhofer P.A . • Pharmaceutical Regulation in the United States: A Confluence of Influences1 an incomplete picture. It is the totality of limited as to dose or how the dose may be these influences, and their interplay with administered.9 each other, that either impact or have the