Just over a week ago, I was honoured to participate in one of the Goethe Institut’s Election Dialogue Forums. The idea behind these forums is to encourage issue-based political dialogue in advance of the elections. The forum I spoke at looked at issues related to public health.

I have written recently about the free maternity programme in this column. I also spoke about it at the Goethe. In addition, I looked at the issue of financing for regional hospitals. The data I found surprised me, although this is an issue I have worked on for a number of years.

Let’s recall the history: Prior to devolution, there were seven provincial hospitals. In addition, there were four “high volume” level 5 hospitals considered to be similar in terms of the level of care they offered and the regional nature of their catchment areas.

In 2013, the National Treasury argued that it would cost the exchequer Ksh10 billion to finance these 11 facilities. While these hospitals were to be devolved, the Treasury was concerned that they could end up being underfinanced by counties.

The reasoning was sound: Coast General Hospital serves the region, but is located in Mombasa. If devolved to Mombasa, this would mean that Mombasa would bear all of the costs of servicing the region, but the other Coastal counties would not contribute to the hospital’s budget.

This is a common problem and can be dealt with in several ways. One way to deal with it is to provide a national grant to these facilities. This grant is paid for by everyone and ensures that the county does not bear an unfair cost.

Treasury proposed to give the full Ksh10 billion as a conditional grant. Parliament demurred and cut the grant to closer to Ksh4 billion, arguing that while host counties should receive support, they should also contribute to the facilities, since they still benefit disproportionately from hosting them.

This was not a totally unreasonable argument, but there was little analysis of how much they would need, or how to ensure that they contributed their share. A leap of faith was made that host counties would top up the additional Ksh6 billion.

So the question arises: did they?

How would we answer this question? We would need to know how much each of these hospitals costs to run, which we do not know. However, if you accept that the Ksh10 billion in 2013/14 rose by inflation over the past few years, and you note that there are 11 hospitals, their average cost must be a little over Ksh1 billion.

Extrapolating from the formula used to allocated funds to these hospitals, we can take a couple of examples and estimate more specific costs.

Let’s take Nyeri and Kisumu. I estimate that these hospitals cost about Ksh1.17 billion and 1.08 billion respectively to run in 2015/16.

So how much did they receive? This turns out not to be a straightforward question. But again we can make some guesses. The 2015/16 budgets I have from Nyeri and Kisumu give figures for the hospital budgets. These figures are Ksh588 million and Ksh430 million respectively.

Each of these counties received a grant from the national government for their hospitals in 2015/16, out of the total Ksh3.6 billion distributed to all 11 hospitals. Nyeri received Ksh369 million and Kisumu received Ksh339 million.

But this grant is included in the amount that the counties budgeted, meaning that the size of the grant does not further reduce the deficit facing the facilities. Altogether, this leaves a deficit against cost of Ksh582 million in Nyeri and Ksh650 million in Kisumu.

Now, it is possible that the situation is not as bad as that. Counties have tended to budget in a confusing way. Some of them have budgeted for hospitals but then budgeted separately for staff. So this could mean that the budget for the hospital under that budget line is not the full budget. Hospitals also collect their own fees and in some cases keep these fees and underreport them, so they have more money than what is in the budget.

Kisumu estimated Ksh720 million from user fees in 2015/16, for example. That is not extra funding, but if the hospital raised more than its share of that, it could have kept and used those funds. It is hard to believe that these kinds of things would eliminate the deficits, but we don’t know for certain.

Four years into devolution, I still don’t know how much it costs to run these facilities, or how much they receive. But that is not the scandal. The scandal is that it appears that no one knows, that there are no publicly available documents available that tell us, and that nobody seems bothered.

Jason Lakin is Kenya country director for the International Budget Partnership. E-mail: [email protected]