MOI UNIVERSITY SCHOOL OF MEDICINE COBES IV RESEARCH PROJECT REPORT RESEARCH TITLE: AWARENESS ABOUT NATIONAL HEALTH INSURANCE

FUND BY RESIDENTS AGED ABOVE 18 YEARS FROM LANGAS ESTATE, ELDORET, KENYA RESEARCHERS:

ANGELINE N. TENGE DORCAS K. MUSYOKI LAJJA P. DHIREN ELIJAH M. YULU

MED/71/08 MED/16/07 MED/35/07 MED/29/07

DECLARATION
We the undersigned, hereby declare that this is our original work: ANGELINE N. TENGE DORCAS K. MUSYOKI LAJJA P. DHIREN ELIJAH M. YULU MED/71/08 MED/I6/07 . .

MED/35/07 . MED/29/07 .

SUPERVISORS:

DR.NJIRU DR.OWITI.

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ACKNOWLEDGEMENT
We would like to thank MU-SOM for installing the COBES programme into the curriculum and COBES committee for ensuring the implementation. This programme is an essential training tool for the medical students; who eventually are equipped with knowledge on field research. We also acknowledge the help of our tutors, Dr.Njiru and Dr.Owiti without whose guidance and support the writing of this report would not have been carried out to completion. We are grateful for the time and sacrifice that they made in the writing of this report. And above all thanks to God.

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DEDICATION
Report is dedicated to all residents of Langas estate. We hope that through this study, Kenyans will appreciate the importance of NHIF.

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LIST OF ABREVIATIONS
NHIF National health insurance fund COBES Community based education and learning IREC International research and ethics committee MU-SOM Moi university school of medicine

ABSTRACT
TOPIC- knowledge, attitude and practice towards the NHIF in Langas estate Eldoret town. BACKGROUND- Health insurance like other forms of insurance is a form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses. The collectism is usually publically owned or else is organized on a non-profit basis for the member of the pool. OBJECTIVES-Main objective was to find out how many people actually knew about NHIF. From the study, it was possible to access how the people of Langas got NHIF cover and their attitude towards NHIF. STUDY DESIGN-cross sectional study. SETTING- Langas estate in Eldoret town. STUDY POPULATION-Residents of Langas town who are above 18 years and possessed identity cards. METHODS-Data collecting tool was an interviewer administered questionnaire. RESULTS-Of the 150 respondents interviewed,84% knew about NHIF and their knowledge was derived from media 19%,work 36%,friends 24% and health personnel 21%. Of the interviewed respondents,85% thought NHIF is important. Only 39% of the interviewed respondents had a cover. CONCLUSION-Majority of Langas residents know about NHIF and think its important. But only a few have the cover.

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TABLE OF CONTENTS
DECLARATION..................................................................................................................................ii ACKNOWLEDGEMENT..................................................................................................................iii DEDICATION.....................................................................................................................................iv LIST OF ABREVIATIONS.................................................................................................................v ABSTRACT.........................................................................................................................................vi TABLE OF CONTENTS...................................................................................................................vii LIST OF TABLES AND FIGURES...................................................................................................ix CHAPTER 1: INTRODUCTION.........................................................................................................x CHAPTER 2: LITERATURE REVIEW........................................................................................xi ...........................................................................................................................................................xiv CHATER 3: RESEARCH OBJECTIVES................................................................................xiv 3 .1STATEMENT OF THE PROBLEM ................................................................................xiv 3.2 OBJECTIVES ..............................................................................................................................xv Broad Objective .................................................................................................................................xv Specific Objectives.............................................................................................................................xv 3.3- RESEARCH QUESTIONS ........................................................................................................xv 3.4 JUSTIFICATION.........................................................................................................................xv 4.1-Study area ...................................................................................................................................xvi 4.2-Study design................................................................................................................................xvi 4.3-Study population.........................................................................................................................xvi 4.4-Sampling method.........................................................................................................................xvi 4.5-Sampling size..............................................................................................................................xvi 4.6-Eligibility criteria........................................................................................................................xvi 4.6.1-Inclusion criteria.......................................................................................................................xvi 4.6.2-Exclusion criteria....................................................................................................................xvii 4.7-Data management.......................................................................................................................xvii 4.7.1-Data collection........................................................................................................................xvii 4.7.2-Data analysis...........................................................................................................................xvii 4.7.3 Data presentation.....................................................................................................................xvii 4.7.4 Minimization of bias...............................................................................................................xvii Information bias................................................................................................................................xvii Interviewer bias................................................................................................................................xvii 4.7.5. Ethical considerations...........................................................................................................xviii CHAPTER 5: FINDINGS.................................................................................................................xix ..........................................................................................................................................................xxiv ..........................................................................................................................................................xxiv CHAPTER 5: DISCUSSION..........................................................................................................xxvi As indicated in the findings, majority (36%) of the respondents acquired information concerning NHIF from their work place. NHIF personnel go to work places sensitizing and ensuring that all employees have information about NHIF and have a cover. It is also a requirement in most work places that employees have a NHIF cover. ....................................................................................xxvi CHAPTER 6: CONCLUSION AND RECOMENDATIONS.....................................................xxviii 6.1 Conclusion...........................................................................................................................xxviii

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6.2 Recomendations..................................................................................................................xxviii Appendix 1: COBESIII RESEARCH PROJECT (QUESTIONNEIRE).......................................xxix CONSENT FORM..........................................................................................................................xxix APPENDIX B: BUDGET ESTIMATES........................................................................................xxxi APPENDIX 3: REFERENCES......................................................................................................xxxii

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LIST OF TABLES AND FIGURES

Figure 1: Pie chart showing age distribution of respondents interviewed........................................xix Figure 2: Pie chart showing the marital status of the respondents ..................................................xix Figure 3: Pie chart showing respondents level of education............................................................xx Figure 4: pie chart showing the number of people who know about NHIF......................................xx Figure 5: Column graph showing the source of information for NHIF............................................xxi Figure 6: Pie chart showing attitude towards NHIF.........................................................................xxi Figure 7: Doughnut showing the practice of NHIF.........................................................................xxii Figure 8: How people acquired their NHIF cover..........................................................................xxiii Figure 9: Relationship between level of education and practice of NHIF.....................................xxiii Figure 10: Relationship between age and practice of NHIF...........................................................xxiv Figure 11: Relationship between marital status and practice of NHIF............................................xxv Table 1: Budget................................................................................................................................xxxi

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CHAPTER 1: INTRODUCTION
The right to health requires that health facilities, goods and services be available, acceptable and of good quality. Furthermore people must be able to access services free from discrimination. A health insurance program is a service of insurance companies that keeps you insured against any serious illness like cancer. If you are unfortunately happen to suffer from this serious disease ever in your life you will not be worried about the cost of treatment as you can get the sum for treatment as far as success of treatment is concerned. Health insurance like other forms of insurance is a form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses. The collectism is usually publically owned or else is organized on a non-profit basis for the member of the pool. The advantage of this health insurance program is very unique. One needs not spend a penny from their pocket because the whole cost of treatment is settled by insurance company. It is a great relief to the members of the family as well because they need not worry about treatment. In Kenya the National Hospital Insurance Fund was restructured in 1988 after an act of parliament made the fund an autonomous parastatal governed by a board of directors. The NHIF has a mandate to enable all Kenyans to access quality and affordable health care services, and contribution to the fund is mandatory to all salaried employees. As such civil society must consider its efficiency and impact when examining the state of the right to health in Kenya.

CHAPTER 2: LITERATURE REVIEW

In Australia, there is free universal access to hospital treatment and subsidized out-of-hospital medical treatment. It is funded by a 1.5% tax levy on all taxpayers, an extra 1% levy on high income earners, as well as general revenue. People whose taxable income is greater than a specified amount (currently $70,000 for singles and $140,000 for couples) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The Canadian insurance system is different since each province administers its own health insurance program. The federal government influences health insurance by virtue of its fiscal powers - it transfers cash and tax points to the provinces to help cover the costs of the universal health insurance programs. Under the Canada Health Act, the federal government mandates and enforces the requirement that all people have free access to what are termed "medically necessary services," defined primarily as care delivered by physicians or in hospitals, and the nursing component of long term residential care. The UK's National Health Service (NHS) is a publicly funded healthcare system that provides coverage to everyone normally resident in the UK. The costs of running the NHS (est. 104 billion in 2007-8) are met directly from general taxation. The United States health care system relies heavily on private health insurance, which is the primary source of coverage for most Americans. According to the CDC, approximately 58% of Americans have private health insurance. Public programs provide the primary source of coverage for most senior citizens and for low-income children and families who meet certain eligibility requirements. In Kenya, health insurance is under a parastatal body-National Health Insurance Fund. It is mandated to provide medical insurance to all its members and their dependants. NHIFs core function is to collect contributions from all Kenyans earning an income of over Ksh. 1000 ($12) and pay hospital benefits out of the contributions to members and their declared dependants (spouse and children). According to the amended NHIF Act, beneficiaries are both in-patients and outpatients (section 22 of NHIF Act, 1998), but outpatient services are not yet operational.

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Formal sector employees' contributions are deducted and remitted to the Fund by their employers. This is done by Cheque or through e-banking. The employer gets a Certificate of Contributions Paid (CCP) book and official receipt from NHIF. For members under the voluntary category, they pay Kshs.160 per month (Kshs.1920) per annum. For those in formal employment, contributions are made as per their income. Claims are submitted by hospitals directly to NHIF after the contributors have been discharged from the hospitals. The claims are examined by the Fund to ensure validity before payment. The NHIF membership is open to all Kenyans who have attained the age of 18 years and years and have a monthly income of more than Ksh. 1000. NHIF operations have been computerized and decentralized, enhancing efficiency in settling claims and effective management of membership database. The Fund also increased its service accessibility through the current networked 23 fullyfledged branches, 7 satellite offices and service points at most district hospitals countrywide. The branches function independently to offer services similar to any other office across the country. Health insurance is considered private when the third party (insurer) is a profit organization (Republic of Kenya, 2003a). In private insurance, people pay premiums related to the expected cost of providing services to them. Therefore, people who are in high health risk groups pay more, and those at low risk pay less. Cross-subsidy between people with different risks of ill health is limited. Membership of a private insurance scheme is usually voluntary. Private health insurance has been offered by general insurance firms, which offer healthcare insurance as one of their portfolio of products. Therefore, their intention may be driven by the profit motive as business enterprises rather that the pursuit to promote the general health of Kenyans. Wangombe et al (1994) identify two categories of private health insurance in Kenya: direct private health insurance and, employment based insurance. Direct private health insurance is very expensive and only the middle and high-income groups afford it (Nderitu, 2002). In the employment-based plans, the employer provides care directly through employer-owned on site

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health facility, or through employer contracts with health facilities or healthcare organizations. These are both voluntary health schemes and are not legislated by the government. According to Tec link International Report (1999), few firms provide healthcare insurance in the strict sense of insurance in private healthcare insurance in Kenya. The general insurance firms offering healthcare insurance as one of their portfolio of products include American Life Insurance Company (ALICO), Apollo Insurance, GMD Kenya, Kenya Alliance Insurance Company Ltd, and UAP Provincial Insurance. Other firms run medical schemes and they are in two categories: the first category provides healthcare through own clinics and hospitals (these include AAR Health Services, Avenue Healthcare Ltd, Comprehensive Medical Services, Health Plan Services), while the other category provides healthcare through third party facilities (examples are Bupa International, Health Management Services and Health First International. According to the NHIF Act, the benefits payable from the Fund are limited to expenses incurred in respect of drugs, laboratory tests and diagnostic services, surgical, dental, or medical procedures or equipment, physiotherapy care and doctors fees, food and boarding costs (Republic of Kenya, 1999). In practice the NHIF only pays for the cost of bed occupancy. A member cannot claim benefit from the Fund if he or she is entitled to compensation for hospitalization and illness from another source (section 36) such as the Workmen's Compensation Act (Chapter 236 of the Laws of Kenya). At present, the NHIF suffers from a variety of problems, which impair its role as a successful risksharing scheme. Among these problems are reimbursement policies, which have encouraged growing lengths of stay at the hospitals (especially private hospitals), increased value of claims, and expansion of the private-for-profit sector. In addition, the overall rapid and uncontrolled growth of approved facilities for reimbursement purposes has led to rapid expansion of claims, both appropriate and fraudulent, from these facilities (Kraushaar and Akumu, 1993). Another problem has been uneven distribution of payment at different categories of hospitals, which was noted as far back as 1989 (Alexandre and Franey, 1989). Berman et al (1995) observe that the criterion on which NHIF establishes reimbursement rates for health facilities has perverse incentive effects on providers. Because the reimbursement rate is dependent on, among other

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things, the bed capacity of the facility, private providers have an incentive to either expand capacity or to misrepresent their capacity to be assessed a higher reimbursement rate. The stated philosophy of the Fund is that benefits should not be related to contributions and that the basic dictum: "From each according to his ability and to each according to his need" should apply. There is evidence, however, that there may be a reverse cross-subsidy from the poor to the wealthier (Akumu, 1992). This mainly happens because of the disparity in the distribution of health facilities and personnel. Most health facilities and personnel are located in urban areas, where most of the non-poor live. As Kraushaar and Akumu (1993) indicate, a reverse crosssubsidy from the poor to non-poor is harmful.

CHATER 3: RESEARCH OBJECTIVES 3 .1STATEMENT OF THE PROBLEM

Awareness about national health insurance fund by residents aged above 18 years from Langas estate, Eldoret, Kenya

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3.2 OBJECTIVES
Broad Objective To find out the level of awareness of NHIF among Langas residents. Specific Objectives 1. To find out the knowledge and attitude of Langas residents towards NHIF. 2. To find out how many of the sampled individuals have NHIF cover. 3. To find out where members get information about NHIF. 4. To find out the relationship between the level education and knowledge about NHIF. 5. To find out the relationship between employment and contribution towards insurance cover.

3.3- RESEARCH QUESTIONS

1. What is the level of awareness and attitude of Langas resident towards NHIF? 2. How many individuals in Langas have NHIF?

3.4 JUSTIFICATION
Health insurance cover is vital because it helps people get timely medical care and this improves lives and health. Few people in Kenya are contributors towards the same since only 1million people in Kenya are beneficiaries of the same. There is no data to show the number of subscribers in Langas sub-location especially the self-employed.

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CHAPTER 4: RESEARCH METHODOLOGY 4.1-Study area The study was carried out in Langas sub-location in pioneer location in Kapsaret division of Eldoret town. 4.2-Study design The study was a cross-sectional study. 4.3-Study population It involved residents of Langas sub-location who were above 18 years and had identity cards. 4.4-Sampling method Sampling technique was purposive sampling .Our study area was Langas estate. 4.5-Sampling size It was arrived at using the following formula N=Z2(pq)/d2 Where N=sample size Z=confidence unit (statistical constant=1.96) P=prevalence taken as 50% q=1-p d=maximum allowed sampling error 8% I.e. sensitivity=92% N=1.962(0.5*o.5)/(0.08)2 =150 4.6-Eligibility criteria 4.6.1-Inclusion criteria Residents of Langas town above 18 and possessed ID cards.

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4.6.2-Exclusion criteria Residents who were above 18 but were dependent e.g. school going or did not have ID cards 4.7-Data management 4.7.1-Data collection The research tool was a Researcher- administered questionnaire. Both qualitative and quantitative data was obtained using the research tool. The research tool was standardized, subjected to supervisor review and pretested before use. 4.7.2-Data analysis Percentages, descriptive analysis e.g. bar graphs, pie charts, column graphs, and doughnut and was used for data analysis. 4.7.3 Data presentation After cross-tabulation of values for analysis and calculating percentages, data is presented in form of graphs and charts. 4.7.4 Minimization of bias Information bias It was minimized by the following: 1.Clear definition of terms which were difficult to understand. 2. Use of standardized researcher-administered questionnaires. 3. Subjecting the research tools to supervisor review and pre-testing. Interviewer bias When carrying out the interview, interviewer bias was avoided by using questions which were not suggestive or leading and directing the answers of the respondents.

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4.7.5. Ethical considerations 1. Verbal or written consent was sought from all participants in the study and the right to withdraw from the same was reserved. 2. The nature and purpose of the study was clearly explained to each participant before commencement of the study. 3. The confidentiality of the data obtained from the participants was guaranteed. 4. Research team obtained approval from IREC.

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CHAPTER 5: FINDINGS
The data collected included the biodata, knowledge about NHIF, attitude towards NHIF, and the practice of the participants. Figure 1: Pie chart showing age distribution of respondents interviewed

As shown above, about half (49%) of the sampled population, were in the 21-30 age group while those between 31-40 followed with 29%. Figure 2: Pie chart showing the marital status of the respondents

Married respondents were the majority making two thirds (65%) of the research population. Singles made up 28% and 2% , 4% for divorced and widowed respectively.

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Figure 3: Pie chart showing respondents level of education

Regarding level of education, there was an almost equal distribution with 34% of the respondents having attained primary education, 28% secondary and 31% tertiary. A minimal group of respondents (7%) had not received formal education. Figure 4: pie chart showing the number of people who know about NHIF

Knowledge about NHIF to the residents was impressively at 84% (126 respondents) while the remaining 16% didnt have any information about the same.

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Figure 5: Column graph showing the source of information for NHIF

Sources of information about NHIF were a variety. Overall, the work place was identified as the main source of information with a total of 46 (36%) of the 126 respondents who knew about NHIF. Friends, health personnel and media followed with 30 (24%), 26 (21%) and 24 (19%) respondents respectively. Figure 6: Pie chart showing attitude towards NHIF

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Attitude towards NHIF from the interviewed was a positive for the majority with 85% saying they thought that it was important.

Figure 7: Doughnut showing the practice of NHIF

Despite a large number thinking that NHIF was important; only 39% (59) had subscribed.

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Figure 8: How people acquired their NHIF cover

From the research, it was determined that 36 of the registered 59 (representing 61% of the subscribed group) obtained the insurance cover through formal employment while 23 (39%) were voluntary subscribes.

Figure 9: Relationship between level of education and practice of NHIF

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Level of education correlated in direct proportion to the number of subscribers. Roughly half of the subscribed respondents (51%) had attained tertiary level of education, 30% were secondary school leavers and the number decreased to 17% for primary school leavers. Figure 10: Relationship between age and practice of NHIF

Respondents aged 21-30 had the highest subscription representing 56% of the subscribed while those between 31-40 represented 32%, 10% for 41-50 and 2% for below 20.

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Figure 11: Relationship between marital status and practice of NHIF

Married respondents were found to make a large of those subscribed with a 73% followed by the single at 19%. Those without the cover provided a variety of reasons as to why they had not subscribed. Among others, the reasons were: 1. 2. 3. 4. Hectic procedures during registration High monthly charges Delays in processing cards Lack of coverage for the initial two months.

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CHAPTER 5: DISCUSSION
As indicated in the findings, majority (36%) of the respondents acquired information concerning NHIF from their work place. NHIF personnel go to work places sensitizing and ensuring that all employees have information about NHIF and have a cover. It is also a requirement in most work places that employees have a NHIF cover. Of the interviewed respondents, 85% of them thought it was important because it reduces the cost of health care and in case of emergencies one can easily access the health care. It also covers both the low income and high income earning people. In addition, it pools resources nationally to assist in the medical insurance of its members. This is in keeping with the direction NHIF has been mandated with by the constitution. The main objective of the Fund is to facilitate the provision of accessible, affordable and quality healthcare services to all its members irrespective of their age, economic or social status (Republic of Kenya, 2003c). Despite the fact that majority of the people knew about NHIF, only 39% had a cover. Reasons for the low subscription included the high monthly charges considering that majority of the population in Langas are low income earners. As indicated by a publication by KIPPRA report 2004, the major challenge facing NHIF is getting subscriptions from the low income earners especially employees in the informal sector and the jobless. Hectic procedures during registration and long queues were cited as other reasons. Moreover, delay in processing the NHIF cards for new applicants contributed largely to low subscription. Likewise, there was a concern about lack of coverage for the initial 2 months after application. Finally, harsh penalties in case of defaulting subscription scared the defaulters. NHIF cover was mostly acquired through formal employment (61%) and voluntarily (39%). This implies that the work place plays a big role in helping workers acquire the cover. This concurs with KIPPRA 2004 research where they noted that the focus of NHIF has been mainly on formal sector employees. This has left out those in the informal sector, those in agriculture, and pastoralists.

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Out of those who had the cover, 51% had tertiary education, 30% secondary, 17% primary and only 2% with no education had NHIF. This may indicate that the higher the level of education, the better the practice of NHIF. In a study by Hisamichi S. etal about Relationship between health practices and education level in the rural Japanese population. It was found out that people with higher education levels have better health practices insurance being part of those practices. This was the case of the sampled population. Of the 39% with NHIF cover, 73% were married, 19% were single, 5% were widowed and 3% were divorced. Thus, responsibilities improve NHIF practice. A publication by the State of Arizona Healthcare coverage and health care Practices 2006 showed that married people have better health practises and therefore not a surprise that majority of those covered in our sample population were married.

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CHAPTER 6: CONCLUSION AND RECOMENDATIONS 6.1 Conclusion

Majority of the residents of Langas know about NHIF and think its important though only a few have the cover. Marriage and level of education have a direct influence on the practice of NHIF. Majority of those covered acquired it through formal employment.

6.2 Recomendations
1.To NHIF: They should review the penalty to defaulters. They should increase the speed of processing the cards for the new applicants. They should carry out more campaigns especially through media to encourage more people to apply for the cover. 2.To the residents:-acquire NHIF cover because of its benefits.

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Appendix 1: COBESIII RESEARCH PROJECT (QUESTIONNEIRE)

RESEARCH TOPIC: AWARENESS ABOUT NHIF BY RESIDENTS ABOVE EIGHTEEN FROM LANGAS ESTATE IN ELDORET.

CONSENT FORM
I m a student in Moi University carrying out a research on awareness about NHIF by residents aged above 18 years from Langas estate , Eldoret, Kenya. Are you willing to participate? YES SIGNATURE DATE .. A) PERSONAL DATA/BIODATA. Please mark where appropriate(X) 1. AGE (in years) Below 20 21-30 31-40 41-50 Above 50 2. MARITAL STATUS Single Married Divorced/Separated Widowed 3. LEVEL OF EDUCATION None Primary NO .

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Secondary Tertiary-University/college B) KNOWLEDGE ABOUT NHIF. 1) Do you know about NHIF? Yes A) Media B) Area of work c) Friends D) Health personnel e) Other sources C) ATTITUDE TOWARDS NHIF 1) Do you think NHIF is Useful/Important/Necessary? Yes No 2) If yes, give the reasons/why? .............................................................................. 3) If no give reasons/ why? .............................................................................. D) PRACTICE OF NHIF. 1) Do you have an NHIF cover? Yes No 2) If yes how did you acquire it? i) Formal employment ii) Voluntary No 2) If yes, how did you know about it?

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APPENDIX B: BUDGET ESTIMATES

Item Pencils Pens Rubber Ruler Sharpener Note books Foolscaps Document folder Box file Stapler Staples Flash disc Compact discs Photocopy, printing binding cost Lunch Transport Air time allowance Sub total 10% Contingency TOTAL(KSHS)
Table 1: Budget

Quantity 170 170 170 4 4 50 4 reams 4 4 4 4 boxes 4 20 and 96 96 4

Price for each 20 20 20 50 50 200 400 200 500 500 200 2000 50

Total 3400 3400 3400 200 200 1000 1600 800 2000 2000 800 8000 1000 9000 9600 3840 4000 54 240 5424.0 59,664.00

100 40 1000

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APPENDIX 3: REFERENCES
1) Coverage Matters: Insurance and Health Care, Washington, DC: National Academies 2) Buchmueller, Thomas C., Kevin Grumbach, Richard Kronick and James G. Kahn. 2005. 3) Medical Care Utilization and Implications for Insurance Expansion: A Review of the Literature, Medical Care Research and Review 62 (1): 330. 4) Hadley, Jack. 2003. Sicker and Poorer: The Consequences of Being Uninsured,Medical Care Research and Review 60(2, suppl):3S-75S;Legal and other constraints on access to financial services in Kenya: survey results. 5) KIPPRA Private Sector Development Division. SR No. 1, 2001,Thinking about regulating? The better regulation guide. KIPPRA Private Sector,Development Division. SR No. 2, 2002. 6) Manda, D.K., M.S. Kimenyi and G. Mwabu. A review of poverty and antipoverty,Initiatives in Kenya. KIPPRA WP No. 3 7) Kimalu, P.K., N. Nafula, D.K. Manda, G. Mwabu and M.S. Kimenyi (2001).,Education indicators in Kenya. KIPPRA WP No. 4 8) Geda, A., S.N. Karingi, Njuguna S. Ndungu, M. van Schaaijk, M. Were, W.,Wassala and J. Obere (2001). Estimation procedure and estimated results of the,KIPPRA-Treasury macro model. KIPPRA WP No. 5 9) Kimalu, P., N. Nafula, D.K. Manda, G. Mwabu and M.S. Kimenyi (2002). A,Situational analysis of poverty in Kenya. KIPPRA WP No. 6 10) Kiringai, J. and G. West (2002). Budget reforms and the Medium-Term Expenditure,Framework in Kenya. KIPPRA WP No. 7 11) Ngeno, N.K., H.O. Nyangito, M.M. Ikiara, E.E. Ronge, J. Nyamunga (2003).,Regional integration study of East Africa: the case of Kenya. KIPPRA WP No. 9

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