171. The Hospital Management Services Fund (HMSF) was established vide Legal Notice No. 155 of 2009 and operationized in the financial year 2010/11. During the financial year, a total of Kshs 879 million was disbursed to over 270 hospitals. In the same year, 3.2 billion was collected through user fees in these facilities. User fees (cost-sharing revenue) continue to be an important source of financing health services in hospitals, especially in supplementing the operation and maintenance (O&M) funding. Cost-sharing revenue collections have tripled from Kshs 1.03 billion in 2002/03 to Kshs 3.2 billion in 2010/11. However, cost sharing also continues to be a hindrance to accessing healthcare especially for the lower end of the population. If these resources were to be pooled, they will provide a more effective way of addressing healthcare needs than is currently happening. The development of the draft Health financing strategy, is aimed at strengthening the pooling of resources under social health insurance and ensuring their efficient use. 172. In the past five years, through its Health Services Sector Fund, funds pooled from both Government and private sector actors have been disbursed directly to health centres across the country with the aim of increasing access to health services, addressing equity in health service delivery and improving quality and responsiveness of health systems and services to the needs of the population. It also aims to increase efficiency and effectiveness in the management of financial resources by empowering the Facility Management Committees, reducing bureaucracies in the disbursement of financial resources to levels I-III facilities. This has strengthened the intended focus on health care. Between November 2010 and 30th June 2011, a total of Kshs 353,352,000 had been disbursed to 653 Health Centres. 173. While universal health coverage remains a key challenge in Kenya the Government remains committed to its provision. In 2004 and again in 2011, there have been serious but unsuccessful efforts to enact laws providing for universal health coverage. However efforts to move towards universal coverage continue to be implemented progressively. The National Health Insurance Fund (NHIF) has been the main vehicle for this effort and since 2006 it has increased its membership of formal and informal sectors alike and unlike private insurance companies, provides in-patient cover to the elderly. There are ongoing efforts to develop an alternative scheme referred to as the National Social Health Insurance (NSHI) which is yet to be implemented, with the hope of making health insurance more accessible to the poor through decentralization. 174. One of the most ambitious and laudable first steps that has been undertaken by the Government through NHIF is the roll out of a medical cover for civil servants and Disciplined Services which began in 2012. The teachers union followed suit with another enhanced cover for teachers with NHIF. This is a comprehensive medical insurance cover for its employees and their eligible dependants. The programme offers out-patient and in-patient services to teachers, civil servants and members of disciplined forces in a cover worth Kshs 4.5 billion annually. However, accountability issues in the Fund remain a challenge in the achievement of universal health coverage. Currently, only the formal sector employees are contributing to NHIF on mandatory basis. The informal sector, that includes farmers, livestock owners, small businesses (a number who are financially able) only enroll on voluntary basis. 175. Pursuant to government restructuring following the first general elections since the promulgation of the Constitution, the health sector has had several reviews of performance, addressing challenges and aligning its targets to the Constitution as well as rationalizing role sharing between the National and County Governments. Among key challenges identified are the institutional deliveries which are at a 40