Devolving healthcare system in Kenya

Kenya altered the course of its history with the passing of a new constitution in 2010.  The new constitution marked the end of a centralised government and in its place put a two-tiered system consisting of a lean government and devolved county governments. The transition of authority from the national to county governments has created turbulence in many sectors, healthcare included. ESTHER KIRAGU sheds light on decentralising health care services in the country.

The health function is a critical element to the welfare and prosperity of an individual and a country. In fact, an improvement in a country’s economy, health and welfare of its people is one of the key indexes used to assess the economic performance of a country.

While health spending has increased dramatically worldwide, many countries including Kenya struggle to offer affordable, quality health services to its citizens. However, the government is committed to providing Universal Health Coverage (UHC) and this was first demonstrated in 2013 following the waiver of payments for primary and maternal health services in public health facilities.

Despite this, the health sector in Kenya is marred with various problems such as underfunding, poor quality care and poorly staffed health facilities, which lead to overcrowding, and limited service provision. In addition, there is a huge disparity in the delivery of health services between rural and urban areas as indicated in the Devolution of Healthcare Services in Kenya, a 2013 report by KPMG. The report says that approximately 78 per cent of Kenyans live in rural areas, a disproportionate share of healthcare facilities is located in urban areas.

One of the main ways the government hopes to overcome these and other problems in the health sector is through devolution. This means that rather than health being a national government responsibility, it will be handled by the county governments. The counties will bear overall responsibilities for planning, financing, coordinating, delivery and monitoring of health services toward the fulfillment of the constitutional right to attain highest health standards. The national government will only be in charge of national referral health facilities such as Kenyatta National Hospital (KNH) while counties are in charge of county health services.

Many Kenyans hoped devolution would address the persistent regional disparities in the distribution of health services and inequality in resource allocations. However, this may take a while if the current varied levels of preparedness within the counties is anything to go by. Some counties that are relatively disadvantaged will take a little more time to build their capacity and ability to use devolved resources well. But the fact that planning is supposed to take place at the county level means that the expectation is that counties will prioritise and address local needs.

Ironically, some of these problems are the very same ones that the national government faced from time to time and were often highlighted in the media. For instance, finance seems to be a constant thorn considering the strikes and threats of strikes by healthcare workers, claims of delayed salaries and poor working conditions.

Borrowing a leaf

The Kenya Institute for Public Policy Research and Analysis (KIPPRA) suggests, in its December 2013 publication, that counties can finance healthcare by establishing and promoting mandatory micro health insurance schemes, and use of already established institutions in their localities such as tea, coffee and milk cooperatives to reach beneficiaries. Under such an arrangement, the vulnerable would be easily identified.

The publication cites an example of Rwanda where it is said that about 98 per cent of the population have health insurance. As a result, since 2000, maternal mortality ratio has fallen by 60 per cent and the possibility of a child dying by the age of five has dropped by 70 per cent. In 1999, the Government of Rwanda started 54 micro health insurance schemes in three rural districts where people pay a certain amount annually and then get free care at health centres and also transport services to and from some health facilities at district level.  As a result, members of such schemes consume fewer drugs per consultation because they seek health care at an early stage. This is a preventive rather than curative measure.

Worldwide, there have been mixed experiences in devolving the health function with some countries succeeding in leveraging devolution to improve health care and others failing. For instance, in 1991 the Philippine government introduced a major devolution of national government services including health services. The aim was to improve management of services and make them more available to the people. What followed, however, was the opposite of what devolution was meant to achieve; breakdown in management systems between national and local levels of government, decline in quality of health services in rural and remote areas, poor staff morale, decline in maintenance of infrastructure and under financing of operational costs of services, forcing the government of Philippines to take a step backwards and review the policy.

According to a research paper conducted by the Health Organisation Research Norway (HORN) in 2005, dubbed Health Care Devolution in Europe; Trends and Prospects, Finland stands out as the only country in Europe in which most health care powers are in the hands of municipalities. Norway is also unique in that health care is split between two local government tiers: until 2002, counties were in charge of hospitals while municipalities were responsible for primary and community care.

Present steps made

Healthcare in Kenya varies tremendously, depending on location, choice of hospital and need for treatment. In April 2014, the government launched a collaborative health insurance subsidy programme (HISP) to extend financial risk protection to Kenya’s poorest by providing them with a health insurance subsidy, which covers both inpatient and outpatient care in public and private health facilities. The first phase of the program covers 125,000 Kenyans in 23,500 families, selected from a poverty list developed by the Ministry of Labour and Social Protection and Services, across the country’s 47 counties. The results are then validated at community level to ensure the programme benefits the most needy.

Worldwide, there have been mixed experiences in devolving the health function with some countries succeeding in leveraging devolution to improve health care and others failing

As a step towards universal health, in February 2015, President Uhuru Kenyatta launched an ambitious Ksh 380 billion project to equip 94 hospitals nationwide. The10-year project is aimed at providing two selected hospitals in every county with modern equipment for surgical theatres, surgical procedures and sterilisation, laboratories, kidney dialysis, intensive-care unit facilities, digital X-rays, ultrasound and imaging. If successful, the project will especially benefit people suffering from cancer, diabetes or kidney failure at the county level.

While launching the project, the President emphasised on the need for all Kenyans to register with the National Hospital Insurance Fund (NHIF), the primary provider of health insurance in Kenya, saying many uninsured Kenyans are driven into poverty because they cannot afford treatment for chronic or catastrophic illnesses.

NHIF is compulsory to all salaried employees, but for the self-employed and others in the informal sector, membership is contributory for a fixed premium. There is also private health insurance, which may be unaffordable to a common man, but it is necessary in the country because without it, healthcare costs would be very expensive and covering all the costs for emergency care out-of-pocket can be impossible.

But even before the devolved system in Kenya becomes fully functional, already there seems to be lack of a clear division of responsibilities between national and county governments, financing of health facilities and minimal understanding among stakeholders in the health sector on the devolution process.

Already, members of Kenya Medical Practitioners, Pharmacists and Dentists’ Union (KMPDU) issued a strike notice on February 10, 2015 over the failure of the government to pay their January salaries claiming that the delays in salaries had become too common. There were media reports that at least 25 out of the 47 counties were yet to pay doctors their January salaries.

And the problems don’t end there. Not everyone is supporting a devolved health care system. Some of those against it have raised fears over loss of jobs and business opportunities for others. For instance, what will be the role of the Kenya Medical Supplies Authority (KEMSA), which supplies medicine and medical provisions to all public hospitals countrywide since county governments are not obliged to source medical supplies from the organisation?

Despite all the problems facing the system presently, many people are aware that every process has a starting point and this is the case even with devolution. Since devolution is here to stay, the focus ought to be towards embracing it and seeking solutions to the challenges of the system in order to promote quality health care.

The county and national government have a big responsibility and must therefore work together to achieve the objectives of devolution. Of utmost importance is the need to increase the understanding amongst stakeholders and the public on how devolution in the health sector is supposed to be realised in order for it to be successful. After all, knowledge is power.