We must rethink the funding and place of Level 5 hospitals in Kenya

Sometime in 2012, before the General Election, a policy paper was distributed, I believe through then Health Minister Prof Anyang’ Nyong’o, proposing several ways in which the health sector would be managed in light of impending devolution.

One of the principal proposals was to convert the existing eleven High Volume (Level 5) hospitals to referral facilities so that they would then be managed by the national government.

In a season of extreme – I dare say justified – suspicion of the intentions of the central government, the policy proposal was laughed out of town. It was then agreed that the Level 5 hospitals would be retained as county hospitals.

Three years into devolution, I am convinced that as a nation we made a monumental policy error on this aspect of health devolution.

For the avoidance of doubt, I am not joining the many naysayers who believe we made an error in devolving health generally. Health needed to be devolved. That decision is indeed paying off albeit slower than we would all have wished.

Absent of the expected complaints by health professionals and their unions, there are already notable improvements in primary health provision in most counties.

Ask the people of Nyeri, Kapenguria or Bomet about re-centralising health and you will have riots.

The error I believe we made was in transferring the Level 5 hospitals to counties instead of classifying them as referral hospitals. First is the equity question: Is it equitable for the residents of Eldoret and Nairobi and their environs to have the exclusive benefit of referral hospitals, while large swaths of the country have no such facilities?

Equity demands that we attempt a fairer distribution of referral facilities across the country and the Level 5 hospitals, which were situated generally around the former provinces, would have been a more equitable arrangement.

Second is the question of funding. The Level 5 hospitals are struggling from underfunding and are thereby delivering below standard referral services. In the financial year 2012/13 the amount of funds allocated to these hospitals was about Sh7 billion. After devolution this amount was reduced to Sh3.4 billion and given as a conditional grant to the counties where the hospitals are situated. In the last two years this grant has been gradually reduced and now averages Sh2 billion a year.

Naturally the counties in which these hospitals are situated are allocating some funds, but way below the amounts needed to have them operate at pre-devolution levels.

The incentive to fund them is compromised by the knowledge that almost 50 per cent of the patients coming to these hospitals are not locals but emanate from other counties. The hope that the counties in the regions would contribute funds to top up the deficits has not materialised.

The result is that due to the breakdown of the regional referral system, many counties are purchasing ambulances and rushing patients needing referral to Nairobi and Eldoret.

I had an interesting discussion with a senior officer at Kenyatta National Hospital who told me she panics any time she sees ambulances being launched by counties. She knows exactly where they are heading.

The breakdown of the regional referral framework and its impact on health should concern all Kenyans and force us back on the drawing board.

There are two possible solutions. On one hand, we can create a legal framework that obliges neighbour counties to jointly fund and manage the Level 5 hospitals as regional institutions. This is a legal minefield but without a legal obligation I am doubtful that these regional arrangements will work.

The other option is to accept that we made an error and revert these hospitals to the national government as regional referral hospitals. Provided it does not compromise the revenue allocations to counties for health, I do not see violent opposition to these transfers.

In this way we can hold counties accountable for provision of primary health and demand effective referral services from the national government. This matter requires urgent attention. There are decisions on which we can afford to prevaricate and niggle about in the normal Kenyan tradition but not when such decisions concern the health of Kenyans. On this one