Let's strive to build a robust health system

As part of the ambitious Big Four agenda, President Uhuru Kenyatta rolled out the Universal Health Coverage (UHC) pilot in December 2018. The pilot was meant to provide publicly-funded healthcare to about 3.5 million people in Machakos, Kisumu, Nyeri and Isiolo counties and was to be followed by a nationwide roll-out in 12 months.

Unfortunately, 20 months on, the pilot has ended, leaving citizens holding useless UHC cards. They now have to pay for services which have been free of charge during the pilot phase. For them, it is back to square one; only those who can afford it can access healthcare.

Medicare comes at a cost and approximately 1.5 million Kenyans are impoverished by high medical costs annually. Things are worse now with the Covid-19 pandemic.

After the first coronavirus case was reported on March 13, quarantine and isolation centres especially in public referral hospitals, hotels and hostels were bombarded by desperate cries of patients unable to pay their bills. Apart from the lucky few who had NHIF cards, the majority shouted at TV cameras urging the government to lift fees for isolation and quarantine. A few even threatened to commit suicide, demanding to be let free.

At the time, the country was under pressure to scale up its contact tracing and laboratory testing capacity. With support from regional and local partners and resilient health workers, Kenya had significant success in tracing, testing and patient care.

Stay-at-home

Many things worked through sheer determination of individuals. An emergency response centre was established and with it an emergency hotline, 719, to serve public needs and anxiety. The Health ministry and other government agencies established a risk communication process including daily pressers on case progression, several committees were established and partners came in in their numbers with support, both in cash and kind.

Measures were announced; stay-at-home directives, curfew orders, closure of worship houses and cessation of movement, all well-meaning and necessary.

As the pandemic unfolded, it was clear that several gaps remained. Inadequate community engagement meant members of the public obeyed orders, not for pandemic control but to be on the right side of the law. Those who did not were met with severe police brutality and the peace lovers stayed away in fear. That sometimes resulted in untoward effects such as home deliveries after expectant mothers feared venturing out to seek health services during curfew time.

Whereas the response was timely and adequate, we hadn’t paid attention to community ownership of the response. That's why some decided to run away from isolation and quarantine centres while others wondered aloud on social media why they were being forcefully held in these centres. Trust between the government and people waned by the day, starting unnecessary and distractive misinformation.

As this evolved, pressure on laboratories, unavailability of personal protective equipment, inadequacy of health workers as well as scarcity of health commodities like oxygen were emerging. It was clear that everyone was looking at the national government for both resources and guidance with governors sounding helpless at times.

We have learnt a lot through these challenges. The Covid-19 pandemic has reminded us that it’s not enough to strengthen the tactical crisis response to epidemic outbreaks. A crisis response however well executed will not be effective without strengthening the underlying health system.

A strong equitable resilient health system that is trusted by the people and serves their health needs where they live and work is necessary for pandemic control.

For that to happen in Kenya, a few basic principles should be applied.

First, the government needs to put its money where its mouth is. For a country desiring socio-economic development, investment in health is key to developing the human capital necessary for this growth. Adequate health financing is important. The current expenditure of around Sh200 billion combined between national and county allocations, including donor funds, is inadequate.

The allocation amounts to slightly above Sh4,000 per person per year. Compare this with a country like United Kingdom which allocates about Sh400,000 to health per individual (100 times!) or Botswana at Sh23,000 or Namibia at Sh30,000.

Most vulnerable

This means Kenya is spending just about 2 per cent of its GDP on health. The target should be around 5 per cent. Kenya needs to progressively double its health budget allocation from public coffers.

Secondly, more money doesn’t mean better health unless the money is linked to performance. For a long time, Kenya has continued to use input-based financing in public health facilities. A target to achieve universal health insurance, starting first and foremost with the most vulnerable, for a significant health benefit package will lead Kenya towards an output-based financing path.

But even where output-based financing by NHIF has worked, only 30 per cent of all reimbursements go to public facilities, yet they are almost all registered as NHIF providers. This leads me to the third principle – facility heads, health workers, and communities must know that better quality and service will lead to more resources to further improve their services. This is called facility autonomy.

In Kenya, the Public Financial Management Act does not allow facilities to collect fees either from patients or reimbursement from NHIF, all money goes to the central revenue account at the county. In many cases the cash never gets back to these facilities, but in a few cases trickles back through a painful process leaving demotivation in its wake.

Imagine a school which collects fees from parents and sends all of it to a central county account and has to ask for money for every expenditure, including repairing a broken water pipe! Just like we allow public schools to manage their fees collections plus national government transfers through an oversight structure called Board of Management, we must also allow health facilities similar autonomy with oversight from health facility committees.

Finally, we must create structures that allow for full community participation because communities are not just recipients of healthcare but creators of health enabled by strengthened community health systems.

This is the journey to an equitable, resilient health system for this and the next pandemic. This is the journey to realisation of UHC.

We must bounce forward to where we want to go NOT back to where we were before.

-Dr Githinji is Group CEO of Amref Health Africa, co-chair UHC2030 and board member Africa CDC