Blog

By Drs. Wairimu Mwaniki and Leon Ogoti
KMA Public Health Committee

Universal Health Coverage (UHC) refers to a global health system that ensures all individuals have access to quality healthcare services without having to endure financial destitution. UHC has two fundamental goals: optimizing the impact of healthcare services, and eradicating financial crisis, impoverishment or bankruptcy that may arise from high healthcare costs (WHO, 2010).
In Kenya, the Universal Health Coverage pilot programme was launched on 13th December 2018 in Nyeri, Kisumu, Machakos and Isiolo Counties. These counties were selected as pilot sites based on the prevalence of unique health needs among their populations. Nyeri County was selected due to the high burden of non-communicable diseases; Kisumu due to the high prevalence of infectious diseases like Malaria; Machakos due to high prevalence of injuries associated with road traffic accidents; and Isiolo due to the concerning cases of maternal mortalities. However, of the four Counties, only Isiolo and Machakos carried the limping pilot to its’ uneventful conclusion. Kisumu was a non-start from the beginning and Nyeri eventually terminated the pilot due to financial constraints. Fortuitous as it might have been, launching the National UHC program in the year where the World has experienced the biggest Health Crisis in a Century would have been a master stroke by the Ministry of Health but alas the failure to effectively transition the pilot into a fully functional national project presented instead another opportunity for private allies to cash in and citizens to keep wallowing. When this project will eventually be re-implemented is still unclear.

Health systems for Universal Health Coverage are governed by 3 pillars: service delivery, health financing and governance.
Kenya’s expenditure on health as a percentage of the total government expenditure oscillates between 4% & 6% when viewed against the 12% recommended in the Kenya Health Sector Strategic Plan, and the 15% in the Abuja Declaration which Kenya is a party to. This inadequate financing added to weak accountability systems and structures, and wanton corruption in both the National and County Governments has manifested as a crippled healthcare system which is incapable in its current state of achieving the objectives of good health status, equity, efficiency, acceptability, and sustainability (Sessional Paper No. 7 of 2012 on Countries in Africa).
Seven years on, Devolution has had and continues to have its highs with never seen before development in marginalized areas such as Turkana, Samburu, Kilifi among others yet healthcare across the country continues to deteriorate. One would argue that the progress indicators in Reproductive Health, HIV, TB and Malaria the biggest contributors to death and disease are not commensurate with the financial investment made especially from partners and this situation is worsened by the exponential rise in Non-Communicable diseases which are expensive to manage and contribute to over 50% of admissions and 70% of in-hospital deaths.
The perennial problems that continue to bedevil the sector were either inherited from the National Government or emerged during the poor transition of the Health Ministry functions to Counties by the Transition Authority, later the Inter-Governmental Relations Technical committee. This led to:
• Devolution of functions without funds;
• Erratic and haphazard cascade of funds from National to County governments with recurrent infighting despite clear constitutional dictates;
• County treasuries collapsing Facility Improvement Funds structure and appropriating them as county revenue to the detriment of hospitals;
• Inconsistencies in payment for initiatives meant to provide free health care such as Linda mama, Eduafya etc.
• Conditional grants intended for Level 5 Hospitals being swallowed up by County Treasuries for ‘other uses’;
• Ill funded Public Hospitals with funds channelled from National Government, UHC or partners being retained at higher administrative levels for alternate use; and
• Poor strategies advocating for enrolment to NHIF for Kenyans in informal employment with only 20% of Kenyans covered.
These key gaps in resource allocation and mobilisation along with oversights and lack of accountability in governance are some of the factors that have caused challenges in achieving Universal Health Coverage in Kenya.
The result has seen many Kenyans who live below the poverty line having to spend out of pocket for their health. For every Ksh. 100 spent in healthcare in Kenya, Ksh. 30 is out of pocket, without which an individual cannot access the treatment he/she requires. This explains why 7milllion Kenyans never seek treatment even when they absolutely need it – they simply cannot afford it. This goes against the right of every individual to get quality healthcare and is a tragedy for a country that is the 5th largest economy in Sub-Saharan Africa.
Another resource that is a major cog in the successful delivery of Universal Health Care, is the human resources for health. In Kenya this remains one of the main impediments to the successful roll out of Universal Health Care coverage in the country. Since advent of devolution Human resource management i.e. hiring, remuneration and welfare which under the National Government was seemingly organized, has taken a backward and seemingly tangential approach with many Counties using cronyism, nepotism, bribery and tribalism as a gate keeper to ensure that the Industry needs come a distant second to personal wants to the detriment of the Sector.
Lack of adequate healthcare personnel in facilities has been continuously recognized as a barrier to a resilient and responsive health system in Kenya. Using international standards, the gap between the staff recommended to offer optimum, quality services vis-a vis the staff actually available to offer the services has been a crutch in ensuring Kenyans receive Health care in the manner in which policy makers envision.
According to WHO, the recommended doctor to patient ratio is 1:1000 while the recommended nurse patient ratio is 1:120 In Kenya, the current doctor to patient ratio is 1:6505 for medical doctors and 1:1250 for nurses. Among these doctors, only 51% work for the public sector with a significant proportion serving in administrative positions either at the Ministry headquarters in Nairobi or in various capacities as either CECs, Chief Officers or Directors of health and subsequently not being directly involved in patient care (KMPDC, 2018) this is despite over 80% of Kenyans seeking medical care in public healthcare facilities.
There is also inequity in the distribution of human resources for health, with dire shortages in human resources being seen in the most desperate and remote parts of the country with many specialists across cadres clustered around major towns and hospitals even when they might be needed just as much elsewhere. This has gravely affected health service delivery across the nation.
The COVID pandemic has and continues to unmask the inadequacies and inefficiencies of the public health sector in Kenya. The ailing public sector that is continually being run down by County Governments remains unable to satisfy even the most basic health care needs of Kenyans and creates a lacuna that cannot be filled by the Private sector with its’ extremely prohibitive health care costs. Further, poor emergency preparedness and planning, supply chain gaps such as those seen at KEMSA, poor leadership even in the face of a global crisis where soberness was most called for with a wealth accumulation over lives approach and abdication of roles by both the National Government and the County Governments have led to mini crises such as:
1. Deficiency in PPEs available to front line healthcare workers.
2. Limited access to COVID-19 testing not only to prevent hospital acquired infections for workers and patients, but also support pandemic control and mitigate community spread failure to do this has made it difficult to establish the true magnitude of the pandemic and resulted in a raft of public health measures that are increasingly difficult to justify and are poorly adhered to anyway.
3. Health personnel calling in sick because of contracting COVID-19 at the workplace, with some healthcare workers losing their lives to the disease straining existing facility resources.
4. Understaffing and lack of adequately trained critical care personnel e.g. ICU medical staff to man COVID-19 facilities in the counties.
5. Burnout by staff due to long working hours and inadequate psychosocial support to prevent negative coping mechanisms.
6. Absence of proper and fully kitted isolation facilities designated to give medical care to healthcare workers suffering from COVID-19.
7. Lack of medical insurance covers for medical personnel to ensure that health workers who contract infections at their workplace, of which they are at a higher risk, can be protected from financial ruin.
The biggest evidence of continually poor investment in healthcare is the recent series of industrial strikes that since devolution have become a part of the Health Worker Calendar and have persisted even during the pandemic with chronically underemployed, often overworked, under protected and poorly remunerated workers donning activist hats in a desperate attempt to get Government to resurrect hospitals from the cement and stone shells that they are to facilities that are actually capable of providing the much needed quality care services.
In conclusion, for all Kenyans to enjoy health as a Human Right as in the Universal declaration of Human Rights and a constitutional right it is mandatory that Government:
1. Put more emphasis towards implementing local(KHSSP) and international agreements on health financing
2. Improve human resources for health, through adoption of the Health Service Commission which will ensure quantity and quality of workers is maintained through hiring and training commensurate with National needs.
3. Make accountability an ingrained process of governance, with the necessary checks and balances and offenders brought to book.
This will go a long way in getting Kenya on the path towards Universal Health Coverage offering all Kenyans an opportunity to receive quality care wherever they are and whenever necessary allowing all individuals to live productive and dignified lives irrespective of their ethnicity, race or religion.

KMA Public Health Committee
Dr. Leon Ogoti - Public Health Convener KMA

Theme: Building back better: towards an inclusive, accessible and sustainable post COVID-19 world by, for and with persons with disabilities.
Today marks the 29th anniversary of the ‘International Day of persons with Disability’ and in a COVID-19 year where most if not all of us, have had our ability to conduct activities as we would like hampered or restricted. It is as good a time as any to take a moment to really think about a life in the day of a person with a disability.

A disability as defined by the WHO, is a continuing condition that results in substantially reduced capacity in communication, learning, social interaction or physical movement among others; and that necessitates continuous support in aids and services to the individual for him to sufficiently overcome the functional impairments that are often compounded by attitudinal and environmental barriers.
Statistics
Globally, The World Health Survey and The Global Burden of Disease, using a population estimate of 7 Billion people found that approximately 800million people aged 15 years and above had a significant disability and 150million people had a severe disability, defined as an impairment that severely limits necessary functional capacities.
Preliminary statistics obtained from the 2019 Kenyan census show the number of people living with disability as only 2.2% of the population (1 million people) with more disabled women than men, and an overwhelming majority of the disabled (0.7million) living in rural areas, these figures were a far cry from the postulated 15% (6 million people) Kenya Statistics on Disability.
This gross under reporting of people with disabilities in the census data will doubtless have a negative impact for the next decade on the design of policies and programmes targeting PWDs (People living with Disabilities), will result in under funding of programs and efforts aimed at inclusivity of PWDs in education, health and employment and overall result in a persistence and an inevitable worsening of the challenges faced by this group of Kenyans.
Disability and Health
When it comes to Health care and disability there exists great opportunity. Often times, it is as a result of preventable health care allied reasons that people end up disabled and yet it requires the presence of equitable, accessible, low-cost and quality health care services to ensure that all people with disabilities are able to live their most productive lives in spite of the extent of the disability.
A WHO multi-country study in Africa found the common causes of disability were largely preventable ranging from infectious diseases such as Polio, meningitis, Otitis, Trachoma, Tuberculosis and Malaria, to trauma, malnutrition from micronutrient deficiencies and Birth related complications.
Aside from the risk factors, persons living with disabilities are often at risk of secondary illnesses that may arise as a consequence of their poor physical and social environments such as; anxiety, depression, physical injuries from falls and road accidents, chronic malnutrition and respiratory illnesses. These represent their unmet health needs as they tend to receive insufficient attention and information commensurable with their conditions to allow for proper prevention and management. Further, due to their increased vulnerability they are prone to being victims of violence which is increased 6-fold if a mental health condition is present. The increased risk also translates to children with the violence being both physical and sexual and may result in teenage pregnancies and other reproductive complications. There is also a higher substance abuse problem due to co-occurring illnesses in depression and anxiety orchestrated by stressors such as unemployment, solitude and poverty, and conversely, they are less likely to receive treatment for the addiction.
Treaties
Kenya is a party to the Convention on rights for disabled persons that was adopted in 2008 and whose tenets are mirrored in articles 27, 28 and 43 of the Constitution of Kenya, 2010. These binding agreements demand that the Government works to ensure that all persons with disability in Kenya are treated equally, with respect and dignity and that they receive their fair share of economic and social rights. This requires that the issues they face are mainstreamed, prioritized and funded, and not left to specialized groups and organizations, who are meant to complement existing efforts.
Focus areas in Health
Most urgent action is required in establishing accurate and reliable data on all people with disability in Kenya, prioritizing their needs and allocating resources towards supporting programs and efforts dedicated to improving the quality and access to education, health care and employment.
Full implementation of Universal Health Coverage to ensure the preventable causes of Disability are combated through effective immunization programs and campaigns, high quality antenatal and perinatal services, access to diagnostic equipment, medicines, treatment technologies and proper rehabilitation services distributed equitably across the 47 counties and increased health promotion activities in our communities led by Community health extension workers and volunteers.
Educating the communities and demystifying misconceptions around various forms of disability, on reducing the stigma associated with persons or families to which disabled persons belong. Educating the communities on their needs and exposing them to the capabilities they possess more so for children.
Facilitating easy access to health care facilities for those with disabilities as well as ensuring the infrastructure at health facilities caters to the diverse range of disabilities in the region, minimizing financial stress to services for the disabled, enhancing access to information both preventive and as pertains their health and ensuring respect and dignity is accorded to those seeking health services by all health professionals.
Lastly, establishment and strengthening of community based rehabilitation (CBR) which has a role in identifying people with unmet needs in the community, providing community health and rehabilitation responses and referring complicated cases to the mainstream health system. CBR has shown great benefits in overcoming barriers to health access as well as offering inclusion for education, livelihoods and social life alleviating poverty and discrimination which are drivers of poor health among those living with disabilities.
As we celebrate this day, it is the responsibility of each one of us to act favorably and warmly towards those living with disabilities, to offer not only compassion, warmth, care and attention but also to champion for their rights locally and globally. Ensuring that our work environments and health facilities are disability-friendly and working together with communities to protect, educate, nurture and promote social and physical environments designed to include everyone in the post-COVID world.

WORLD AIDS DAY OPINION PIECE

KMA Public Health Committee
By Dr. Wairimu Mwaniki

2020 has been a difficult year for the world as a whole. The Coronavirus disease, a respiratory infection caused by the novel COVID-19 virus, has morphed from being a little known about illness to a global pandemic. The effects of the pandemic have spared nobody, particularly vulnerable and key populations. One such demographic includes PLWHIV. Research on COVID-19 and it’s association with HIV is ongoing. At the moment, scientists have more questions than answers on the relationship between the two viruses.
The pandemic has taken a huge toll on global healthcare particularly in low and middle income countries. Economies have taken major blows with many families losing their sources of livelihood. The health sector has not been spared either. The soaring number of COVID-19 patients continues to overwhelm healthcare systems across the globe. Many countries do not have the necessary capacity to manage the COVID-19 pandemic as per stipulated international health guidelines. In addition, the current approach to self-protection, social distancing and isolation has been extremely difficult to sustain. Scarcity in resources channelled towards the management of the disease has begat an overloaded healthcare system that continues to crumble under the pressure of the pandemic. This has translated into poor service delivery to patients, particularly PLWHIV.

The current health crisis analogous to COVID-19 is already affecting health seeking behaviour among PLWHIV. In poor resource set ups, people just do not have enough resources, particularly financial ones, to regularly seek medical attention even when sick . Unfortunately, the COVID-19 pandemic has also challenged the accessibility of antiretroviral treatment (ART) Significant cuts in HIV funding to poorer countries and major breakdowns in the ART supply chains due to importation set backs precipitated by the pandemic are some of the factors that have rendered HIV treatment inaccessible to many.

The COVID-19 pandemic has also taken a major emotional and psychological toll on PLWHIV. The stigma and overall fear associated with the Coronavirus disease is a situation that is all too familiar to PLWHIV. Those who have tested positive for COVID-19 have had to face the effects of double stigma and virus-shaming as a result of the two pandemics. PLWHIV are ailing from COVID-19 in silence for fear of being stigmatised by family and healthcare personnel.
The double stigma being levied on PLWHIV who also get infected with the COVID-19 virus is however unwarranted. PLWHIV who are on ART and have achieved viral suppression are not at an increased risk of suffering from severe COVID-19 infection compared to the general population. However PLWHIV who also suffer from co-morbid conditions like cardiovascular or lung disease may be at a higher risk of becoming infected with the virus and of suffering more serious symptoms. There is currently no evidence to support any protective benefit of antiretroviral therapy to the SARCOV2 virus. However, adhering to antiretroviral therapy has been shown to greatly reduce the risk of severe COVID-19 infection.

In conclusion, robust healthcare systems focusing on prevention, early diagnosis and early initiation of care is key in safeguarding the healthcare of PLWHIV. They must not bear the brunt of increased stigma as a result of the COVID-19 pandemic. We all need to act in empathy and embrace peace, love and unity during these trying times

On Wednesday 19th KMA President Dr. Were Onyino accompanied by our CEO had a meeting with the NHIF CEO Dr. Peter Kamunyo at the NHIF OFFICES to discuss issues raised by doctors which include:

1. Surgical pre-authorization form,
2. Separation of facility and doctors’ fees,
3. Approval of forms by consultant or senior House registrars and registrars in training institution,
4. Approval of contracts & Enpanelling,
5. Technical review of procedures before approval,
6. Health Systems Research 
7. Doctors Charges.

They agreed on the following on the issues raised:

• Surgical pre-authorization form. – KMA articulated the issues with the new NHIF preauthorization form requesting for doctors’ personal details to be excluded from the pre-authorization forms. Instead an electronic verification platform be established linked with the KMPDC database which is the custodian of all Doctors’ data. This will prevent the use of the data in fraudulent claims and activities. It was agreed that NHIF will relook the form details and make changes to protects doctors’ data.
• Separation of facility and doctors’ fees- KMA through managed healthcare committee will work toward projects aimed at costing services provided by Doctors under the NHIF scheme.KMA suggested that there be a  separation of the packages to take into consideration the doctors’ fee and institutional costs to guarantee quality delivery of healthcare service.

• On Approval of forms by consultant or senior House registrars and registrars in training institution. KMA will request the Medical Council KMPDC to recognize the Senior House Registrars and define their scope of practice which will enable NHIF update their database to include them in the list of recognized specialties to provide the much-needed services. The SHR are not authorised currently to sign claim forms by NHIF with many forms signed by them being rejected. This is despite the fact that they are Consultants awaiting insertion of their names into the Consultants’ register at KMPDC. This has forced them to resort to using their senior’s details to get the necessary approvals. KMA proposed that NHIF recognizes this group and their scope of practice.

• Approval of contracts & Empaneling -KMA reported that its members have experienced delays in accreditation of medical facilities. In as much as this role was transferred to KHPOA, the period between accreditation and contracting by NHIF takes long. KMA president proposed digitization of the process to fast track it. KMA proposed that there be an interagency collaboration where both accreditation and the due diligence visit for purposes of contracting be combined for efficiency purposes and avoid the duplication of roles.
• On technical review of procedures before approval, KMA proposed there be involvement of doctors in authentication of the preauthorization claim forms and proposed that KMA provide the technical support towards achieving this.
• With doctors charges there is currently a challenge with NHIF meeting the medical council recommended doctors’ rate according to the KMPDC fee guidelines thus KMA will work with specialist associations and the medical council to advise on rates and the scope of practice for the different specialties based on regions which NHIF can honor.
• Health Systems Research- NHIF every year collects massive data on health system from its clients and this if analysed would generate lots of information to influence health policy. KMA through the managed Health committee shall work with NHIF to promotes health systems research in collaboration with other partners in the health sector.
• KMA discussed with NHIF to consider a model where the gatekeepers in primary healthcare are the Medical Officers who will be supported by other cadres to ensure quality delivery of Healthcare to mwananchi in keeping with its mission. This has been successfully implemented in other jurisdictions with UHC programmes. This will avoid wanton wastage of resources by ensuring proper utilisation of the expertise within our disposal.