Challenges facing the attainment of Universal Health Coverage in Kenya

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.

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