BOSIRE: The system is rigged against real universal health coverage


Having every Kenyan on medical insurance does not translate to universal health coverage

Tuesday January 30 2018

Eleven years ago, as a young intern doctor at the Kenyatta National Referral Hospital, I was quite impressed to receive a patient who had been air-lifted from the northern frontier for highly specialised care.

She had developed severe high blood pressure in pregnancy, leading to multiple organ damage. She needed critical care and renal dialysis to save her life.

I was young, naïve and excited that the hospital helipad was actually not just decorative! I thought this medical evacuation was standard care available to all patients in hard-to-reach areas in Kenya.

Reality hit home two months later when we received a 17-year-old female patient from Moyale.

She was an Ethiopian who had crossed the border as a refugee. She fell ill and could not access even basic laboratory tests to diagnose her condition.

She was referred to us, and arrived after 13 hours on the road, hanging onto life by a thread. I could not understand how such a sick patient could be subjected to road transport, yet she clearly needed air evacuation.

She stayed with us for five weeks while all manner of tests were conducted on her. She died without a diagnosis.

These incidences came to mind when I heard of the mother in Homa Bay County who had quintuplets and lost them all due to inadequate ante-natal and neonatal care.

While in the developed world, survival of quintuplets is almost taken for granted since the first surviving set in 1972, in Kenya it is still a miracle when quadruplets survive.

A colleague once narrated how he sat twiddling his toes in Homa Bay County, four years ago, as a mother lost her baby because they were stranded on an island on Lake Victoria, unable to safely transfer the mother to the mainland for surgery.

Why did this happen? Despite the county investing in ambulance boats, the lake was besieged by a nasty storm that made it dangerous for the boat to make it across the angry waters.

 By the time the waters were navigable, death had robbed the mother of her baby and the still calm of the lake brought pain instead of relief.

As we continue to tout universal health coverage in Kenya, I keep wondering whether we truly understand what it means. If all Kenyans had medical insurance cover, would that translate to universal health coverage? Unfortunately, our system is not yet structured to provide this.

Even in private hospitals, sub-specialty services are only fulfilled by the main hospital usually based in Nairobi.

 All other branches of the hospital fall far below par in terms of staff complement, infrastructure and even just the aesthetic beauty of the facility.

The population targeted for care is indirectly discriminated against, and where an upgrade is needed, they are referred to the main hospital in the capital city.

This has been the trend even in public hospitals, where there has been unequal investment in the health sector since independence.

 Health resource availability is literally dependent on the size of the city within which a hospital is domiciled.

A patient requiring specialised care is referred to Nairobi or Mombasa or Eldoret, irrespective of whether they are seeking care in a public or private hospital. This is so instinctive that we do not even think about it. Yet it is a clear demonstration of our neglect of a large segment of the society that is regarded as not sufficiently empowered economically, to pay for the services.

How then shall universal health coverage be achieved if we cannot bring these specialised services to our most disadvantaged? Take for instance the noble Linda Mama programme. The care provided to a mother seeking services at the Moi Teaching and Referral Hospital in Eldoret will be miles above that provided to the mother in a health centre in Wesu in Taita Taveta County, despite both mothers being entitled to the same privileges under the National Hospital Insurance Fund (NHIF).


For this reason, mothers move to urban centres to deliver their babies in well-equipped faith-based and public hospitals while we continue to have bad outcomes in the rural and marginalised areas.

Empowering an individual mother with a NHIF card means nothing when she starts to bleed profusely after delivery and the nearest facility with capacity to provide a much-needed blood transfusion is 270 kilometres away on a road fit for camel caravans.

Universal health coverage must be built on equitable access to health, built on the pillars of adequate financing, human resources, technology, adequate medical supplies, research and health systems management.

It goes beyond the immediate health sector to country infrastructural development that enables physical access to care; education to increase empowerment and create demand for advanced service delivery in every corner of this country; and good governance to root out the cancer of corruption that shall be the death of the country if we can’t stop it from bleeding our systems dry.

Devolution of health was intended to be the beginning of establishing universal health coverage by having key decision makers on the ground with a realistic view of what the local needs are. It must be strengthened to achieve this without fear or favour. Mediocre politicising of this key function is too costly for us to ignore.

Counties that have been marginalised for decades must be supported to improve access to care, through strengthening and implementation of policies, adequate financing, supportive supervision and proper collection of data and its use in decision-making.

 Mission hospitals such as Kijabe have demonstrated that one can be based in the rural areas and still provide sub-specialty care. I look forward to the day patients will travel to Makindu for specialised orthopaedic care!