Universal Health for all: The wins and challenges

On an average day, when referred for treatment, Ms Rebecca Owako* covers 72 kilometres by road from Kombewa to Kisumu and back to get treatment at Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH). She spends Sh200 a day on bus fare, this is exclusive of other expenses which she has to incur. For the last two weeks, she has travelled twice to the hospital and back to her Kombewa village without getting any treatment.
Since September, Ms Owako has had to deal with a swollen face, hands and feet in addition to less urine output due to possible kidney failure, a diagnosis made by the first doctor who attended to her at Kombewa health facility. The 40-year-old mother of four was then referred to JOOTRH, which is one of the biggest referral hospitals in western Kenya, for kidney tests.
“The first time I went; I was told that the reagents to do the kidney test were out of stock. The second time, I got a notice at the laboratory that the test could only be done for inpatient,” says Ms Owako. She is now forced to consider other options including waiting for the reagents to be restocked, having the test done at a private health facility, or travelling to Moi Teaching and Referral Hospital, Eldoret or Kenyatta National Hospital for the test.
Her choices are further hampered by the fact that she doesn’t have the money required to seek treatment elsewhere. A notice seen by the Healthy Nation during a visit to JOOTRH dated October 28, 2019, states that there are some reagents out of stock and therefore the hospital is unable to conduct some of the tests. These tests include urinalysis, renal function tests and a complete blood count (CBC), which is used to evaluate patients' overall health and detect a wide range of disorders, including anaemia, infection and leukaemia.

THE UHC PILOT PROGRAMME

Kisumu is one of the counties the government chose to pilot Universal Health Coverage (UHC) alongside Machakos, Isiolo and Nyeri. The decision to launch the programme in the four counties was evidence based considering their health burdens.
Kisumu was identified because it leads in the infectious diseases category especially for HIV/AIDS and tuberculosis. Machakos has the highest number of injuries mostly from accidents. Nyeri is part of the pilot because it leads in the non-communicable diseases segment especially diabetes. In Isiolo, the government seeks to establish how the package is well suited for nomadic and migratory populations.
The programme dubbed AfyaCare, was launched by the president on December 13, 2018, in Kisumu. It was geared towards granting Kenyans access to affordable healthcare without financial hardship. The President highlighted that with a UHC card, Kenyans in the four counties would access health services ranging from emergency to child health. He pointed out that the programme would adopt a primary healthcare approach that would entail scaling up immunisation services, maternal and child health services including family planning, skilled delivery, and antenatal and postnatal care services.
Now in its 11th month, the government has deemed UHC as a highly successful venture with Health Cabinet Secretary Sicily Kariuki saying that it has brought forth critical best practices, lessons, and gaps that will inform scaled-up implementation. However, a spot check of facilities in the four counties tell a different story. Sources in the four piloting counties have intimated that they have only received UHC funding from the National government for two quarters.
They say that the funding for the quarter that ended in July is the last they got and that it is unlikely that more funds will be released as the pilot is coming to an end soon. There has been little transparency from the government in matters regarding UHC, there has been no transparency on the formulation process and the success and or failures of the pilot. For example, before the budget was read this year, the Budget and Appropriations Committee (BAC) said that the Ministry of Health was yet to table a report on the success of the ongoing UHC trials in four counties.

CHANGE OF GUARD

In August this year, the health ministry announced plans to change from Kenya Medical Supplies Authority (Kemsa) to the National Hospital Insurance Fund (NHIF) as the driver of UHC. Nonetheless, there has been no evidence of increased enrolment of Kenyans to the national insurer. “Key Institutional reforms in NHIF and Kemsa shall ensure improved service delivery. Kemsa is being repositioned to be a strategic provider for our health commodities and NHIF to be a strategic purchaser of health, that is, a purchaser of the UHC essential health,” said the health CS Sicily Kariuki during the announcement.
In the pilot phase funds were split 30 per cent to health facilities and 70 per cent to Kemsa to provide commodities. The four counties were to be supplied with drugs by Kemsa after the government promised to give Sh3.22 billion to Kemsa as a one-off seed fund to achieve this objective. The government was expected to release the funds for drugs as well as an additional Sh20 million for anticancer products by the beginning of July.
It is not clear whether the money was dispensed to Kemsa and if the supply of drugs to the said counties has been consistent. With the constant stock outs in the counties, it is not clear whether the blame should be diverted to the government or the authority.
In Isiolo for example, the county chief officer of health Mr Ibrahim Alio says that although 70 per cent of the UHC funds go to Kemsa they still have to source for drugs from other medical bodies since Kemsa only delivers 70 per cent of required drugs.
“The authority cannot deliver what we need and so we have to get medicine from Mission for Essential Drugs and Supplies (MEDS), because Kemsa sometimes lacks even the basic commodities,” he said. In August, the Authority could not supply the counties with drugs reportedly because the World Bank, UHC donor, did not factor in the budget money for drugs and non-pharmaceuticals.

OVERSTRETCHED RESOURCES

In Nyeri County, the biggest facility in the county, the Nyeri County Referral Hospital has been noted for overcrowding of patients. A visit to the facility revealed that the maternity wing is swamped, forcing the women to share beds. A medic at the facility who sought anonymity revealed that the number of inpatients have gone up, which has led to the staff being overstretched. “In maternity, you cannot refer a patient backward, once they show up in labour we have no option but to admit, even if it means they will share a bed,” said the medic. Even with 380 facilities spread out throughout the county and a national referral hospital in Othaya, patients flock the facilities they prefer.
In Mukurueini hospital, Nyeri County, the 100 healthcare workers at the facility see about 4,000 patients monthly since the introduction of UHC. The number of patients has tripled according to the facility's data, despite the fact that Njokiini health centre which is a few minutes away is barely getting any patients.
The situation in Isiolo County is vastly different. Here, the hospitals are 49 kilometres apart and the only teaching and referral facility is completely overburdened. Women travel from as far as Bassa which is 280 kilometres away from Isiolo town to access medical care.
The only other available health facilities are in Garbatulla and Merti which are supposed to relieve the Isiolo Teaching and Referral Hospital but are not easily accessible. The hospitals have experienced a surge in numbers following the UHC pilot, especially in the dentistry departments where the county data shows a 300 per cent increase.
County chief officer of health Mr Ibrahim Alio believes that the increase in numbers requires an increase in the health workers and the hospital's infrastructure. The county registered 202,000 people in the UHC pilot and the facilities have been forced to make changes to ensure service delivery is seamless. Mr Alio says that they have extended the working hours for consultations to 6pm from 5pm and the pharmacy department now closes at 10pm. “The staff is overstretched especially at the Isiolo Referral, the entire county has 57 health facilities [catering to an estimated population of 268,002] and patients come from far, we cannot turn them away. The increase in inpatient admissions means we have to increase everything including basics such as food rations,” he adds.

THE COST OF UHC

The belief that UHC is meant to be free is something most Kenyans believe. For example, in Machakos County, at the Kivaani Hospital where the Health CS launched the UHC registration last year, we meet Mr William Mwathani. Mr Mwathani got into a motor vehicle accident last month and the doctors say he needs some screws to reattach his bones. Medics explain that this is not free and that he has to pay out of pocket since the devices are not supplied by Kemsa. He, however, remains adamant that the services ought to be free.
“We were told that when you get the card, the services are free and yet we have to pay out of pocket, these people want to make money,” he says. His misconception about UHC is not surprising given that only 31 per cent of Kenyans are aware of the Universal Health Coverage programme.
A 'Nationwide Perception Study on Universal Health Coverage in Kenya' found that the level of awareness of UHC is very low and that it highest in regions with a UHC pilot county. This is something that Mr Victor Bwire, deputy chief executive officer and programmes manager at the Media Council of Kenya agrees with. He believes that there is a state of policy confusion, especially on how the focus on the private sector to provide the greater bulk of resources for Universal Health Coverage (UHC) and haggle over the management of public resources for health services between the national and county government persists.
“The responsibility of providing quality and accessible healthcare for all lies on the national and county governments with the national government being responsible for policy formulation and managing referral hospitals while county governments are charged with managing health facilities within their jurisdiction,” says Mr Bwire. Unfortunately, he reveals, this is not what is happening, and Kenyans’ pursuit to access health is frustrated, thus the realisation of UHC soon might be a pipe dream.
As Kenya looks to the roll-out of UHC following the one-year pilot the perennial underfunding of healthcare and shortage of human resources in Kenya could be the biggest detriment in the rolling of Universal Healthcare Coverage (UHC) in the country. However, the ministry of health remains hopeful. The CS admits that the biggest challenge of UHC has been human resource saying that interns and community volunteers will help to deliver the roll-out of the programme.
“We have agreed on a government policy that we are taking in interns, the other move which is even more sustainable at the local level, is the hiring of community health workers. We have 40,000 of them to bring in. “The other issue has been absenteeism, so we are looking at a governance framework for purposes of supervising to ensure there is productivity.”
On matter of drug shortages, the CS recognised that proper quantification from the counties was a challenge. “But as we start we will do joint quantification to have a certain degree of accuracy,” she said.