Strain between National and County governments threatens health reforms

Deputy President Rigathi Gachagua with the Council of Governors at his official Karen residence. [DPSC, Standard] Implementation of the health agenda by the Kenya Kwanza administration lies in the balance after county governments distance themselves from the ongoing health reforms. A row between the two arms of government was sparked over the weekend after governors skipped the official launch of stipend payments to Community Health Promoters (CHPs). The event was officiated by Deputy President Rigathi Gachagua at his Karen home last Friday. The county bosses had been officially invited to the event, in a letter written by the Chief of staff at the Deputy President's office, Wanjiku Wakogi, dated February 14, 2024. After the snob, governors have now convened a meeting in protest against usurping health functions, by the national government. In a letter addressed to respective governors in charge of the health, housing and trade committee, dated February 14, 2024, CoG CEO Mary Mwiti raised concerns about the national government infringing on county roles. The concerns, she said, cut across various devolved functions including health, housing, and trade. "The severity of these transgressions is escalating daily, notably through direct budget support for devolved functions channeled through National Government Ministries, departments and agencies at the Counties as well as the deliberate use of members of parliament to roll out these programs and projects disregarding the Constitutional role of Counties and causing a lot of disorder in County Governments," reads a section of the letter written by Mwiti. Mwiti said continuous written communication from the CoG to the National government to address the concerns has proven futile. The proposed health agenda for the meeting includes payment of stipends to CHPs by the Ministry of Health and timely Disbursement of County Government Allocation (Danida). The meeting will also address the import of the three health Acts to the counties. The Acts include the Primary Healthcare Act 2023, the Social Health Act 2023, and the Emergency and Chronic Illnesses Act, 2023. The meeting is scheduled on Thursday, February 22, from 10am, at CoG offices. But efforts by The Standard to reach out to Mwiti, CoG chairperson Anne Waiguru and governors to deliberate on the matter were not successful, as they did not pick up phone calls, nor respond to texts. In a quick rejoinder, an insider at the Ministry of Health dismissed claims by CoG, maintaining that governors skipped the official launch of CHP pay because they wanted the Sh3 billion sent into the county government account for pay. "They (counties) didn't want CHPs paid. They wanted money sent to counties, but the national government paid through mobile money. Counties don't want to commit," said the insider. Insiders said governors have been engaged in reforms, a section of CHPs, who are aimed at realising the Primary Healthcare agenda, by the Kenya Kwanza administration. The governors according to the source also attended meetings held by Health CS, health committees at the Senate and National Assembly in the formation of the Social Health Act, among other reforms aimed at realising Universal Health Coverage. "CoG selected a secretariat that has jointly been engaged with the ministry, senate, and national assembly. Not unless they're saying the secretariat is not theirs," said an insider who pleaded not to be identified because of the sensitivity of the matter. 'On bills, they were engaged, they met at Chaka and continued with meetings in Mombasa. Them coming to claim not being involved, is wrong" But despite their involvement, the insider said several counties have not launched the CHP kits, whereas some have not allocated a budget for paying the CHPs. Further, the source accused counties of failing to strengthen their facilities for UHC. With the reforms, he said counties will benefit more, because a big junk of money will be dispatched to public hospitals, unlike currently, where private hospitals benefit more from the National Health Insurance Fund (NHIF). "Social Health Authority (SHA) is buying services from public, private and Faith-based organisations, but counties do not want to provide services," Previously, he said facilities were allocated some money, and the money had a capitation that was sent to counties, whether they provide services or not. He maintained, "What they do not want is the issue of accountability, and community health promoters being paid by the national government. We know when they receive the money, they will not pay" Head Division of Community Health Dr Maureen Kimani said on CHPs there was an engagement between national and county governments, in February last year. It was agreed to have promoters receive a stipend of Sh5,000, shared between the two entities, at Sh2,500 each. On Friday, the national government officially launched the commencement of pay, though several counties had started paying. At least 34 counties have paid stipends to the promoters, whereas 13 have not committed. "Launch of the pay was a third commitment-first commitment was providing them with kits, then gadgets and recently stipends," said Dr Kimani. The CHPs document health details that are captured in the Ministry of Health database. Kimani said CHPs have screened at least 2.9 million households since October last year. "More than 1 million people have been screened of diabetes, with thousands referred to hospitals. The Ministry is able to see daily activities by the CHPs through the digital gadget," she said. "They are doing more, and the stipends are meant to motivate them to do more,". The CHPs are targeting 12.5 million households, according to KDHS data. Apart from CHP issue, mid-last year, governors also raised concern on creation of health laws, aimed at repealing the National Health Insurance Fund (NHIF), saying they had been sidelined. Governors maintained that there was need to involve counties in the initial stage of preparing the bills namely Social Health Insurance Fund Bill, Facility Improvement Financing Bill, Primary Health Care Bill 2023 and Digital Health Bill 2023, that were later signed into Act by President William Ruto On October 19, 2023. "Our input as CoG should be incorporated in these bills before they go out to the public. Your legal team and our legal team which have not sat anywhere should have sat and agreed on the issues before they go out to stakeholders," said Tharaka Nithi Governor Muthomi Njuki, also the chairman of CoG Health committee, in a presser. Njuki further emphasised that two levels of government need to respect and avoid inter-governmental disputes, which have happened before. Surprisingly, in a quick turn of events during the launch of CHPs, Njuki praised the bills, saying CoG had been engaged. In a recent interview with The Standard, SHA chairperson Dr Timothy Olweny maintained that county governments have been engaged in the changes happening. Dr Olweny said counties are expected to enhance the capacity of their human resource, medical supplies and technologies to guarantee access to quality healthcare services by all Kenyans. Controversy also rocks the Sh63 billion Managed Equipment Services (Mes) project after the government agreed to terminate a nine-year agreement with counties. The MES project is now referred to as National Equipment Support to Counties (NESSC). Pulling out came after the National Treasury Cabinet Secretary Prof Njuguna Ndung'u allocated a total of over Sh9 billion under the MES project Out of the allocation, each county is supposed to receive sh200 million annually for the leased equipment. In a document signed in Naivasha, by CoG and Health CS Susan Nakhumicha, it was agreed that all pending issues on MES and related services deployed by the National Government in counties have been upon by the two levels of government. But months later, an insider hinted to The Standard that counties negotiations for the new arrangement are yet to commence. The MES project was signed on 5th February 2015, by the MoH and respective MES service providers, during the tenure of Cleopas Mailu. XN Iraki, an Economist and Professor at the University of Nairobi on his part, said "the wrangling is about money". The solution, he observed, lies in delineating the roles of county and national government. "The central government has maintained a stranglehold on county health pursues, for example, through leasing equipment. This will affect the delivery of health services, which is already wanting," said the economist.

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