Is UHC possible? A critical look at the pitfalls and opportunities

President William Ruto, Health CS Susan Nakhumicha and Governor Anne Waiguru during the official opening of the new 341-bed Kerugoya County Referral Hospital.. [Hiram Omondi, Standard]

Esther Wambui had a faint smile as she clapped her hands slowly while standing at the gate of Kerugoya Level 4 Hospital where she had come to see the doctor.

About 50 metres from where she and many others stood, President William Ruto was cutting the ribbon to officially open the new 341-bed Kerugoya County Referral Hospital.

"We love our governor for this great achievement. With this new, big facility, there is no doubt that health services will improve," said Ms Wambui.

The Sh1.6 billion five-storey medical complex, touted as one of its kind in the region, consists of a 12-bed intensive care unit (ICU), 12-bed high dependency unit (HDU), 40-crib newborn unit, four operation theatres, an oxygen plant with a capacity to produce 450 litres of gas per minute, among many other amenities.

"This is a dream come true and a demonstration that devolution works," said Kirinyaga Governor Anne Waiguru during the hospital's launch on Tuesday.

Critical question

After all the fanfare, it was time to settle down and answer the critical question; is it possible or practical to implement Universal Health Coverage (UHC) programme driven by the national government in a country where the health function is devolved?

Since 2013 when devolution started, healthcare in Kenya has faced several challenges - constant doctors' strikes or threats of strike, bickering and mistrust between counties and the Ministry of Health, and complaints by health workers of discrimination in the implementation of UHC.

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The national rollout of UHC has failed twice and the government's third attempt slated for later in the year faces an unexpected obstacle: Kenyan healthcare workers are not boarding that ship.

On May 31, 2023, Health Cabinet Secretary Susan Nakhumicha wrote to the Council of Governors (CoG), informing it that the government was renewing the contracts for 8,571 health workers it employed under the UHC programme.

Health Cabinet Secretary Susan Nakhumicha. [Benjamin Sakwa, Standard]

The healthcare workers under UHC pilot programme are employed and managed by the national government under different terms from those of their counterparts employed by the counties.

Health workers' unions have termed this discriminatory.

Peterson Wachira, an official at the Kenya Union of Clinical Officers - the second most populous health workers union with 26,804 members as of 2022 - said the hiring is "irregular, and our biggest contention is on the inequity in the pay."

"A clinical officer under UHC earns about 48 per cent less than what their counterpart on permanent and pensionable terms earns, yet they work in the same hospitals and for the same number of hours," Wachira said.

Allay fears

However, on Tuesday, Governor Waiguru, who is also the CoG chair, sought to allay these fears.

"As the chair of the Council of Governors, I can assure you that the devolution of healthcare services has had a significant impact. For the last 10 years, county governments have invested heavily in healthcare equipment and infrastructure, healthcare service delivery, and human resource development," she said.

On May 19, CoG released a statement, declaring a crisis in the implementation of devolved health services due to "deliberate steps by the Ministry of Health to claw back on the health function."

"So far, we note with concern that all engagements and agreements made between the Ministry of Health and the Council of Governors have been bluntly disregarded and there is a clear demonstration of lack of goodwill from the Ministry of Health," read the CoG statement signed by Waiguru.

Three days later, a section of the media reported that President Ruto and health workers' union officials met in February to plan the takeover of the health function from the counties.

According to the report, the meeting, which took place at State House, proposed the formation of the Health Risk Commission, an independent body that will oversee the management of human resources for health, including recruitment, promotion, and provision of all services in the health sector.

However, in Kerugoya, the president assured Kenyans that his administration does not have any plans of taking over the health function.

"I know there is a big debate on this matter. But I want to assure the people of Kenya that the health function will be and has been better managed by our counties and that is how it is going to be going forward," he said.

Kerugoya County Referral Hospital. [Courtesy, Standard]

Ruto said he has agreed with governors that the national government will collaborate with all counties in delivering health in four areas.

They include equipping all government hospitals; the formation of a special kitty called "facility improvement fund" to ensure health resources are not diverted to other functions; and the payment of community health promoters by both counties and the State on a 50-50 basis.

"My government has already allocated Sh15 billion for the support of community health promoters. We must work on promotive and preventive health and towards this, we will train and equip 100,000 community health promoters in Kenya to achieve the ratio of one promoter for every 100 families," said the president.

He also underscored the need to form the Kenya Health Human Resource Advisory Council to create harmony between health professionals, counties, and the national government and harmonise the provision of health services.

"We also agreed to support our medics to continue with their professional training. So, when a doctor goes back to school for professional training, how do we fill the gap they leave?" he posed.

Doctors in various counties always threaten to withdraw services over a lack of support for professional training, delayed salaries, promotions, and hiring of more doctors, among other grievances.

"We need to have consultants and doctors employed and others promoted to the right job groups. This has not happened five years down the line," says Kenya Medical Practitioners Pharmacists and Dentists Union (KMPDU) Secretary General Davji Atellah.

"We are losing many of the consultants to other countries and that is because of the frustrations they go through in the county referral hospitals."

Kirinyaga County Health Chief Officer Stanley Mureithi says the capacity building of medics is a national government function, and the State should pay salaries of all medics who go for higher education to enable counties to fill the vacancies.

Dr Mureithi says successful implementation of UHC is possible only with "proper consultation" between the two levels of government.

False start

He says UHC is a welcome policy whose initial priority focus was on promotive and preventive health at the grassroots level, but the government had a false start at the pilot stage when it concentrated on curative and rehabilitative care.

"You give people NHIF cards so they can go to the hospital when they are sick but what you should have done is promote good health practices so that you prevent people from getting sick," he says.

The chief officer says it is through devolution that health infrastructure and other resources can be taken closer to the people through Level Two and Level Three hospitals that are key in implementing promotive and preventive health.

According to a 2020 report by the World Bank, the number of government health facilities in Kenya increased by 33.6 per cent from 4,456 to 5,953 between 2013 and 2020, thanks to devolution.

As a result, over 90 per cent of the population live within five kilometres or one-hour travel time to a health facility.

In Kirinyaga, apart from the new referral hospital, which is now a Level 5 facility, the governor said she has completed seven other health centres and dispensaries to enhance UHC.

They are Kamwana, Kiamwathi, Kianjiru, Umoja, Kiaumbui, Matandara, and Joshua Mbai Laboratory. Others lined up for opening include Mucagara, Riakithiga Laboratory, Kiandai, Kavote, Ndaba, Njegas Health Centre female ward, Kiandieri and Kandongu Laboratory.

Dr Mureithi is confident that with proper collaboration and continuous consultation between the two levels of government, UHC is possible and every Kenyan will see that devolution of the health function was the best decision.

But how long will this collaboration last?