Universal health care sabotaged by greed and ignorance of the law

Clinical officers with placards written their pleas to the government at greenpark terminal during the Kenya union of clinical officers peaceful demonstrations to afya house ,SHA, parliamentary buildings on delayed posting of interns, absorption and payment of gratuity for UHC staff and deliberate discrimination and exclusion of clinical officers from Sha on 5th March 2025. [David Gichuru,Standard] One of the sad realities emerging from the 2025/26 budget proceedings in Parliament is that our budgets are prepared first and foremost to serve the big people in the Executive and Parliament. Public good and services are purely subsidiary priorities at national and county governments. For instance, it was a shocking revelation from State House budget submission that outside the constitutional limitation on the number of Cabinet Secretaries, President William Ruto has unilaterally created a parallel cabinet disguised as advisers. The appointees serve no known cabinet level departmental responsibilities, yet draw salaries, benefits and allowances of either a Cabinet Secretary or Principal Secretary. Similar behaviour exists across the counties from the county bosses. Yet, the very reason why Kenyans demanded a cap on the number of Cabinet slots and abolish the position of deputy ministers was to reduce the burden and waste of the 2007-2013 'Nusu mkate' type of government. The funding for this excessive Executive baggage loaded on taxpayers is neatly hidden by creating several layers of departments within the presidency and governors' offices at the county level. For example, according to the summary budget estimates of 2012/13, the last fiscal year of the former President Mwai Kabaki in office, the entire presidency budget (including State House, Cabinet Office and Office of Prime Minister) was Sh4.35 billion. The Budget for the Vice President was included in the Ministry of Homer Affairs, the Cabinet portfolio then headed by him. In the 2025/26 fiscal year, the presidency alone will gobble over Sh18.85 billion, more than four times the allocations in 2013. As has been the trend in the past three years of the Kenya Kwanza administration, this allocation will be blowout by March 2026, and the presidency will be back to Parliament for additional allocation through supplementary estimates. An important point to note here is that the salaries and benefits of the President and the Deputy President are not included in this allocations as theirs is drawn directly from the Exchequer through the Consolidated Fund services. The technical question to ask here is: what is driving the cost allocations to the presidency? Is it that inflation has drastically increased costs of goods and services that much in about 12 years? Or is it the costly taste and preferences of the current occupant of the office? Shouldn't there be a limit of what taxpayers should pay or a sort of scientific model to guide expenditures at the highest executive offices in the country? Another notable allocation that exposes the greed of politicians is the National Government Constituency Development Fund (NG-CDF) allocation of Sh58.8 billion. This is curious because the High Court determined the Fund as incurably unconstitutional that it must die at the stroke of the midnight on June 30, 2026. The technical interpretation of this ruling was that the Court only allowed only a grace period to wound-up ongoing projects that were funded under the Fund. So why are we allocating additional billions to fund it in its year of death? Of great interest for this column today is an event that may pass as incidental, but speaks volumes to the reality of our devolved governance system, and financing for healthcare in the country. In a colourful event days ago, President Ruto lined up governors at State House to flag-off disease surveillance vehicles in the 47 Counties. For avoidance of doubt, the Constitution guarantees access to quality and affordable healthcare as a constitutional right under Article 43. To actualise this right across the country, primary healthcare was fully devolved to the counties with all facilities of levels one to five under the management of the county governments. Only level six facilities, and health policy, research and development components of the health sector were left at the national level. Level six facilities are funded separately as independent entities under the Ministry of Health budget. A quick question that easily comes to mind is, why does the ministry have to procure motor vehicles centrally at the national level, only to hand them over to the counties? This follows a similar vein where the national government unilaterally signed for the managed Medical Equipment and Supplies (MES) facility and then forced it on counties in complete disregard to individual county needs, priorities and capacity. The costs were forcefully recovered at source from each county equitable share. While the Ruto administration had committed to abolish MES scheme on assumption of office, last year news emerged that the administration quietly procured a similar facility and started forcing it on to county governments. It appears procurement of disease surveillance vehicles confirms that the Ruto administration is still acting big behind the scenes to control the billions of shillings meant for provision of basic healthcare services at the community level. While someone may argue that this probably is part of the research component, then who shall take up the maintenance, fuel and other administrative costs at the county level? Who are the researchers or data trackers at the county level who shall need the vehicles? Going back to the 2025/26 fiscal budget estimates currently under consideration under the National Assembly, there are allocations of Sh13.1 billion, Sh3.2 billion and Sh330 million for Primary Healthcare Fund, Community Health Promoters and County Health Facility Equipment respectively. All the three programmes are implicitly under primary healthcare that is a fully devolved function. But the money remains at the national level 12 years down into devolution. However, the problem of health financing is just not the meddling and/or withholding of health budgets at the national level, majority of the county government have also proved chaotic in handling healthcare services and related financing. Under the formula used to share the equitable revenue share among counties, health services account for a proportion of 17 per cent of the money allocated to a county. In addition, Parliament passed the Facility Improvement Financing (FIF) Act, 2023, that become effective November the same year. The primary objective of this Act was to protect the FIF collected by each health facility to be retained, planned for and used at the respective facility where it was collected. Effectively therefore, FIF is in the class of restricted revenues that can only be used to defray emergency and unique expenditures at the facility level. The Act exclusively demands that each health facility defined as an entity, that is, from level two to five facilities, must have their own bank account to which FIF funds are banked and utilised from. The mandatory signatories are the medical superintendent and facility administrator for hospitals, and the facility in-charge and the sub-county accountant for the health centres and dispensaries. Thus, by deed of the FIF Act 2023, FIF is not deemed as part of the Own Source Revenue (OSR) that mandatorily must first flow to the County Revenue Funds (CRF). The Act also establishes a separate governance structure for FIF at the facility level to prepare workplans, budgets and expenditure at facility level, outside the normal lengthy county budget appropriation procedures. FIF must be treated as supplementary, not a substitute of the county government allocation to the health sector from the equitable share. Unfortunately and tragically so, many counties have not operationalised FIF and continue treat it as part of the OSR. If the country is to attain reasonable gains on universal health care, the Executive at both levels of government will have to comply with the established legal frameworks and keep off private greed into the health kitty.

Universal health care sabotaged by greed and ignorance of the law

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