Health funding crisis; Kenya's big 2023 headache

In the coming years, Kenya will need to have a difficult conversation on the structure, form, choice and scope of its health funding. [iStockphoto]

Brenda (not her real name) is overwhelmed with joy, as she steps out of Gilgil Hospital.

Her two-year-old twins just tested HIV negative.

It has not been an easy journey for the HIV-positive mother, but adherence to ARVs, viral load tests and care for the babies has finally brought joy to the 43-year-old.

At birth, the babies were put on prophylaxis (zidovudine and nevirapine) - drugs that prevent transmission of HIV from mother to child.

"My toughest days were breastfeeding. But today, I am the happiest human on earth," says Brenda, crying tears of joy.

ARVs are used for treatment and prevention, including the prevention of mother-to-child transmission.

The drugs suppress viral load, which depends on the consistent and sustained use of ARVs.

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Walking to a hospital to collect free ARVs takes Brenda down memory lane years back, when the medicine was affordable to only a few, as the HIV/AIDs pandemic killed hundreds of Kenyans without help.

The mother of four aged 23, 19, and two-year-old twins tested HIV positive in 2003, after experiencing episodes of Sexually Transmitted Infections (STIs).

She would later be put on ARVs. For 19 years, she has successfully managed to control a viral load successfully leading to meaningful livelihoods.

Brenda is not the only one under the same status, but thanks to the Global Fund, which funds the program alongside malaria and TB, alone.

Last month Kenyan Government pledged to co-finance Sh1.2billion ($10 million) to the kitty, an increase of 66 per cent, from Sh723 million ($6 million), made in 2019.

President William Ruto announced the pledge during the United Nations General Assembly (UNGA).

Even though Global Fund has improved health indicators in fighting HIV, TB, and malaria, health actors are warning that relying 100 per cent on external life-saving commodities is not sustainable.

In the coming years, Kenya will need to have a difficult conversation on the structure, form, choice and scope of its health funding.

"Global Fund is fantastic because it is there, but Kenya is ambitioned to be growing, and the donors who have been funding are reducing the amount, and some pulling out," said Dr Daniel Mwai, a lecturer of health economics at the University of Nairobi (UoN).

According to a recent study, in the last three fiscal years alone, donor contributions to HIV/AIDS, TB, and malaria through the MOH budget have each dropped by almost 35 per cent.

Dr Ruth Masha, the lead Global Fund proposal development for Kenya, and the CEO National Syndemic Diseases Control Council (NSDC) said the situation is dire if the trend continues unmitigated.

"For HIV support, the signs are on the wall, and we must think differently, for example, negotiate how to get the drugs. Right now, there is fear of what happens tomorrow," she said.

Masha urges the national government to deliberately increase funding for the health sector, and the national government to help in addressing endemic diseases in respective localities.

Apart from domestic allocation, Masha said the country should negotiate with investors to set up ARV manufacturing plants for low-cost supply, and stop new infections, more so among young people, stop sexual violence like rape and gender-based violence among girls.

"We need to promote abstaining among teenagers, and have those who cannot abstain, use condoms. Those having sex are few, so let's encourage those not having sex not to," said Masha.

Masha's letter speaks to an area the Kenyan government has been faulted for successive years of underfunding; preventive and promotive aspects of healthcare.

Dr Rose Oronje, the Director-Public Policy & Knowledge Translation & Head of AFIDEP Kenya Office, says Kenya's budget is growing but unfortunately, most of it is going to recurrent expenditure.

African Institute for Development Policy (AFIDEP) is an African research policy institute established in 2010 to help bridge the gaps between research, policy and practice in development areas.

"Allocation to Primary Health Care (PHC) Remains minimal despite its criticality to health outcomes," she said.

And although county governments are the primary custodians of health function according to the Constitution, recent AFIDEP Kenya research indicates that the 28 percent of the budget they are dedicating to health is still lower than the 35 percent allocation pre-devolution.

Experts agree that additional domestic finances for health are urgently needed if Kenya is going to score significant gains in 2023. Besides, Kenya has to curb wastage, address inefficiencies and corruption in the health sector.

"It's not all doom and gloom actually. The good news is there is notable political and policy momentum as we cross into the new year. The ongoing Kenya Health Financing Strategy 2020-2030 is a step in the right direction," Dr Oronje said.

The strategy seeks to ensure adequacy, efficiency and fairness in financing health services, mobilize resources required, maximize efficiency and value for money and ensure equity in the allocation of health funds.

"In the coming year, Parliament will need to enhance its oversight role over health funds, sustain increments in health budgets, track expenditure, and undertake reforms needed to improve expenditure of public resources," she adds.

The MOH's National and County Health Budget Analysis for the year 2020/21, again funded externally by USAID and PEPFAR, acknowledged that the Kenyan government is beginning to step up its role.

While underscoring the cold reality of donor on-budget funding's declining trajectory, it acknowledged that government has significantly increased funding for donor-supported strategic services to offset the decline in donor funding, especially for HIV/AIDS and malaria.

However, there was a rider: "Government expenditures have traditionally fallen short of initial allocations, leaving uncertainty as to the resources that will be strategically targeted and expended in full. Despite the decline, core disease programmes, such as HIV/AIDS, TB, and malaria, remain dependent on donor funding."

The report recommended that increased resource allocations be prioritized efficiently to target donor-dependent health initiatives, including HIV, TB, and malaria.

Secondarily, it added, the ministry should prioritise areas that have received inadequate budget allocations, like preventive, promotive, and reproductive, maternal, neonatal, child, and adolescent health.

"Policies that help mobilize private investment in healthcare services can serve to drive economic growth in addition to helping supplant reduced donor funding," it said.

"The MOH can encourage growth in resources directed to the health sector by pursuing policies to catalyse private investment, such as reducing regulations, expanding the contracting capabilities of private health providers, and actively encouraging local private institutions to invest in the health sector," the report also recommended.