The devolution of health is critical for the holistic development of some parts of the country which for a long time have been marginalised. The ASAL counties, for instance, have seen tremendous growth not only in health service delivery but also in other spheres of economic development.
Lodwar town, the capital of Turkana, did not have a single metre of tarmac until the advent of the devolved governments. Counties that did not have provincial headquarters were equally disadvantaged as they did not have adequate infrastructure to support critical sectors such as health.
However, even though some milestones were covered in the last two five-year cycles of devolution, counties such as Busia, Turkana, Vihiga, Siaya, Kwale and Migori, among others, do not enjoy the privilege of the infrastructure of former provincial capitals and continue to face significant challenges in health service provision compared to the previously headquartered ones such as Kisumu, Kakamega, Nakuru, Mombasa and Nyeri.
A similar picture is evident across the other spheres of health systems' building blocks. For instance, in human resources for health, whereas Kisumu County has more than 20 consultant gynecologists, and several other specialists, Siaya still grapples with retaining the few consultants that it attracts. To support the health sector in Siaya, development partners have had to contribute up to about 50 per cent of the healthcare workforce at some point. Such a state of affairs suggests that health services in some counties would stall without the support of development partners.
The trend in skewed distribution and availability of health infrastructure and other health actors is also apparent in the private sector. Robust private health facilities despite having a presence in counties that were not initially provincial headquarters are heavily invested in former provincial capitals. In the case of Nyanza, almost all the development partners have offices in Kisumu with almost all the staff residing in Kisumu.
To this end, counties such as Siaya, Homa Bay, Migori, Kisii, Nyamira, and even Vihiga rely heavily on Kisumu for critical aspects of health service delivery including supply chain (Kemsa depot), medical training, and referrals for more skilled services, just to mention but a few.
The need for supra-county, regional blocks was made even more obvious during the implementation of the pilot UHC programme. Kisumu, Machakos, Isiolo, and Nyeri were the pilot counties. It does appear that the inherent imbalances and interdependence were either not well thought out or completely overlooked.
The reality is that between 30 per cent to 40 per cent of the patients seeking health care at the Kisumu referral hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital are from Siaya, Vihiga, Nyamira, Busia, Homa Bay, Migori, Kakamega and some parts of Kericho which complicates distribution and access to universal healthcare given the quota system that is in use.
The crux, therefore, has been how to ‘disaggregate’ residents from the many different counties as non-Kisumu residents and work out the use of the quota system equitably. Consequent to such challenges is a system that has become quite complex, with limited resources to make necessary adjustments during the implementation period.
Given that health is a continuum of care from primary health care to the highly complex level six facilities such as KNH; it would be foolhardy to ever imagine that residents of Siaya and such counties will ever achieve equitable services in the next many years. There is therefore an incessant need for strengthening the regional blocs to address the historical imbalances as we move towards universal health for all. Although not entrenched in the Constitution, the discussion about the need for regional economic and health ecosystems continues.
These regional blocs reflect the picture of the disease burden and the uniqueness of the other social determinants of health that do not respect physical boundaries. Perhaps the UHC pilot should have been rolled out along one of these blocs with lessons learned contextualised to the other blocs during the scale-up phase. The implementation also ought to reimagine models where private hospitals can offer some specialised services to the general public at an agreed-upon rebate. There are indications that we probably would have realised better results if we structured the referral system along the blocs and not by individual counties.
A few models similar, albeit in their infancy, can already be mentioned as pathways for a more efficient rollout given their successful impact. USAID/CDC’s mapping of regional support for HIV services based on the prevalence of HIV across the country; KNH and KUTRRH partnership with Nyeri and Kiambu counties respectively. Learning from these and the vibrant economic models such as the Lake Region Economic Bloc may therefore be a faster route to achieving Universal Health Care through consolidating scarce resources, minimising duplicity of functions, tiering of services, and enhancing public-private partnerships.
Indeed, in the words of the late Moi University, Professor of Gynaecology, Prof Nyunya, “the slope between the national government and the county governments is too steep – we need a supra-county mechanism to better manage the regional health issues.”