Devolution of health docket has borne fruit despite obstacles

Health CS Susan Nakhumicha during a past event. [Samson Wire, Standard]

The 2010 Constitution was a turning point for Kenya.

It reconfigured the balance of power by devolving power and responsibilities from the national government to 47 elected county governments, and recalibrate powers between Executive, Legislature and the Judiciary. In addition, the Constitution strengthened right-based approaches to health by providing that every citizen has a right to the highest attainable standard of health.

The biggest gains in the health sector have been made during the devolution era. County governments' progressive investment in the health sector has resulted in improvement of key health indicators. Today, many more Kenyans are able to access high quality health services within their counties compared to the pre-devolution era. Let me highlight some key progress areas.

First, through devolution, access to high quality health services has improved. During the first five years of devolution, county governments invested heavily in developing and upgrading health infrastructure after inheriting some vastly dilapidated health facilities from the national government due to decades of under-investment in health.

Today, counties have built and operationalised hundreds of health facilities, enabling most Kenyans to live within a 5km range of health services as recommended by the World Health Organisation. In addition, counties have significantly expanded the scope of services available to citizens. For instance, renal dialysis for patients previously only available in a few national hospitals is now provided at county level. Specialised surgeries, cardiology services, neurology are just but a few specialised services that counties have scaled up.

The capacity of a health system to effectively deliver services is commonly measured against its capacity to ensure that no woman dies while giving life. The devolution era has yielded significant results in this regard, increasing access for mothers and reducing morbidity and mortality for both the mother and baby. With 89 per cent of mothers currently delivering under skilled care as compared to 66 per cent before devolution, there has been a rapid decline in maternal and child mortality rates.

Between 2014 and 2022, Kenya's under-5 mortality rate reduced from 52 deaths per 1,000 to 41 deaths per 1,000, and the infant mortality rate from 39 to 32 deaths per 1,000. While noting that early investment in effective prevention strategies enhances good population health, reduces morbidity and mortality including from lifelong chronic illnesses and saves resources in both healthcare and social services, county governments stepped up these interventions.

Second, let me talk about the health workforce. One of the biggest successes of devolving health has been the health workforce. Devolution has allowed Kenya to rapidly build up a large pool of highly qualified health workers across all cadres, and at the same time ensured that these important resource is more equitably distributed across the country.

In the past 10 years, county governments have hired a large number of health workers causing the total health workforce to more than double compared to pre-devolution numbers. Between 2016 and 2021 alone, the total number of health workers in counties improved by 61 per cent from 59,726 to 96,453.

In addition, the distribution across Kenya also improved, as county governments executed customised strategies to attract, develop and retain high quality healthcare workers.

Today, counties in hard to reach areas have significantly more health workers compared to the pre-devolution period. For example, Turkana had less than 10 medical officers before devolution, a number that has increased six fold to 61 doctors in 2023.

It is also important to note that through supporting health workers to go for further studies, county governments have driven a rapid emergence of health specialists, even in areas where there were none before, which fosters a better skill mix. The number of community health volunteers (CHVs) increased to 107,839 in 2023, covering most villages. Counties are now making efforts to remunerate all CHVs in recognition of their important roles in healthcare.

Third, essential medicines and other medical commodities are central to a good health system. Although county health authorities made efforts to ensure all health facilities have adequate supply of medicines and commodities, the efforts are largely hampered by inefficiencies and lack of transparency at Kemsa. Most counties pay Kemsa timely, but delivery of medicines is done both late and in inadequate quantities.

Fourth, financing health remains a key priority of county governments, with most counties allocating more than 30 per cent of their total budget to health despite having 14 devolved functions. Despite this, there has been disproportionate allocation of funds for health between the two levels of government, especially given that the national government has significantly less roles compared to county governments.

For instance, in the financial year 2022/23, the government allocated Sh146.8 billion to the Health ministry while all counties put together received an estimated Sh102 billion for health, given that the total equitable share for counties was Sh340 billion.

Kenya's investment in health is below 15 per cent prescribed by the Abuja declaration. Therefore, there is need to devolve more funds for health to follow functions and also increase resource allocation to the health sector. We know that many times, disease come alongside physical, psychological and financial burdens that often leave families in poverty.

Majority of families never recover from these shocks. County governments continue to push for a more accountable National Health Insurance Fund that covers citizens from catastrophic expenditure on health, that is priced at a cost that citizens can pay and that makes timely reimbursements to service providers.