SHA crisis: Can counties offer cure?

Doctors hold a peaceful demonstration outside the parliament building on 18th March 2025. [Edward Kiplimo,Standard] One argument we have heard is that health is so problematic that the national government was willing to devolve it to whoever wanted it in the new Constitution! Health is comparable to tomatoes, which are very perishable. Once citizens are sick, you can't wait. Apart from being a problem child, it's not clear why health was devolved. Maybe doctors were too busy working to lobby for a commission like teachers. How has health faired in the devolved units? It did not go as expected. A study on Devolution@10 notes that despite some perceived improvements in health services due to increased county government investments, access to quality healthcare across various counties remains suboptimal with inadequate, inaccessible, and poorly managed health services. A disproportionate focus on curative over preventive services, limited resources and infrastructure, management issues like corruption and political interference, sociocultural barriers like traditional beliefs, and a lack of health education are identified as key deterrents to optimal health outcomes. Frequent changes of Cabinet Secretaries in the health docket also show the sector is not that healthy. Were devolved units ready for this task? It takes a huge part of the county's budget. Skills shortage is another big challenge. Some counties like Nairobi have excess capacity; most medical schools are located there, and students do not want to leave Nairobi after graduation. One curious observation is the number of jobless doctors despite the demand for doctors in some counties. The second issue is that, like other functions, the Health Ministry has not let the counties go. Think of equipment leasing and the Kenya Medical Supplies Agency (Kemsa). There is too much centralisation, which hampers efficiency and makes it hard for counties to get better deals. The bigger part of the health budget is with the counties, but citizens still complain of access and cost, particularly after shifting from the national hospital insurance fund (NHIF) to the Social Health Insurance Fund (SHIF). The paradox is that by devolving the health function, economies of scale are hard to achieve. Perhaps counties need to talk to each other. Can they share specialists and facilities such as labs and mortuaries? The third issue is data sharing. If a patient falls ill in one county, we have no reference to his prior health. Sharing data would make planning easier. Counties can even charge each other once we know where the patient hails from. The availability of a patient's history would make diagnosis easier, particularly in cases of emergencies. Fourth, doctors' and nurses' strikes are a symptom that all is not well in the county health systems. The call for a national health commission is another symptom. Add the frequent harambees to raise medical funds. In the last 100 years, the extension in life expectancy was driven largely by improvements in hygiene, not advances in medical technology. The counties face a lot of pressure to address non-communicable diseases like cancer, diabetes, or heart disease. What percentage of the health budget in counties goes to "modern diseases" compared with improvements in nutrition and clean water? What about mental illnesses? Interconnectedness among key stakeholders will improve health. Bad roads make evacuation hard, a lack of power leads to the loss of essential drugs, and a lack of education keeps superstitions alive and gives business to herbalists and witch doctors. Poor nutrition and a lack of clean water make citizens prone to diseases. Sick citizens are not productive, and the county economy falters. The use of gas to cook and electric cars could reduce respiratory diseases. Even simple things like house designs could make a difference to our health. The ultimate test of the health system is life expectancy. Has it gone up in the counties? We are now shifting from the National Hospital Insurance Fund (NHIF) to SHIF. Should health insurance be devolved so that each county has its own scheme to take care of the context? Pastoralists and urbanites have different health issues. Let's have more synergy. The national and county governments should work together, sharing resources, data, and innovations. Private, public, and mission hospitals share little. Could we add herbalists? What do counties share? With sports, there would be less worry over obesity and heart diseases. Sports are the golden route to better health. Do you recall walking and sports during Covid-19? Why didn't we maintain that tempo? Why do we ignore sports after school? Sports will improve our physical and mental health. They would keep us from substance abuse, too. Religion is a factor in health. Beyond reducing anxiety, it often keeps some away from modern medicine. Think of Akorino. Churches and other religious organisations also invest in and own health facilities. The World Health Organisation (WHO) has great policies on health. How are they cascaded into grassroots and counties? Do the citizens feel them through better health? What more can we do to improve the health in the devolved units? Research shows that many hospitals are now "referral." They should be centers of health research in the counties. How much of the country's health budget goes to research? Lifestyle, climate change, and genetics have given us new diseases. Continuous research would help us address these new diseases. How much have we mapped our genes? Diseases like dementia and cancer were rare in rural areas. Why now? Incentives for doctors and nurses to stay in counties are needed. Doctors are relocating back to the city, claiming it has a "conducive" work environment. One doctor who came back to Nairobi asked me, "What shall I do in the countryside after work or over the weekend?" Our traditions were healthy. That is why we had no diseases of development. Traditional foods were nutritional and healthy. Remember, food was boiled, not fried. Real estate should focus on liveability. Why do we crowd houses without parks and "breathing spaces?" Charity begins at home. What are the family traditions on matters of health, staple food, hobbies, and family harmony (for emotional health)? Let us introduce health basics early. In Class Five, we did an experiment where someone puffed a cigarette through white handkerchiefs. The teacher then asked, "If the white handkerchief turns grey with one puff, what of your lungs if you smoke all your life?" Very few of my former classmates smoke today. Finally, let us not re-invent the wheel. Let's learn from other countries and counties on how to improve national health. Canada and the Scandinavian countries are good benchmarks. Kenya's youth population may mask the health issues, particularly in the rural areas where the majority live. Through continuous research, we can unmask the health issues at the grassroots and address them. Health is an input into our productivity and economic growth. That is not about to change.

SHA crisis: Can counties offer cure?

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