DEVELOPING INFRASTRUCTURE AND HUMAN RESOURCES FOR HEALTH
I addressed myself to the issue of health financing last week with specific reference to Universal Health Care (UHC) as is expected of us from article 43 of our Constitution. But UHC cannot exist, nor be implemented, in a vacuum: it needs a health system which works effectively in terms of the health care givers and administrators as well as the institutional architecture of the health system.
Today, therefore, I want to address the issue of human resources and infrastructure for health.
The Constitution gives responsibility of providing health to the two arms of government: national and devolved. The national government is responsible for policy making, financing, training of health personnel, keeping of standards, establishing rules and regulations for the provision of health care, research and provision of health commodities at a cost to the counties.
The counties, on their part, deal with health matters where the rubber touches the ground. The counties are the ones which make sure that the health infrastructure exists and works, health personnel are paid and work, and that from the family to the wider society, primary and public health are both delivered efficiently and satisfactorily.
We should not, at the same time, forget that the private sector—private and faith-based facilities—do offer health care services at a cost to the public. The faith-based facilities, very often highly subsidized by those who run them, are much more accessible to our people than the purely private ones. The cost factor in private health facilities is a conversation we need to seriously have so as to determine how the advantages that UHC brings can open doors to our people in accessing private health care services. The constitutional provision that every Kenyan should have access to affordable and quality health care, including reproductive and mental health, should apply to both public and private health care services in the context of UHC.
Over the last 8 years, with the advent of devolution in particular, there has been tremendous improvement in health care provision in our country, due, no doubt, to the role that county governments have played in creating health facilities and employing health personnel. From Mandera to Narok, from Tana River to Uasin Gishu, one can count hundreds of dispensaries and health centers which only came into being over the last eight years. As we go through the COVID-19 pandemic, we have learnt the importance of ensuring that every county has a laboratory in which tests can be done and results obtained through proper diagnosis that can help save a life. Thanks to devolution, such actions were taken quickly and necessary infrastructure established in a county like Mandera.
That is why our policy must be based in further strengthening devolution rather than weakening it. This means building further on what we have so far achieved through giving counties adequate resources to fulfill their mission.
Counties need more resources for institution building and human resources development. Proposing at least 35 per cent of the national budget to go to counties is actually a very modest proposal. Since Schedule Four of our constitution clearly divides functions between the national and county governments, the principle of resources should follow functions should be strictly adhered to in the Division of Revenue Bill every year. The 35 per cent of the budget is qualified by the phrase “at least” before it. In other words, this percentage can go up as we continue to cost the functions of the two sides of government.
The recent unfortunate saga with KEMSA’s mismanagement of the purchase of commodities in the public health sector, including the so far inconclusive issue of the COVID billionaires, must draw our attention to the wider need to clean up the governance and management of this state agency.
Reformed substantially during the Coalition Government in 2008-2013, provided with a viable legal framework and management structure which drew in a lot of support from development partners, KEMSA has unfortunately become a pale shadow of its otherwise viable former self. It needs to recapture lost ground. It cannot do this if it continues to enjoy the monopoly status that the change in law gave it in purchasing medical commodities for counties through a framework which is, by its very nature, monopolistic. Let KEMSA regain its efficiency by competing in the open market and providing pharmaceuticals and non-pharmaceutical commodities to national and county government facilities at competitive market prices.
Being the largest consumers of KEMSA commodities, counties need representation on the KEMSA Board commensurate with their consumptive weight and deserved interest in shaping policies and performance of KEMSA.
Restructuring KEMSA would save the country from misadventures like the purchase of managed equipment services witnessed a few years ago. That misadventure was itself a result of the monopolistic nature of KEMSA which leads to wastage and inefficiencies.
With the rapid changes in technology, KEMSA should be going for equipment leasing instead of purchase. The lease agreement would have provisions for the supplier to upgrade the equipment in line with technological changes.
What is applicable to KEMSA equally applies to the NHIF in which counties are equally significant players in the mission for which this body was set up.
The legal instruments governing the work, management and output of NHIF, in terms of implementing Universal Social Health Insurance, will have to take into account the vital part that counties must play in the Board of NHIF. It is completely outdated to continue calling this body National Hospital Insurance Fund. What we are insuring are not hospitals but health. Focusing on hospitals is a rather morbid way of interpreting the mission of such an important insurance scheme.
What we are insuring is the health of our people: family, preventive, public and curative health. Hence, we must call this body the National Health Insurance Fund.
Finally, we need to address ourselves to the issue of human resources for health. I must begin by commending our health workers, from the Community Health Workers at the grassroots to our specialists in referral facilities for the good work they have done, and continue to do, during this COVID-19 pandemic. The pandemic has also revealed to us the stark realities in shortages in our human resource needs in the health sector.
To begin with, we need to continue training more and more carders and specialists for our health sector. We need to build specialist institutions like the referral facilities which both the national and county governments have embarked on aggressively since the advent of devolution. The role of the private sector here cannot be ignored. But post graduate training, while encouraged by both the national and county governments, has continued to be a big problem for counties. The present model where counties lose their workers who go for post graduate work in national referral facilities while being paid by their counties is an exploitation of the counties and is not sustainable. It depletes counties of vital human resources at a very high level.
I propose that a National Board of Human Resources for Health be established in which the national and county governments are the key partners to determine the funding for high level training and post graduate work, and suggest the establishment of institutions locally that can facilitate such training as need arises. For example, Kenya is highly in need of an Institute of Genetic Engineering and Biotechnology given our current debate on the need to research into, understand and deal with such viruses through vaccines (prevention) and drugs that can cure the resultant diseases.
Rt. Hon. Raila Odinga, EGH
August 9, 2021