When it comes to the cost of medical care, a popular saying goes that majority of Kenyans are one medical emergency away from poverty. It is therefore not surprising that Universal Health Coverage (UHC), one of President Kenyatta’s Big Four Agenda, has quickly gained traction relative to the other three pillars — enhancing manufacturing; food security and nutrition; and affordable housing. In fact, while execution for the other three is still being planned, the UHC pilot in Isiolo, Kisumu, Machakos and Nyeri counties was launched by the President in December 2018.
Despite the undeniable urgency to implement UHC, Kenya has to get it right. This is a major policy shift with massive implications for the future wellbeing of Kenyans and the economy. Two factors will determine success or failure of the UHC initiative which seeks to make healthcare accessible, affordable and of high quality. These are the model of investment as well as governance and accountability measures.
The model Kenya will adopt to achieve UHC is crucial, especially from the cost perspective. UHC is NOT free healthcare. One way or the other, Kenyans will have to pay for it from our taxes and through a mandatory contributory scheme. The cost of healthcare has been rising steadily. The Kenya Economic Survey 2018 shows that public expenditure on health services increased from Sh38 billion in 2013/14 to an estimated Sh66 billion in 2017/18. Despite heavy investments by the government in health services, more than half of total health expenditure is non-public, meaning that most of the health expenses are not met by the government.
According to the 2015/16 Kenya National Health Accounts, private sources of funding accounted for 40 percent of total expenditure, compared to 37 percent from public sources and 23 percent from donors. For UHC to succeed, public funding for healthcare will need to increase significantly so as to reduce the high out-of-pocket costs – a major contributor to the financial ruin of families – and bridge expected decline of support from donors over time.
A multisectoral approach towards prevention
To make UHC affordable, Kenya has to adopt a primary health care approach with substantial investment in preventive measures. Overall, it is cheaper to prevent than to treat infectious diseases such as malaria, waterborne and airborne diseases. Preventive measures could considerably reduce costs associated with treating and managing Non-Communicable Diseases (NCDs). NCDs in Kenya are not merely a growing challenge but are already a massive burden on our health system. The Ministry of Health’s Kenya Health Sector Strategic and Investment Plan for 2014-2018 estimates that between 50 percent and 70 percent of all hospital admissions, and up to 50 percent of hospital deaths, are as a result of NCDs.
To be successful, preventive healthcare measures require a multi-sectoral approach. For example, the outbreaks of cholera in different parts of the country in the last few years could have been prevented through improved water and sanitation infrastructure – not within the prime mandate of the Ministry of Health.
Greater efforts to promote physical activity such as developing walking and cycling lanes, promoting physical education in schools, provision of public playgrounds, and curbing drug and substance abuse –important NCD risk factors – are all under the mandate of a broad spectrum of other government ministries and agencies, including transport, lands, education and the police service.
In reality, the focus of the UHC initiative as it is currently unfolding in the pilot phase appears to be on treatment and services at the health facilities. This I learned while attending a recent forum addressed by a Governor and a CEC Health from two of the four counties privileged to be piloting the initiative. The pilot phase funds have been split 30 percent to health facilities to provide services, and 70 percent to the Kenya Medical Supplies Authority to provide commodities. It is highly questionable whether a focus on commodities should be the main thrust of the programme.
Transparency and accountability
This brings me to the second critical factor for UHC success. Transparency in the formulation process, accompanied by firm governance and accountability measures during implementation will be necessary to achieve UHC objectives. Numerous government programmes that have plowed huge sums of money without robust accountability and performance management measures have come to naught. Without belabouring the point, UHC is too important a programme to be condemned to a similar fate.
The experts who have been appointed to drive the UHC process and all other stakeholders, including the public, should be firm that the initiative be informed by credible evidence and lessons learned from similar successful ventures in other countries. Selfish interests must not be allowed to torpedo a once in a life-time opportunity.