Rejoinder to Chatterjee on Hope for Universal Health Coverage in Kenya:

Consider this, a country in the midst of a doctors strike is touted as a trailblazer towards universal healthcare coverage. A country with a region of its nation with the highest maternal mortality rate in the world, and with a non-responsive health administration is viewed as a bastion of good healthcare governance towards universal healthcare. The assertion by the UN regional coordinator Mr Siddharth Chatterjee in an article in HuffPost -Kenya can lead the way to universal health coverage in Africa is preposterous, absurd and myopic at best. I hereby seek to give a rejoinder to the assertions he made.

First of all and on a cynical note, I find the timing of the article to be in bad taste and with a motive that I can’t quite put my finger on. It’s a great coincidence that his article would seek to give a rosy picture while the health system is in shambles, decrepit and on the precipice. With no mention of the current scenario on the ground.

Kenya is a country with millions of individuals unable to access healthcare services due to multiple factors and has not shown any leadership towards reversing the trend. In the post 2015 Sustainable Development Goals (SDGs) era, Good health and well-being is touted as a goal worth aspiring for and Universal health coverage as a path towards it. Not to criticize such a noble goal, I just have to say the goal is broad and does not have enjoiners such as sustainability and responsiveness to the will of the people of each nation. Thus it’s bound to be interpreted differently by different people with varying results.

With a healthcare budget quarter of the Abuja declaration 15% goal, it’s ironic that Kenya can manage to do much with that allocation. In fact if it ever did manage to achieve anything, it would be the new gold standard with which all other health systems should follow. I have on other occasions stated my views on the path towards Universal health coverage and still argue that increase in the government share of Total Healthcare Expenditure is a basic requirement.

Secondly the political will and leadership has been lacking and needs to be made aware of the interrelationship between health and economic development .So, unless the political leadership gives tacit approval to a move to UHC, any efforts would be herculean. I saw hope for greater lobbying for the cause of universal health coverage locally.

Despite devolution of healthcare service delivery, challenges in access of care abound and the current standoff between doctors and the government rolls back any gains attained unless it is addressed with urgency, fairness and finality. The fluidity of human resources for health will further increase through internal and external brain drains of the stand-off and it’s only a matter of time before the health system collapses. So, an international agency like the UN should have been in the forefront to advocate for a rapid and amicable solution.

Financial barriers to access of care has been a key factor in lack of better health indicators. But with the increase in innovative financing schemes aimed at pooling of risk and addressing the community needs have truly helped .The increase in NHIF membership to all sectors of the population is a noble attempt to ensure fewer Kenyans suffer from catastrophic healthcare expenditures through out of pocket payments. Expansion of NHIF coverage without a review of the currently prevalent  provider-determined fee-for-service payment system, the cost of care will increase without a commensurate improvement of outcomes since there is no incentive towards improving quality of care and reducing costs. Moreover, the healthcare financing system needs to be evaluated to determine whether a tax-funded single payer health system or a risk-pooling health insurance exchange akin to the about to be repealed Affordable Care Act in the United States would be beneficial to the people. According to me an open-market health-insurance system is a trap that would not enhance access of care to the people. Various studies have shown the importance of tax-funded health systems and their impact towards increase in health and social development indicators. So, I again call for a more conservative look at health financing to ensure government commitment to the health of the people as enshrined in the constitution before seeking external private equity for investment.

As for the assertion by Chatterjee that maternal mortality rates reduction in 2008-2014 was attributable to government efforts to make primary and maternal services free, it’s debatable. The government free maternity program started in 2013 and most likely the reduction in the maternal mortality rates were due to factors prior to the adoption the government directive. It is even worrying to see the impact of the current industrial action by doctors and the periodic go-slows by all health workers due to hitches in the devolution of healthcare services. As for the Beyond Zero campaign, other than structural measures improvement such as purchase of mobile vans there have not been many studies that have attributed the gains in maternal health in any part of the country to the  initiative. It is still in its infancy and is most likely an intervention that needs to be studied in detail.

Kenya is a hub of technological innovations and its true this can be used to further improve access of care through telemedicine and remote diagnosis and consultations. However any initiative geared towards this is bound to attract vulture capitalists with a desire to benefit from the poor through introduction of closed-system innovations that tie the government and other facilities to their software for a skewed profit sharing. Imagine Uber and Netflix model for healthcare, where a seed company in New York gets to harvest some amount for any procedure reported through the system or consultation through the teleportal. An alternative to this shylock economy is to empower local technology wizards to come up with home-made solutions to the telemedicine dilemma. Currently,the Kenyan healthcare scene has also attracted attention of New York attention, in the hope that health information system for telemedicine falls into their hands. With telemedicine and integrated health information systems, come Health Analytics. A field that has the potential to give solutions to population health through models and predictive algorithms that could shape decision making and further reduction (or increase in care if it falls to the wrong hands.)

Finally if the international organizations are truly looking out for the best for Kenya and Africa, they should stop commodifying healthcare and pushing for private-based investments through the Global Financing Facility and other umbrella ventures. Instead they should work with the governments to come up with solutions that ensure universal health coverage.

Keeping with the spirit of philosophical endings, United Nations has the moral imperative to ensure none of humanity are forced to endure further suffering through still-born initiatives.But if the status quo remains, Kenya CAN NEVER be a beacon to achieving universal health coverage.