Don't Intimidate,Innovate.....How to Improve Kenyan Health System

Like any developing country, Kenya faces challenges in ensuring the national and county budgets balance and that there is good distribution of resources .It is for this reason that the Ministry of Health including the devolved functions of service delivery in public health facilities would get only 3.7% of the government budget. Health is a driver of GDP growth of a nation and the greater your investment in it the better the returns on GDP. So I just call on the county and national governments and related bodies to evaluate how to implement and continue improving the following to enhance healthcare service delivery and health in Kenya.

Review NHIF and other insurers’ payment methods and reimbursement rates

Recently NHIF introduced greater coverage for contributors both in private facilities seeking surgical interventions. These Increased payouts from NHIF towards surgical cases may seem like a great idea, in fact there have been human interest stories in local press touting how much of a relief it is for the common man.

Read:NHIF Surgical cover eases pain of costly healthcare for Kenyans

However, let’s remember that there is wide variation in the cost of care in different facilities even though the surgical procedure may be the same and the surgeon probably the same.For as long as there is no benchmark rate applicable in all facilities then the cost of care will continue to rise.The government hospitals could do the same surgeries at a fraction of the cost. NHIF does not reimburse at the same rate for the two facilities. For example, a surgery for appendectomy at a government facility is not reimbursed the same rate as private facilities. Am sure if the government facilities were reimbursed the same, the burden on the tax payer for recurrent expenditure in terms of emoluments for doctors would be a thing of the past. The county hospitals would be able to sustain the operations and even subsidize the county governments’ other functions through returns from NHIF. What county governments should fight more should be greater coverage of NHIF in public facilities and improvement of the facilities and terms of service of all health workers in order to even attract private insurance providers to utilize their facilities. Better equipping county hospitals would in the end have greater benefits in terms of increased payouts from NHIF and other insurances.

There is also a need to re-look at our overall provider payment methods.Hospitals would prefer to continue with the status quo of fee for service because they are cushioned against any losses. while insurances might prefer to try a different model.You can read more about this: Read:Taming Runaway Healthcare Costs

 

Invest in preventive healthcare and population health management programs

In as much as treatment of diseases is important, the greatest impact of interventions can be realized through public health programs of better access to water, sanitation and other environmental health determinants. Counties need to invest more in proper utilization of the health data in their areas to improve the environment and healthcare outcomes for the citizens’ .They also need to ensure better water supply, treatment and proper sewage treatment and drainage systems.

Increase tax-funded health coverage in public hospital

If the above and other interventions involving no increase in health budget fail we would have to increase the tax-funding for health. On many occasions I have elaborated that in a society like ours, health-insurance schemes would have challenge of sustainability because of our not so “peculiar” habits. Currently the formal insurance penetration rate in Kenya is still very low despite the availability of the NHIF which has a big potential population. In the recent past there have been attempt to encourage more people to join the NHIF through voluntary contributions. This attempt has increased the risk in NHIF, one called adverse selection. Adverse selection arises when the population covered by an insurance starts to comprise more of the sicker members of the society rather than a blend of young, healthy population and older, sicker patients. The level of adverse selection that the system can take depends on many factors and only hope can save NHIF if it continues to embrace this system. Furthermore, we traditionally have an informal social health insurance in the form of Harambees which have made it difficult for us to adopt the western concept of insurance. This calls for a rethink of the insurance programs to adhere to the needs of the population and develop products that meet these needs rather than chock the populace with a one size fits all system. Alternatively the government just needs to improve the service delivery in public facilities and with a minimal co-pay method to sustain the operations of the hospitals together with the tax-funding.

These are not the only viable options for improving healthcare in Kenya,but just my thoughts and how I think we could proceed,Other alternative ways can be sought also.In the meantime I just sit here hoping against all hope that sanity in healthcare leadership prevails and that the poor of this nation benefit from affordable,quality care.

Final Nail in the Coffin of Public Healthcare System in Kenya ?

On 7^th March 2017 the President of Kenya, H.E Mr. Uhuru Kenyatta issued an open threat to doctors in the public sectors who were on strike, ”Resume work or get fired”. This act just when some mediation activity was being finalized courtesy the religious leaders signaled a government unwilling to give resolution of the strike a chance. Whatever the legality or genuineness of the strike ,we have to look at this utterance by the President during the Devolution Conference as one that emboldened county governors to take drastic steps to fire doctors and with it reduce the high wage bill they were possibly asking for. What many people don’t understand is that the net impact of such an utterance may have just cost a few thousand patients their lives as the consult of a specialist in a public hospital was a treasured and very rare occurrence that many spend months on the waiting list for a specialist appointment, but It was all lost in one statement.

I hate to say I told you so, but….I told you so. With the imminent sacking of most Kenyan doctors and the promise to the populace that the government will hire foreign doctors to fill the gap left, you have to realize that the second phase towards full privatization of healthcare will be complete soon. Phase three of the privatization involves actively seeking out doctors to join group practices and form consortiums that can provide consultancies to the government hospitals at a fee. This is the way, the breakup of the doctors union will be achieved. Doctors who want in on the action in the consortiums will be asked to renounce their union membership before being allowed to share in the new arrangement of doctors- for-hire. At individual level doctors would have nothing to lose in accepting the new arrangement as they would be assured of better terms of service and better conditions of work. However, Kenya has a deficit of medical doctors and is struggling with a disproportionate illness as compared to the rest of the world. The country is emerging as a major focal point of increased cancer cases in the world. This together with the non-communicable diseases increases call for greater investment in tackling the problem and to safeguard the economic growth of the last decade towards an industrialized nation by 2030.But the moment the government turns back the hand of time and rolls back the gains in health outcomes such as maternal mortality, infant mortality and general health indicators you have to wonder at the sanity of it.

Doctors want improved service provision

Sacking doctors does not in any way help the economic growth of the nation because economic growth is related to level of healthcare improvement in a country. Doctors have all along been advocating for greater government investment in ensuring better healthcare to the bottom of the pyramid Kenyans whose only source of healthcare provision is the local dispensary and district hospital. Proper equipping of the facilities, availability of supplies and sound oversight holds the promise of better health outcomes with minimal per capita cost. However if the intention of anyone is to alienate healthcare from the lives of the poor and to commodify health service provision, many will be left without proper healthcare and facing reduced  greater burden of diseases.

 Creating commercial health workers

Doctors are intelligent knowledge workers who cannot be held captive to any machinations to try and castrate their desire for better terms of service and conditions of work. They will find ways to adapt and already many doctors have started thinking beyond the confines of the borders of the country and we only have to expect a big brain drain soon. Moreover, the nudge they are experiencing will force the few remaining doctors and specialist to move to the private sector and group practices with market-oriented service provision. This will mean fewer doctors and specialist in public hospitals and reduced quality of care and outcomes for the poor unfortunate enough to seek care in government facilities. The private health sector in the country will however will grow in leaps and bounds with market-dynamics forcing focus on lifestyle diseases and aesthetic medicine industry. The specializations involving the diseases of the poor will be neglected and the morbidity and mortality associated with them will be greater.

Public-Private Partnerships

In the spirit of Private-Public-Partnerships (PPPs) most district hospitals will have a private wing dedicated to the provision of better healthcare to those with the financial ability to pay the charges and managed by private firms to ensure “efficiency” instead of strengthening efficiency within the public sector. Later, more government facilities will be urged to give space for PPPs in the false hope that it would ensure provision of quality care at affordable rates. Mercenary doctors will be on hand to treat patients as long as their share is assured. As for the other Kenyans unable to afford the amenity wing, they will not be able to access the same level of care and will just receive palliative care for malignancies, and symptomatic treatment for chronic conditions. The law of demand and supply will obviously make it impossible for the poor to afford specialist care unless they can sacrifice all their little earthly possessions to seek care in the private facilities of the country. So, again I ask, how will the doctors be adversely affected?

Reduced payroll expenses for governments

For the governments both at county and national level however, they only see the reduction in the payroll expense from the offloading of the baggage of doctors’ salaries as a line item in their budgets. This myopic thinking will be the norm and groupthink among governors will ensure uniform implementation of the sack order and replacement of doctors with other cadres of health workers involved in primary care provision. One day in the future, current governors and other government functionaries will regret it because in life you can’t always be on the top of the ladder and one day, they will taste the feeling of not getting a doctor to attend to them when they need it the most.

Private healthcare investment

Another possible enticement for the government is that a market-oriented approach to healthcare will ensure that the populace ceases to look at health service provision as a merit good and instead as a personal good subject to the faulty law of demand and supply. With this thinking the government will be assured of reduced expenditure in the form of payroll expense and increased foreign healthcare investment in line with the recent statement by World Bank President of the availability of $1billion for investment in the next five years. These investments together with others of a similar nature will make doctors lose their sense of social justice and be more inclined to sell their souls to the devil.

So, the choice is clear, reform and improve public healthcare for future generations or break it down for short-term gains of reduced expenditure but with increased fallout. I urge the government planners to think wisely before trapping future generations in an error that could be corrected now.