Universal healthcare is realistic
In an international conference attended by professionals and leaders from 13 countries across the globe in the Dutch city of Rotterdam this week, it was observed that any country, at whatever stage of socio-economic development, can provide its people with universal healthcare.
The word “universal” means simply “all” in the English language. In other words, any government determined to provide all its people or citizens with healthcare is capable of doing so, provided, as defined in our own Constitution, it is clear about “affordable, quality and accessible” healthcare. So why have we not done this in Kenya over the years, and what are the chances of doing so successfully now?
When the National Hospital Insurance Fund was launched in 1966, Kenya pioneered as perhaps the only country in the developing world to have such an insurance scheme. But NHIF then was far from being a universal healthcare scheme: It was limited to civil servants for in-patient care only. Moreover, civil servants could only use it in private health facilities.
Some time much later in the 1980s, when cost sharing and “private wings” were introduced in public facilities, civil servants could use NHIF in public facilities; but it still remained a facility confined to civil servants who were the only contributors to the fund.
Attempts were then made, during the reformist Narc government in 2004, to establish universal healthcare, and to transform NHIF from being a “hospital” insurance fund to a “health” insurance fund, with the government paying insurance for those who were too poor to pay, ie indigents. While Parliament approved the bill, the President declined to sign it into law following “advice” from the Treasury and some business interests.
During the coalition government of 2008-13, as Health minister I revived debates on transforming NHIF into a full health insurance scheme, covering both in and out patient care, opening up contribution to everybody, including the informal sector, and revising the rates so that the better to do contributors would progressively pay more than the lower income earners or the poor people. We also expanded the scope of coverage to include diagnostic, pharmaceutical and referral services.
Notwithstanding tremendous resistance we received from selfish and entrenched interests among some private health providers, the government finally approved the new NHIF, and it is what we have today. It is in this context that we need to situate the present drive towards universal health coverage in Kenya.
The major question we need to ask ourselves is: Is NHIF, as we know it today, a sufficient condition for ensuring we succeed in delivering healthcare?
Definitely not. But the NHIF, given the critical role it has played in the evolution of expanding access to affordable healthcare, is indeed “a necessary” condition for expanding what we have into “affordable, quality and accessible” medical care for all Kenyans in the shortest time possible. So what must we do to leapfrog from “affordability” to quality and accessibility of good healthcare for all?
The following conditions will be necessary. First, we must mobilise all who can pay for NHIF contributions to do so on the basis of the principle that says “from each according to his ability and to each according to his need.” The original idea of the NHIF was based on the principle that it is the employee who makes contributions. It is high time that the employer, both in the private and public sectors, also made their contributions to the kitty. And by public sector, I refer to both the national and county governments: They have a large number of employees who are members of the NHIF.
Second, given the levels of poverty in our nation, we know that there are people who are too poor to contribute to NHIF yet, as our citizens, they too need access to quality, affordable and accessible healthcare. That affordability will only be met if we as governments, national and county, bear the burden of these people. The Constitution allows Parliament to vote “conditional grants” to the counties. I suggest that a conditional grant be voted to counties for covering the contribution of indigents to health insurance. This can be calculated in accordance with the poverty indices of all the counties.
Third, there are still certain key factors that provide the context in which healthcare is delivered — governance, management, human resources and institutional capacity. Unless government leaders —county and national — are armed with clear visions, ready with sound policies and committed to deliver UHC accountably and honestly, very little success will be achieved. In this regard, debilitating corruption that has quite clearly subverted most government initiatives needs to be urgently thrown into the dustbin of bad things in our unfortunate history as quickly as possible.
Further, health facilities are managed and run by health professionals be they health administrators, doctors, nurses or laboratory technicians. The sad observation here is that the culture of public service seems to be pronounced by its absence among these public servants. UHC will not succeed until and unless a culture of public service is restored among this carder. The rest of the human resource in health, both professionals and ordinary health workers, will learn a lot from their mangers and those they train under. Once a culture of public service flows from the top to the bottom, it will be much more likely that it will percolate in the whole of the health public service.
My hunch is that one of the ways of reducing nonchalant attitudes in public service in general is to banish the “permanent and personable” terms of service in preference for contract terms.
The matter of institutional capacity has very often been associated with buildings, expensive equipment and elaborate plant. While we need such facilities to establish the institutional capacity to deliver healthcare, all this must be based on “the need to do what with” approach. What is it that we want to do in our healthcare system and at what level?
Kenya is quite advanced in having mapped out our various levels of healthcare delivery and what we need at what level. What we need to do now is to do some gap analysis to see what we lack at what level, and how to fill such gaps within the shortest time possible. With requisite human resource requirements, appropriate management capability and culture and adequate institutional capacity--including drugs, equipment, soft ware etc, we should be able to deliver UHC because our people will pay for the good quality medical care through NHIF.
But NHIF, on its part, must deliver its part of the bargain without fail, just as much as the Kenya Medical Supplies Authority must do.This “gap filling” initiative needs to be taken seriously by the national and county governments. In many ways, it is much more serious at the level of human resource.
The following questions need to be candidly asked and candidly answered. How many nurses, clinical officers, laboratory technicians and doctors do we need in each county for the optimum delivery of UHC? To what extent are we optimally using the human resource we have today? What explains the under-utilization of what we have and how can we correct the situation?
If we have genuine shortages, can we mount a realistic “Marshall plan” to bridge the gaps? We can ask the same questions with regard to institutional capacity. The realistic and competent answers to these questions will determine whether or not we leap into the future to have affordable, quality and accessible health care for all Kenyans.