Devolution of Healthcare Services in Kenya
There have been arguments for and against what the 2010 constitution stipulated i.e. the devolution of health care services in Kenya. Those for devolution argue that counties will ensure equitable distribution of health resources and proper prioritization of health care services; as per the needs of the County. It is assumed that each county will put in place mechanisms to ensure a vibrant health care system and to enhance efficiency in service delivery.
Those against devolution of healthcare functions have argued that health care resources are limited and devolution only stretches them further. Most critically, they argue that counties lack capacity to manage a vibrant healthcare system. Tribalism and claninism and inefficiency at the county level are likely to lower the health care standards in the country.
What is my opinion?
a. Not all healthcare functions need to have been devolved.
b. Procurement of healthcare equipment should be centralized. It is easier and more economical when procurement is centralized
c. Medical services should have remained a function of the national government; this would ensure a national system of training, equipping, developing and managing personnel and health facilities
d. Preventive services should have been devolved and made the mainstay focus of the counties. This would mean the counties investing more in community health programs, vaccination, immunization, homecare services and outreach services to prevent diseases
e. intergovernmental relations and coordination mechanisms are necessary to ensure health services and facilities are properly shared and benefit all in the nation
f. Each county having an independent health system is disadvantageous to members of the health fraternity; it limits progression and psychologically consigns to local issues rather than feeling part of a strong and vibrant national health workforce
The Devolution Experience
So far, counties are failing in effectively and efficiently tackling health care issues. This is because, in most counties, they have not appointed individuals who understand health management systems into the county executive committee. Some have gone as far as picking retired teachers to head such a docket. The result is that no system is being worked out; instead reactionary responses are the norm.
The desire for the political class to subdue everyone seems to affect health operations. In some counties, MCAs, some of whom did not see the light of post secondary education want to dominate and dictate terms to health workers. How can we have a health system that is not weighed down by petty chang’aa politics of the village? It requires that in terms of pecking order, on matters health, the health workers be given their due dignity, respect and space to work
Counties have failed in prioritizing health issues. Rather than focus on the system and make choices based on evidence based models, popular programs seem to be the choice. What has become popular is county governments introducing what looks like ambulances and everyone in the county goes gaggers in celebration. What is the priority in our county? Are ambulances a priority? Definitely, means of transport for sick people will always be a priority; however, what is the point of having ambulances if roads to the villages are inaccessible. Do ambulances accurately and adequately address the problem of transport challenges in the county? Can an efficient transport system in our counties serve even the sick more than ambulance provisions?
It would be helpful if counties realized that, in the long run, we would gain more through facilitation than actual implementation. How can counties focus on facilitation? Each County Executive Committee and Assembly needs to have a thorough understanding of issues affecting the health sector in the respective counties. The starting point would be to commission a county health audit where health professionals would evaluate the situation and deliver recommendations. Such recommendations would then have to be transformed into a county health policy inline with the national health policy. The county health policy would then be a guiding reference point for necessary health legislations in the country assembly and health programming by the health ministry of the county.
The legislation and programming should be guided by principle of facilitation; this means that the county government has to be seen as facilitator and provide necessary facilitation. Instead of spending money on capital goods like ambulances, how can the county improve infrastructure and enhance access to health care services even at the village level? How can the county government encourage private sector investment in the county health sector? Would it not be better if instead of ambulances more health care centers, closer to the people, are built, furnished, staffed and equipped?
Ambulances are only feasible as an intervention when we have proper road networks, the ambulances are fitted with proper equipment, there are enough resources to run the ambulances e.g. fueling, the facilities are spacious and efficiency has been achieved in the health sector. In a county like Bungoma, those who manage to get themselves to the hospitals do not receive proper health services. Are we providing ambulances for access to quality healthcare or mediocre healthcare services? In my county, a spot check at the Bungoma District*Hospital will definitely reveal long patient queues, congested rooms, understaffing, unmotivated employees, lack of enough equipment, lack of enough drugs or medicines, poor hygiene standards among other ills.
Maybe such issues should be priority focus rather than spending on vehicles that will not save many.
The vehicles may not save many because of the disease burden in the counties. The disease burden is high because basic prevention strategies like community awareness and sensitization programs are non existent. The disease burden is high because apart from ignorance, the people can not afford medical care and hence engage in unhealthy practices like using improper doses and self-medication. Even if the ambulances got the people from the muddy villages into town, do we have mechanisms of ensuring patients who are critically ill can easily be airlifted for specialized care say at KNH despite their economic status? If it were my doing, working on community health insurance schemes, partnering with AMREF and Flying Doctors, Working closely with private investors to enhance access and quality of health care would be a better focus.
In conclusion, issue of health management aside, there is need to build capacity at the county level when it comes to health programming. Professional CECs have to be engaged and evidence driven prioritization of interventions done. Each intervention has to be evaluated against current needs and future needs. An integrated approach that is people driven, where people are the forefront of reducing the disease burden in a county would yield awesome resources. This is the spirit of devolution, that local level participation in health cares is realized for sustainable results.