The big UHC financing dilemma

On December 12 this year President Uhuru Kenyatta will officiate the national roll-out of the Universal Health Coverage (UHC).

The initiative launched two years ago and piloted in four counties— Machakos, Nyeri, Isiolo, and Kisumu—as part of the government's Big 4 Agenda, with an aspiration that by 2022, all persons in Kenya will be able to use the essential services they need for their health and wellbeing through a single unified benefit package, without the risk of financial catastrophe.

As the national roll-out approaches, it's the numerous challenges identified in the piloting counties that are raising doubts on the success of the initiative.

Financing

One of the main issues is the financing dilemma. While UHC is all about accessible and affordable healthcare, proposals in the current financing model borrow heavily from the inefficiencies of the National Health Insurance Fund (NHIF) that in the past have locked out millions of Kenyans from services.

One of those who have experienced the faults in the new system is Charles Kilonzo, a local of Mbilini village, Machakos County, one of the piloting counties.

In mid 2018, Kilonzo was riding his motorbike home when he was knocked down by a speeding vehicle.

He suffered a broken leg and fractured back, and spent five months at Machakos Level five referral hospital.

Being the breadwinner, he could no longer ride or perform any heavy activity. The family is now struggling and still owes the hospital Sh70, 000.

This is despite Machakos County being chosen as one of the counties to pilot emergency and accident matters in UHC. Residents here are forced to buy the medical devices that are used in the replacements of the broken bones.

Mr. Kilonzo, spent Sh187, 000 buying the device both for his back and his left leg.

"I am left without anything (nimebaki tu vile mnaniona). I was surprised that the UHC card was only for painkillers. I bought some drugs and paid part of my hospital bill using my NHIF card. Why were we even registering for the UHC programme, why do we need the card anyway?" he questioned.

For two years, after the removal of the orthopedic implant, Kilonzo has had constant pain and found himself on and off crutches. Life has been very difficult.

Dr. Ancent Kituku Nzioka, the Machakos County health minister explained to the Healthy Nation that the devices could not be included in the piloting UHC model because of the cost implication.

"Unavailability and expensive nature of the devices made it impossible for them to be included in the programme," Dr. Nzioka said.

He confirms that with the national roll-out, they are considering looking at the model to be used so that everyone is included. "What we need to know is that UHC is not free, however, we need to look at the model to be used in the national rollout that will make health care accessible to those most vulnerable," Dr. Nzioka told the Healthy Nation team in his office at the referral hospital.

Piloting counties got a Sh3.17 billion conditional grant (each getting Sh800 million) to roll out the programme. Of that 70 per cent of the money was channeled to Kemsa to purchase drugs and basic medical equipment.

Kemsa failure

In Isiolo County where healthcare facilities are an average of 49 kilometers away, delays in service provision have been experienced in the county with mothers especially being on the receiving end of this.

While on a visit to some of the facilities in the counties, most patients surveyed said that they have never used their UHC card.

Lack of medication from Kemsa was the biggest challenge during piloting, with Isiolo Governor Mr. Mohamed Kuti, who is also the chairman of the Council of Governors (COG) Health Committee and Kisumu Governor Professor Anyang Nyongo reporting that failure in the piloting process was majorly contributed by the Kemsa monopoly. Mr. Kuti decried the high prices for commodities, the turnaround time of orders and poor quality products, and the shortage of human resources as the agency failures.

The governor said during piloting most laboratories had no reagents and the models of equipment being complicated with all the counties having different suppliers with different service contracts.

"Kemsa could not purchase different reagents for all the counties on time. We had to wait for long for them to be delivered yet people were suffering," Prof Nyongo said.

He adds: "When there were technical hitches with the machines, it took time for the suppliers to service them yet laboratories diagnosis should be a priority."

The Council of Governor's chair, Wycliffe Oparanya told the Sylvia Kasanga led committee that Kemsa must be well structured and have regional warehouses to supply the counties with drugs if the country still hopes to achieve the UHC agenda.

"Kemsa drugs are too expensive as compared to other suppliers. Also, their ability to avail the products, the products' shelf life, and late delivery of orders during an emergency is a challenge," Mr. Oparanya said.

"Kemsa can even take up to a week to deliver products during an emergency," the governor adds.

While Kemsa got the UHC budget to ensure that all the facilities are well stocked, the counties were allocated drawing rights and could order drugs from the agency.

Financial barriers are the biggest obstacles to quality healthcare in the country. A mix of public, private, and donor resources supports Kenya's health sector. Between 2009 and 2013, donor financing fell from 34.5 percent to 25.6 percent, while financing from public sources rose from 28.8 to 33.5 percent.

Conversely, private financing for health increased from 36.7 percent to 39.8 percent over the same period. This is worrying because a huge part of private funding is in the form of out-of-pocket payment, which rose as a proportion of total health spending from 25 per cent in 2009 to 29 percent in 2013 and 32 percent in 2018 (KHHEUS, 2018).

The high out-of-pocket expenditure denies the vulnerable access to healthcare, while many are forced to sell assets to offset hospital bills, thereby impoverishing them further. It is estimated that healthcare puts 1.5 percent of households in Kenya below the poverty line every year.

While some in the piloting counties say that they have never benefited from the programme, others are praising it since they have tasted its fruits.

David Munene, a community health worker in Nyeri town tours the 216 households registered under him during the yearlong UHC pilot programme. One thing he remains certain of is that the pilot has been beneficial for the residents.

Mr. Munene who has worked closely with families like that of Mr. Peter Kabacia who suffers from arthritis says that the UHC pilot has made it possible for them to access certain services for free.

Mr. Kabacia states that his lab tests and X-ray were all free. One thing that however disappointed him was the lack of some of the medication needed after being prescribed by doctors. Mr. Kabacia says that when he received a message in March this year that the UHC pilot had been terminated, he was heartbroken.

Kisumu was identified as a piloting county because it leads in the infectious diseases category, especially HIV/Aids and tuberculosis while Machakos recorded the highest numbers of injuries mostly from accidents.

Nyeri leads in the non-communicable diseases segment, especially diabetes while Isiolo was picked to establish how the package would be suited for nomadic and migratory populations.

Capacity lacking

Another headache noted during the pilot was that of human resources. Mr. Wario Galma, the Isiolo County CEC says that they have had to employ two cohorts of health workers to assist with the workload in the county.

"Ministry of Health has supported the recruitment of staff but some of the people posted here did not tally the needs we had requested," he says.

Mr. Galma added that they proposed in the Intergovernmental Partnership Agreement (IPA) for the national rollout of UHC that the national government provide specialists and give counties a grant to hire their staff.

He added that some medical equipment received from the national government also was not relevant to the county's needs because they were not able to maintain them as some facilities did not have the capacity such as staff or electricity.

Mr. Wario says that the pilot failed in making an entry and an exit strategy and there was no clear communication.

"The first two-quarters of the funds came but we never got in the last quarter which was quite disappointing because the people were still expecting services," he says.

Machakos County on the other hand does not have a neurosurgeon. The County has committed to continue funding UHC and has since increased the health budget to 32 per cent of the total budget.

"This is a service that we need to continue giving our people," Dr. Nzioka says. During piloting, those accessing health care in Machakos County increased with over 2million people getting outpatients and over 30,000 got inpatient services.

Another challenge noted at piloting was the lack of meaningful engagement with civil society and clarity on what the UHC package covers.

"Greater participation contributes to accountability; the rollout was more of political mileage so that citizens can believe that the government is delivering," George Collins the Executive Director, Transform Empowerment for Action Initiative (TEAM), says.

Mr. Collins considers openness, accountability, and integrity as the game-changer in UHC.

"Our biggest problem is that none of the governors can authoritatively say that they have clear data on who needs to benefit from UHC. How are we going to justify that only a certain class can access UHC?" he asked

Meanwhile, residents from piloting counties have been asked to revert to paying their National Hospital Insurance Fund (NHIF) to access services in the hospitals.

NHIF as solution

The government is now considering going the NHIF way since Kemsa did not meet their end of the bargain.

A raft of policy interventions to fast track the national rollout have been unveiled. President Uhuru Kenyatta listed ongoing reforms at NHIF as one of the determinants for the successful roll-out of the intervention.

Other policy interventions outlined by the Head of State include the establishment of a mandatory scheme for all Kenyans to be managed by NHIF and regulated by the Ministry of Health.

"…in line with the clarion call of "leave no one behind", the Government will provide health insurance cover to initially one million households who are vulnerable and unable to meet even that low-cost premium," the President announced. Already, national biometric registration of needy households for UHC by NHIF is ongoing in all the counties.

As the national rollout commences, fresh registration is supposed to happen countrywide.

"Any person who attempts to defraud the NHIF or abuse its processes will be dealt with accordingly as provided for under our laws," the President said. This clearly states that even the Head of State has his doubt with the insurer. Health experts on the other hand and some county bosses are questioning why we had to go the NHIF way given the many corruption scandals that have befallen the national insurer. "We need to look at very many issues before we finally consider going the NHIF way, we do not want to see failures," Dr. Nzioka said

"We are really in need of this programme but NHIF has to win the trust of Kenyans by delivering, or they will be held accountable," Mombasa Governor, Ali Hassan Joho said during the launch of biometric registration in Mombasa.

Confirming the UHC model for the national rollout, Dr. Patrick Amoth, Director-General said the Ministry of Health will act as the National Scheme for all persons' residents in Kenya whether one is formally employed or not, including the very poor.

The NHIF package will cost Sh6, 000 per household per annum and will cover the most vulnerable households while making it easier for the people who can pay to do so. "Ensure that your membership is up to date at all times," Dr. Amoth says.

For the national roll-out, the government has allocated Sh6billion to cater for 1million Kenyans across the 47 counties.

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