Graft, wastage and delays in funding dogged piloting of UHC, studies show

Unless the challenges that faced the pilot phase of the Universal Health Coverage (UHC) programme are addressed, the government’s goal of ensuring Kenyans access quality and affordable medical care by next year will not be met.

The programme improved hospital attendance but the success of the pilot phase was undermined by inadequate funds and failure to match hospitals with performance or needs.

A large proportion of the money pledged was not given to the counties involved and what was remitted arrived late.

Implemented for 12 months in Machakos, Nyeri, Isiolo and Kisumu counties, the scheme was launched by President Uhuru Kenyatta at the end of 2018.

In 2019, Isiolo’s outpatient visits doubled the previous year’s, the highest improvement in the of the four regions. It was followed by Machakos where outpatient numbers rose by about a third while Nyeri recorded an 18 per cent rise. Ironically, outpatient visits in Kisumu fell by a third.

The World Health Organization has identified linking funds to the needs of communities and performance of hospitals as a major principle of health financing.

The strategy was not executed properly in the UHC pilot phase, the results of a rapid review of the project in Isiolo by ThinkWell – an organisation that runs the Strategic Purchasing for Primary Health Care project in Kenya – show.

While the pilot phase was a step in the right direction, it failed on some aspects of strategic purchasing, according to ThinkWell Public Finance Management Technical Adviser Boniface Mbuthia.

“When it came to allocating the money, there was no known criteria,” Mr Mbuthia said.

Some Sh3.9 billion was budgeted for the project in the four counties and divided across four areas. Three-quarters of the money was set aside for basic and specialised care services, followed by activities for health system strengthening (15 per cent), community health (12 per cent) and public health services (one per cent).

The four devolved units discontinued user fees at level four and five hospitals since the national government reimbursed lost revenue through conditional grants.

Isiolo was to receive about Sh285 million or nearly 40 per cent of the allocation for the county, while the Ministry of Health transferred the remaining money to Kenya Medical Supplies Authority (Kemsa) directly for drugs and equipment.

However, the county had only received half the amount – about Sh143 million – by July 2019.

Though the funds were to be transferred on a quarterly basis, no further amounts were received in the second half of 2019, according to the counties’ annual budget implementation reports.

The remaining money was received in May last year, long after the pilot phase has lapsed.

The ministry chose the four counties based on several criteria. Isiolo was selected because it has a high maternal death rate, Kisumu has high incidence of communicable diseases, Machakos is prone to road traffic accidents resulting in many injuries and deaths while non-communicable diseases are prevalent in Nyeri county.

These needs did not factor in the funds provided, Mr Mbuthia told the Healthy Nation.

“A lot of drugs were given to hospitals in Isiolo. The number of outpatient visits doubled but there was a shortage of health workers,” Mr Mbuthia added.

Isiolo county government was to recruit 135 health workers but only 23 were hired.

The reason given by top county officials was delayed funding by the government.

Incentivise patients

According to a UHC survey dissemination report by the People Health Movement Kenya, it was difficult to access some dispensaries in Isiolo for they were as far as 40 kilometres from patients.

Isiolo County Community Health Service Coordinator Siad Guyo told the Sunday Nation that some services should be decentralised.

“There is need to decentralise specialised care further to sub county hospitals to ease the burden on the county referral hospital,” Mr Guyo said.

He added that continuous training and mentoring of community health workers is important.

Despite Machakos being chosen to pilot emergency and accident matters, an investigation by the Sunday Nation found that residents were made to buy medical equipment used in the replacement and repair of broken bones.

The reason given by the county health department was that the devices could not be included in the piloting UHC model because of costs.

Despite a delay in the disbursement of money to Kemsa by the Ministry of Health, ThinkWell Kenya Director Anne Musuva says the agency could have done more to meet the needs of the counties.

Apart from linking the needs of the population to funding, strategic purchasing also helps in accountability, where hospitals and providers are paid for services, Dr Musuva said.

She added that an example where this applies is the Linda Mama initiative, which reimburses up to four antenatal visits and four postnatal visits.

Depending on the level and whether they are private, public or faith-based, hospitals are given Sh2,500 to Sh5,000 for normal delivery, Sh1,000 to Sh300 for every antenatal visit and Sh250 for a postnatal attendance.

“This signals to providers to incentivise patients to attend maternal clinics,” Dr Musuva said.

The approach removed unnecessary inflation of deliveries and enhanced accountability, something that lacked in the UHC pilot phase.

The UHC dissemination report found that some health workers in Nyeri took advantage of the influx of patients to create artificial shortages of medicines that were later sold to desperate families illegally.

The Ministry of Health has identified strategic purchasing as an important lever for making progress towards UHC and efforts have been made to create strong data and information management systems such as the Kenyan District Health Information Software.

However, the policy and practice have not yet been implemented.