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Policy, legal and strategic grounding

Through the Kenya Health Policy 2014-2030, Kenya Health Sector Strategic Investment Plan 2013-2017, and Kenya National eHealth Policy 2016-2030, the Government is committed to putting in place strategic interventions aimed at accelerating, achieving and maintaining UHC through increased and diversified financing options. It is also worth noting that UHC has been adopted in the President’s ‘Big Four Agenda’, which include achieving food security, providing affordable housing, manufacturing, and provision of UHC and guaranteeing quality and affordable health care for all by 2022. The Parliamentary Budget Office (PBO) notes that the ‘Big Four Agenda’ is not necessarily ‘a silver bullet that will propel the economy to higher growth and development’. The PBO also underlines that the success of the ‘Big Four Agenda’, especially on health, is dependent on partnerships between the National Government and County governments as health is a devolved function.

More counties embrace UHC…

Key specific government initiatives towards the implementation of UHC include elimination of user fees in primary healthcare facilities, Linda Mama, Boresha Maisha (free maternal health programme), the voluntary National Hospital Insurance Fund, and Health Insurance Subsidy Programme (HISP).

Present quality of healthcare in Kenya
Devolution has two main structures, the National Government and the County Governments, as provided for in Article 6 (2) of the Constitution of Kenya 2010. The country has 47 County Governments with distinct health functions devolved to them by the National Government. According to the Kenya Health Policy 2014-2030, the National Government’s mandate on health is as follows:

1. Leadership of Kenya Health Policy Development;
2. Management of national referral health facilities;
3. Capacity building and technical assistance to counties; and
4. Consumer protection (including the development of norms, standards and guidelines).

On the other hand, the same policy document outlines County Government health functions as follows:

1. Responsible for county health services, including county health facilities and pharmacies;
2. Ambulance services;
3. Promotion of primary healthcare (PHC);
4. Licensing and control of undertakings that sell food to the public;
5. Cemeteries, funeral parlours and crematoria; and,
6. Refuse removal, refuse dumps, and solid waste disposal.

According to the Kenya Health Policy 2014-2020, the healthcare service delivery system in Kenya takes a hierarchical structure. It begins with primary healthcare, graduating to higher levels of healthcare, where complicated cases are referred to. Primary care units include dispensaries and health centres. The current structures consist of the following six levels:

1. Level 1: Community
2. Level 2: Dispensaries
3. Level 3: Health centres
4. Level 4: Primary referral facilities (sub-county hospitals)
5. Level 5: Secondary referral facilities (county hospitals)
6. Level 6: Tertiary referral facilities

A number of policy guidelines have been developed at national level to ensure provision of quality healthcare, namely: non-communicable diseases (NCDs), cancers, and infection control policy, among others. In addition, Kenya has also adopted a national quality assurance framework – the Kenya Quality Model for Health (KQMH), which provides ways to attain optimal levels of patient safety and high quality health service. The quality assurance framework also provides for the introduction of joint health inspection checklists (Wangia and Kandie, nd). These checklists emphasise on risk-based ranking of facilities and enforcement follow-ups. A quality assurance framework, grounded on local and international stakeholder’s input, is a good step towards accreditation and total quality management − which are necessary for achieving the highest standard of quality healthcare as envisaged in the Kenya Constitution 2010.

Health financing is a crucial element of providing quality health service and pushing forward the UHC agenda. The World Health Organisation (2010) points out that for a country to achieve UHC, it should make adequate provisions for resources. In addition, prudent utilisation of available resources is critical in order to enhance efficiency. Njuguna and Pepela (2019) argue that in order to cushion people from financial risk, healthcare should be funded mainly through pre-payment mechanisms (such as NHIF schemes), while reducing Out-Of-Pocket (OOP) payments to a bare minimum. According to WHO (2010) report on financing health systems, many countries are faced with the following three fundamental questions:

1. Where and how they can find the financial resources they need;
2. How can they protect people from financial consequences of health;
3. How they can make optimum use of resources.

The National Government is committed to implement UHC and has increased the budgetary allocation to health services by 57.8 percent, from Ksh61.8 billion in the financial year 2017-18 to Ksh97.5 billion in 2018-2019. Development expenditure on health services increased by 77.7 per cent to Ksh59 billion, equivalent to 60.5 percent of total expenditure in 2018-19. The recurrent expenditure expanded by 34.6 per cent to Ksh38.5 billion in 2018-19.

Country Government health services expenditure was projected to grow by 28.7 per cent from Ksh84 billion in 2017-18 to Ksh108.1 billion in 2018-19, out of which Ksh77.5 per cent was to fund recurrent expenditure, while spending on development activities almost doubled to Ksh24.5 billion. The share of the total government expenditure on health to total government expenditure grew from 5.8 per cent in 2017-18 to 6.8 per cent in 2018-19.

While setting aside financial resources for UHC is a good step, political commitment is equally important. In Kenya, UHC is at the centre of the President’s ‘Big four Agenda’ and most County Governments are supporting it (see section 6.2 on case study). According to UNDP (2019), different countries take different approaches in mobilising funds for UHC. France, for example, uses earmarked taxes (first a payroll tax and later an earmarked income and capital tax), while Brazil and Ghana earmark part of their social security contributions and value added tax. In a  number of countries, UHC systems are funded mainly by tax revenue, namely; Spain, Portugal, Denmark and Sweden (WHO 2010). Other countries such as Japan, Thailand, Turkey and Vietnam do not have specific amounts earmarked but use budget priority (UNDP, 2019: 228). It is pertinent to note that some countries such as Kenya and Laos People’s Democratic Republic (PDR) rely on a relatively high percentage of total health expenditure funded from external assistance sources (WHO, 2017).

According to the World Health Report (2010), countries whose population have 100 per cent access to a set of health services usually have relatively high levels of mandatory, prepaid or pooled funds – ranging between 5 to 6 per cent of their respective gross domestic product (GDP). Therefore, no government can achieve UHC without the use of compulsory contribution schemes, pre-paid and pooled public resources, hence the way these funds are mobilised, allocated and spent is at the core of sustainable health financing agenda (World Health Organisation, 2017).  There are three key factors that influence a country’s capacity to set aside financial resources for supporting UHC (World Health Organisation, 2017). These factors are:

1. Affordability: this is partly linked to the level of income per capita or GDP per capita (level of economic growth) and the flow of funds from external partners/funding agencies.
2. The level of political and public commitment to health: this has to do with the government’s willingness to invest in health as opposed to other sectors of the economy and how much the public is willing to pay to access high quality healthcare. Engagement with the political process to understand the politics of enhancing UHC is a critical component to enable implementation of health financing reforms.
3. Prevailing attitudes towards concepts such as solidarity: the willingness of the well-off population to subsidise the costs of providing health services to other people, poor or ill.