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Healthcare financing gaps: Financing gaps exist in the provision of UHC in Kenya. Apart from the government coming up with innovative ways to increase the national health budget, it can also tap into other sources of funding to bridge these gaps. The government can introduce specials taxes such are Sin Tax (on alcohol and tobacco), airtime tax, and improve tax avenue collection. Sin Tax is levied on goods that are detrimental to human health. Debt swaps for health and guarantees can also be negotiated by the government (UNDP, 2019b). A debt swap is “a method of transforming debt into resources for development. Debt swaps are a type of debt relief, often as part of the official development assistance (ODA) funding: instead of paying back the debt to creditor countries, debtor countries use the debt money for their social development, such as education and health care” (UNDP, 2019b:27). This means money meant for debt repayments can now be redirected to social development, including health financing for UHC. However, debt swaps depend on donors’ willingness to cancel the debt. The government can also continue seeking donor funding of the health sector. It can continue working towards removal of user fees for the poor, indigent and marginalised through provision of subsidies (HISP) and introduction of social protection insurance (Government of Kenya, 2019a). Also, it can gradually increase its budget allocation to the health sector from the current 7 percent of the Total Government Budget towards the Abuja Declaration target of 15 per cent of Total Government Budget. This is, however, dependent on the level of a country’s economic growth.

Infrastructure gap: This is made worse by skewed distribution of health infrastructure, with a bias to urban areas. Most of the equipment is also obsolete and urgently needs replacement. The government should create an enabling infrastructure for quality service delivery through promotion of Public Private Partnerships (PPP). Also, a model of lease financing can be explored further as it reduces the need for upfront capital, with monthly rentals paid for using the assets. The Kenya Managed Equipment Service is a good example of this. The owner of the assets gives the right of use to the government and gets periodic payments (UNDP, 2019b). Another recommendation is to rationalise hospital infrastructure and create a network of hospitals within counties and inter-counties to optimise efficiency, like in the case of Brazil and Central Asia (Kimathi, 2017).

Corruption in the health sector has been highlighted at various forums as one of the biggest impediments to UHC. Plunder is common, including donor funds. This leads to inefficiency, shortage of human resource and inadequate supply of other HPTs at public health facilities. Combating corruption and prudency in management of public and donor funds should be strengthened.

Human capital deficit: The Kenya Health Policy 2014-2030 aims at ‘achieving adequate and equitable distribution of a productive health workforce’ (Kenya Government, 2014). This can be done through identifying training needs. Also, postgraduate training and internship programmes should be promoted as part of capacity building. Faith-based health facilities can also work out arrangements/agreements with county governments where some workers can be deployed to support public facilities. Mechanisms should be put in place to attract, retain and motivate workers, especially in marginalised areas.

Health Product and Technologies (HPT): Kenya, Malawi, Peru and Haiti are among early adopters of electronic medical records. Kenya should strengthen its Health Information System (HIS) to facilitate procurement of health products and related modern technologies and timely distribution to health facilities. The system can also help in ‘micro-targeting those furthest’ (UNDP, 2019:69), hence improving access to quality UHC. The system should also have the capacity to trace drugs and equipment to guard against dangerous products entering the supply chain. In January 2020, KEMSA signed a contract with Postal Corporation of Kenya to use its wide transport network to distribute HPT. It is important to put in place an effective and reliable procurement and supply system. The Kenya Health Policy 2014-2030 categorises HPTs as:

• Strategic: vaccines and drugs for TB, HIV/Aids, epidemics;
• Special and expensive: cancer drugs and immunosuppressive agents;
• Essentials/basic products.

Strengthen research and development: KEMRI should focus more on public health and health systems, traditional medicine and drug development; biotechnology; infectious parasitic diseases; non-communicable diseases; reproductive health, and adolescent and child health. The agency, working with international partners, should re-energise research on how best to implement UHC and the emerging challenges.

Strengthen the capacity of PPB to ensure that only registered pharmacies operate and that the drugs they procure and sell are of unquestionable quality. They should increase monitoring and evaluation of pharmaceutical companies to guarantee high standards of HPTs. The PPB should monitor and ensure adherence to set standards and regulations.

The Constitution of Kenya (2010) introduced a decentralised/devolved health sector. The system aimed to ‘allow the County governments to design innovative models and interventions that are suitable to their unique health needs and ‘encourage effective citizen participation and make autonomous and quick decisions on resources’ (Kimathi, 2017:55). However, in almost all the counties, the health sector is faced with mammoth challenges, mirroring most of the challenges experienced at the national level. These challenges range from capacity gaps, inadequate human resource, lack of critical legal and institutional infrastructure, runaway corruption and antagonistic relationship with the national government (Kimathi, 2017). These challenges have led to stagnation of healthcare and a decline in the gains made on UHC. However, Makueni County has pioneered the implementation of UHC and the experience and lessons learned can serve as an inspiration to other counties.

Universal Health Coverage in Makueni County, Kenya

Kenya has just completed piloting UHC in Kisumu, Nyeri, Machakos and Isiolo counties. The remaining counties were to start rolling out the UHC programme from January 2020, apart from Makueni, which pioneered the implementation of Universal Health Coverage in Kenya in a project referred to as Makuenicare. According to the proceedings of a conference held in Makueni in April 2018, UHC is achievable. Objectives of the conference were: to deliberate on current national and country government strategies on health; create an enabling environment to address health systems; and develop a framework of action to realise UHC (Makueni County, 2018:6). Some of the key achievements of UHC/Makuenicare, as outlined by the County Governor during the conference, include:

1. Dedicating 33.7 percent of the county’s annual budget to healthcare;
2. Increasing healthcare facilities from 109 to 232 by April 2018, which greatly reduced the average nine-kilometre distance that people walked to the nearest health facility for treatment. The Kenya Health Policy 2014-2030 aims to reduce this distance to five kilometres (Government of Kenya, 2014). This clearly enhances accessibility to healthcare.
3. Makueni County manufactures its own oxygen in Wote town. UHC is also about reducing costs and ensuring provision of affordable healthcare;
4. The county has increased its recruitment of health workers from 977 in the financial year 2013-2014 to 1462 in 2017-2018 to meet an influx of patients from other counties attracted by Makuenicare;
5. Trained workers in various cadres, namely; specialist doctors, medical officers, dentists, nurses and clinical officers;
6. The county constructed Makindu Hospital Trauma Centre to serve accident victims on the Nairobi-Mombasa Highway, and others in the county;
7. Makueni is implementing a local UHC scheme where a household pays an annual fee of US$ 5 (Ksh500) to access healthcare services. This is quite affordable, although it is not clear which health package benefits one can access.
8. Makuenicare has seen an extraordinary enrolment rate of 91 percent, all registered with the local insurance scheme, compared with only 8.8 percent in 2013.
9. The county has upgraded healthcare facilities and built newer ones in its quest to implement UHC. By April 2018, the number of health facilities had increased from 22 to 47, coupled with an increase in the number of professionals.
10. A 120-bed capacity Makueni County Mother and Child facility is under construction.

The Makueni UHC conference highlighted challenges facing implementation of UHC, such as shortage of government budgetary resources, corruption, weak health systems, high poverty levels, difficulties in reaching vulnerable people, selecting the right package of benefits, integration of the informal sector and poor distribution of human resources. Most of these challenges are similar to those identified at national levels (Government of Kenya, 2018; Government of Kenya, 2014), and County Government levels (Kimathi, 2017. The way forward is highlighted below.

The Kenya Government should come up with innovative ways of funding UHC, such as increasing the health sector budgetary allocation. Funding should be increased from the current 2.5 per cent of GDP to 5 percent as recommend by McIntrye et al. (2017).

1. The country’s health system is mainly anchored on donor funds and out-of-pocket payments (Barasa, Nhuhiu and McIntyre, 2017). There have been clear cases of people incurring some form of OOP in public health facilities, even after removal of user fees, thus exposing them to financial risks. Promotion of partnerships and collaborations with the private sector, encouraging prepayment schemes (insurance schemes and taxes) and pooling them to ensure access and minimal financial risk. Prudent management of available finances, both at National Government and County Government levels.
2. Increase human resources in the health sector. MakueniCare shows the huge number of people seeking UHC, thus putting pressure on health personnel and equipment.
3. Training healthcare workers at all cadres. They should be sensitised on the UHC system and the lessons learned in the pilot projects in Makueni, Kisumu, Nyeri, Isiolo and Machakos.
4. The government should build more health infrastructure, especially public health facilities, in peripheral areas. There should be equitable distribution of health facilities and equipment. The Kenya Health Policy 2014-2030 projects to have health facilities within five kilometres of every home.
5. Win the support of politicians and other leaders to prioritise UHC and develop policies that promote it.
6. The government should put in place policies, strategies and plans to spur economic growth and economic development so as to enhance tax revenue, hence the capacity to increase budgetary allocation to health.

Subsidized scheme for poor, indigent and elderly

The Health Insurance Subsidy of the Poor (HISP) is designed to target vulnerable sections of the population and is implemented by the NHIF. The programme was launched in 2014 in all 47 counties in Kenya with the objective of improving health indicators of the poor, as well as reducing their financial burden. The HISP is a fully subsidised health insurance programme for the poorest echelon of society (Government of Kenya, 2019a). The health programme covers outpatient and inpatient care. The World Bank provided U$20 million (about Ksh2 billion) for the first phase. Beneficiaries are drawn from a government poverty list covering all the 47 counties (World Bank, 2014).

According to the Government of Kenya (2019a), a total of 181,415 households are registered. They benefit from a Transfer Programme for Orphans and Vulnerable Children. In 2014, a pilot programme for Older Persons and Persons with Severe Disability (OP&PWD) was launched, targeting 23,000 households (about 142,000 people) to benefit from inpatient services from this government cash transfer scheme. Those on the list were targeted through proxy and community verification tactics (Government of Kenya, 2019a). The benefit pay-out ratio achieved is 50 percent. Members benefit from the NHIF Supacover, which allows them to receive comprehensive services from contracted public and private health service providers (Government of Kenya, 2019a, Barasa et al., 2018). In 2016 the HISP programme was expanded to cover about 170,000 households (about 600,000 people), including outpatient services (Barasa et al., 2018).