Provision of UHC is part of the Kenya’s efforts to attain the highest standard of the desired status of health. It aims at ensuring all Kenyans quality, promotive, preventive, curative, and rehabilitation health services without suffering financial hardship. UHC lowers the healthcare cost in the economy; forces doctors to offer the same standards of services in the country; and eliminates administrative costs by reducing the need to deal with private insurance firms. However, the implementation of UHC in Kenya is faced with myriad challenges:
Healthcare financing: is a critical challenge in implementing UHC. According to the NHIF Strategic Plan 2018-2022, healthcare funding challenges include low total funding of healthcare, which is just 7 percent of the total Government Budget compared to the Abuja Declaration target of 15 percent and inefficient use of available funds (both technical and allocative inefficacies). For example, in health insurance schemes, there has been weak management of benefit utilisation; existence of multiple fragmented health insurance pools at national, county, donor, and private sector levels; leakages in the flow of healthcare funds of over 30 percent; low health insurance coverage (about 17 percent coverage) meaning 85 percent of the population does not contribute towards insurance; and inadequate funding for research and development for the health sector in the country (Government of Kenya, 2018). The WHO (2017) also argues that healthcare financing is one of the key challenges to implementing UHC. The health sector in Kenya is hugely financed by the private sector, including households’ out-of-pocket (OOP) expenditure (Government of Kenya 2014).
Service delivery: The high incidence of communicable diseases accounts for the highest proportion of disease burden in the sector. Together with the increase in the prevalence of non-communicable diseases (NCDs) – hypertension, heart disease, diabetes, cancer and substance abuse – this is putting pressure on the health sector (Government of Kenya, 2018; Government of Kenya, 2014). Poor service delivery in maternal and child health nutrition, exacerbated by inadequate emergency services for delivery, underutilisation of antenatal services and inadequate skills and competencies of health workers, were noted. While there is evidence of skewed distribution of health infrastructure and human capital with a bias for urban areas, migration threatens to turn the tables on this advantage. There has been a marked rural-urban migration of people between 20-34 years, contributing to unparalleled growth of urban populations, thus putting pressure on health facilities, especially in informal/slum settlements, which ordinarily are their first point of residence. This skewedness in the distribution of health infrastructure and health workers is also evident in urban areas – perhaps mirroring the core-periphery theory. This theory is based on the notion that as one region becomes economically prosperous, it grows and spreads, and as the former peripheral areas grow and become prosperous, they push the underdeveloped and marginalised areas further out. Instability in the region is also a big challenge – with Kenya hosting many refugees.
Human resources challenges: This is characterised by skewed distribution of skilled health workers, with rural and peripheral or marginalised areas facing huge gaps, while some urban areas have surplus personnel. Yet in Kenya, about 70 percent of the population lives in these rural and remote areas (Government of Kenya, 2014). The human capital deficit in the sector is felt at both National and Country government levels.
Industrial action among various health cadres demanding better working conditions and terms of service has occasionally presented serious challenges to service delivery in the sector. Therefore, there is a need to enhance human resources in the health sector (WHO, 2017; Government of Kenya 2018, and Government of Kenya, 2014). The Economic Survey report 2019 indicates that the number of health personnel increased from 165,333 in 2017 to 175,681 in 2018 (Government of Kenya, 2019). The report further shows that registered nurses accounted for the highest proportion of personnel at 29.9 percent, with enrolled nurses taking the second slot at 13.3 per cent in 2018. The proportion of registered personnel per 100,000 population increased to 368 in 2018 from 355 in 2017. Despite these improvements, there is more to be done to address human resource gaps.
Health products and technologies: Inadequate budget for procurement of health products and related modern technologies and distribution of the same to health facilities are a challenge. Health information systems need to be addressed (WHO, 2017). Lack of data is a big issue in most LMICs, and it points to a disconnect in the flow and sharing of data between the client and the health service provider. Kenya, Malawi, Peru and Haiti are among the early adopters of electronic medical records, which demonstrates ‘how an information system can help with micro-targeting those furthest’ from healthcare (UNDP, 2019:69).
Health infrastructure: Skewed distribution of available health infrastructure with a bias towards urban areas. This is compounded by the existence of obsolete equipment that requires replacement. The number of health facilities have grown in recent times. According to the Government of Kenya (2019), medical clinics rose by 18.6 per cent to 3,646 in 2018, out of which 94.2 percent were private clinics. This points to the extent to which people are likely to suffer financial risk, considering that those seeking services from most private clinics will have to pay out-of-pocket. The number of dispensaries and health centres increased in 2018 by 11.6 percent and 3.1 percent to 4,597 and 1,806, respectively, most of which were publicly owned. Health facilities increased by 9.7 per cent to 10,820 in 2018. Overall, public facilities increased by 2.5 percent to 5,246, equivalent to 48.5 per cent of total health facilities, while private hospitals increased by 22.3 percent to 4,327 in 2018. Faith-based organisations (FBOs) and non-governmental organisations (NGOs) accounted for 11.5 per cent of the total health facilities.
Leadership and governance: Weak multi-sectoral coordination, especially in the devolution of human resources management, and lack of decentralised trade unions to engage and agree on comprehensive bargaining agreements (CBAs) with county governments. There is also weak regulation and coordination of conventional and traditional medicine; and lack of adherence to set standards and regulations, leading to an influx of counterfeit drugs.
The re-emergence of diseases such as TB is a major health problem. Although there has been a decline in HIV prevalence, the number of infections has been increasing.
Climate change: Unpredictable weather patterns are affecting human health through increased disease vectors, waterborne diseases and under nutrition caused by floods and droughts. A study by the United Nations Development Programme (UNDP) (2019:186) revealed that in Kenya, Ethiopia, and Niger, ‘children born during droughts are likely to suffer from malnutrition. At the global scale, the issue of climate change is no longer a hoax.
A high dependency ratio of 5.4 (UNDP, 2019) means that there is a huge financial burden on individuals who have to shoulder the burden of care. According to UNDP (2019), globally there were 18.8 million internal displacements associated with disasters in 135 countries. Disasters caused by floods displaced 8.6 million, storms – including cyclones, hurricanes and typhoons – accounted for 7.5 million, and there were 2.7 million others.
Another concern is that, given limited resources, many countries have over time adopted a selective approach which prioritises certain areas over others. The WHO is working with countries to move back to a primary healthcare model which aims at addressing all of a person’s health needs, as opposed to just treating specific diseases (WHO, 2019).
Rapid population growth: The population of Kenya was 47.6 million during the 2019 census, up from 38.6 million in the 2010 population census. One of the strategies, therefore, is to revisit the healthcare system and related human resources if the country is to access good quality and affordable healthcare and cope with the growing population.