UNLOCKING ACCESS TO HEALTHCARE IN KENYA: AVENUES AND STUMBLING BLOCKS Unlocking Access to Healthcare in Kenya Avenues and stumbling blocks Natalya Oberst March 2021 Discussion Paper 002 UNLOCKING ACCESS TO HEALTHCARE IN KENYA: AVENUES AND STUMBLING BLOCKS Published in March 2021 by The Brenthurst Foundation (Pty) Limited PO Box 61631, Johannesburg 2000, South Africa Tel +27-(0)11 274-2096 Fax +27-(0)11 274-2097 www.thebrenthurstfoundation.org All rights reserved. The material in this publication may not be reproduced, stored, or transmitted without the prior permission of the publisher. Short extracts may be quoted, provided the source is fully acknowledged. 1 UNLOCKING ACCESS TO HEALTHCARE IN KENYA: AVENUES AND STUMBLING BLOCKS Contents Executive Summary ……………………………………………………………………………………………………………………………. 3 Introduction ………………………………………………………………………………………………………………………………………. 4 Health Financing in Kenya – High Stakes or Penny Ante? …………………………………………………………………… 5 Social Health Insurance Programmes …………………………………………………………………………………………………. 8 Does Kenya’s NHIF Complete the UHC Puzzle? ……………………………………………………………………… 9 UHC: Roadblocks and Missing Puzzle Pieces ……………………………………………………………………………………. 10 Individual Cover at Universal Cost, Demand Financing Alone Won’t Work …………………………. 10 Remuneration, Representation and Recourse …………………………………………………………………….. 11 Infrastructural Cracks ………………………………………………………………………………………………………….. 12 Conclusion ……………………………………………………………………………………………………………………………………….. 13 Figures Figure 1: Recommendations ………………………………………………………………………………………………………………. 3 Figure 2: Government Expenditure By Sector 2018/2019 ………………………………………………………………….. 6 Figure 3: Donor Funding As % of Total Development Budget …………………………………………………………….. 7 Figure 4: Recurrent and Development Expenditure At National Budget and Country Level ………………. 7 Figure 5: Insurance Providers in Kenya ………………………………………………………………………………………………. 9 Figure 6: Per Capital Health Expenditure (Kshs) ……………………………………………………………………………….. 11 2 UNLOCKING ACCESS TO HEALTHCARE IN KENYA: AVENUES AND STUMBLING BLOCKS Executive Summary financing strategies and the politicisation of health policy choices. In investigating the barriers to accessing quality healthcare in Kenya, inefficiencies This paper argues that better investments in service delivery and economic exclusion in the health sector, good governance and emerged as the main deterrents to a people-centred policy approach to attaining universal access to health economic growth will pave the way for services. Though the ongoing interventions economic recovery in Kenya and other under the universal health coverage African economies, once the health effects umbrella are a step in the right direction; of the COVID-19 pandemic have been demand side policies, through social subdued. In this regard, the steps taken by insurance programmes, have so far proved the incumbent, Kenya’s 4th president insufficient in stimulating health seeking Uhuru Kenyatta, in seeing the UHC behaviour particularly in impoverished promise to completion; will not only communities. Further, supply side gaps determine his legacy, but also set the threaten the sustainability of the UHC stage for his successor in the upcoming framework as a result of ineffective 2022 elections. Figure 1: Recommendations 3 UNLOCKING ACCESS TO HEALTHCARE IN KENYA: AVENUES AND STUMBLING BLOCKS Introduction Secretary-GeneralI aptly stated that governments will face “a stark choice: Singapore, during the early 1960s, suffered continue misguided policy choices or from similar socio-economic challenges collectively chart a new path that leads experienced in developing countries today. from recovery to a more resilient, more Running water and electricity as well as equal and more environmentally basic necessities pertaining to health and sustainable world”. education was a privilege only enjoyed by elites. Fast forward to 2021 and the story Since the onset of the pandemic, the is quite different. With a current life health sector has become the central expectancy of about 84 years and per feature of economic debate and policy capita income of $88,155, the country rhetoric. Globally, the World Health placed eleventh worldwide, in the most Organization has pressed for more recent Human Development Index investments in the health sector to rankings. enhance preparedness for the next health crises. While Africa is no stranger to What caused this drastic shift in economic disease outbreaks, the continent still faces stature? a long road ahead when it comes to One of the critical push factors that building more formidable health systems. enabled Singapore to realise such gains in As a continent, the challenges facing the productivity was the country’s investment health sector are deeply rooted in scarcity. in human capital. Of health workers, financing and effective In curating the sustainable development governance structures. In Kenya, the story blueprint, the United Nations selected is no different. Insufficient government health and education as key priority areas, funding, unequal distribution of health with good reason. The development of personnel and scanty distribution of human capital and economic growth are medical equipment, impede the process of complementary, if not dependent, on each providing accessible and quality other. Productivity gains that emerge with healthcare. strategic investments in human capital are The government’s Vision 2030 focuses on as extensive as they are exponential. the “Big Four” agenda, which in part, aims Economic growth must account for the to provide universal health coverage human element, if it is to yield the (UHC). However, the extent of coverage is intended economic transformation. yet to materialise, despite the impending Over the past decade, investments in 2022 deadline. UHC, perceived more as an health and education have remained altruistic government pledge to its citizens, dismally low in Sub-Saharan Africa. is geared toward expanding access to Funding allocated to both health and quality healthcare for the marginalised and education in the region have averaged at economically ostracised in Kenya. about 5% of GDP.1 This misalignment of The current approach to UHC provision is development objectives and policy choices bipartite: reduce the ratio of out-of-pocket has greatly impacted the trajectory of (OOP) expenditure to total household economic growth on the continent. expenditure and fully subsidise the cost of Alluding to the post pandemic recovery essential services. But, funding gaps of up period, Mukhisa Kituyi, UNCTAD I See United Nations Conference on Trade and Development. (2020). Trade and Development Report. 4 UNLOCKING ACCESS TO HEALTHCARE IN KENYA: AVENUES AND STUMBLING BLOCKS to 39% reported in the health sector hint At county level, construction projects at some inefficiencies in the disbursement combined with grants and transfers take and utilisation of current financing.2 up more than half of the development budget, whereas 70% of the recurrent Although unlocking access to healthcare expenditure is distributed as personnel lies in reducing financial barriers to remuneration4. demand, care cannot be delivered if the supply is ill-equipped or grossly These dissimilar budgetary allocation overburdened. If the root causes of service strategies in the national and county delivery inefficiencies on the supply side health departments are not only inefficient are not corrected, the attainment of UHC but they are also counterintuitive to the will remain an aspiration with little attainment of UHC. Aside from the lack of proximity to reality. Focusing on both cohesion in implemented health financing demand and supply side challenges, this strategies, international aid dependence discussion underscores inefficiencies in also provides a false sense of financial Kenya’s health sector and provides a set of security as it is often politically volatile and pragmatic recommendations which are to some extent, unreliable. The United instructive to the larger African context. States, one of Kenya’s closest allies, allocates about $1 billion annually in development assistance to Kenya, two Health Financing in Kenya – High thirds of these funds are directed toward II Stakes or Penny Ante? the health sector. Eight years after the decentralisation of Although such support is fundamental to government services in Kenya, county the attainment of UHC, the health budgets have systematically unpredictability of donor funding results increased whereas national health budgets in fragmented and short term value have declined. Although the devolution of delivery to local communities5. For health services can explain the shift in example, after the re-enactment of the expenditure at the national level, the controversial anti-abortion “gag rule”III utilisation of disbursed funding at both under the Trump administration in 2017, county and national level remains some reproductive health programmes uncoordinated and inconsistent. pertaining to abortion were suspended in Kenya. Without local government backing, At the national level, the health sector this disruption resulted in the closure of receives about one fifth of the funding reproductive community health facilities allocated to education (Figure 2). Grants which no longer qualified to receive and transfers take up between 60-70% of funding from the United States the recurrent budget while a larger government. In the context of UHC, proportion of the development budget is pronounced donor dependency obscures allotted to