What if Kenya approached UHC the same way it is handling COVID-19?
Boniface Mbuthia (ThinkWell Kenya, Nairobi) and Nirmala Ravishankar (ThinkWell, Washington DC)
COVID-19 has thrown existing health system weaknesses in Kenya into sharper relief; for example, analysis of facility data showed that only 22 out of the country’s 47 counties had any ventilators at the start of the pandemic. While the Government’s handling of COVID-19 has elicited its share of criticism and push back, here we discuss what we view as three good practices related to the stewardship of the response by the Ministry of Health (MOH). And argue that these governance practices would be good to retain and apply to steering health financing reforms that are necessary to build a stronger, more resilient health system capable of responding to the interconnected goals of health security and universal health coverage (UHC).
Having a clear plan
MOH released a national contingency plan for responding to COVID-19 in January, 2020 and the President constituted a National Emergency Response Committee to lead a “whole of government” policy response in late February. The MOH-led National Taskforce, which is responsible for implementing the contingency plan, has been working through various sub-committees on the technical and operational aspects of the response including resource mobilization, communication, case management, capacity building for healthcare workers, and access to testing. MOH has issued a series of guidelines and protocols, and continues to adapt its policies and plans in response to ground realities.
The same level of clarity would be desirable to see in the country’s UHC plans. In December 2018, MOH launched the Afya Care UHC pilot program in 4 counties, wherein the county governments discontinued all user charges at public health facilities and, in return, received an extra allocation for commodities and additional funds from the National Government to cover service delivery costs at public facilities and through community health workers. While MOH issued guidance on how counties are to use these resources, the document missed some key elements of the program like an explicit benefit package or how the counties should pay providers. MOH has developed a draft policy to guide the scale-up of the program, which the National Government is poised to do in the new fiscal year that starts on July 1. While the policy document is a good start, an operational manual that gets into the details would be a good next step before the scheme is rolled out.
Coordinating all actors to implement the plan
We have seen the MOH play an active role in coordinating different stakeholders towards addressing the health threat that is at hand. The National Taskforce includes representatives from key government agencies, development partners, non-governmental organizations, and civil society groups. It has mobilized COVID-19 contributions from the private sector and directed them to meet identified needs. The National Taskforce is making a concerted effort to track financial and in-kind contributions from development partners and coordinating its distribution to different parts of the country.
This degree of coordination stands in contrast to a highly fragmented health financing landscape. There is a critical need for MOH to align public funding of health services across Kenya’s 49 public purchasers or “payers” of health services, namely MOH, 47 county departments of health, and the National Hospital Insurance Fund (NHIF). Their respective role in paying for different parts of the health benefit package that undergirds the goal of UHC in the short, medium, and long term warrants greater discussion among all key stakeholders, with MOH at the helm. In the context of current discussions about the UHC policy, clarity is also needed about what will happen to key health financing schemes like the NHIF-operated Linda Mama scheme that allows all Kenyan women to access maternal health services free of charge at public and private facilities when the UHC pilot is scaled-up.
Sharing information with the public
Since early-March, when the first cases of COVID-19 were detected in the country, the National Taskforce has religiously prepared and disseminated situation reports about COVID-19 to the public every day -- even weekends and public holidays! The reports, which offer metrics related to testing and treatment, the distribution of cases across the counties, and reflections about emerging challenges, are accessible through the MOH website, and relayed through both conventional and social media platforms. MOH has also engaged the media to pro-actively disseminate public health messages in multiple languages.
This approach of openness would be very welcome in the discussions around the country’s UHC plans and performance. Even as MOH prepares for the scale up of the UHC model, information about what worked (and what did not) in the pilot counties has not been shared with the general public, as was noted recently by 74 civil society organizations and private sector groups in their response to the new budget. Sharing the proposed UHC policy and other detailed plans with civil society organizations and the public for comment would be ideal. We appreciate that having daily reports about the country’s progress towards UHC in not practical; MOH releasing quarterly reports on the program to the public and engaging stakeholders and the public on program expenditure and performance with similar regularity would be a step in the right direction.
National government stewardship for health financing reforms: towards a new normal
We did not set out to review MOH’s handling of the COVID-19 response. Or speak to specific decisions it has taken to curb the spread the disease and mitigate its impact. We chose instead to focus on the glass half full, commending MOH for what we view as good practices in its stewardship of the response. And advocate for greater clarity of plans, unity of purpose, and public accountability in health sector governance as it steers the health system towards improved health security and the goal of UHC.
 MOH. 2018. “Guide to the Use of Allocated UHC Funds.” Nairobi: Ministry of Health.