The Kenyan government is currently pursuing a policy on devolution of services across many sectors, including health. Our Nairobi team has therefore been following the Kenyan devolution process closely. In particular, we have been keen to understand how the transfer of responsibility from the Kenyan national government to county levels will impact on the poorest, and how access to better information could play a part in supporting Kenyans to get the best out of these changes.
Earlier this month, we convened one of our regular #Africacounts round table forums for health sector stakeholders, to discuss the challenges and potential opportunities around devolving healthcare. Participants explored three key areas:
- Prioritisation and resource allocation for health
- Openness in health care service delivery and
- Sustainability of health systems.
Below, we outline the four key learnings and the overarching message which we took away from the event.
1. There is need for further discussion and debate on defining ‘health as a right’
Stakeholders emphasised the need to refer to the relevant sections of the constitution and supporting legislation on devolution, and in particular, the sections that enshrine health as a right, as a first step towards ensuring that devolution works. Participants identified an urgent need for clarity in defining what the constitution implies in its provision for the right to health.
“How will you measure achievement without agreeing on what the right to health entails?”
Agreeing on a definition of what the ‘right to health’ entails will create shared expectations which will, in turn, ensure standardisation, policy harmonisation, and costing, as well as resource allocation. It will also enable monitoring by the people and reduce the likelihood of unequal provision within and between counties
2. Open Governance provides an opportunity to enhance accountability and improve healthcare service delivery
If available in the right level of detail, open data on healthcare services could empower health sector stakeholders to demand accountability and keep county governments accountable for effective service delivery. Opening up data/information (on resource flows, services, morbidity, disease trajectories), will enhance meaningful citizen participation in decision making and bolster accountability.
However outside the big cities, Kenya will probably lack enough ‘infomediaries’ (or data interpreters), who are necessary to transform ‘big data’ into formats that citizens can consume and understand. Challenges in harmonising and integrating new and old data management systems, building skills and capacity, and historical reluctance to share government data, are key issues that county health stakeholders will need to contend with in making meaningful use of open data. Wolfgang Fengler notes: “If not managed well, decentralization may lead to greater inequality [in Kenya]. Some counties will start at a relative disadvantage …they will be the least equipped in practice to make efficient and transparent use of their resources”
3. Counties should explore resource streams beyond national government allocations
Participants envisage potential conflicts between the national and devolved governments with regards to the division and allocation of resources. Due to divergence in health systems, resource endowments and demand for health care, priority setting and resource allocations are bound to vary across counties. Maintaining standards, with the inherent inequalities that exist, will thus be tricky. Nonetheless, participants brainstormed and suggested a reasonable range of alternative funding that county governments could pursue. These include:
- National government disbursements, as stipulated in the revenue sharing laws,
- External/extra budgetary resource streams like grants and loans,
- Localised/community based health insurance schemes
- Efficiently managed public-private partnerships and
- User fees/cost sharing
4. For better use of health resources: invest more in preventative measures
“No matter how lean and efficient a healthcare system, it cannot be sustainable unless growing demand for healthcare is slowed”
Global focus is shifting towards developing ‘sustainable health systems’. Participants urged the Kenyan government to consider policies that nurture healthy societies and reduce demand for healthcare. Currently, it was felt, Kenyan health policies overemphasise responsive and curative healthcare service delivery at the expense of preventive programmes. In order to succeed in providing quality and sustainable healthcare services, the county health systems must work instead towards reducing the burden of disease. To make better use of resources, counties should invest more in addressing the underlying causes of illnesses and infections that demand huge expenditures of public funds.
“We must observe the correlation between the environment, nutrition and health. Most of the health cases that doctors deal with in Kenya are largely preventive”
An ongoing process
The overarching message from the forum was that devolution is an unfinished, ongoing process with many challenges, but also many opportunities for greater accountability for service delivery if properly executed. It must involve a constant search for the most efficient balance between centralised steering and county-level autonomy.
We believe that some responsibility lies with the citizens in effectively devolving the health function in Kenya. Health sector stakeholders must temper their expectations with pragmatism, and be proactive, working with others in the sector to keep monitoring progress and hold their counties accountable for the provision of health care service delivery that they need.
For further consultations and information on this forum, please contact: Kenn.Okwaroh@devinit.org |Twitter: @Okwaroh. Kenn Okwaroh is an analyist in DI’s Nairobi office.