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Dying to live: Kenya’s search for universal healthcare

The question of how to raise domestic revenue for health is something that policymakers across Africa continue to grapple with. In recent decades different options have been tried and tested –user fees, small-scale community based health insurance, private insurance schemes, and taxation. Today Kenya, like many countries in the region, is left with a complicated patchwork of different schemes offering different levels of coverage to different population groups. Merging these into a single national risk pool which uses public financing to provide for all citizens will improve access to healthcare and reduce administrative costs.

One way of raising more money for health would be to introduce an earmarked tax on diaspora remittances. “According to the Central Bank of Kenya, money remitted by the diaspora is growing monthly,” says Dr Jane Chuma, a health economist and senior research scientist at Kenya Medical Research Institute in Kilifi. “Last year, over $1 billion (Sh85 billion), higher than the revenue earned from coffee or tourism, was remitted to the country. Putting a little levy on foreign transactions could raise significant money for health. In 2009, Gabon raised $30 million (Sh2.6 billion) from diaspora remittance tax, which they put into health care.”

Another option is to merge existing funds to create a single National Social Health Insurance Fund which pools all the resources that are currently available for health into one pot and stop the duplication of effort. “Tax funds allocated to health, NHIF contributions, community health insurance schemes and donor money, if pooled together, can create a large enough single pool. This will ensure that both the rich and the poor are covered while reducing administration costs. As there will only be one organisation buying services, it will have bargaining power.”

During the NARC government when Charity Ngilu was the Minister for Health, there was some discussion about starting a National Social Health Insurance Fund in Kenya. It was passed by Parliament but the president did not sign it. ‘The big boys’ as Hon. Raila Odinga said in Kenya’s first presidential debate on February 11, ‘shot it down’. These ‘big boys’ included private health insurance schemes and private hospitals.

“What Kenya needs are leaders who are willing to put the private sector to task. That they either be part of these reforms or lose altogether by not working together with the public system under universal health care. There are many innovative ways of using private doctors to provide health care in public facilities. What we lack is political will and leadership,” says Dr Chuma.

Whatever the means of raising money, people need to be confident that the money will not be misused. The history of National Health Insurance Fund is plagued with corruption and there is little trust in the public that they will deliver should they take on the role of National Social Health Insurance Fund. “A new institution would need to be in place to swallow NHIF. It would require re-branding, with a new board and new staff. It shall require a lot of work to build trust in the public health care system where beneficiaries will be expected to seek services,” says Dr Chuma.

Public health facilities need to be closer to the people, be well equipped and charge no fees. In this way, each citizen in the country will be able to walk into any health facility, get whatever treatment is required and walk out without paying a shilling. However, removing charges alone will not be enough to keep patients coming. The public health facilities have to be fully staffed and well stocked with medicines. It is not enough, for example, to say that giving birth at a maternity ward is free and then expect mothers to buy gloves, cotton wool and drugs because there are none available at the facility.

A commonly-held fear of a ‘walk in, walk out’ health facility is that providers will be overwhelmed by people who may not need the service but take advantage of its availability because it is free. This is an unfounded fear because there are other costs related to seeking care like costs of transport or the cost of losing a day’s work to go to a health facility. Few therefore, will come to the facility when they really do not need services.

To reduce costs of payments for treatments, the government will need to invest heavily on preventative measures to reduce the heavy burden of infectious diseases. At the moment more money is going to curative rather than preventative health care. The greatest weapon against infectious communicable disease is good hygiene. This will require the government to provide safe water and improve waste disposal. The second greatest weapon is provision of essential vaccines followed by use of insecticide-treated bed nets. To reduce costs on the National Social Health Insurance Fund, the government will need to invest in these simple tools or face an unnecessary dent on the health fund.

As we usher in a new government in a few weeks, our hopes are high. The President-elect, Uhuru Kenyatta, through his coalition’s manifesto, has promised free primary health care for all Kenyans as well as raising government health financing from 6 percent to 15 percent. Politicians make appealing promises during the campaign period but we will have to wait to see if they will be brave enough to fight for this agenda. The situation is urgent, as annually, about 1.5 million Kenyans are pushed below the national poverty line due to health payments.

Tabitha Mwangi is a freelance science journalist based in Kenya. Her articles have appeared in The Daily Nation and The East African. She has a PhD in epidemiology and worked in the Kenya Medical Research Institute for 10 years before becoming a writer.

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One Response to “Dying to live: Kenya’s search for universal healthcare”

  1. Joel Lehmann says:

    Nice article; only comment is that from my most recent experience (a series of interviews with key opinion leaders from all perspectives of the health sector) there is good hope for good collaboration between public and private sector. One needs to keep in mind that according to Kenya’s “Vision 2030” strategic blueprint, the public sector is poised to become a purchaser, not a provider of healthcare.

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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni