UNIVERSAL HEALTH COVERAGE IN KENYA

I set out to try and explain Universal Health Coverage (UHC) in the simplest means possible due to incessant questions regarding its proposed adoption by the government of Kenya through the ministry of health. Little did I know I was about to open a Pandora’s box! I got overly immersed and it no longer became a question of answering a simple question but having you truly appreciate the complex simplicity that is achieving good healthcare for all.

Universal Health Coverage means that ALL people have access to the promotive, preventative, curative, rehabilitative, and palliative health services of sufficient quality enough to be effective. Take note of the succession here-promotive and preventive before curative. Ideally, we would invest in public health systems before figuring out how to cover up for the crippling cost of managing non-communicable diseases.

The objectives of UHC are:

· Equity

· Quality

· Protection from financial risk

These goals are achieved by focusing on three key dimensions:

· “who is covered?”

· “which services are covered?”

· “how costs are covered?”

These reflect critical policy choices that have to be made to come up with the perfect ratio suitable for the specific population.

In line with this, it is important to debunk what UHC is NOT. UHC:

· Is not a simple blueprint or recipe applied uniformly by all. It is not a one-size-fits-all approach. Each system must be tailor-made to suit the specific needs of the community without compromising on equity.

· Is not free coverage for all health interventions. Basic UHC packages cover a pre-determined spectrum of services particularly targeting essential health services.

· Is not just about health financing. In an effort to ‘sell’ the concept of UHC a lot of emphases is placed on the financial protection while that of quality (delivery systems, workforce, technologies, quality assurance, governance, and legislation) is disregarded.

· Is not individual-based but population-based. Primary healthcare has shown to be the most efficient and cost-effective way to achieve UHC.

The success of UHC, therefore, will be pegged on successfully achieving the objectives outlined. The question then becomes, have we set up adequate structures to address each objective? Again, this could determine if we win or lose and losing would mean a tremendous loss in tax-payer money! Let’s close in on the objectives.

Equity

Whereas equality is based on everyone having equal right to access health services, equity ensures that additional measures are taken to ensure the marginalized groups with less access to health services are at par. One of the most appropriate ways to measure equity in healthcare is the use of a wealth quintile. This helps to actively identify those with less spending power who can’t access services. They are also most likely disadvantaged in terms of geographical proximity to services and lack of knowledge.

Effective coverage, therefore, is a proportion of the population receiving a particular service over those needing the service. The percentage in the burden of disease among the poor may also be compared to national percentages. Incomplete analysis of equity maintains exclusion and undue haste to implement UHC would risk a scenario where interventions reach the most privileged groups of people first and then trickle down to the poor and marginalized — the inverse equity hypothesis.

Case in point: % of births delivered at a health facility

National average: 61.2

Kirinyaga County: 92.5

Kilifi County: 52.6

Bungoma County: 40.8

Tharaka-Nithi County: 77.7

West Pokot County: 25.8

There are clear gaps in coverage in West Pokot and Bungoma counties despite having 87 and 105 public health facilities compared to Kirinyaga with 60. This shows that there are gaps that would need to be filled to achieve the objectives on equity.

Quality

This is the degree to which health services increase the desired health outcomes of individuals or the population. Ensuring safe, effective, patient-centered, timely, efficient and equitable services.

Quality primary healthcare being the most efficient and cost-effective way to achieve UHC enables a focus on people’s health problems, determinants of health through evidence-based policies and empowering of individuals and communities as advocates for health. Health system strengthening through evidence-based policies would go a long way in promoting quality towards UHC. A focus on essential health services, disease control priorities (DCP), determinants of health in our setting have a powerful potential to improve health outcomes and reduce catastrophic healthcare spending.

The Donabedian model is a framework for assessing the quality of healthcare. Here, inferences are drawn about quality of care based on information collected from 3 categories:

▫ Structure — Includes buildings, staff, machinery, and financing.

▫ Process — Involves the delivery of care; interaction between patients and service providers.

▫ Outcomes — The effects of care on the health status of the person or the population.

Case in point: A comparison in structure (no. Of doctors per 100,000 people) and outcomes (%of mother-to-child HIV transmission)

Number of doctors per 100,000 people

National average: 10

Kirinyaga County: 5

Kilifi County: 4

Baringo County: 6

Tharaka-Nithi County: 13

West Pokot: 5

The number of doctors available in the population would directly impact the quality of expertise available for them and thus health outcomes of the population. Gaps are evident in Kilifi, Kirinyaga and West Pokot counties particularly.

%of mother-to-child transmission cases

National average: 8.5

Kirinyaga County: 10.1

Kilifi County: 5.9

Baringo County: 9

Tharaka-Nithi County: 9.7

West Pokot County: 0

Mother-to-child HIV transmission could be a reflection of the promotive and preventative efforts coupled with access to healthcare services. Despite Tharaka-Nithi having supposed better structure (more doctors), the health outcomes (HIV transmission) may be poor if there are deficiencies in public health promotion. It is imperative that the GoK invests in facility infrastructure for health system strengthening. Counties must also find an appropriate balance between promotive, preventive and curative functions to attain a UHC system that works.

Financial Protection

Courtesy of ifmsa.org

A lot of focus has been placed on this objective. Financial protection focuses on the redistribution of prepaid resources to individuals with the greatest health needs to reduce out-of-pocket spending. Currently, those with limited resources have to choose between seeking health services and facing financial difficulty OR forgoing much-needed care. This directly impacts health outcomes. Three systems of financing have been used for UHC worldwide:

· Single-player system- Here the government pays all the healthcare expenses through insurance.

· Two-tier system- The government provides minimum insurance coverage for everyone while allowing voluntary purchasing of supplementary insurance.

· Insurance mandate- The government mandates citizens to purchase insurance (whether public or private).

Each system has its advantages and challenges depending on where it is set. It is estimated that 20–40% of health sector resources are wasted. There is a need, therefore, for innovative financing. A good example is the performance-based financing practiced in Burundi. Proper financing systems enable not just more money for health but more health for the money. Victims of underfunded and inefficient systems include the health system itself (underpaid staff working with limited resources) and the population who lack access to services.

Financial protection can be monitored by taking into account:

▫ The incidence of catastrophic health expense out of pocket.

▫ The incidence of impoverishment due to out-of-pocket spending.

The 2001 Abuja declaration saw AU countries pledge at least 15% of their annual budget to health. Kenya currently spends about 7%. With NHIF (the state corporation mandated to provide health insurance) currently marred with alleged corruption scandals, the ministry should consider possibly increasing the pool of insurers to be able to accommodate the needs of the population. The government also needs to reaffirm its commitment to improving healthcare by increasing its budgetary allocation for health.

In conclusion,

It is crucial that we learn from the mistakes of our predecessors on this UHC journey. Implementation of the UHC program without addressing existing gaps will further strain the overstretched system. The destination mentality displayed (to achieve UHC by 2022) seeks to neglect the journey and set us up for failure. Adoption of UHC will not magically heal our existing wounds. If we are to gain universal health coverage, it will have to be done right. Everyone MUST know what they’re signing up for.