Esther Wambui smiled faintly as she clapped slowly at the Kerugoya Level 4 Hospital gate.
Wambui had come to this facility in Central Kenya to see a doctor.
About 50 meters from where she and many others stood, Kenya’s President William Ruto was cutting the ribbon at another gate to open the new 341-bed Kerugoya County Referral Hospital.
World Health Organization says every country has a different path to achieving UHC and deciding what to cover based on the needs of their people and available resources.
“We love our governor for this great achievement. With this new, big facility, there is no doubt that healthcare services will improve,” she said.
Ms Wambui’s sentiments are echoed in many parts of the country by people who yearn for quality healthcare services close to them, as the Kenyan government promised to provide through Universal Health Coverage (UHC).
The Government of Kenya launched a pilot UHC program in 2018 to ensure that Kenyans can access quality healthcare services at a low cost, and easily.
Since 2013 almost every county has been upgrading its health infrastructure, and services, even as workers protest over unpaid or delayed salaries, lack of commodities, and working conditions.
The World Health Organization (WHO) prescribes the ratio of one doctor for a population of 1,000 and recommends UHC as one of the means to achieve this.
WHO says every country has a different path to achieving UHC and deciding what to cover based on the needs of their people and available resources.
Kenya’s case is particularly unique – the national government wants to implement UHC yet the healthcare function is devolved to the semi-autonomous 47 counties, and each county has its challenges and opportunities.
Governors declared a crisis in implementing devolved health services due to deliberate steps by the Ministry of Health to claw back on the health function.
Since 2013, when the first set of elected governors took office, almost every county has been upgrading its health infrastructure, and services, even as healthcare workers protest over unpaid or delayed salaries, lack of commodities, and working conditions.
Despite what has been described as teething problems, governors who won reelection five years later did not abandon their healthcare plans, and those who beat the incumbents picked up where the losers left off.
One of the governors who picked up where their opponents left off is Kirinyaga’s Anne Waiguru, who is also the current chair of the Council of Governors (CoG).
As the chair of CoG, she has to lead from the front, and show that even with Kenya’s unique situation, UHC will be achieved.
On June 13, 2023, President Ruto opened Kirinyaga County’s five-story medical complex, which Governor Waiguru put up from scratch at 11 million dollars.
The Kerugoya County Referral Hospital, a Level Five facility, has a 12-bed intensive care unit (ICU), 12-bed high dependency unit (HDU), 40-crib newborn unit, four operation theatres, an oxygen plant with a capacity to produce 450 liters of gas per minute, among other amenities.
“This is a dream come true and a demonstration that devolution works,” Governor Waiguru said during the ceremony. “This complex is a culmination of a purpose-filled, tireless stand that we started in 2019 to deliver the best healthcare services to our people.”
The health workers under UHC are managed by the national government and have different terms from their counterparts working for the counties.
The hospital is one of Governor Waiguru’s flagship projects and she has also completed seven health centers and dispensaries while another eight are slated for opening later in the year.
“As the chair of the Council of Governors, I can assure you that the devolution of healthcare services has had a significant impact,” Waiguru said.
“For the last ten years, county governments have invested heavily in healthcare service delivery, human resource development, equipment of health facilities, and health infrastructure development.”
Kenya’s healthcare sector has faced many problems – medics’ strikes or threats of strike, bickering, and mistrust between counties and the Ministry of Health, and complaints by health workers of discrimination in the piloting phase of the UHC program.
On May 19, 2023, CoG released a statement declaring a crisis in implementing devolved health services due to “deliberate steps by the Ministry of Health to claw back on the health function.”
“So far, we note with concern that all engagements and agreements made between the Ministry of Health and the Council of Governors have been bluntly disregarded, and there is a clear demonstration of lack of goodwill from the Ministry of Health,” reads the statement signed by Waiguru.
The health workers under UHC are managed by the national government and have different terms from their counterparts working for the counties.
Three days later, the Daily Nation reported that President Ruto and union officials met in February to plan the takeover of the health function from the counties.
According to the report, the meeting proposed the formation of an independent Health Risk Commission which will oversee the management of human resources, including recruitment, promotion, and provision of all services in the healthcare sector.
The government piloted UHC in four of the 47 counties in 2018. However, since then, the program’s national rollout has failed twice. The government’s third attempt, slated for later in the year, faces an unexpected obstacle: Kenyan healthcare workers are not boarding that ship.
President Ruto dismissed reports that his administration was planning to take over the health function from the counties.
On May 31, 2023, the Cabinet Secretary for Health, Susan Nakhumicha wrote to CoG that the government was renewing the contracts for 8,571 health workers it employed under the UHC program.
The health workers under UHC are managed by the national government and have different terms from their counterparts working for the counties. Health workers’ unions have termed this discriminatory.
Peterson Wachira, an official at the Kenya Union of Clinical Officers — the second most populous health workers union with 26,804 members as of 2022 — said the hiring is “irregular, and our biggest contention is on the inequity in the pay.”
“A clinical officer under UHC earns about 48 percent less than their counterpart on permanent and pensionable terms, yet they work in the same hospitals and for the same number of hours,” Wachira said.
“I want to assure the people of Kenya that our counties will manage the health function better, and that is how it will be from now on.”
In Kerugoya, President Ruto dismissed reports that his administration was planning to take over the health function from the counties.
“I know there is a big debate on this matter. But I want to assure the people of Kenya that our counties will manage the health function better, and that is how it will be from now on,” he said.
Ruto said he had agreed with governors that the national government would collaborate with the counties to deliver health in four areas to achieve UHC.
Doctors in various counties have several grievances and are always threatening to withdraw services over a lack of support for professional training, delayed salaries, and promotions.
The collaboration would see the equipping of all government hospitals, the formation of a special kitty called “facility improvement fund” to ensure health resources are not diverted to other functions and the payment of community health promoters by both counties and the State on a 50-50 basis.
“My government has already allocated 107 million dollars to support community health promoters. We must work on promotive and preventive health; towards this, we will train and equip 100,000 community health promoters to achieve the ratio of one promoter for every 100 families,” President Ruto said.
“We are losing many consultants to other countries, and that is because of the frustrations they are experiencing in the county referral hospitals.”
He also underscored the need to form the Kenya Health Human Resource Advisory Council to create harmony between health professionals, counties, and the national government and harmonize the provision of health services.
“We also agreed to support our medics to continue their professional training. So, when a doctor goes back to school for professional training, how do we fill the gap they leave?” he posed.
Doctors in various counties have several grievances and are always threatening to withdraw services over a lack of support for professional training, delayed salaries, and promotions.
“We need to have consultants and doctors employed, and others promoted to the right job groups. This has not happened five years down the line,” says Kenya Medical Practitioners Pharmacists and Dentists Union (KMPDU) Secretary General Davji Atellah.
“We are losing many consultants to other countries, and that is because of the frustrations they are experiencing in the county referral hospitals,” Atellah said.
Kirinyaga County Health Chief Officer Stanley Muriithi said the capacity building of medics is a national government function, and the State should pay salaries of all physicians who go for higher education to enable counties to fill the vacancies left.
“You give people National Health Insurance Fund cards to go to the hospital when they get sick but what you should have done is promote good health practices to prevent people from getting sick.”
Dr Muriithi said achieving UHC through “proper consultation” between the counties and the State is possible.
He added that UHC is a welcome policy whose initial priority was on promotive and preventive health at the grassroots level.
Still, the government had a false start when it concentrated on curative and rehabilitative care at the pilot stage.
“You give people National Health Insurance Fund (NHIF) cards to go to the hospital when they get sick but what you should have done instead is promote good health practices to prevent people from getting sick,” he said.
The number of government health facilities in Kenya increased by 33.6 percent from 4,456 to 5,953 between 2013 and 2020, thanks to devolution.
He said it is through devolution that health infrastructure and other resources can be taken closer to the people through Level Two and Level Three facilities that are key in implementing promotive and preventive health.
According to a 2020 report by the World Bank, the number of government health facilities in Kenya increased by 33.6 percent from 4,456 to 5,953 between 2013 and 2020, thanks to devolution.
As a result, over 90 percent of the Kenyan population live within five kilometers or one-hour travel time to a health facility.
Dr Muriithi is confident that UHC will succeed eventually, but for people like Ms Wambui and the rest of the Kenyans, the wait is protracted and costly despite the optimism. They need UHC now.