Medicine that’ll give Kenya right universal health cover

President Uhuru Kenyatta’s inauguration day speech committed his administration to the attainment of Universal Health Coverage (UHC) by 2022.

A laudable pledge to accelerate the realisation of citizens’ right to health enshrined in the Constitution. This commitment is also in line with Sustainable Development(SDG) Goal 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

UHC means all Kenyans should access health services that are of good enough quality to work, whenever they need them, without facing financial hardship. The health services are expected to be responsive to the needs of the citizenry.

UHC should be viewed as a health system goal: equity in service use, quality and financial risk protection. It is therefore concerned with much more a particular insurance scheme and its members.

UHC is an explicitly political agenda that can reshape the distribution of public goods and services as well as opportunities for citizens. UHC is affordable for all countries if they make it a priority.

Moreover, the costs of UHC are more than offset by the benefits gained and by the savings obtained from a healthier society.

The move towards UHC requires reforms that will impact the entire health system: stewardship (governance and leadership), financing, and service delivery (health workers, commodities, equipment and information). Health financing is concerned with three roles: revenue generation, pooling of resources and purchasing of health services.

Countries should aim to generate revenues that are adequate, stable, and predictable in a way that is fair and administratively efficient.

Evidence shows that these features are best met when the main source of funding is public, usually from pooled government revenues.

In fact, all countries already rely to some extent on public financing from government revenues. Global experience has shown that no country achieves UHC by relying on donor funding.

To achieve UHC, Kenya needs to increase its level of public financing of health services. The increase in public spending should be used to reduce reliance on payments made at the point of service delivery (out of pocket payments).

All Kenyans, including those in the informal sector, should be entitled to automatically and compulsorily participate in the health financing system regardless of whether they contribute to a particular insurance scheme.

This is because compulsory participation builds solidarity which is essential in strengthening the social contract between citizens and the State.

Evidence shows that the best way to deal with the informal sector is to fully fund coverage for them from government revenues to which they contribute through direct and indirect taxes.

Health funds should be pooled in way that balances the risk of ill health across the population from rich to poor, healthy to sick and young to old.

This means fund pools should be large enough to cover populations with different health risks, and would ideally cover the entire population.

Kenya’s existing health fund pools (which are more than 50) need to be integrated or merged. Integration would mean maintaining separate pools and using some form of mechanisms to transfer funds among the pools. Merging, which would be less technically demanding, would mean combining all the pools into one.

Purchasing involves determining what health services to buy, for whom, from whom and at what price.

Purchasing is critical to ensuring UHC goals of equity, efficiency and quality. Without strategic purchasing, revenue generation and pooling will not deliver UHC.

This means it is possible to cover 100 per cent of Kenyans, but neither deliver good quality services nor protect from financial risk.

To achieve the best quality, a strategic purchaser should select health service providers, have clear contract specifications, use financial and non-financial incentives, and provide guidance and support to service providers. Health service providers need the freedom to respond to these incentives and requirements.

To ensure equity, a purchaser should seek to offer a package of benefits that addresses the unfair differences in health outcomes.

For example, the purchaser would initially focus on primary health care which addresses many of the problems that unfairly affect the poor. The purchaser should also selectively contract providers that offer services in marginalised areas.

To ensure efficiency, the purchaser should select those health services that maximise the welfare. For example, if we were asked to give priority to cosmetic surgery or immunisations we would likely rank immunisations higher than cosmetic surgery.

The process for selecting these services should have clear criteria and be transparent.

The government should take a central role in stewarding UHC reforms and provide a platform for co-ordination, accountability for and institutionalisation of these reforms.

Health is a largely devolved function. The national government cannot implement the required reforms without engaging the 47 county governments and other stakeholders throughout the process.

Let the UHC agenda remain at the top of the Government priorities so that the momentum is not lost.

Kenneth Munge is Health Policy and Systems Researcher and PhD Fellow at the Health Economics Research Unit | KEMRI Wellcome Trust Research Programme