Challenges of Implementing Health Policies in Developing Countries.

Introduction

The term “policy” refers to a standard set of principles that guide a course of action. We define health policy as laws, regulations, plans, and actions that are undertaken to achieve health goals in a society (Pollack Porter et al, 2018). Health policy provides the context and framework within which health care and public health systems operate (Heiman HJ et al, 2015). “Health Policy is intended to be a vehicle for the exploration and discussion of health policy issues and is aimed in particular at enhancing communication between health policy researchers, legislators, decision-makers, and professionals concerned with developing, implementing, and analyzing health policy (Busse Reinhard, 2011).

Policy implementation denotes the mechanisms, resources, and relationships linking health policies to program action. Additionally, it entails both technical as well as relational aspects—not only specifying the individuals and institutions responsible for implementation but also ensuring that the institutions have the capacity for implementation and that the relations among institutions are conducive for collaboration.

The promulgation of the new constitution in Kenya in August 2010 effectively ushered in devolution as the latest and highest form of decentralization in Kenya (Kimathi, 2017). On 7th July 2017, Kenya ushered a new era of health reform through the Health Act, No 21 of 2017. According to its preamble, this Act was intended 'to establish a unified health system' in a bid to realize the constitutional threshold of 'the highest attainable standard of health (Beauttah Brian, 2018). The Kenya health policies give directions to ensure considerable developments in the position of health in the country. Accordingly, these guidelines are aligned with the country’s development agenda, Vision 2030, the new constitution, and global commitments. Under the government’s supervision, the health policies show the ministry of health’s commitment to guaranteeing highest possible standards of health in Kenya (Agnes W. Kibui et al, 2015).

Policies in the Kenyan health care sector are clearly aimed at improving the health for the entire population. In a previous report it was found that policy documents are well supported by data about e.g. expenditures on health and burden of disease. National Health Accounts (NHA), Public Expenditure Reviews (PER) and Kenyan Demographic and Health Surveys (KDHS) are examples of reports used for policy purposes in the health sector. However, it was noted in the report that even though health expenditure and other data are used for policy purposes in the Kenyan health sector, the policies are not followed (SIDA, 2005).

For successful implementation of this policy, there is need to monitor the implementation progress, identify the challenges and mitigate them and determine better strategies for implementation based on emerging implementation issues (Wamalwa Emmanuel, 2015).

In the National Health Sector Strategic Plan (NHSSP) 1999–2004 it is clearly articulated that health services shall be concentrated to meet areas such as reproductive health, integrated childhood illnesses, increased immunisation, environmental health, HIV/AIDS and malaria. Yet, the KDHS, 2003, reveal that there has been a decline in both medical antenatal coverage and in child immunisation rate between 1998 and 2003. Regarding malaria, no more than 22 percent of the households had a mosquito net in year 2003, to be compared to the target of 60 percent in year 2006. Furthermore, the latest NHA and PER show that the development of expenditures and allocation to different levels of health care services in part goes against the policy goals stipulated in the NHSSP. The current proportion of expenditure on health as a share of total government spending, 8 percent, is well below the goal of 15 percent adopted by African leaders in the Abuja Declaration of 2001 (Kenya NHA 2001/2002) (SIDA, 2005).

Kenya health policy

The Kenya Health Policy 2012-2030 offers guidelines to ensure momentous improvement in the status of health in Kenya, in line with the provision of the new constitution of Kenya 2010, Vision 2030, and other global commitments. The policy exhibits Kenya’s health sector’s obligation, under the national government supervision, to ensure that Kenya attain the highest possible standards of health, in response to the needs of its citizens. Health Policy 2012-2030 is designed to be all-inclusive, balanced, and rational. Therefore, it concentrates on the two major obligations of health, including contribution to economic development provided in the new constitution of Kenya 2010 and Vision 2030 (Agnes W. Kibui et al, 2015).

?Problems of Policy Implementation

Interpretation of policy directives requires the translation of knowledge on interventions into the particular local context. Factors to take into account when interpreting health policy include (Jenkin?et al?2013):

·????????Local resources, including human resources and infrastructure

·????????Specific characteristics of the population

·????????Baseline incidence of the health problem

·????????The latency period?before an effect of the intervention will be observed

·????????Local variations in the likely effectiveness of particular interventions

Gunn (1978 in Hunter 2003) has identified ten common barriers to effective health policy implementation:

1.?????The circumstances external to the implementing agency impose crippling constraints

2.?????Lack of adequate time and sufficient resources

3.?????The required combination of resources is not available

4.?????The policy to be implemented is not based on a valid theory of cause and effect

5.?????The relationship between cause and effect is indirect and there are multiple intervening links

6.?????Dependency relationships are multiple

7.?????There is a poor understanding of, and disagreement on, objectives

8.?????Tasks are not fully specified in correct sequence

9.?????There is imperfect communication and coordination

10.?Those in authority are unable to demand or obtain perfect compliance (Rebecca Steinbach , Rachel Kwiatkowska, 2017)

Challenges in Kenya

Generally, two major obstacles for implementing policies in the Kenyan health sector; the first major obstacle concerns operational management of policies. Policies being too broad, which made operational management very difficult? Policies based on academic discussions and constructed by consultants. The consultants did not consider practical operational management and did not succeed in bringing key decision maker on board. Leading to a lack of consensus among policy makers and among those who were to implement respectively.

Linked to this, conflicting polices have been formulated, e.g. to cut back on recurrent costs at the MoH, implying a reduction the number of civil servants, while at the same time improve the quality of services and the follow-up and monitoring of policies. The second obstacle concern decision makers confidence in the information that policies are based upon. A further point raised during the interviews was the weak linkage between the Ministry of Health and the devolved units. A general problem when implementing policies is that the priorities at the central and at the devolved levels are not harmonized (SIDA, 2005).

1.?????Poor Coordination of Policies

There is poor coordination of implementation of public health policies among various implementing agencies. This leads to duplication and scramble for the scarce resources. Another example of policy working in a discordant manner is partnership with international development partners especially in the area of HIV and AIDS (Wilfred Chacha, 2016). One fundamental implementation challenge is that the responsibility for health policy implementation usually rests with a different set of governmental actors than the ones who designed the policy. Policy designers often do not understand the perspective of the implementers. The process of policy implementation thus requires working with and through a set of actors and organizations to communicate policy objectives, ensure availability of resources, achieve ownership of the policy by implementers, manage conflict and cooperation, and sustain policy changes (Paola Abril Campos et al, 2019).

2.?????Poor Participation in the Implementation of Public Health Policies

Many health policies do not involve all the stakeholders for effective implementation. Public health policies require multi-sectoral approach in implementation. Surowiecki (2004) emphasized the importance of participation by demonstrating how the combined intelligence and input of groups of people can create optimum conclusion about whatever they want to do. He states that “often crowds, like markets-or other forms of collective thoughts –are “smarter” than individuals who participated in them. The community like markets is made up of diverse people with different levels of information and intelligence, and yet when you put all those people together, they come up with intelligent decisions” (Wilfred Chacha, 2016).

3.?????Political environment

The development and planning in the health sector has faced several challenges over the years. Political instability and violence in some regions in Kenya has slowed down developments in health care. Post election violence in 2007-2008 was also a major setback to the national government’s program to develop the health care system. (Agnes W. Kibui et al, 2015).

?4.?????Pressures on health workers and compromised quality of care

Despite increased demand for services, no steps were taken to support health facilities and more clients led to increased staff workloads, reduced motivation and staff burnouts. It also strained facilities’ physical capacity; for instance, some hospitals were forced to fit many beds into small ward spaces and in some cases, mothers were made to share beds (Tama Eric et al, 2017)

5.?????Inconsistent and unpredictable disbursement of funds to health facilities

There have also been problems with reimbursements to facilities – which have been both inconsistent and unpredictable. This has made it difficult for facilities to plan how to spend funds, and was a substantial challenge for hospitals that were dependent on it to run the facility (Tama Eric et al, 2017)

6.?????Poor communication of the policy

Political pressure to deliver election campaign promises resulted in the Free Maternity Services Policy being implemented rapidly without official guidelines. This led to a lack of clarity about what services were covered, especially in relation to ante- and post-natal care. As a result, some clients were still required to make direct payments to healthcare facilities for supplies such as cotton wool or gloves, and (antenatal) laboratory tests (Tama Eric et al, 2017)

7.?????Corruption

Corruption also undermines the county and national efforts of developing the health care system and providing equitable and affordable health care to the citizens. Corruption compromises the distribution and use of financial resources directed to the development of health care. As a result, many plans and development projects stall because of lack of funds. (Agnes W. Kibui et al, 2015).

8.?????Lack of adequate health care financing

Established in 1966, the National Hospital Insurance Fund 140 (NHIF) is a compulsory scheme for all salaried formal sector employees whose income exceeds a certain set minimum. From the beginning, the insurance has covered the contributor’s spouse and children under 18 without discrimination on the type of ailment suffered or number of children. By year 2003, the scheme was covering over 9 million people (30% of the country’s 30 million) with about 1.3 million individual. As of 2003, the NHIF system coverage comprised 414 health institutions, 120 of which were run by government, 210 run by the private sector, 63 by NGO/Church-missions, and 21 by communities/foundations all with a bed capacity of 36,463. In 1998 NHIF was corporatized through an amendment to the 1966 Act and is currently fully autonomized and is run by a broad board of directors drawn from all the healthcare providing sectors; it receives no budget funds from the state (Richard G. Wamai, n.d). This has posed great challenge to financing of health care in line with health policies.

9.?????Traditions and Beliefs

?Beliefs Traditions and religious beliefs also hinder the government’s efforts to provide high standards of health care in the country. Some traditional and religious beliefs discourage members against seeking medical attention in dispensaries and hospitals in their regions. Such beliefs also prohibit members from taking medicines in case of an illness. These traditional and religious beliefs are a major challenge to the national and county governments with regard to control infections and non-communicable diseases and deaths. Some family members are also involved in practicing religious beliefs that forbid receiving any medical care from practitioners even to ailing members. Additionally, some parents avoid taking their infants for immunization owing to such traditions and beliefs. As such, the government should carry out civic education in order to change the mindsets of these communities and educate them on the importance of health care to them and their members (Agnes W. Kibui et al, 2015).

A study by Emmanuel Wamalwa (2015) that sought to determine the challenges facing implementation of free maternity services policy, based on the health workers’ perspective; Majority of the respondents indicated that there was staff shortage, overwhelming workload and inadequate supplies were the major challenges. Other challenges included abuse of the free services, uncooperative clients, financial challenges and lack of managerial support.

Recommendations

• The government should accelerate discussions and implementation of public –private initiatives for creation of sustainable models of healthcare financing to achieve Universal Health Coverage.
• Embrace technology in healthcare sector to ensure that resources allocated are not hampered by poor governance and the lack of accountability in the use of resources.
• Develop a standard referral system monitoring toolkit and curriculum to train health workers on the referral policies and guidelines to improve processes between the facilities.
• Adequate fund for implementation, monitoring and evaluation to provide regular supportive supervision for improved healthcare and accountability at all levels.
• Improvement of remuneration to enhance motivation of healthcare workers.
• Improve working conditions to motivate the healthcare workers and the policies implementers.
• Improvement of supplies and making the supplies regular to enhance delivery of healthcare services.
• Strengthen the systems for proper ethics and governance in line with the constitution including the fight on corruption
• Providing training opportunities for healthcare workers to enhance skills and improved supervision from management.

Conclusion

In brief, people including health systems specialists face a number of challenges when implementing health policies; hence, they need to possess necessary capabilities and understand how address these challenges accordingly. Some root barriers include difficulties in convincing people regarding the existence of the problem and the need for the policy, opposition from key stakeholders, lack of clarity on roles and responsibilities for implementation, conflicts with other existing policies, lack of coordination and collaboration between parties responsible for implementation. Furthermore, there can be lack of motivation or political will and inadequate human or financial resources. However, there are essential way to address such barriers that include planning and designing appropriate health policies after identifying a problem. At the same time, stakeholders need to examine the root cause of the challenge and develop targeted strategies to address each barrier. Finally, people need to have the ability to overcome the barriers such as having individual and institutional skills and competencies in policy implementation.

References.

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2.?????Beauttah, Brian. (2018). The Right to the Highest Attainable Standard of Health: The Relevance of Pre-Hospital Emergency Medical Services (EMS) in the Kenyan Health Sector.

3.?????Busse, Reinhard. (2011). Health Policy's future course. Health policy (Amsterdam, Netherlands). 100. 1-3. 10.1016/j.healthpol.2011.02.003.

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6.?????Paola Abril Campos & Michael R. Reich?(2019)?Political Analysis for Health Policy Implementation,?Health Systems & Reform,?5:3,?224-235,?DOI:?10.1080/23288604.2019.1625251

7.?????Pollack Porter, K. M., Rutkow, L., & McGinty, E. E. (2018). The Importance of Policy Change for Addressing Public Health Problems. Public Health Reports, 133(1_suppl), 9S-14S. https://doi.org/10.1177/0033354918788880

8.?????Rebecca Steinbach , Rachel Kwiatkowska. (2017, May 31). Problems of Policy Implementation. Retrieved from https://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4c-equality-equity-policy/principle-approaches-policy-formation

9.?????Richard G. Wamai,( n.d). Healthcare Policy Administration and Reforms in Post-Colonial Kenya and Challenges for the Future, fromhttps://www.sylff.org/wp-content/uploads/2009/03/wamai.pdf

10.?SIDA. (2005).NHA Policies in the Kenyan Health care sector – Why are they so difficult to implement? Health Division Document 2005:3, from https://www.sida.se/contentassets/187525db225449488987c8de9e20b454/policies-in-the-kenyan-health-care-sector---why-are-they-so-difficult-to-implement_629.pdf

11.?Tama Eric & Molyneux Sassy & Waweru Evelyn & Tsofa Benjamin & Chuma Jane & Barasa Edwine. (2017). Examining the Implementation of the Free Maternity Services Policy in Kenya: A Mixed Methods Process Evaluation. International Journal of Health Policy and Management (IJHPM). 2017. 1-11. 10.15171/ijhpm.2017.135.

12.?Wamalwa, Emmanuel. (2015). Implementation challenges of free maternity services policy in Kenya: the health workers’ perspective. Pan African Medical Journal. 22. 10.11604/pamj.2015.22.375.6708.

13.?Wilfred Chacha, (2016). Implementation of public health policies in Baringo county, Kenya, from https://ir.mu.ac.ke:8080/xmlui/bitstream/handle/123456789/1065/Rotich%20Wilfred%20Chacha%202016.pdf?sequence=1&isAllowed=y