'Resolving challenges of devolving healthcare delivery for the attainment of better and equitable healthcare services for the people of Kenya’

In a landmark 2010 vote, two thirds of Kenyans approved a new rights-based constitution that incorporates mechanisms for greater public participation, representation and civil engagement. Devolution of the government represents one such mechanism. By transferring authority to lower administrative levels, devolution aims to bring government closer to citizens, increase transparency and enable Kenyans to hold their government accountable. Likewise the constitution envisages a devolved health sector wherein health services are more accessible to citizens, are more responsive to specific populations’ needs and are more equitably distributed.

The experience of healthcare delivery has varied in different counties. Some have allocated sufficient funds to them, while others have struggled. As the county authorities are conducting tasks such as procurements or planning on their own and learning necessary rules and procedures for the first time, there are some obvious “teething” problems. The main issue of lack of feedback from sub-county level or point of service and the lack of involvement of beneficiaries or sub-county authorities in decision making remains nearly unchanged even after devolution.

Theoretically, the transfer of powers and responsibilities from national to county government serves to stimulate county tax effort and therefore augment existing resources for health. Furthermore, since county authorities are assumed to be sensitive and responsive to local needs, the devolution creates an opportunity to trim down excess capacity, pattern the menu of health services provided to local condition, and avoid costly delays in managing epidemics and disasters. However, it’s unfortunate that the theory has challenges when it comes to applying it practically on the county levels and the decentralization program poses some practical problems. Resolving challenges deterring healthcare delivery for the attainment of better and equitable health services include;

Devolution of Decision Making

In order to address the challenges of healthcare on healthcare delivery, it would be of utmost importance to increase the understanding amongst stakeholders on how devolution in the health sector is supposed to be realized. Decisions making on planning, fund allocation and human resource management to the county government should also be discussed. To do this effectively, there should be a consensus among the participants including representatives from the civil society, the county health management team and the health care workers on the need to sensitize stakeholders such as healthcare workers and communities on the legal policy frameworks that are informing devolution in the health sector. County health strategic investment plans, the County Government Act, the Health policy, the intergovernmental relations act, and the public finance management are to be included. To ensure smooth transition of devolution of healthcare; sub-county authorities should convene in a forum, discuss challenges experienced in their respective sub-counties, come up with possible solution and present it to the county level. The county level should discuss and analyze the challenges and the presented possible solutions. The county will evaluate the possible solutions, identify the solutions that can be implemented and those which are beyond their capabilities are presented to the national government for further considerations.

Human Resource

There are human resource issues that rose due to devolution of healthcare. The counties should initiate the reform process by defining job descriptions and ensuring that employees understand these. Having explicit and measurable benchmarks to measure performance which in turn guide promotions based on merit as opposed to tenure will improve performance. At the moment counties are disowning health workers who were employed under ‘economic stimulus’ and ‘clinton foundation’ by the national government. The health workers employed by the public service commission are also frustrated by delay of remuneration and also lack of initiatives in promotions. To resolve this challenge, the counties should deploy all the health workers working under contract or economic stimulus into their respective station and establish health body within every county that will ensure the health workers are paid in time and their frustrations are addressed.

Most of the specialist are based in the major counties especially Nairobi therefore the poor or less funded counties lack specialist for various kind of health specialist such as surgeons. This is a challenge since patients to seek medical attention from another county which maybe expensive and time consuming. The aim of devolving healthcare delivery to counties was to avail and deliver healthcare to inaccessible, poverty stricken areas thus ensuring equality and equity in the provision of health services in counties. To ensure equity when it comes to provision of health specialist among counties, the established counties health body or authorities spearheading creation of policies and regulations of the forty seven counties should carry out harmonization of health workers in all counties. Harmonization will ensure equal distribution and deployment of specialist in respective counties, decongestion of counties that are overstaffed, propose retirement and employment of health workers. Furthermore, the county health authorities should also ensure remuneration and promotion of the health workers are managed equitably. The county health authorities should also manage training of staff especially the employees who are to hold higher offices at the county and sub-county levels for instance, in leadership skills, and management of human resource. Specialization is the hallmark of modern economic systems. Health programs should be managed by subject specialists with support from management experts with business experience.

Prioritize a Basic Set of Services

The county health body should prioritize those services that they absolutely must deliver and can cause the most impact with such as childhood immunization, safe births and family planning rather than maintain a huge and inefficient network of costly and underutilized hospitals and clinics. However, there should also be upgrading of areas that have few health equipment and also establishment of new health facilities especially in areas which are far to reach. All health institutions should be properly equipped and facilitated with enough human resources and infrastructures.

Community Oversight

All counties should implement a Kenyan health policy known as the “community strategy” Rooted in the principles of universal health access and improved service delivery at the community level, this strategy will seek to engage households and communities as active participants on the health decision making and priority setting. Framed within the broader context of devolution of the Kenyan health sector, the strategy will serve two key purposes: It will provide a framework for building viable, community-level infrastructure for health service delivery and It will establish a mechanism for transferring health governance authority to lower administrative levels. Strong empowered communities should represent the foundation of the newly devolved health sector, and the community strategy will provide a pathway for communities to assume their expanded responsibilities. Following promulgation of the new constitution, the Kenyan government and the like-minded partners will accelerate implementation of community strategy in sub-counties and counties.

Evidence based Advocacy

Decentralization caused more than the mere transfer of powers and responsibilities to county governments. Since county decisions have impact on neighboring jurisdictions, decentralization also alters the incentive structure faced by county government interacting with one another. The counties should improve their advocacy with finance and planning departments within the health sector at the county and sub-county level, using tools such as cost effectiveness/ cost utility analyses to make their case for increased funding for needed programs and by objectively demonstrating performance to ensure continued funding.

Decentralization of structures and Infrastructures

Decentralization caused more than the mere transfer of powers and responsibilities to county governments. Since county decisions have impact on neighboring jurisdictions, decentralization also alters the incentive structure faced by county government interacting with one another. Factors such as spillover effects for instance cross-border use of the local facilities (hospitals, cemeteries, mortuaries) and the spatial bias of retained hospitals also influence the provision of the local health services. Spillover effects can be clearly identified in Kiambu County where the county increased revenue expenses on cemetery charges for individuals that belonged to other counties. The negative effects of cross-border use on the local spending can be minimized by resource or cost-sharing arrangements among municipalities. Instead of subsidizing county government that attracts disproportionate number of non-resident users, the national government can capitalize on existing mutual help practices in the locality. However the best way to reduce the adverse consequences of cross border use is the charge access fees to non-resident users can be waived in the meritorious cases such as emergencies and for indigent patients. Furthermore, the county health authorities should also ensure remuneration and promotion of the health workers are managed equitably. The county health authorities should also manage training of staff especially the employees who are to hold higher offices at the county and sub-county levels for instance in leadership skills, and management of human resource.