Fully devolve, fund health docket

The 2010 Constitution was a turning point for Kenya. It reconfigured the balance of power by devolving power and responsibilities from the national government to 47 elected county governments and recalibrating powers between the Executive, Legislature and Judiciary.

It strengthened rights-based approaches to health, providing for the citizen’s right to the highest attainable standard. The biggest gains have been during devolution.

First, access to high quality health services for Kenyans has improved. In the first five years, county governments heavily invested in developing and upgrading health infrastructure after inheriting dilapidated facilities from the national government due to decades of neglect.

They have since built and operationalised hundreds of health facilities. As a result, most Kenyans live within a five-kilometre range of health services as per WHO recommendation. Counties have significantly expanded the scope of services.

For instance, renal dialysis, specialised surgeries, cardiology services and neurology were previously available in a few national hospitals.

Devolution increased access to maternal care, reducing morbidity and mortality for the mother and her baby. Today, 89 per cent of mothers deliver under skilled care, from 66 per cent. In 2014-2022, under-5 mortality rate fell from 52 to 41 deaths per 1,000 and infant mortality from 39 to 32 deaths per 1,000.

Secondly, one of the biggest successes of devolving health is the workforce. The country has rapidly built up a large pool of highly qualified health workers across all cadres with the resource equitably distributed. In the past 10 years, counties have more than doubled the health workforce. In 2016-2021 alone, the number of health workers in counties improved by 61 per cent from 59,726 to 96,453.

The distribution of health workers across the country also improved as counties executed customised strategies to attract, develop and retain high-quality healthcare workers. Counties in hard-to-reach areas have significantly more health workers than in the pre-devolution era. For example, Turkana County had less than 10 medical officers before devolution, a number that has increased six fold to 61 doctors in 2023 – and this is a similar story in most many counties.

Increased volunteers

By supporting health workers to take up further studies, which was hitherto limited, counties have driven a rapid emergence of specialists, even in areas where there were none before, which fosters a better skill mix.

This has allowed counties to provide a wide range of specialised health services even in areas where these were not available before devolution. Counties also increased the number of community health volunteers (CHVs) to 107,839 in 2023, covering most villages, with some paying stipends for this cadre amid concerted effort to remunerate them.

Thirdly, essential medicines and other medical commodities are central to a good health system. County health authorities put in effort to ensure all health facilities have adequate supply of medicines and commodities but these are largely hampered by inefficiencies and lack of transparency at the Kenya Medical Supplies Authority (Kemsa). Most counties pay Kemsa promptly but supplies are made late and in inadequate quantities.

Fourth, financing health remains a key priority of county governments. Despite having 14 devolved functions, most counties allocate more than 30 per cent of their budget to health. Despite this, there has been disproportionate allocation of funds for health between the two levels of government—especially given that the national government has significantly less roles compared to county governments. Given that the total equitable share for counties was Sh340 billion in Financial Year 2022/2023, for instance, the national government allocated Sh146.8 billion to the Ministry of Health and Sh102 billion for health for all the counties.

Kenya’s investments in health are below the 15 per cent agreed in the Abuja Declaration; thus, there is a need to both devolve more funds for health to follow functions but also increase resource allocation to the health sector. Disease mostly has physical, psychological and financial burdens that often leave families in poverty. The majority never recover from these shocks. County governments thus continue to push for a more accountable National Health Insurance Fund (NHIF) that covers the citizens against catastrophic expenditure of health, is priced at a cost that citizens can pay, makes timely reimbursements to service providers and is sustainable.

The health gains under devolution were made in very difficult circumstances. Health functions were devolved without the requisite resources, causing huge underfunding of counties. The National Treasury frequently disburses equitable share funds late and some functions were not fully transferred. As such, there is an urgent need to conclude the unbundling of health functions, transfer all the remaining devolved functions to counties and ensure that resources follow functions. The national and county governments must strengthen their collaboration and partnership.

Mr Njuki, the governor of Tharaka Nithi County, is the Chair of the Health Committee, Council of Governors (CoG). [email protected].