Road to UHC: The devil is in the implementation.
UHC means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.
This far, we have primarily addressed two of the four acts enacted to spearhead Kenya’s Universal Health Coverage (UHC) journey - Social Health Insurance Act and Primary Healthcare Act.
These have elicited debate. I would like to think it is because they address key service delivery components, but we all know it’s complicated.
Instead of an analysis, I will tell a story that hopefully captures the spirit of the Digital Health Act and Facility Improvement Fund. At the very least, I hope it paints a picture of the nuances surrounding the implementation of Universal Health Coverage.
A clinician supervising a Health Centre used his savings to buy a motorbike to get to his workstation, some thirty kilometres away. The Health Centre was not only in a rural part of Kenya but was so remote that there was no public means of transport. Most people had to walk for at least an hour to access any named road.
Questionable working conditions
Ideally, the clinician was to be provided living quarters and on paper, this had been allocated and there were notifications that the facility offered delivery and maternity services – which occasionally occur in the middle of the night.
All other healthcare workers, decrying the poor working conditions had resigned and now worked in private healthcare facilities. They hoped to use their skills in other ways, outside referring patients to the next best facility.
The clinician had only one other administrative assistant whom he had retained on a locum basis. He explained that for every patient it was essential that they maintained some sort of record, and this didn’t necessarily require clinical skills. This made it easy to get some part-time help while he triaged the patients, diagnosed, prescribed and dispensed. At that moment, he had two medications in stock – a painkiller and an antihistamine. If you didn’t have allergies or weren’t in pain, he would have to write you a prescription for you to go buy outside the health facility.
Facility improvement pathway
He was aware that the county had received a shipment of medication, but these somehow didn’t trickle down. He had asked for staff to be hired as there was an existing budget line – they would only be replacing those who had resigned. He wasn’t sure if that, like many other issues he had raised had been swept up in bureaucratic processes or simply funds had been redirected to competing priorities.
Politics aside, he hoped that all this would change with the Facility Improvement Fund - monies generated in healthcare facilities could be used by the facilities or those within that network. There would be no paper-based maternity rooms or waiting for medication to trickle down. More power to the facilities so to speak.
Role of digital health
When I asked him why he chose an administrative assistant over a clinical assistant? Yes, he had limited resources and could only retain a records keeper who could double as a cleaner. But he also mentioned that record keeping was crucial even in the current working conditions. Why? Forget the bigger picture of the data informing statistical analysis and surveys. It was this information that he would use in planning – which medicine or diagnostics was required and how much.
The seemingly optimist understood the importance of records and could extrapolate it to digital health records. The details of the Digital Health Act were lost to him. Certainly, they sounded interesting from digital superhighway to e-health and e-waste, he couldn’t wait to see its implementation. For now, he knew that he needed evidence to make a case for his patients, facility and himself.
Therein lies the significance of these two acts.
The Digital Health Act and Facility Improvement Fund are necessary to grant medical staff like this clinician and many others like him, a degree of autonomy. And he can infer that these would make a big difference.
Such autonomy is the key to local decision-making based on the awareness of the unique needs, and specific histories of the various communities which make up our beloved Republic of Kenya.
Follow UHC conversations weekly on one Health Lens podcast
Dr Wangari is a medical doctor; [email protected]
