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Governance issues that spell danger for health initiatives
Universal Health Care (UHC) cards at Ichamara Health Centre in Nyeri County on June 10, 2019.
The centerpiece of the Universal Health Coverage (UHC) initiative launched by President William Ruto on October 10th, 2023 is the Primary Care Networks (PCNs) whose spine is the Community Health Promoters (CHP), a network of local primary care service providers selected from within the communities that will form the critical node linking the health provision systems and the public.
Armed with a toolkit containing some basic digital tools like a thermometer, a blood pressure machine and a digital device that records, stores and transmits patient data, these volunteers will help in the promotive and preventive programme that aims to detect health issues early and manage minor ones at the community level. Each promoter will be responsible for monitoring the health status of each person in 100 households.
The CHPs will be expected to interact with families to inter alia, identify health needs, provide health education and information, identify signs and symptoms of diseases, manage minor ailments like diarrhoea and refer individuals to health facilities for more specialised care. It assumed that most of the CHPs have been trained to execute this assignment.
On the face of it, the planning and rollout of the project is laudable. It is anchored in the National Health Policy (2014 – 2030) the National Health Sector Strategic Plan (2014 - 2018, 2019 - 2023) and the Kenya Health Financing Strategy (2018 - 2022). It is enjoying strong presidential support and, ordinarily a strong contributor to success of government initiatives. The activation of 100,000 CHPs during the launch has been commended as a powerful statement of intent on the part of the government to deliver on its campaign promises.
However voices are being raised about the chances of its success given the many governance gaps that have not been addressed in this and many other aspects of Kenya’s health delivery systems.
At a recent workshop moderated by governance experts from the African Health Governance Institute (AHGI), it emerged that the provision of health services (which is a fully devolved function), is hobbled by a myriad of governance issues.
The participants, who included members of County Executive Committees, Chief Officers and technical experts from USAID and AMREF, intimated that the implementation of Primary Health Care programme could be undermined partly because county budgets were not prepared to accommodate the accruing cost of consumables required to replenish the PCN kits. The fact that this critical sustainability concern had not been exhaustively discussed and mitigated at the planning stage is a big governance issue.
It was also not evident that the programme structure considered the diversity in the health priorities of each county and the need to be context specific. The CECs present indicated that they had not been involved in the planning phase of the PHC project.
This governance challenge stems from the lack of clarity around decision-making processes in the health sector generally. These processes must be streamlined to ensure prioritisation, coordination and sustainability.
Other instances cited with regard to the lack of governance in the PCN programme included the unco-ordinated training and deployment of county health teams, lack of clear demarcation of the national and the devolved functions in health with regard to the establishment of primary health care and lack of decision-making autonomy by the Governors, as the county bosses.
If they had been involved, the planning and execution of the project could have benefitted from learning and embracing other unique, county-specific governance structures in the counties that had worked well as promoters of PHC. This is true even if these have not been legally provided for. A one-size-fit-all solution was unwieldy and unsustainable in counties with varied priorities — from maternal, child health and nutrition issues; to cancer treatment and trauma; diabetes, hypertension and other non-communicable diseases; HIV and TB.
Some examples of unique responses mentioned included the Mashinani development committees in Laikipia County, the El Muron initiative in Turkana Country, and the CSOs round table in Kilifi County. These local alternatives deployed governance structures that are community-driven and are more representative of the people; strongly holding the governments to account for the delivery of necessary services.
The AHGI policy and advocacy technical lead, Dr Nelly Bosire, underscored the fact that the gaps in the PHC project had the potential to undermine an extremely important initiative with huge potential to make a transformational impact towards the provision of high-quality, equitable and affordable health care for all.
Fraud an illegalities
She said that it was the inability or unwillingness to address governance issues that gave rise to fraud and illegalities like the recent allegations regarding NHIF reimbursements to private hospitals; or requests by some Governors to have their county referral hospitals converted into parastatals, in order to benefit from more funding necessary for enabling their function. If all those responsible were committed to upholding proper governance protocol, then such issues could be avoided.
At the county level, it was crucial to involve other county departments to achieve a common understanding that optimal health service delivery relied on other sectors like water, agriculture, and education for success. County assemblies too needed to be brought into the conversation because they played a key role in budgetary allocations, and by extension in the sustainability of the projects.
- The writer is a communications and media consultant. [email protected]
