Taskforce unearths a 'sickly' healthcare system in Mandera

A dysfunctional governance structure; absence of the county's own health policy, strategic plans and legislation guiding investment in health; a health law that is largely flawed; and a public healthcare system that is not connected to the communities it serves, with all facilities operating boards and committees.

These are some of the things that a task force found to be wrong with healthcare in Mandera County.

The task force, led by Prof Khama Rogo, has exposed the rot in the Mandera health sector and proposed quick resolution for better services.

The much awaited task force report on health reforms leaves Governor Mohamed Adan Khalif with a ‘lot’ to do to improve services.

The report, released on Monday, paints the picture of a sick healthcare system that is in dire need of resuscitation for residents to enjoy the fruits of devolution.

The task force noted that despite the county administration making some strides in the past 10 years, health services were below expected standards.

It was observed that the Mandera County healthcare narrative remained largely curative, which needed to change for the county to realise the goal “where every household is identified, reached and served with dignity”.

“This can only be achieved when the county prioritizes investment in Primary Health Care (PHC) which will reduce congestion in the secondary health care facilities,” Prof Rogo said.

It was observed that the Mandera County Assembly passed a Health Services Act in 2019 that is flawed and difficult to implement.

The County Health Management Team (CHMT) is bloated, with no clear terms of reference, resulting in officers with no role, yet key programmes are not functional.

The same CHMT developed the Annual Work Plan without involving the community, facilities or sub-county teams’ input. The same work plan never determined the budget process and the allocations were determined by the treasury chief officer.

The Health department is also poorly financed, according to the task force, and in the 2021/2022 financial year, the department only received 22 per cent of the total county budget.

Some 26 per cent of the health department budget went to development, with 74 per cent going to recurrent costs.

Human resources for health gobbled 46 per cent of the recurrent budget while health products and technology received 13 per cent, leaving only one per cent to support preventive and promotive health service delivery.

The county health department underperformed in critical revenue mobilisation such as all schemes of the National Health Insurance Fund (NHIF) including Super cover, Linda Mama and EduAfya claiming Sh50 million in the last financial year.

Private health sector claimed Sh295 millions in the same period.

Operational inefficiencies, poor empanelment of public health facilities and low NHIF membership were cited as causes for poor revenue mobilisation.

Prof Rogo questioned why it remained difficult for a resident from the county to sell a goat to cover his family for a year under NHIF.

Mandera is yet to pass legal provisions to guide collection, retention at source and use of user fees at Level Four and Five hospitals.

Many health facilities built in Mandera are not operational because they did not meet the required standards, the task force found out.

“There has been a huge focus on the construction of health facilities but some of these facilities are either partially operational or not complete. Many structures built as far back as 2014 are still non-operational because they don’t meet the standards and needs of the intended purposes and users,” Prof Rogo said.

At least 15 facilities built under Governor Ali Roba’s reign between 2013 and 2022 remain nonfunctional.

Mandera East has six nonfunctioning facilities, Lafey has one, Mandera North has six, Mandera West has three, Mandera South has three while it is only in Banisa and Kotulo that newly built facilities are operating.

It was reported that the infrastructure norms and standards were never followed and user department heads were never consulted.

“The Public Health department, which is mandated with overseeing planning, including plan approvals, inspection, supervision and ascertainment of the fitness of these buildings were not involved in most of these projects. This has resulted in stalled projects and unfit structures that do not serve the purpose of the intended,” read the report.

It was revealed that Mandera County Referral Hospital is considered a Level Five referral facility but it is still registered and operates as a Level Four hospital in terms of the scope of services.

Most of the sub county hospitals in Mandera do not meet the standards and norms of a Kenya Essential Package for Health (Keph) Level Four despite upgrading of these facilities in the past 10 years.

Banisa, Lafey and Kutulo sub-county hospitals are examples of health facilities that do not meet the standards for Keph Level Four facilities and require substantial investment.

Most facilities in Mandera were built where there are no supporting amenities like water, electricity, good road network and security, making it difficult to operationalise them.

Only 38 per cent of Level Two facilities and 46 per cent of Level Four facilities have reliable water sources while availability of electricity was also low. None of the facilities have internet connectivity while none of the Primary Health Care facilities have staff housing.

The Mandera County Government procured and distributed modern medical equipment to all health facilities in the last five years but there was no standardisation of specifications to inform investment in equipment that could serve the users in remote locations.

“Some equipment remained unused while some were obsolete and littered the hospital yards and stores. The laboratory and radiology units are literally a “United Nations of Equipment” making purchase of consumables a nightmare,” reads the report.

There is no maintenance plan for medical equipment in Mandera including cold chain equipment at all levels and laboratory equipment are never calibrated for more than a year.

The team found out that radiology services are not available at Banisa, Lafey and Kutulo sub-county hospitals, while at Mandera North and West sub-county hospitals, the radiology units have never been operationalised because the building does not meet the standards on a radiation unit.

Poor asset inventory management was reported across the county and even the Mandera County Referral Hospital lacked an asset inventory.

It’s not all doom and gloom, however. Mandera has increased the number of health facilities from 54 in 2013 to 112 by last year, which has reduced the distance covered by residents when they seek medical services.

The task force observed that specialised services such as renal, ICU, diagnostic services (CT scan and Laboratory) have expanded at Mandera County Referral hospital.

Functional oxygen plants have been installed at the referral hospital and at Elwak sub-county hospital.

The maternal mortality rate has reduced from 3,795/100,000 live births in 2013 to 385/100,000 live births, according to Kenya Population and Housing Census of 2019.
Skilled delivery has increased from barely 39 per cent in 2013 to 55 per cent while deliveries in health facilities have grown from 36 per cent to 50 per cent as the number of stunted children fell from 26 per cent to 21 per cent.

Comprehensive specialised services in Mandera are weak and only offered at the county referral hospital where 10 out of the 11 consultants are based, an indication of poor management and deployment of specialists.

“Services such as orthopedic and trauma are rudimentary and non-existent in most of the sub county hospitals. Physiotherapy, dental, eye, ENT and ICU services are sup-optimal in the county referral hospital and lack in most of the Level Four facilities across Mandera,” Prof Rogo revealed.

Most locals attributed poor health services in the county to the disrespectful attitudes of healthcare workers, long patient queues, lack of diagnostic radiology equipment and lab tests especially in primary health facilities.

High rate of misdiagnosis, inappropriate prescription of drugs and frequent stock out of essential drugs and poor emergency and referral system structures are some of the reasons keeping locals away from public hospitals.

Mandera still needs more health workers despite increasing the number from 115 in 2013 to 1227 to meet the UHC goal.

The task force found out that the recruitment process of health workers in Mandera was disorganised, unresponsive to needs and was tainted by political influence and clannism rather than technical competence and merit.

Mandera county lacks a clear policy and plans on staff training and opportunities for professional advancement.

The task force also found out that there is no Electronic Medical Record (EMR) system in all the Level Four and Level Five facilities with the exception of Elwak sub-county hospital.

At Elwak hospital, the EMR is nicknamed the Elephant and is privately managed, costly and lacks interoperability with the Kenya Health Information System (KHIS).

While pledging his commitment to implement the task force recommendations, Governor Khalif said since the onset of devolution, Mandera has achieved a lot.

“We have more healthcare workers and facilities now than before. In addition, many of our young men and women have graduated from colleges in the last 10 years, creating a significant pool of healthcare professionals we can tap into,” Mr Khalif said.  

However, the county boss noted that despite noticeable progress in the last 10 years, Mandera is yet to reach the level it deserves.

He said the teething challenges Mandera faces cannot be solved in a day.

“These are not small challenges and cannot be solved by tinkering around the edges. Instead, they require bold and innovative solutions, which is precisely what the Health Reform Task Force has recommended,” he said.

Mr Khalif appealed for support from the national government in streamlining the health sector.

“To drastically improve the low health indicators in our County and reduce the burden of healthcare costs from our neighbors, we need support from the national government and development partners in implementing the Task Force recommendations and developing the necessary health infrastructure to deal with cross-border disease outbreaks,” he said.