A meeting between President William Ruto and a health workers’ union officials on February 14 to plan the takeover of health functions from counties has angered governors.
The meeting, which took place at State House, also proposed the formation of the Health Risk Commission, an independent body that will oversee the management of human resources for health, including recruitment, promotion and the provision of all services within the health sector.
This is seen by the county bosses as an encroachment on the devolved function and they have since warned the national government to stop interfering and frustrating the sector.
During the meeting, Kenya Medical Practitioners and Dentists Union (KMPDU) Secretary-General Davji Atellah and other health experts said the counties’ inability to manage the sector had led to the failure of the health system.
“We have assured the President of our support for primary health care, but only if nurses and doctors are involved. This is the only sector where the government’s bottom-up agenda can be applied,” Dr Atellah said. “If the dispensaries and health centres in the communities are functioning and have enough drugs and staff, then that’s the bottom-up approach. Even with the employment of community health promoters, a lot of cases of diseases that are diagnosed will be nowhere. We need to be serious about the health care we have promised Kenyans.”
In response, the President promised to invest heavily in primary health care and employ community health promoters to provide health care for all Kenyans. Three days after the meeting, President Ruto made a public announcement that he was committed to ensuring access to health care for all Kenyans, regardless of socio-economic status, and that he would recruit 100,000 community health promoters to focus on primary health care.
A letter seen by the Nation shows that the Ministry of Health planned to conduct a sensitisation programme for the promoters on the use of electronic tools and procurement of kits from May 15 to June 20.
The President said the community health promoters will be jointly funded by the two levels of government, with the government paying Sh2,500 and the county paying Sh2,500. The Ministry of Health has already allocated Sh519 million to pay stipends to the health promoters and provide mobile devices to roll out electronic community health information systems.
Currently, the remuneration of community health workers (CHWs) varies from county to county. Some counties have passed legislation formally recognising them and paying them a stipend, as well as providing mentoring and supervision. Others only pay for their National Health Insurance Fund accounts, while others provide nothing.
CHWs provide essential community health services such as improving access to health products and services, maternal and child health, nutrition, family planning, disease prevention and management, and promoting healthy behaviours.
The Ministry of Health has since written to development partners asking them to quickly train the health promoters. These are the same partners that have been working directly with counties to support CHWs’ activities.
Two months after the meeting, the President ordered the reconstitution of the Kenya Human Resource Advisory Council to address the counties’ health workforce challenges. He said the council was already provided for in the law and called on counties to nominate members to the board.
The governors say all these moves point to a plot by the national government to wrest health functions from the counties, which they say will be strongly resisted. They have since warned that the national government taking over the training, remuneration and deployment of CHWs, the backbone of primary health care, would be an illegal transfer of constitutional functions.
Council of Governors chairperson Anne Waiguru said in a statement that several areas, including the provision of primary health care, deployment of community health workers (now called promoters), attempted establishment of primary health care networks, creation of institutions and authorities within the sector, and proposed changes and legislation by the Health ministry have severely compromised the implementation of the devolved health function.
“The Council of Governors calls on the Ministry of Health to desist from reclaiming the health function and stop interfering in the role of county governments,” said Ms Waiguru. The Kirinyaga County boss questioned why the Health ministry was interested in building the capacity of promoters without involving counties when the management of CHWs is a devolved function.
“We urge development partners to stop supporting and funding national government ministries and interventions in devolved functions. This (trend) is prevalent in the health and agriculture sectors,” Ms Waiguru said.
Tharaka-Nithi Governor Muthomi Njuki, who chairs the council’s health committee, said the national government should instead provide funding for CHWs as conditional grants to the devolved units.
“Why would you ask the same people who are funding the same activities at the county level to fund the same activities at the national level? If the national government is sincere, they would have asked for additional funding through the counties. We are the custodians of the health budget,” said Mr Njuki.
He continued: “The Ministry of Health is trying to change the dictates of the constitution and want to take away some of our functions through constitutional amendments, but we will not allow that to happen and the counties are united to ensure that devolution and devolved functions are protected from interference.”
The uproar by the governors, the Nation understands, was triggered by a letter from Chief of Staff and Head of Public Service Felix Koskei directing the Health ministry to work with the county governments to fast-track the assessment of all county hospitals. The assessment, according to the April 28 letter, is to ensure that the government has up-to-date data on equipment and human resources in all facilities.
Mr Koskei also directed Health Cabinet Secretary Susan Nakhumicha to liaise with the Kenya National Bureau of Standards and other government institutions to procure 90,000 kits for community health promoters to set up primary health care networks.
“Ensure that the kits are procured and ready before the launch and that all community health promoters are validated,” the letter stated.
KMPDU officials have told governors to stop clinging to a function they have mismanaged for the past decade.
“Why would they want to cling to it when they cannot manage it? This is dishonesty on the part of the governors. Devolution of health was the biggest mistake that ever happened to this country. It has just been one problem after another. Can you show us what you have done so far?” Dr Atellah asked.
The counties, he said, have not employed any health workers for over 10 years, have accumulated a debt of over Sh200 billion with the Kenya Medical Supplies Authority, and a number of county laboratories are not operational.
“Health should be managed and budgeted for like our country’s military. This will relieve the counties from having to borrow from the banks. Health workers will be employed and we will give Kenyans the best service,” he said.
“As it is now, the health service in this country is worse than it has ever been. The counties are in debt, they get loans from the banks at higher interest rates and they use a lot of it to pay salaries. They are unable to employ doctors and nurses because they do not have the financial muscle,” Dr Atellah said.
He urged the President to set up the Health Risk Commission and allocate funds to it to deal with all issues in the health sector.
“This will ensure that there is money for employment, drugs and utilities. In the last 10 years, nothing has happened in the sector except the building of infrastructure. The buildings the governors are competing to build have no doctors, no nurses, no drugs, they have never used the money to equip the existing hospitals,” Dr Atellah charged. He said money meant for the health should be managed separately, citing the education and military sectors, which have their own budgets.
“If you look at the education sector, the Teachers Service Commission has its own budget, there are monies meant for recruitment and promotion of teachers and procurement of materials. It is independent and functioning. For health, money is given to the counties,” he said.
Kenya Union of Clinical Officers Secretary-General George Gibore said if governors do not want to let go of the health budget, they should reflect on what’s happened in the sector and whether this is the direction the country wants to take.
“We know the challenges we have gone through in the sector over the last 10 years of devolution. Do we really want to see more of the same? What can be done to provide a solution and ensure that we strengthen the health system to achieve our goal of universal health coverage? We have had enough,” said Mr Gibore.