What you need to know:
- We shouldn’t pursue the American healthcare model. America is a rich country with less than 10 per cent of its population uninsured (2016 data), compared with Kenya, where more than 95 per cent are uninsured.
- From a good public health system, we can deal with many other issues that if not dealt with, become expensive health matters. These include nutrition as a strategy to stem stunting that leaves many people impoverished; lifestyle that is bringing new health problems through non-communicable diseases like diabetes, coronary heart diseases and hypertension, three of the diseases that drain family health budgets
- The national government should therefore focus on specialist centres of excellence and legislation for building community hospitals and primary care centres with clear specifications and standard operating procedures.
This is the third of four articles addressing President Uhuru Kenyatta’s “Big Four” legacy agenda. Today I focus on affordable healthcare.
When the President announced this agenda last December, I wanted to know the correct understanding of the term affordable healthcare. My questions were: Will it meet the hopes that citizens have on access to healthcare? Do citizens know what to expect?
I sought answers to these questions from would-be beneficiaries. The expectation of many ordinary citizens and several experts is that the system will be a universal healthcare system that they think will provide greater financial protection to every citizen.
However, the words that the President used were affordable healthcare, which is significantly different from universal healthcare. The term affordable healthcare gained greater currency in the United States during President Obama’s tenure. It has the element of co-pay or coinsurance with the state, hence the deductibles (based on income levels) from one’s income towards an insurance policy. It is the reason the rich felt that they were subsidising the poor.
According to the World Health Organization, “Universal health care (also referred to as universal health coverage, universal coverage, universal care or socialized health care) usually refers to a health care system that provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.”
We shouldn’t pursue the American healthcare model. America is a rich country with less than 10 per cent of its population uninsured (2016 data), compared with Kenya, where more than 95 per cent are uninsured. Kenya does not even feature in the top countries with either public social or private insurance. Indeed, the US is the only country with more than 50 per cent of its citizens with private health insurance.
With our unique background and problems, we must innovate within our context. That is why I am rooting for universal healthcare (UH) and as such, my proposals will assume that what the Kenyan government will implement is UH.
With this definition I am in no way advocating to fight health insurance services in Africa. The risk of attempting to bring the private sector into universal health is that they will have too many conditions. The American Affordable Care Act made an attempt to prohibit insurers from denying coverage for pre-existing health conditions, but the private sector will still find a way to discriminate since their motive is profit.
PUBLIC HEALTH SYSTEM
Developing a good healthcare system starts with an efficient public health system and deals with the root cause of many health problems we face today. According to the Centers for Disease Control, a good public health system entails:monitoring health status to identify and solve community health problems; diagnosing and investigate health problems and health hazards in the community; informing, educating, and empowering people about health issues; mobilizing community partnerships and action to identify and solve health problems; developing policies and plans that support individual and community health efforts; enforcing laws and regulations that protect health and ensure safety; linking people to needed personal health services and assure the provision of health care when otherwise unavailable; assuring a competent public and personal healthcare workforce; evaluating effectiveness, accessibility, and quality of personal and population-based health services; and researching for new insights and innovative solutions to health problems.
Although we have different regulatory bodies, people’s health is violated on a daily basis. Yet, someone is earning money for not doing their job to secure the health of the people. For example, several motor vehicles across Africa continue to spew carbon monoxide into the air, causing particle pollution in the air we breathe. Several studies (see for example Cancer Research UK) show that such pollution causes cancer. Cancer alone has impoverished many families trying to pay for the care of their loved ones.
From a good public health system, we can deal with many other issues that if not dealt with, become expensive health matters. These include nutrition as a strategy to stem stunting that leaves many people impoverished; lifestyle that is bringing new health problems through non-communicable diseases like diabetes, coronary heart diseases and hypertension, three of the diseases that drain family health budgets; hygiene to eliminate opportunistic common diseases like scabies, chronic diarrhoea, trachoma, athlete's foot and more that are costly to treat; preventive care where public health officials proactively spray breeding grounds for mosquito to avoid malaria (this used to happen sometime back but was abandoned).
COMMUNITY HEALTH SYSTEM (CLINICS)
Community health systems, when working efficiently, play a key role in decongesting referral hospitals. At least every Ward or sub-location must have a functional primary care facility equipped with an ambulance to transport complex cases to advanced centres. For greater efficiency, a comprehensive study on the disease profile should be done in order to provide relevant resources since some diseases are only common to some areas of the country.
Citizens lost trust in community health because of poor governance, where medical personnel stole medications to sell to the very same beneficiaries. To manage these centres, technology must play a key role in developing the supply chain of medications. Several countries now use a combination of artificial intelligence, Internet of Things, and big data analytics to monitor such critical facilities and contain the costs of ever-evolving health needs. The price of medicines must remain an open data to whoever is concerned with efficient operation of the systems and the general public. Relaunching community health centres without leveraging technology will be a waste of resources.
EMERGING CARE MODELS
The efficiency of the public health and community health systems should reduce the burden of referral hospitals. There are emerging innovative care models that expand primary care to create a facility to deal with patients with what McKinsey in its study Meeting healthcare’s evolving needs calls “proactive, systematic, and intensive care for people with long-term conditions and complex health needs.” This will basically be a health maintenance of people who would otherwise occupy hospital beds even though their conditions are well understood to be dealt with outside normal hospitals. These include the elderly with multiple long-term conditions that can stay in cheaper facilities than in hospitals.
With hospitalisation, the McKinsey study suggests three models that we can borrow from. These include specialist centres of excellence, perhaps built by the National Hospital Insurance Fund, to cater for the many serious diseases that make Kenyans to seek out-of-the-country intervention. This can be managed through a public private partnership to offer global-standard services that can restore confidence in local curative measures. Even with insurance, our healthcare costs will continue to escalate until we create confidence locally. Existing private hospitals have not seen the entrepreneurial opportunities that exist in healthcare, as they continue to undermine inclusivity in the sector through inflated prices. Some do not even have emergency-room response capability as they are run by cartels in the sector. This has to be disrupted through NHIF interventions if we truly want to see affordable healthcare.
To augment specialised hospitals, each county must have at least five community hospitals dealing with general issues that require hospitalisation like general accidents, maternity and minor surgeries. These, however, must have strong links to specialised centres through e-health as well as collaborations. The success of these community hospitals depends on how much we have learnt from the ineffective referral system in the country that has proven expensive. Since we now have fibre optics across the country, services like radiology report interpretation should be centralised with only technicians at the community hospitals.
THE INDIAN EXPERIENCE
The final model is that of building, as envisaged by McKinsey, more efficient models of planned elective care. Here they discuss the case of Narayana Health in India.
It “is one of the global pioneers of low-cost, high-quality elective care: the organization was set up to provide cardiac care for all, and has used lean processes, new workforce models, and a high-throughput approach to drive down costs while achieving outcomes on par with many developed-world hospitals.
One analysis found that costs at Narayana were 4 to 15 percent of those at a sample of US hospitals (when correcting for wage differentials), and that its 30-day post-surgery mortality rate for coronary artery bypass procedures at its Bangalore hospital was below the average of the sample hospitals.”
There is much we can learn from other parts of the world to develop a more inclusive healthcare system. The elephant in the room is our management structure of the healthcare system. Health services are devolved and this makes it difficult to implement any model without dealing with political issues first.
The national government should therefore focus on specialist centres of excellence and legislation for building community hospitals and primary care centres with clear specifications and standard operating procedures. This is not easy but some of the agenda for the President could be achieved. If we build confidence at the specialised centres and eliminate the need to travel abroad to seek care, we will have achieved much of what the President wants for his legacy.
The writer is an associate professor at the University of Nairobi’s School of Business. Twitter: @bantigito