Cynthia Khamala Wangamati and Ruth Prince, October 2019
Kenya has recently made high-profile political commitments to achieving universal health coverage (UHC) nation-wide by 2022. This move offers our research team a chance to follow developments, engagements and debates about UHC in Kenya, as they unfold. In December 2018, Kenya´s president, Uhuru Kenyatta, announced plans to “pilot” UHC in 4 of the country´s 47 counties, by making health care free in all government health facilities for a period of one year. On 13th December 2018, he launched the universal health coverage “pilot” project, dubbed Afya Care – Wema Wa Mkenya, stating (1), “Starting now, all Kenyan residents in the four counties with a UHC or the Afya Care card will have access to free health services across public health facilities.”
The UHC initiative is part of the President´s “Big Four Agenda”. Rolling out UHC in Kenya is to be achieved through two phases. The first, “pilot”, phase, provides access to free health services across public health facilities in four of Kenya´s 47 counties: Kisumu, Machakos, Nyeri and Isiolo. This pilot phase will “provide lessons” to be used in scaling up UHC in the remaining counties. The extension of universal health coverage to the entire country by 2022 forms the ambitious second phase of the program. According to media coverage, the UHC initiative is “expected to herald the transformation of the country´s health sector, which is marred by poverty and lack of medical insurance” (2). Since there is, as yet, no official national policy document on UHC, the “journey towards UHC”, as it is described, is intentionally constituted as a realm of experimentation.
Before the launch of the pilot UHC project, many of Kenya’s counties had been experimenting with various health insurance models for extending financial and social protection to the poor and vulnerable. Meanwhile the national government had set up a technical expert working group to assess the feasibility of an insurance model based on the already-existing national health insurance scheme (the National Hospital Insurance Fund, NHIF). However, accusations of corruption, which emerged in 2018, raised questions about public trust in this institution. It is perhaps for this reason that President Uhuru announced the UHC pilot as constituting “free health care” through the possession of a “UHC card”. Reference to health insurance was left out of this model, despite efforts to extend health insurance coverage and a raft of policy documents (3, 4, 5).
Given the government´s earlier emphasis on a health insurance model of financial protection for UHC, the announcement of UHC as being “free health care” – effectively the provision of free health care at the point of contact – in government health facilities, came as somewhat of a surprise to the local government officials tasked with implementing UHC. Although they generally agreed that UHC is a “good thing”, as one of our informants told us, “before, people could not afford health care and were just suffering at home”, these civil servants were given little time to make preparations for the huge increase in patients coming for free healthcare at public facilities when user fees were removed in December 2018. The delivery of medicines through the parastatal Kenya Medical Supplies Agency (KEMSA) initially began well, but laboratory services quickly became handicapped by problems in supply chains of reagents. While patients received free health care, they faced long waiting times for consultations, laboratory tests, radiology services and operations. By May 2019, supplies of medicines and provision of some laboratory services were dwindling, forcing patients to use private pharmacies and laboratories if they could afford them. In Kisumu County, health workers have been overwhelmed by patient numbers. During 2019, strikes by health workers demanding better pay and conditions of work draw attention to the challenges of rolling out universal health coverage under conditions of austerity (6, 7). Nurses strikes, lasting from July to October 2019, have paralysed services, raising questions about the meaning of UHC.
In Kenya, everyone agrees that UHC is a good thing as it directly addresses lack of access to affordable health care and financial protection (of the poor). The launch of UHC has generated an important national political debate about relations between poverty, health care and the state responsibility for citizens. What is unclear is the direction in which UHC is heading, and the destination of current experiments with UHC. Even those most closely involved in implementation have little information about what will happen next.
This piece was written by Cynthia Khamala Wangamati and Ruth Prince. Anthropologists Ruth Prince and Jacinta Victoria Muinde have been closely following developments in Kenya, following civil servants tasked with piloting the UHC experiment, and conducting interviews with NHIF officials, NGO staff, and health workers as well as ordinary citizens and their families.
Sources:
- Mwangi, D. President Uhuru Launches Universal Health Coverage Programme Kenyans.co.ke, 14 December, 2018. https://www.kenyans.co.ke/news/45270-residents-dangerously-siphon-fuel-after-tanker-overturns-video (accessed 26.07.2018].
- Kahongeh, J. Universal Health Coverage: What you need to know. Daily Nation, 4th December 2018, https://www.nation.co.ke/news/Universal-Health-Coverage-explained/1056-4895006-vclblfz/index.html (accessed 26.07.2018].
- Barasa E, Rogo K, Mwaura N, Chuma J. Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage. Health Systems & Reform. 2018;4(4):346-61.
- World Bank. Improving Health Care for Kenya’s Poor. World Bank News, 28th October 2014, https://www.worldbank.org/en/news/feature/2014/10/28/improving-healthcare-for-kenyas-poor [accessed 27.07.2019].
- Njuguna, D, Wanjala, P. 2019. A Case for Increasing Public Investments in Health: Raising Public Commitments to Kenya’s Health Sector. Ministry of Health 2019 http://www.health.go.ke/wp-content/uploads/2019/01/Healthcare-financing-Policy-Brief.pdf. [accessed 26.07.2019].
- Ojina, E. Doctors’ orders: A bitter pill for Nyong’o as medics down tools. Daily Nation, 8th October 2019
- Cholera ravages Kisumu County as medics’ strike bites. Daily Nation, 26 September 2019, https://www.nation.co.ke/counties/kisumu/Cholera-ravages-Kisumu-as-medics-strike-bites/1954182-5288122-4h9x5c/index.html