The effect of COVID-19 has adversely affected the provision of key services by the government. In the health sector, the pandemic has exacerbated the historical challenges affecting the sector including insufficient health budget, weak relation between the medical personnel and the county government, insufficient medical supplies and poor health infrastructure among others. Universal Health Care (UHC) was rolled out to all counties in January this year after a pilot was conducted in 4 counties in 2018/19 (Machakos, Nyeri, Kisumu & Isiolo). Through UHC, the government aimed to strengthen health systems with emphasis on community health services and primary health care systems, ensuring availability of essential commodities and basic equipment in health facilities as well as removal of user fees in level 4 and 5 public health facilities. So, how has COVID-19 affected the provision of UHC, and how best can the government capitalize on this pandemic?
Universal Health Care
As described in the Kenya UHC Policy of 2020/23, UHC is a health system that ensures all Kenyans have access to the needed health care services without the risk of financial catastrophe.
In Kenya, human right to health is enshrined in the 2010 Constitution, the Kenya Health Policy 2014-30 and several other pieces of legislation. Since health is a devolved function, the Fourth Schedule of the Constitution provides for the distribution of health functions between national and the county governments.
For UHC to be implemented effectively, the national government – through the Ministry of Health – entered into Intergovernmental Partnership Agreements (IPAs) with county governments. The agreement spelled out both the roles for the two levels of government, and the areas for prioritization for investment based on lessons learnt from the pilot conducted in 4 counties.
Under the IPAs, the county governments are required to commit an annual minimum allocation of 30 percent of their budgets to health, and progressively increase it. The national government committed to increase county allocations for the supply of essential medicines and medical supplies including laboratory commodities. The two levels of government also agreed to recruit additional skilled human resources, and also have joint investments in community health services to ensure success of primary health care.
However these IPAs were compromised by COVID-19. The report from the Senate Committee on Health and the Council of Governors in May of this year noted significant reprioritization of UHC resources, to address the pandemic.
COVID-19 is exposing the weakness in the health systems
In Kenya, the first case of COVID-19 was confirmed on March 12th by the Ministry of Health and by August 4th, all the counties had reported the spread of the virus to their respective counties. This has stretched the existing resources including medical equipment and physical structures like isolation centres, testing kits and laboratories. Because of this, health budgets had to be reprioritized.
According to the Budget Policy Statement 2018/19, National government UHC plans for 2017-2022 included the construction of 21 additional hospitals equipped with surgical theatres, radiology and dialysis Equipment, construction of 10 referral hospitals, 50% reduction in out-of-pocket medical expenses and achieving the Universal Health Coverage with target of 85% in 2020, 99% in 2021 and 100% in 2022. These projects were put on hold according to the report by the Health Senate Committee.
Yet COVID-19 containment measures, mass testing, treatment and isolation measures for those who have tested positive, exposed the weaknesses in the Kenyan health system. Following the devolution of the health system in Kenya and introduction of UHC, it was expected that health systems would improve. It was evident that the country was unprepared to respond to the COVID-19 pandemic: this was characterised by lack of capacity to conduct widespread testing, insufficient hospital capacity with only 6,898 isolation beds available against the prerequisite of 30,500 isolation beds (Council of Governors (COG)), equipment shortages such as; testing reagents, Personal Protective Equipment (PPEs) and laboratories. As of June, the office of COG noted that only 12 counties had at least 300-beds that can be used as isolation facilities in the treatment of coronavirus.
Some of the key elements vital to the health system in Kenya affected by COVID-19 include;
- The government budget formulation and spending has been influenced by the outbreak of the virus. It led to the introduction of three supplementary budgets, all of which had UHC budget cuts and the money redirected to address the pandemic. Additionally, according to the National Treasury, external funding support towards interventions such as UHC, malaria and tuberculosis had reduced significantly, an indication that development partners had withheld or reprioritized funding for various interventions as a result of the outbreak of the virus. This resulted in a budget cut meant for country roll-out of UHC amounting to Kshs. 9.4 billion and further Kshs.1.9 billion diverted to hiring more health workers from the initial budget of Kshs. 26.3 billion in FY 2019/20(National Treasury).
- Equity in access to quality health systems between and within counties has been weakened by the outbreak of the virus. The intention of the government under UHC was to provide access to affordable health services to all Kenyans including medical equipment to hospitals, however with COVID-19 the inequality between the ‘haves’ and ‘have nots’ was evident in Kisumu and Nyeri. According to Kisumu health department, patients seeking general outpatient services in level 4 hospitals in the county had risen by 120 percent between 2018 and 2019 and as of mid 2020, the number had reduced by more than half. Similar reports were reported in Nyeri. The charges levied by the government for testing and isolation of COVID-19 patients widened the inequality between the rich and the poor which is against the UHC goal.
- The linkage between the health sector and other sectors has been weakened by COVID-19. According to the Kenya UHC policy 2020-30, the government had undertaken a multi-sectoral approach to ensure all Kenyans have access to UHC. These sectors included education, water & sanitation, energy and infrastructure. However, most of these sectors have also been adversely affected by the pandemic measures; for instance the closure of schools which comes along with suspension of school feeding programs resulting to increased malnutrition among children and households that use to rely on the programme. According to the World Food Programme 368.5 million children across 143 countries rely on school meals, with over 770,000 in Kenya rely on the same. Additionally, over 300,000 people have lost their jobs according to the Kenya National Bureau of Statistics Quarterly Labour Force report, due to the slow-down in the economy. This makes it difficult for people to continue paying for their insurance premiums and makes it difficult for the government to achieve the 50 % reduction in out-of-pocket expenditure of the total health expenditure as envisaged in the UHC policy (currently stands at 24 percent)
How best to capitalize upon this pandemic
Given this context, and with a view to enhancing government efforts in addressing the effects of COVID-19 pandemic, the following considerations can help guide a way forward.
- The government should align the spending with locally defined priorities during the COVID-19 period. It is important to align expenditure to the locally defined priorities as a way of reducing corruption and minimizing wastage. To enhance accountability and transparency there should be regular audits on the budgets and spending especially on procurement related to COVID-19 items. The Office of the Auditor General who is the Supreme Audit Institution in Kenya by now should have conducted an audit on the COVID-19 expenditures to enhance the credibility of the oversight and management of funds by the involved government bodies. The Ministry of Health should spend the hefty donations and budget allocations received in line with the set priorities and plans. Additionally, this is the opportunity the government should utilize to expand and equip the existing infrastructures, employ more health workers, and implement projects that complement the priorities outlined in the UHC plans.
- The government should further expand the social safety nets to cover the insurance premiums for the individuals who lost their jobs. An income shock to families can very easily turn into a crisis, especially those living in poverty and the vulnerable group across the country, especially at a time when the regular healthcare infrastructure is already under stress. Currently, the government is providing several social assistance schemes including the Hunger Safety Net Programme (HSNP), the Cash Transfer for Orphans and Vulnerable Children (CT-OVC), the Cash Transfer for Persons with Severe Disabilities (PWSD), and the Older Persons Cash Transfer (OPCT). These programmes should be extended to include those in the informal sector especially who have lost their jobs. Expanding these schemes will enable the vulnerable and affected people to meet their daily needs including access to health, affordable food and housing. This aligns to the core objective of UHC of providing accessible and affordable health services.
- The government should strike a balance in responding to the effect of COVID-19 and providing universal health care to its citizens. Investing in UHC is equally as important as addressing the pandemic. Most of the indicators affected by COVID-19 – overstretched resources and as a result the government introduced counter-measures in response to the pandemic some of which contributes to the success of the UHC. For instance, the government initiative of expanding health infrastructure across the counties and recruiting more health personnel to meet the demand for health care addresses both the effect of the virus as well as attaining the UHC goal.
- The government needs to build a resilient health system that has the ability to absorb disturbance, to adapt and respond with the provision of needed services. This can be achieved by having a dynamic objective of investments and reforms. With the adverse effects caused by the pandemic in the health sector, the government needs efforts to not only restore how the system functioned before the crisis but to transform and fundamentally improve the health system. According to WHO, full implementation of UHC enables a country to have a resilient health system, therefore the government should equally prioritise UHC alongside addressing the pandemic.