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What county bosses need to rebuild the healthcare industry

  May 8, 2013

Kenya is likely to face challenges as it rebuilds its healthcare system to conform to the demands of devolution and meet the needs of the population.

The anticipated march towards double-digit economic growth is certainly bound to come with increased demand for high quality care from an expanding middle class.

The list of challenges includes country-specific issues such as restructuring to accommodate devolution and universal aspects such as quality, cost and access as well as the high disease burden and the changing patterns of disease.

Devolution of health services is largely understood to mean counties taking up responsibilities to deliver essential health services whilst the central government focuses on policy and regulation.

The division of roles and responsibilities between central and county governments, and equitable resource allocation has the potential to improve health service delivery and enhance accountability.

This potential can only be realised if due care is paid to successful management of the transition process, equitable distribution of resources including use of targeted funding and conditional grants, redefining the role of the government and the National Health Insurance Fund (NHIF) as purchasers of healthcare, strengthening the processes and transparency of the procurement system.

Managing the human resource transition in an equitable and humane manner is critical to the entire process. With the burden of infectious diseases on the rise, hospitals are gradually getting into an overload. There is also a global and national trend in rising non-communicable diseases— both contributing significantly to the economic burden.

The most cost effective way of addressing these issues is to develop a functional public health infrastructure aimed at health promotion and disease avoidance or prevention leaving the medical infrastructure to focus on minimising severity and providing quality care at affordable cost.

Maternal and child health (MCH) requires special mention given the Jubilee government’s promise to make facility-based deliveries free.

The burden of maternal deaths, under five mortality and infant mortality rates are unacceptably high in Kenya. Further complicating and contributing to the problem is the limited breadth and depth of MCH coverage.

The good thing is that programmes to address MCH challenges exist leaving the government with the simple task of finding out what works and rapidly bringing such initiatives to scale.

A key goal of any health system should be to provide safe, high quality care. Challenges in delivering high quality care across the board emanates from the low numbers of human resources for health (HRH) and the high number of unregulated informal healthcare providers.

These include the ‘kiosk’ owner who dispenses over-the-counter medicines and the traditional healers who supplement herbal remedies with mainstream drugs. This has resulted in mal-prescription and over-prescription, particularly of anti-malarials, antibiotics and analgesics.

The low numbers of HRH is largely due to under-investment and poor management of the sector which has in turn led to low numbers at entry, and increased out-migration.

To address this, the governments (national and county) will need to ramp up incentives to attract, train and retain personnel. The healthcare system must also open up to innovation when it comes to training health care workers.

New cadres such as nurse aides, ophthalmic and dental assistants whose emergence arose to perform very specific tasks, have lowered costs and helped improve outcomes in private practice.

Efficiencies have been gained from lower HR costs, greater proficiency and speed resulting from experience and expertise in a small, well defined functional area, and freeing more technically qualified staff to perform other functions.

Quality is further complicated by information asymmetry between the prospective clients (that is, the wider population) and the health care providers. This has resulted in market failure rendering services of the highest quality and best price non-competitive.

The fact that prices are rarely transparent, and that patients cannot assess the quality of services and therefore cannot compare service providers and determine value-for-money have contributed to this sad state of affairs.

To address these issues, the government, as the people’s representative, must focus on effective management of information. A robust platform can be developed with the participation of private sector which allows access to information regarding each institution, health workers, investigations and procedures to help curb malpractice, misuse and abuse of resources.

In the legislative and policy environment the government should lead in the development of protocols for evidence based treatment and rational drug use, policies that improve quality of care and penalise behaviour that leads to delivery of poor quality services.

Regulatory bodies such as the Nursing Council of Kenya, Pharmacy and Poisons Board and Kenya Medical Practitioners and Dentists Board should also be given the teeth to effectively discharge their mandates.

Kenya has also faced a challenge in achieving equity on the universal access front given the inadequacy of physical access and behavioural aspects that affect demand for appropriate care, imbalances in resource allocation to health, and the challenges with HRH.

Challenges relating to the financing of healthcare and in financial risk protection for the masses will be faced due to the dwindling resources available in the face of competing demands for resources, inflation and its effect on spending, and the already high and unsustainable out-of-pocket expenditures on healthcare.

Core to addressing universal access issues will be reorienting our thinking towards equity focused approaches, the gathering and use of data to determine priorities and resource allocation, increasing and targeting public spending on health to improve on quality and efficiency; and to minimise wastage, focus on structuring procurement processes and client management towards methods that are high on economy and effectiveness.

Given the governments leaning towards becoming more a purchaser of health services and less of a provider, it needs to be encouraged to take this a step further by becoming a strategic purchaser.

Its major role will then be to monitor quality, and delist or bar from reimbursement institutions whose practices do not foster the provision of quality services at the best price possible. It will take more than good intentions and lip service to realise the goal of universal healthcare.

Dr. Ngoye is the Director of the Institute of Healthcare Management.


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