Friday, 12 April 2013


President Uhuru Kenyatta made a promise that there will be free health services in all Health centers and Dispensaries. In addition to this, he made a further undertaking to scrap off user fees for maternal and child health care.

These, he said, will be implemented within the first 100 days of his tenure thereby putting a definitive date of July 17th for the full implementation.

From the onset, I have to admit that the thought is one that must be lauded. This very system if implemented will be a sure way of making progress towards achieving the Abuja declaration
 of allocating 15% of the GDP to our health needs. The outline of it also gives a hazy conjecture of affordable health services in a country where almost half of its population lives below the poverty line.

We have to explore the details though in order to inform this promise and foster it to better its implementation. The devil, as they say, is in the details.

The background of  free health services speculates that this will bring along an increase in number of users for the service. Extrapolated, this also implies greater coverage of the population and therefore assumes improved outcomes. Therein lie my questions, is it correct to assume all these without evidence? Will increase in the usage of our health facilities be tantamount to improvement of outcomes?

Making one assumption by itself makes us outright 'wishers' adding a second one like we are doing makes us absurdly poetic.

Health delivery has several prongs that are uniquely intertwined. We have the health facilities, medical and surgical instruments, personnel and the patient. A breakdown in any of these important pillars definitely results in deteriorating outcomes.

The importance of the facilities and medical equipment including medications is apparent.
On medical personnel it is imperative to note that while these program targets the health facilities at the community level nothing is so far mentioned about how medical personnel will be addressed to take in hand the assumed increased usage. The assumption that posting health personnel is equal to getting services delivered is at best a fallacious one. This is from evidence. A good example is India, which has at one time reported an absenteeism of 40 % because of low staff morale. This cannot just be wished away. There is need to start talking about incentives to ensure health personnel deliver in these usually far flung areas where they also work away from their families.

As concerns the patient, an understanding of health seeking behaviors is paramount. We need to understand why a mother would prefer a Traditional Birth Attendant rather than go to a hospital. Is hospital fee the only hindrance? Does the Traditional Birth Attendant tender her services for free? Without making our mothers and potential patients have a ‘demand’ for mainstream healthcare, making it free would not bring them to hospitals. This must be combined with concerted efforts to educate them on the need of using those health facilities. A hundred days is barely enough to reach out to a few dozens of people.

With rough estimates, the cost of rolling out this program would amount to approximately 14 billion Kenyan shillings. This will address key areas and concerns for the purposes of starting it. More will be needed however to keep it afloat as the above estimate does not factor in important costs including; staff motivation, payment of the health facilities casual employees and basic facility maintenance.

Another important hurdle that must be overcome is  that of the constitution. The laws of Kenya fully delegate the running of the facilities to be affected by this program to the county governments. In fact they are so powerful that they decide supplies, distribution of employees and even have a ‘mini’ Public Service Commission. The principle of the program dictates, contrary to the constitution a ‘top-down’ flow of implementation rather than ‘bottom-up’ as is envisaged. This is likely to stir up political undertones.

To this end an unsolicited advice is offered to his Excellency. First, that direction would be more important than speed in this one; he should do away with the ‘100 day- self imposed deadline for the sake of a thorough assessment and implementation of this program. Secondly, he should invite all stakeholders to help him achieve this important policy. KMPDU will at all times be more than willing to participate.

After all an attempt to implement such a program with half measures at hand just to beat a self-set deadline will only win a political argument, the problem however will remain largely unsolved.

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