Introduction
Universal Health Coverage (UHC) in the Kenyan context refers to access to quality health services at an affordable cost, and shields communities and individuals from impoverishment when seeking Health Care. The Kenyan UHC program endorsed under The Big 4 Agenda was actualized in December 2018 as a pilot in 4 Counties in Kenya.
Isiolo County was one of the beneficiaries of the one-year pilot phase of the program. The County covers an area of 25,336 km2 with an estimated population of 287,438 and consists of three Sub-counties namely Isiolo, Garbatulla, and Merti. Isiolo was selected as a pilot County based on its geographical location whose land is arid and semi-arid (ASAL), its low development rate, and the high maternal mortality rate which currently is at 790 deaths per 100,000 population against the national rate of 350/100,000. Most residents are pastoralists who are either, fully nomadic, semi-nomadic, or settled, therefore delivering health care was difficult.
Isiolo County has a poverty index rate of 0.07%, resulting to limited financing forits health care; therefore, affecting health-seeking behaviour. The abolition of user fees at PHC and referral facilities would reduce the level of poverty through medical expenditure. The County had limited health human resource with some facilities having only one nurse manning and attending to the patients.
Map of Isiolo County
IMPLEMENTATION
The principle of implementation of UHC across all the pilot Counties was to offer comprehensive health services for all people in the Counties at no cost. Although there was no guide on the extent and scope of service delivery, the Ministry of Health gave a conceptualized guide to the Counties on the use of UHC funds. In Isiolo, a total of KSh.20,720,797 had been allocated to support Community Services. 30% of the fund is channeled through KEMSA to support CHV kitting and 70% towards CHV training and interventions including supportive supervision and formation of functional community health units. To facilitate basic and specialized services, Isiolo county was expected to get KSh.5,596,625,544. 30% was to be spent on Operations and Maintenance and blood services and 70% was retained in KEMSA for Commodities. KSh.141,145,255.01 was earmarked for health system strengthening with 30% going to Basic Medical equipment through KEMSA, and 70% disbursed in the Counties. However, not all the money was disbursed. Isiolo County registered (90%) 40,000 of the total households and discontinued user fees at level 4 and 5 facilities to enable access to free health care in the public hospitals. The County then got conditional grants for the user fee forgone.
Achievements/ Results of the practice
Increased access to health services in Isi0lo County
Free health care removed the barrier of access by allowing people to get essential services at no cost. This is manifest through the change in uptake of ANC services, increased attendance in the outpatient department, an increase in skilled deliveries, and improved health-seeking behavior.
Construction of new facilities to bring services closer to the citizens.
Ten new dispensaries were constructed: three (3) in Garbatulla Sub-County (Biliqi, Kombola, and Yaqbarsathi dispensaries; five (5) in Isiolo Sub-County (Ngaremara, Noloroi, Lebarsherik, Tuale, and Gotu Dispensaries) and two (2) in Merti Sub-County (Bulesa Goda and Saleti Dispensaries). There was an upgrade of dispensaries to health centers in Merti Sub-County (Bisan Biliqo) and Isiolo Sub-County (Bula Pesa, Eremet, and APU Dispensaries). As a result, the average radius between one facility to the next was reduced from 49 km to 42 km.
Increase in human resources for health by number and skill mix. Primary-level facilities improved from one practitioner to two and some facilities got doctors, and clinical officers while others got nurses. However, challenges of management and transition of the staff took up to two years to be solved when the County accepted to absorb the HRH.
Supportive supervision and coordination were smooth across all facilities. County officers guided, monitored, and evaluated health service delivery even in the marginalized regions of the County. The County did on-the-job training, redistribution of medicine to ensure efficient utilization, and delivering guidelines and SOP to the far flanged Counties.
Improved community health services. Isiolo County currently has 50 C0mmunity Health Units and deployed 760 CHVs and 50 Community Health Assistants (CHAs) serving who are responsible for community health engagement. In 2019, the County partnered with Living Goods, a non-profit organization supporting the digital empowerment of community health workers, to strengthen community health services, and a mark is seen in the digitalization of community health data. Living Goods equipped CHVs with smartphones and tablets to improve on reporting through the Ministry of Health (MoH) data collection tools (MOH513 and MOH514 tools). Isiolo County 760 CHVs were trained on the Basic Module, Integrated Community Case Management of common childhood diseases (iCCM), and Community-based Maternal and Newborn Health (CMNH) as well as on the use of a smart health App.
An uninterrupted and adequate supply of medical supplies
Before the UHC, the KEMSA supply to Counties was erratic. Isiolo had a maximum of KSh.50 million per financial year for procuring supplies. Through the UHC project, Isiolo had an adequate supply of commodities with an order fill rate of over 100 %. KSh.392 million was allocated to commodities.
Challenges
- The implementation of free services resulted in a rise in the overall number of persons seeking treatment. Because there was no corresponding increase in funding, services often degraded in quality, which was the polar opposite of the UHC goal to offer quality services.
- Despite the national government's commitment to the UHC program in the Counties, County Governments made no commitments to the procurement or sustainability services after the shift of UHC from input to output-based financing.
- KEMSA supply for lab reagents was a challenge given the fragmentation in equipment brands which could not all be covered by the reagents being supplied by KEMSA. Later, KEMSA was unable to satisfy the demands of all facilities; what was out of stock in KEMSA including the basic equipment was not supplied to the counties. Currently, the order fallrates go up to 67%.
- After the UHC period the County fell back to the usual erratic supply of medicine despite increasing their allocations to up to 150 million.
NHIF registration numbers in the County are still low. Therefore, the facility benefits less from the NHIF reimbursements. Currently, only 52 % of the Isiolo population has NHIF coverage. County research by the director approximates the potential revenue lost up to KSh.104 million in capitation, Linda Mama. and Edu Afya.
Lessons learned:
- There is a need for more time to be allocated to the implementation of UHC and similar projects. The period for implementation of the pilot phase was short, before the County had mastered the implementation, the allocated period of execution expired hence leaving the Counties on their own.
- There was a need for a linkage between the County and KEMSA. The County fell back into the stock-out challenges they had before the pilot County.
- The need for an alternative financing mechanism for health services became apparent to supplement the government’s allocations for health. This can be made a reality by harnessing private sector capital, having more structured donor engagements, and inventing innovative ways of service delivery.
Sustainability
Since the shift in the mode of implementation of UHC in Kenya from input-based financing (2018 December) to output-based financing (2020-2022), Isiolo County was left with a gap in resources of up to KSh.4,191,489.36 when the pilot phase lapsed.
The lack of a UHC benefit package made the sustainability of services difficult. There was no proper plan for transition regarding forecasting and quantification for commodities. The allocations that the County made for commodities could barely match the funds that had been disbursed through UHC. As a result, stockout of essential pharmaceuticals and non-pharmaceuticals was continuous in lower-level facilities and the county-level facility. The County has a KEMSA debt of up to KSh.78 million.
With the discontinuation of conditional grants for level 4 and 5 facilities, the quality of care reduced in public facilities forcing patients to seek services in private facilities that have an adequate supply. For instance, departments like dental and renal closed down due to the lack of supplies.
For sustainability measures,
- Isiolo County has plans to absorb the UHC contracted human resources for health.
- The County continues to pay stipends for the CHVs to sustain level 1 services.
- The scale-up of UHC took an output financing. Isiolo County registered (50%) 7,808 households for NHIF coverage as indigent through Community level mobilization.
Isiolo County Teaching and Referral Hospital