Background
To ensure equity and provide financial risk protection in accessing essential
health services, low and middle-income countries have adopted different approaches.
The approaches are largely based on learning from best practices and gradual
strengthening of their health systems. This paper provides a descriptive analysis of
health financing and health workforce, and key policy strategies or reforms in Kenya
over the past decade. Summarizing key reform experiences in China, policy options are
proposed to Kenya in its effort to achieve universal health coverage.
Methods
This is a mixed methods descriptive study, utilizing both quantitative
(documents and literature review), and qualitative (in-depth interviews) data collection
techniques. Health expenditure and household expenditure data were retrieved from
Kenya National Health Accounts 2001/02 to 2012/13, and Kenya Household Health
Expenditure and Utilization Survey, 2013 respectively. Indicators including gross
domestic product (GDP), the number of registered health workers, and the number of
health professionals undergoing training were extracted from Kenya Bureau of Statics
reports. Thirty-five in-depth interviews were conducted with key informants in Kenya
to understand key health financing and health workforce reforms over the past decade.
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Based on extensive literature review and nine in-depth interviews with health financing
and health workforce experts, reforms experiences in China were summarized. The
summary of Chinese health financing and health workforce reforms provides a basis for
recommending policy options for Kenya. The summary is not intended to give a
descriptive analysis of health financing and health workforce dynamics in China. A
realistic review guided the authors’ summary, and it is not claimed to be extensive.
Results
A large portion of Kenya’s total health expenditure is from out-of-pocket (OOP)
payments, with households accounting for up to one-third. Public health expenditure
trends have experienced fluctuations, remain stagnant, and low by regional standards.
Most donor funds are off-budget and are a major driver of fragmentation in pooling of
funds. Over the past decade, the government has taken measures to increase the share of
expenditure on primary health care. Health Sector Services Fund (HSSF) was introduced
to ensure timely flow of finances to facilities. However, the implementation of the policy
is challenged by both allocative and technical inefficiencies. Expansion of National
Hospital Insurance Fund (NHIF) among the informal sector workers remains a major
challenge. The government has shown efforts to subsidize health insurance premiums
for the poor and vulnerable through the health insurance subsidy program. The
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program is still in the pilot phase and highly funded by donor contributions, bringing
into question its sustainability.
Training of more health workers might not be Kenyans top priority. The skill mix
among health workers is inadequate as evidenced by the high proportion of nurses
compared to physicians and clinical officers. There is a spatial distribution of health
workers in poor marginalized areas. Measures to recruit and retain health workers in the
public sector have achieved minimal results at best.
Conclusion
The current pattern of health spending presents three main challenges. (I) OOP
payments have increased the burden of care on households and are inequitable,
inefficient and a barrier to access by the poor; (II) Most donor funds are off-budget. The
donor funds undermine strategic prioritization, are disease focused, and rarely support
system-wide health system strengthening; (III) Financial risk and income crosssubsidization
are undermined by OOP payments. Policy reforms must aim to strengthen
revenue collection, increase government health expenditure, reduce reliance on out-ofpocket
payment, strengthen prepayment mechanisms, integrate donor support, and
address allocative and technical efficiencies within the health system. Key lessons from
China include: government leadership in social insurance coverage expansion,
responsiveness to population needs in designing health insurance packages, and
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provision of both supply and demand side incentives to increase health insurance
population coverage. Kenya should adopt a pragmatic approach to providing free health
services at the primary health care level. China experiences show that a mix of
interventions in reducing out-of-pocket payment is more sustainable.
Health workforce challenges lie in the geographical distribution of health
workers across Counties, recruitment and retention of health workers in the public
sector, skill mix of deployed health workers, inadequate quality assurance in health
workers training, and absenteeism. The current trends in health workers’ dynamics
increase inefficiency in the health system and widen inequities in the provision of
quality health services. Lack of rigorous research to provide evidence to policy makers
on the best incentives to motivate health workers makes most of the strategies
unsustainable and ineffective. Key lessons from China include strengthening of health
workforce at the primary health care level. The strategies of primary health care
strengthening include targeted recruitment of new graduates, providing incentives for
experienced health workers to practice at primary health facilities, continuous learning
through collaborations with higher levels facilities, and merging of health professionals
training institutions to improve the quality of training. China’s regional approach to
addressing health workers shortages is a good model for Kenya. Poor regions must be
supported financially by the national government and development partners. Increased
investment must be accompanied by measures to address inefficiencies and leakages