Time to safeguard devolution gains in health sector
The 2010 Constitution was a turning point for Kenya. It reconfigured the balance of power by devolving responsibilities from the national government to 47 elected county governments, and recalibrating powers between Executive, Legislative and Judiciary.
In addition, the Constitution strengthened right based approaches to health by providing that every citizen has a right to the highest attainable standard of health.
Countys’ progressive investment in the sector has resulted in improvement of key health indicators. Today, many more Kenyans are able to access high quality health services within their counties as compared to the pre-devolution era.
First, through devolution, access to high quality health services was improved. During the first five years of devolution, county governments heavily invested in developing and upgrading health infrastructure after inheriting some vastly dilapidated facilities from the National government. Today, counties have built and operationalised hundreds of health facilities. In addition, counties have significantly expanded the scope of services. For instance, renal dialysis that was previously only available in a few national hospitals is now provided at county level. Specialised surgeries, cardiology services, neurology are just but a few specialised services that counties have scaled up. The capacity of a health system to effectively deliver services is commonly measured against its capacity to ensure no woman dies while giving life.
The devolution era has yielded significant results in this regard, increasing access for mothers and reducing morbidity and mortality for both the mother and baby. Also, one of the biggest successes of devolving health has been the workforce. Devolution has allowed Kenya to rapidly build up a large pool of highly qualified health workers across all cadres.
In the past 10 years, counties have hired a large number of health workers causing the total workforce to more than double compared to pre-devolution numbers. Between 2016 and 2021 alone, the total number of health workers in counties improved by 61 per cent from 59,726 to 96,453. Today, counties in hard to reach areas have significantly more health workers compared to the pre-devolution period. For example, Turkana had less than 10 medical officers before devolution, a number that has increased six fold to 61 doctors in 2023 .
It is also important to note that through supporting health workers to take further studies, county governments have driven a rapid emergence of health specialists, even in areas where there were none before, which fosters a better skill mix. This has allowed counties to provide a wide range of specialised health services even in areas where these services were not available before devolution. I also note that essential medicines and other medical commodities are central to a good health system. Although county authorities put in effort to ensure all health facilities have adequate supply of medicines and commodities, these efforts are largely hampered by inefficiencies and lack of transparency at the Kenya Medical Supplies Agency (Kemsa). Most counties pay Kemsa timely, but delivery of medicines is done both late and in inadequate quantities.
Fourth, financing health remains a key priority of county governments, with most counties allocating more than 30 per cent of their total budget to health.
In conclusion, I note that gains made under devolution have happened under very difficult circumstances. Health functions were devolved without requisite resources causing huge underfunding of counties. The National Treasury frequently disburses equitable share funds late; and some functions were not fully transferred. As such, there is urgent need to conclude unbundling of health functions, transfer all the remaining devolved functions to county governments, and ensure resources follow functions. The National and county governments also need to strengthen their col-laboration and partnership.
—The writer is Tharaka Nithi Governor and chair, Health Committee - CoG