Policy levers and priority-setting in universal health coverage: a qualitative analysis of healthcare financing agenda setting in Kenya (original) (raw)
Related papers
Universal health coverage(UHC) ensures that all people can access the health services they need, without being exposed to financial hardship. This calls on governments and health stakeholders to build on the political commitment that health is a good investment and reduce the number of people who pay out of pocket for healthcare. This can be said to true of the Makueni UHC policy. In Makueni county, UHC became a reality with the rest of Kenya playing catch up and learning from their journey. While a policy's entrance onto the political agenda is not random, Makueni county has been able to provide UHC since 2016 dubbed, 'Makueni care'. The quest to achieve UHC is explicitly a political process with a variety of strategies to shape organizational change that accompanies health systems reform capitalize on political windows of opportunity. Political change makes it more possible prepare and identify such political windows and pursue policy and legislation change to underpin the health system reforms. This paper uses Kingdon's (1995) Multiple Streams Framework (MSF) to critically analyze the Makueni county UHC policy. First, it will describe the Makueni county UHC policy. Second, is to evaluate and apply Kingdon's MSF to analyze how the UHC policy came to be constructed as a problem and to consider the proposed policy solutions, as well as the surrounding political forces in Makueni county. Third, is to identify the possible notions of policy entrepreneurs and policy windows in the UHC policy in Makueni county. This is a qualitative case study through extensive document review and semi-structured interviews with key informants. Purposeful sampling was used to have the county executive committee member for health, chief officer health, three directors of health, county health records officer and county health administrative officer provide a deeper understanding on how UHC was identified as a problem, what was involved in policy making and the political process.
Strategic Journal of Business & Change Management
Universal health coverage is an important and noble objective for quality healthcare service delivery for all citizens in any country. However, it needs to be anchored on a robust policy framework. Therefore, a strong policy framework is needed to underline the government's commitment towards this initiative. However, it has not been previously established whether health policies as a strategy significantly affects Universal Health Coverage in Kenya. Therefore, the aim of this paper was to establish the influence of health policy and planning strategy initiatives on achievement of UHC in Kenya. The study adopted a descriptive research design targeting UHC stakeholder organizations including the Ministry of Health, public and private social health insurers, donor fund agencies, as well as public and private healthcare providers in the country. From these, a sample size of 234 organizations were selected using mixed sampling techniques to participate in the study. Data was collected through questionnaires and interview schedules. Data was analyzed using descriptive statistics and inferential statistics, that is, bivariate linear regression analysis. The study found that health policies strategy had a significant relationship with the achievement of the Universal Health Coverage in Kenya. This meant that strengthening health policies will lead to better achievement of UHC. The study recommended that policies aimed at the regulation of the health sector to achieve UHC need to be strengthened so as to improve collaboration among healthcare organizations and the achievement of UHC in the country.
Viewing the Kenyan health system through an equity lens: implications for universal coverage
International Journal for Equity in Health, 2011
Introduction Equity and universal coverage currently dominate policy debates worldwide. Health financing approaches are central to universal coverage. The way funds are collected, pooled, and used to purchase or provide services should be carefully considered to ensure that population needs are addressed under a universal health system. The aim of this paper is to assess the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made. Methods An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. Documents were mainly sourced from the Ministry of Medical Services and the Ministry of Public Health and Sanitation. Country level documents were the main sources of data. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. Results The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector. Conclusions The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.
BMC Health Services Research, 2015
Background: Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders' perceptions on the design to inform future development of health financing policies in Kenya. Methods: We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework. Results: The design of a NHI scheme was marked by complex interaction of the actor's understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor's perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government's commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system. Conclusion: The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.
Analysis of Universal Health Coverage and Equity on Health Care in Kenya
Global Journal of Health Science, 2015
Kenya has made progress towards universal health coverage as evidenced in the various policy initiatives and reforms that have been implemented in the country since independence. The purpose of this analysis was to critically review the various initiatives that the government of Kenya has over the years initiated towards the realization of Universal Health Care (UHC) and how this has impacted on health equity. The paper relied heavly on secondary sources of information although primary data data was collected. Whereas secondary data was largely collected through critical review of policy documents and commissioned studies by the Ministry of Health and development partners, primary data was collected through interviews with various stakeholders involved in UHC including policy makers, implementers, researchers and health service providers. Key findings include commitment towards UHC; minimal solidarity in health care financing; cases of dysfunctionalilty of health care system; minimal opportunities for continuous medical training; quality concerns in terms of stock-outs of drugs and other medical supplies, dilapidated health infrastructure and inadequqte number of health workers. Other findings include governance concerns at NHIF coupled with, high operational costs, low capitation, fraud at facility levels, low pay out ratio, accreditation of facilities, and narrowness of the benefit package, among others. In lieu of these, various recommendations have been suggested. Among these include promotion of solidarty in health care financing that are reliable and economical in collecting; political will to enhance commitment towards devolution of health care, engagement of various stakeholders at both county and national government in fast tracking the enactment of Health Act; investment in health infrastructure and training of human resources; revamping NHIF into a full-fledged social health insurance scheme, and enhancing capacity of NHIF human resources, enhanced awareness amongst members, enhanced benefit package among other recommendations.
Legal and institutional foundations for universal health coverage Kenya
Legal and institutional foundations for universal health coverage, Kenya, 2020
Kenya’s Constitution of 2010 triggered a cascade of reforms across all sectors to align with new constitutional standards, including devolution and a comprehensive bill of rights. The constitution acts as a platform to advance health rights and to restructure policy, legal, institutional and regulatory frameworks towards reversing chronic gaps and improving health outcomes. These constitutionally mandated health reforms are complex. All parts of the health system are transforming concurrently, with several new laws enacted and public health bodies established. Implementing such complex change was hampered by inadequate tools and approaches. To gain a picture of the extent of the health reforms over the first 10 years of the constitution, we developed an adapted health-system framework, guided by World Health Organization concepts and definitions. We applied the framework to document the health laws and public bodies already enacted and currently in progress, and compared the extent of transformation before and after the 2010 Constitution. Our analysis revealed multiple structures (laws and implementing public bodies) formed across the health system, with many new stewardship structures aligned to devolution, but with fragmentation within the regulation sub-function. By deconstructing normative health-system functions, the framework enabled an all-inclusive mapping of various health-system attributes (functions, laws and implementing bodies). We believe our framework is a useful tool for countries who wish to develop and implement a conducive legal foundation for universal health coverage. Constitutional reform is a mobilizing force for large leaps in health institutional change, boosting two aspects of feasibility for change: stakeholder acceptance and authority to proceed.
Health Policy and Planning
Devolution changes the locus of power within a country from central to sub-national levels. In 2013, Kenya devolved health and other services from central government to 47 new subnational governments (known as counties). This transition seeks to strengthen democracy and accountability, increase community participation, improve efficiency and reduce inequities. With changing responsibilities and power following devolution reforms, comes the need for priority-setting at the new county level. Priority-setting arises as a consequence of the needs and demand for healthcare resources exceeding the resources available, resulting in the need for some means of choosing between competing demands. We sought to explore the impact of devolution on priority-setting for health equity and community health services. We conducted key informant and in-depth interviews with health policymakers, health providers and politicians from 10 counties (n ¼ 269 individuals) and 14 focus group discussions with community members based in 2 counties (n ¼ 146 individuals). Qualitative data were analysed using the framework approach. We found Kenya's devolution reforms were driven by the need to demonstrate responsiveness to county contexts, with positive ramifications for health equity in previously neglected counties. The rapidity of the process, however, combined with limited technical capacity and guidance has meant that decision-making and prioritization have been captured and distorted for political and power interests. Less visible community health services that focus on health promotion, disease prevention and referral have been neglected within the prioritization process in favour of more tangible curative health services. The rapid transition in power carries a degree of risk of not meeting stated objectives. As Kenya moves forward, decision-makers need to address the community health gap and lay down institutional structures, processes and norms which promote health equity for all Kenyans.
Understanding The Emerging Issues In The Kenya's Health Sector
The promulgation of the constitution of Kenya on 27th August, 2010 was a major milestone towards the improvement of health standards. Citizen’s high expectations are grounded on the fact that the new Constitution states that every citizen has right to life, right to the highest attainable standard of health including reproductive health and emergency treatment, right to be free from hunger and to have food of acceptable quality, right to clean, safe and adequate water and reasonable standards of sanitation and the right to a clean healthy environment. The Health Sector, therefore, needs to consolidate gains made in respect to provision of service delivery; leverage existing decentralized structures in health; and re-position itself to fulfil these expectations. The two levels of government are under obligation to ensure that the right measures are put in place for successful implementation of Constitution. This paper therefore looks at the emerging issues and their implications in the Kenya's health sector that continues to experience different challenges
Kenya’s Health in All Policies strategy: a policy analysis using Kingdon’s multiple streams
Health Research Policy and Systems
Background: Health in All Policies (HiAP) is an intersectoral approach that facilitates decision-making among policy-makers to maximise positive health impacts of other public policies. Kenya, as a member of WHO, has committed to adopting HiAP, which has been included in the Kenya Health Policy for the period 2014-2030. This study aims to assess the extent to which this commitment is being translated into the process of governmental policy-making and supported by international development partners as well as non-state actors. Methods: To examine HiAP in Kenya, a qualitative case study was performed, including a review of relevant policy documents. Furthermore, 40 key informants with diverse backgrounds (government, UN agencies, development agencies, civil society) were interviewed. Analysis was carried out using the main dimensions of Kingdon's Multiple Streams Approach (problems, policy, politics). Results: Kenya is facing major health challenges that are influenced by various social determinants, but the implementation of intersectoral action focusing on health promotion is still arbitrary. On the policy level, little is known about HiAP in other government ministries. Many health-related collaborations exist under the concept of intersectoral collaboration, which is prominent in the country's development framework-Vision 2030but with no specific reference to HiAP. Under the political stream, the study highlights that political commitment from the highest office would facilitate mainstreaming the HiAP strategy, e.g. by setting up a department under the President's Office. The budgeting process and planning for the Sustainable Development Goals were found to be potential windows of opportunity. Conclusion: While HiAP is being adopted as policy in Kenya, it is still perceived by many stakeholders as the business of the health sector, rather than a policy for the whole government and beyond. Kenya's Vision 2030 should use HiAP to foster progress in all sectors with health promotion as an explicit goal.