The UN in Kenya works with the Keyan Government and partners to ensure health services are delivered where they are most needed. (Credit: UNDP Kenya/James Ochweri)

By Siddharth Chatterjee
NAIROBI, Jan 16 2017 (IPS)

Consider this: every year, nearly one million Kenyans are pushed below the poverty line as a result of unaffordable health care expenses.

For many Kenyan families, the cost of health care is as distressing as the onset of illness and access to treatment. A majority of the population at risk can hardly afford the costs associated with basic health care and when faced with life threatening conditions, it is a double tragedy-inability to access health care and lack of resources to pay for the services.

According to the World Health Organisation, a large percentage of poor households in Kenya cannot afford health care without serious financial constraints as most are dependent on out of pocket payments to pay for services.  Nearly four out of every five Kenyans have no access to medical insurance, thus a large part of the population is excluded from quality health care services.

In 2015, UN Member States endorsed the 17 Sustainable Development Goals (SDGs), expected to guide the development agenda through 2030. The endorsement of the SDG 3 – Good health and wellbeing; formally enshrined Universal Health Coverage (UHC) as a development priority for all countries.

UHC has the potential to transform the lives of millions of Kenyans—guaranteeing access to lifesaving health services while helping individuals and families avoid crippling health expenses and the poverty trap.

Nearly four out of every five Kenyans have no access to medical insurance, thus a large part of the population is excluded from quality health care services.
The situation is not unique to Kenya, but also a case in point for many other developing countries. As a result, UHC has been identified as a key development goal for enhancing countries’ health systems globally.  It is an all-encompassing development issue, including as it does, the full spectrum of essential, quality health services from health promotion to prevention, treatment, rehabilitation as well as palliative care.

Protecting people from the consequences of out-of-pocket health expenditure, which in Kenya forms about a fifth of family spending, is critical. It reduces the risk of people using up their life savings, selling of assets, or borrowing, threatening the financial future of their families as out of pocket health expenditure is also the most inequitable and inefficient.

However, achieving UHC is a formidable challenge because Africa as a continent requires about 50 percent more doctors to achieve UHC, compared to Europe which needs only about 3 percent more. The continent still lags far behind the rest of the world in provision of basic health care services such as immunisation, water and sanitation as well as family planning.

Much of the problem lies with the low prioritisation of health. Less than ten countries in Sub-Saharan Africa have met the Abuja declaration committing to allocate 15 percent of their annual government spending on provision of health care.

Kenya is one of the countries that is yet to reach the Abuja threshold, but several indicators show that the country can be an inspiration for the rest of the continent in achieving UHC by 2030.

One of the steps in the right direction is the government’s move to eliminate payments for primary and maternal health services in public facilities. This has led to tangible improvements in maternal and child health, with maternal mortality ratio falling from 488 to 362 deaths per 100,000 live births between 2008 and 2014.

With consensus that maternal health is a major driver of overall health and economic development, the Government of Kenya in partnership with the United Nations family and the World Bank, with strong support from the governments of the United States of America, United Kingdom, Japan, Germany, Denmark and Norway who have focussed on counties with the highest maternal and child deaths. Significant gains have also been made as a result of the First Lady of Kenya’s Beyond Zero campaign.

Arnaud Bernaert, Head of Global Health and Health Care at the World Economic Forum, remarked that, “Kenya’s efforts has led to an innovative public-private partnership mechanism that has the potential of building business models that will offer the best of both public and private sector in scaling-up the delivery public health services in low-resource settings”.

Another positive direction is the devolution of health – a constitutional change that shifted responsibility for healthcare provision to county governments. This seeks to achieve universal coverage by bringing health decisions closer to citizens, ensuring efficient and equitable resource distribution, thereby improving access to health facilities as well as services.

Recent changes to the National Health Insurance Fund (NHIF) has expanded the coverage for formal sector employees by adding outpatient care and a new initiative specially targeting informal sector has recently been introduced. The new national scheme offers a comprehensive family cover for US$ 60 (6000 Kenyan Shillings) covering both outpatient and inpatient services. New initiatives such as health insurance subsidies for the poor, severely disabled and elderly will help to bring more vulnerable people under comprehensive health insurance cover.

Kenya is already a leader in technological innovation.  This is a capability that must be harnessed to improve health systems to help bring down costs of delivering health care services through telemedicine, reducing inefficiencies in provider payment systems and generating better data.

These improvements could significantly help ameliorate the financial stress that is currently the most significant barrier to achievement of UHC. Some studies have shown that technical efficiency is a big flaw in Kenya’s health facilities, with one reporting that public dispensaries are operating at only 47 percent efficiency.

Kenya is part of various initiatives for developing sustainable financing for health services such as the Global Financing Facility, a partnership that will catalyse greater investments in health services, with a particular focus on women, adolescents and children.

The momentum is already with the country and in keeping with the spirit of the SDGs, Kenya must lead in the moral imperative of ensuring that none of the people who cannot pay for health care are left behind.

Kenya can undoubtedly lead the way in achieving universal health care.

Excerpt:

HIV positive people in New Delhi demonstrate for access to cheap generic drugs. Credit: Mudit Mathur/IPS

By Zofeen Ebrahim
BEIJING, Nov 8 2012 (IPS)

As the northern Indian state of Rajasthan rolls out an ambitious universal healthcare plan, the discontent of the state’s doctors stands in stark contrast to the joys of the 68 million people who will benefit from the scheme.

Just a little over a year ago, the state government began supplying free generic drugs to its massive population, effectively stripping doctors of the ability to prescribe more expensive branded medicine.

Some 350 essential generic drugs are now being distributed free of cost. As a result, outpatient visits have jumped 60 percent and inpatient admissions are up 30 percent, despite the fact that public health facilities are overcrowded and understaffed, and many people have to travel long distances to reach one.

According to news reports, over 200,000 people are currently taking advantage of the programme.

“(This) has broken the cosy relationship enjoyed for decades between doctors and (drug) manufacturers,” Dr. Nirmal Kumar Gurbani, advisor to the Rajasthan Medical Service Corporation (RMSC) that was constituted by Chief Minister Ashok Gehlot to run the scheme, said during a presentation at the Second Global Symposium on Health Systems Research in Beijing last week.

Gurbani, a professor at the Indian Institute of Health Management and Research (IIHMR), added that the ‘Rajasthan model’ is being used as pilot for a similar scheme throughout India, which could bring free drugs to the country’s 1.2 billion residents.

One of the programme’s goals is to end price manipulations of private pharmacies and manufacturers.

“Cipla, for example, produces three kinds of ‘cold’ tablets, which all have the same chemical ingredients. It sells the generic drugs to pharmacies at a wholesale price of about two Indian rupees (0.03 dollars) per pack (of ten tablets) but sells the branded drugs for 23 rupees (0.42 dollars) per pack.

“The chemist then sells all three drugs for anything between 27 to 39 rupees (0.50 to 0.72 dollars) as per the printed price. Thus the patient is at the mercy of the doctor or the pharmacy, and will take whichever drug is recommended to him,” Gurbani explained to IPS.

To counter this practice, the government now buys generic drugs directly from the manufacturers and has “developed infrastructure to hand them over to patients through the 13,874 (approved) drug distribution centres,” Gurbani added.

Patients that are obliged to embark on lifelong drug courses – for conditions like diabetes or heart disease – have hitherto struggled to make their payments.

“A particular brand of medicine used for diabetes costs 117 rupees (2.17 dollars), but we purchase 10 tablets of generic medicines for diabetes at 1.97 rupees (0.036) dollars,” said Gurbani, adding that the difference in pricing certainly did not mean a compromise on efficacy and quality.

Changing lives with free medicine

Gurbani, a former secretary of the Essential Drug List Committee for the Rajsathan state government, says medical expenses are the second most common cause of rural indebtedness in India.

Citing official data, he told the audience at the conference that more than 40 percent of those hospitalised in India needed to borrow money or sell assets in order to afford treatment.

The cost of a single hospitalisation has pushed 35 percent of patients below the poverty line. In fact, unaffordable healthcare has prevented over 23 percent of the sick from consulting a doctor.

The scarcity of medical professionals has contributed to healthcare costs reaching astronomical rates. According to the World Health Organisation, India has just 6.5 physicians to every 10,000 patients. By comparison, China has 14.2 doctors, while Britain has 27.4 physicians for the same number of patients.

The expenditure on drugs alone constitutes between 50 to 80 percent of healthcare costs in India. And all this in a country regarded as the “world’s pharmacy”, Gurbani lamented.

India’s pharmaceutical industry is the third largest in the world with annual production of about 25 billion dollars and domestic sales amounting to 12 billion dollars. India exported medicines worth 13.2 billion dollars in the last fiscal and the government plans to double it to 25 billion dollars by March 2014.

And yet, said Gurbani, “two-thirds of the population do not have regular access to essential drugs.”

Dr. Ravi Narayan, an Indian public health academic who is also part of the All India Drug Action Network, was full of praise for the Rajasthan government’s initiative.

“Rajasthan has a very strong people’s movement and with people like Samit Sharma who heads the RMSC, this was bound to succeed,” he told IPS, on the sidelines of the Beijing symposium.

The runaway success of the Rajasthan model, according to Narayan, has proved that “India is going into the Rajasthan experiment”.

Tamil Nadu, a state of 72 million people, is also providing free medicine for all. Even Karnataka is building on these models, Narayan informed IPS.

With India moving towards universal health coverage (UHC) in the next two years, it has budgeted nearly 300 billion rupees (55.9 million dollars) to fund the programme. It hopes to be able to provide free drugs to 52 percent of the population by April 2017.

The central government will fund 75 percent of the programme, with states doling out the rest.

India’s proposed UHC plan contains many of the features of Rajasthan’s model, such as centralised procurement, regulations to ensure that doctors prescribe cheap generic drugs rather than branded medication, a list of “permitted” drugs and distribution limited to official government health centres.

“It’s not just possible in India, it’s possible all over the world,” said Gurbani.

Obstacles can be overcome

“Conceptually the model has a lot of strength, but it’s difficult from a political perspective. There has to be harmony between the central government and the (28 states and seven union territories) in India,” Abdul Ghaffer, executive director of WHO’s Alliance for Health Policy and Systems Research, told IPS.

With the country’s public health system already under resourced and struggling to meet the needs of 1.2 billion people, 40 percent of whom live below the poverty line, there are serious challenges to expanding the programme nationwide.

There have been occasional shortages of medicines, which Gurbani attributes to the early stages of a project finding its bearings in a geographically diverse region.

“There is the tribal belt as well as the desert and then the urban areas, besides large rural pockets. The needs are different, so at times we ran out of stocks. These teething problems were inevitable; in the course of time, these shortfalls will be eliminated,” Gurbani predicted.

Others at the conference raised thorny questions about the mammoth infrastructure this process will require, hinting that some states may not yet be in a position to set up warehouses and cold storage facilities, or test all the drugs made by roughly 12,000 manufacturers across India.