|A hospital ward in Kenya Photo courtesy|
Since the World Health Organization proposed decentralization as a way to empower communities to take ownership and control of their own health in 1978, the strategy has been variously pursued and implemented in both developed and developing countries as a key management approach on the belief that it enhances efficiency in public sector performance. Kenya has yet to reap these benefits, and with the onward movement to implementing the new constitution, this dispensation should probe to how best counties can benefit from decentralization concepts that has been sired from a genetic pool of proper planning. Indeed the opportunity is ripe for Kenyan planners to ask and answer on how decentralization in health care can help alleviate the daunting task of health budget allocations and resources.
Indeed the problem is systemic in government, but at the third tier of governance which concerns this missive most, Local government, budgeting being a policy reform direction under the larger decentralisation framework, suggests that the once obsolete exercise where resources were (un)wittingly misplaced, should be buffed against needs, wants and downstream uses and these should become completely entangled. It would benefit many a counties to invest valuable human resources in simple health models based on what diseases are both present and dominant in their respective areas. Be it independently in Northern Turkana, or in Southern Amboseli, or in villages in Port Victoria. At the risk of (un)popular debate, health planners should ask if they have lost touch with planning of health care and deliberately given the baton to donors! If not, how do we consumers then answer the following questions?
• What are the tools used by health care workers to budget and to assess the effectiveness of resource allocation at the different levels of government? Are these tools available for the provincial level of governance, and will they be available for counties, alongside technical support?
• When resources (particularly monies) are allocated in any budget, what criteria is the prioritization based on?
• Is there a logical disease burden influence that the allocation of funds within a health department will rely on?
o If there is, what are the principles that these follow, and/or what are the best practices that counties can adopt?
• Why is it that some health budgets are returned to treasury as unused funds?
• And, finally, suppose one gets the 15% allocation asked for in any National health budget (as signed in the Abuja declaration) how do you apportion these monies against mortality and morbidity in order to reduce incidence of the disease. This is almost linked to the point immediately above, but is more inclined towards prevention strategies.
When one re-synthesizes these questions in view of current health policies, budgeting and their compounding effects on service delivery, then there is an inevitable cataclysmic collusion in the making. The genesis of this is found superficially in “pillarization” of programs and engrossed in the workings of a malfunctioned decentralized health care system, with prima-facie evidence from other developing nations of unavoidable breakdowns in the very primary health care systems that supports the rest of the healthcare in the country. More so, as is seen with the after effects of many AIDS programs, the much touted lessons learnt are not easily transposed to other diseases. With current health care service delivery models, the reliance is on treatment, rather than prevention (except HIV and AIDS) and this leads to much higher expenditures (notwithstanding morbidity and mortality) than would have otherwise been prevented.
My instinct charts an accusation against policy planners (particularly those at the provincial level who are now empowered through schedule four of the constitution), that rather than actually budget for a need in health care delivery and then source of funds for that project, the reverse is true, where policy planners end up with a given amount of money (most likely from donors) and the budgets, whether they like it or not, will be appended to those resources. Any deviations, or plans outside these parameters will have to be funded from elsewhere.
The natural question to ask at this point is, “where else does one expect to get money to fund your health budget if you cannot raise the money internally?” The irony of this very question then is, how do you expect to control your health allocations if someone else controls how much, where and on what you can spend on? Indeed, what are the implications when there are health (budget) cuts in the donor countries as is currently in the American offing? There are however other options, for instance, general taxes, social health insurance, private health insurance, medical savings accounts and out of pocket spending (which has become the most common source of financing in many low income countries).
Finally, as the country negotiates the twists and turns of the new dispensation, the benefits of proper policy planning based on systematic methodology particularly at the county level of health governance have never been viewed in better prospects. Consider the options:
1. Better care for people with severe and debilitating illness
2. More coordinated services through local organizational structures and the provision of tailored multidisciplinary care plans
3. Expanded and strengthened primary health care services
4. Established single county based e-health portals
5. Increased and integrated prevention and early intervention strategies particularly for the vulnerable populations of children and young people (for example, extend health and well being checks though community health care workers to 3 year olds)
6. Encouraged and monitored economic and social participation, including jobs, for people with both communicable and non-communicable illness
7. Improved quality, accountability and innovation in all health services
8. And the opportunity to establish a new independent county level health Commission to independently monitor, assess and report on how the system is performing.
It is through this publication, although watered down, that county level governance can be ignited to better plan for health service delivery, particularly now that it has become a necessity rather than a luxury.
By Dr. Isaac A. Choge
The writer is the Monitoring and Evaluation Specialist at the AMPATH-USAID Partnership. This article is written in his own personal capacity, and does not reflect the views in any way of the Organization(s) mentioned.