This may sound obvious to the trained health specialist, but even in countries with mega budgeted resources like South Africa (where I cut my teeth in public health), they have had to learn the hard way. I choose South Africa for obvious reasons of comparison because of similar health challenges in both communicable and non-communicable diseases, similarities in beliefs about diseases, and similarities in funding models which includes funds injected from global partners. It is no secret that the health budget going forward will be stretched with the required workforce of nurses, needed professionals to cover the ratio of patients to doctor (to the World Health Organization (WHO) required standard), administration personnel, pharmacy, assets, machinery (vehicles) etc…but also to fund policy directives like “free” maternal care and the services that go with it.
Sustainability of such a system will have to come from a re-engineering perspective so that primary health care becomes and is practiced as the cornerstone of healthcare. Currently, the Kenyan health system has primary health care, but, a re-engineering process to capture prevention rather than cure needs to be conducted across all healthcare facilities starting with doctors, nurses, pharmacy, cleaners, support and maintenance, human resource management and community health workers.
It is within these uplifting and re-energising efforts of the health care system that we can prevent rather than cure some of the diseases that will choke health care facilities like hospitals where treatment costs per patient is usually in the order of hundreds if not thousands of percentages more. Simply put, primary health re-engineering’s vision should be long-term focused, high-impact and scalable to the whole country, evidence-based, flexible, multi-sectorial (especially at local level where a community-centred integrated approach is critical (common beliefs), and it must promote partnership but retain community ownership. If we can get primary health care right, then the huge budget required for treatment will no longer be needed.
Alongside primary health care re-engineering, HSS will need to be implemented across all health care facilities. Health System Strengthening has the support of WHO in building blocks including: service delivery, strong health workforce, information, health products (eg vaccines), financing, and most importantly, strong leadership and governance (Measuring Health Systems Strengthening & Trends: A Toolkit for Countries” (WHO 2008)). These inputs into HSS will be heavily reliant on experts who at the county level will have to offer sustained efforts of support and the most likely area to look to would be learning and support institutions such as universities and research centres. These usually house experts in the different fields, and payment would be a “trade-off” between using much needed health data (information) for publication purposes (which experts generally don’t have) against services. This is a practice that is working in South Africa and many Western countries. This is a cheap if not free “consultancy” service, and recognition rather than pay is a currency many professionals trade it.
Sometimes hospitals are going to have to deal with diseases that many a times are broadcast on national television portraying disfigured people, children born with ailments, extreme cases unmanaged at lower level facilities, and painfully, mostly ask for donations for treatment.
Many a times, these are old world diseases and in some parts of the world have been completely eradicated. Although these cases are expensive to treat, they are usually few and can be accommodated by a special fund which business people can attach advertising or other secondary income generation to. It is embarrassing that not a single high profile person has set up such a fund and am sure (in my experience of old world diseases) the resources available to treat such patients far outweigh the cost of treatment. It is the process of nudging business people in the right direction that will most likely tip the scale.
Finally, multi-sectorial inputs and co-ordination are key in reducing the amount of resources spent and thus the national health budget. Costs can be saved from proper utilization of vehicles, duplicated services, strict performance based salaries, following guidelines in terms of employment, expanded roles of workers for example nurses, and making services professional with part time health workers as opposed to full day employment. A case in point are the reduction of hours that a nurse will work, such that they are not overloaded with patients in the morning hours and yet the afternoons are spent having tea and chatting away, when in fact facilities can have another group of fresh nurses coming in to relieve sometimes overworked morning staff. Other cost cutting measures include zero funded items like conferences, meetings, lunch and dinner for participants, per-diem for workers who would actually not spend that money if they were at home, and drug management such that drugs that will otherwise expire are always used first.
These are some of the basic yet effective strategies that have lifted South Africa from an otherwise buckling health system and if prudent, some of the same that a performance contract should include between the incoming Jubilee government and the new Cabinet Secretary for Health. A big job, but there are professionals both within and outside Kenya who will provide the technical support and small strategies needed to ensure the much taunted free health care for Kenyans becomes available and is sustainable.
By Isaac Ang’Ang’A Choge, PHD
Monitoring and Evaluation Manager at the Aurum Institute.
The views expressed here solely remain those of the writer.