HEALTH REFORMS NEED A CHANGE MANAGEMENT PLAN

Health reforms – shock-and-awe strategy

The new administration has promised Universal Health Coverage (UHC) to Kenyans. To achieve this, it has adopted a shock-and-awe strategy for managing health reforms. It is premised changing the health laws first, then aligning everyone to fit into these laws. As expected, sudden change comes with some opposition in the absence of a change management plan.

Healthcare Financing Reforms – Social Health Authority (SHA)

The most dramatic of the health reforms was the passage of three healthcare finance acts that replaces National Health Insurance Fund (NHIF) with a Social Health Authority (SHA). The effect of this was to impose a higher contributory mandate on salaried workers, abolish health schemes that had been previously developed over many years, and a proposal to register all Kenyans afresh into SHA, and a requirement to register all health facilities anew for purposes of reimbursement, doing away with the work NHIF has done over the years. These are dramatic changes.

National Health Insurance Fund (NHIF)

NHIF started 60 years ago as a health scheme for civil servants. It had evolved slowly to provide various medical insurance schemes for various groups of the population. The previous administration chose NHIF as the vehicle to on-board regular citizenry into some form of insurance cover, in an effort by government to provide UHC. Whereas NHIF had its challenges, it had gradually grown and was largely responsible for the increase in medical insurance coverage over time. Proposals to reform and improve NHIF to gradually address the challenges of healthcare financing had previously been made.

Primary Healthcare Fund (PHF) Emergency & Chronic and Critical Illness Fund (ECCF)

Then new health laws introduced two tax-financed health funds, PHF and ECCF. Previously there were tax-funded health schemes like Linda Mama. Linda Mama stopped paying its providers a year ago. Linda Mama brought out the human resources for health deficit very clearly. Despite the benefit at the consumer level (many mothers did deliver at heath facilities with Linda Mama cards) the management of the challenges that emerged was wanting i.e. reimbursement of providers and improvement of human resources for health components and equipping of hospitals. These schemes also had been introduced suddenly and the lessons from their introduction and executions should have formed some basis of learning for the two new funds.

Facility Improvement Fund (FIF)

The reintroduction of the FIF through law was also sudden, but FIF is not new. The disappearance of FIF with onset of devolution, was as sudden as its reemergence. Pre-devolution FIF was the driver of the gradual growth of health facilities. FIFs sudden disappearance was as a because governors identified health facilities as cash centres. They closed previously devolved individual hospital accounts and centralized county collections including FIF to county bank accounts. This effectively undevolved health facility autonomy. The result of this was that money trickled back to the facilities, if at all, in an inefficient manner, leading to service delivery problems.

DIGITAL HEALTH ACT.

Digitization of heath has been fast tracked again with the passage of the digital health act. Digitization of health has its advantages as well as its challenges. Digitization allows for easier analysis of the data collected allowing data-driven decision making. This is easy for the part of health that deals with commodities such as pharmaceuticals and non-pharmaceuticals.

Digitization and doctor-patient interaction

Digitization though is a hindrance to the traditional doctor-patient interaction. It shifts patient care away from touching the patient to touching the computer. Because at the end of a doctor-patient interaction something must be keyed in, slowly by slowy health workers are treating the computer more than the patient. When the system ‘goes down’ the doctor-patient interaction is affected, resulting in increased waiting times and increased turn around times. Data may also be incomplete or inaccurate because health providers tend to minimize the amount of data they key in to avoid very prolonged contact times necessitated by the system. This can be improved by employment of more health workforce, but the usual excuse of wage bill means that the problem will persist.

Digitization and data protection

A major drawback of digitization is the issue of confidentiality and data protection. Any health data in a system is visible to many people who may access the system, and breaches of health data can lead to serious legal implications and a reduction of trust in health systems. Many people want their health data private and the current data privacy rules provide very harsh punishments to providers for data breaches. Moreover, the Hippocratic oath is based on confidentiality and some level of secrecy. Digitization must thus have a delicate balance of utility and data protection.

HUMAN RESOURCES FOR HEALTH (HRH)

Human resources for health is key to executing health reforms. Without people health reforms cannot work. Yet traditionally HRH is the area that is least taken care of. In the new dispensation the Kenya Health Human Resources Advisory Committee (KHHRAC) was launched with much aplomb. The highlight of its work was the October 20th 2023 Kericho declaration where KHHRAC promised many good things in the HRH space. The output of this is yet to be seen. KHHRAC again face the problem it faced as soon as it was enacted in the Health Act 2017, its advisory nature. The Health Service Commission as proposed during the time of constitution making, and during the Building Bridges Initiative, complete with a HSC Bill, would probably be a good solution to the HRH problems bedeviling the sector. Resistance to the HSC continues especially at the Council of Governors level because to the perception that it will take away the funds that come with healthcare. This is in fact not true as the HSC will free the quarter of 35% of recurrent budget that the county is disallowed by law to go above since this budget will be a HSC budget. The counties will then be able to employ more personel to cover their gaps.

HEALTH SYSTEMS CHANGES – LESSONS FROM THE PAST

Poor health system in the 90s

Throughout the health journey both in Kenya and around the world there are lessons to be learnt from a change management direction that health systems choose to take. In the 1990s the public health sector had collapsed and there was literally no health service delivery. The services were poor, the human resources for health demotivated, the health leadership structure was upside down, and there were no health commodities. Patients only came to hospital to get a diagnosis from the health professionals but footed the bill of care. A mother in labor for instance was given a prescription of the items she needed to purchase for the purposes of delivery, including the anaesthetic drugs in case she ended up with a cesarean section. Poor health service delivery was probably a major factor that determined the 2002 Kenyan elections.

A new government and a plan in 2000s

The new government in 2002, Identifying what needed to be done, set about making incremental changes in each of the health service delivery pillars through a well thought out policy paper dubbed ‘reversing the trends’ health policy. This was the National Health Sector Strategic Plan 2 (NHSSP2). Health had previously been on a downward trend. This policy sort to reverse this gradually, and it did.

Health governance

Health governance and leadership was rectified by appointing the highest qualified personnel as heads of the health institutions. In a hospital where there was a consultant, (s)he was made the medical superintendent. Because healthcare provision hierarchical, governance of health institutions improved. It is important that the caliber of personnel given leadership positions in health institutions is appropriate. It is difficult not to show respect to a leader whose qualifications are higher than yours. In the health sector at the policy level, provision of technical guidance for the health sector was domiciled in the office of the Director of Medical Services (DMS).

Human resources for health pay

Human Resources for Health was improved via a Kenya Medical Association (KMA) proposal that sort to increase health workers take-home pay via the introduction of allowances that were unique to health. An example of this was risk allowance. Health workers are exposed to various health risks in their line of duty like tuberculosis and needle prick injuries that could lead to HIV. The death of health workers during COVID-19 Pandemic was evidence of the risks faced by this group of professionals. The introduction of these allowances to the pay of health workers led to a better take-home pay and led to the retention of more health workforce. In fact, health workers migrated from the private health sector to the public health sector. The numbers of health workers employed increased. Morale became better.

Support supervision and the performance contract

A performance contract (PC) was developed to measure the incremental improvements resulting from the new health policy. The PC captured the needs of the health facilities. It was marked quarterly via well executed support supervision plan carried out by the Ministry of Health, Provincial Director of Medical Services (PDMS) teams and DMSO zonal teams. Support supervision resulted in an improvement in all aspects of the health system. It generated data that lead to data-driven decision making. From the PC and the supervision identified the health gaps in health infrastructure, human resource and health finances, deficiencies in health commodity supplies. These gaps were incrementally sorted out and health service delivery improved slowly but surely and more health services became available to the populace. More medical internship centres opened. Healthcare financing improved and the health sector indeed moved from a net expenditure sector to a financier of Treasury. These changes were gradual and incremental and well thought out prior to roll out, and they produced good results.

Change management plan

The speed at which current changes in healthcare are being made, and the magnitude at which they are being made, may in my view have monumental challenges that may delay successful actualization. There is need for change management plan in place, with very specific realistic timeline, very clear transitions, with inclusion of all stakeholders in the healthcare space is a basic minimum. Baring this then teething problems of the proposed health reforms will go on for ten years in a similar manner with the sudden devolution of health.

But as they say, time will tell!

Dr. Simon Kigondu is the President of Kenya Medical Association.