Health is a shared function between County and National Government. During the clamor for a new constitutional dispensation the input of the Kenya Medical Association (KMA) was clear – national government would manage the curativehealth i.e., all the health facilities that served as one large continuum of healthcare services from level 2 facilities to level 6 facilities. The human resource component would be transitioned from the Public Service Commission to the Health Service Commission (HSC). The county governments would take care of the social determinants of health via public health strategies that would lead to prevention of disease through investment in water and sanitation, housing, environment and disease surveillance for early detection and prevention of disease and pandemics.
In 2013 transition to devolved healthcare was done, albeit in a manner that elicited a lot of debate. The transition was done twice. The initial legal notice of February 2013 was correctly interpreted to give the public healthcare, that is primarily preventative, to county governments. National Government was mandated with curative healthcare that were the national referral health facilities. National Health Sector Strategic Plan 2 (NSSP2) was the context in which devolution of health was crafted, where all health facilities were part of the national health referral network. The August 2013 legal notice, while not revoking the February 2013 legal notice devolved health in a manner revoking the February 2013 legal notice devolved health in a manner not envisaged by the constitution. The human resource for health issues that were anticipated by the second devolution of health have played out in the devolution decade.
Human Resources for Health before and during the devolution decade
The devolution decade has had many ups and downs in matters human resources for health. On one hand I commend the devolved health units for increasing the human resources for health. The stories of doctors on the other hand are a mixed bag of issues. All doctors got stuck in their last place of posting when devolution was announced. The reason given was that health was a devolved function.
Prior to devolution there was a smooth natural progression in the doctor’s career. From internship the doctor was deployed automatically as a medical officer. After working for a few years, the doctor then did get a postgraduate course and got government sponsorship for post graduate training in one’s field of interest. On completion the doctor would serve the government for a mandatory three-year period in an area of need, posted by the Ministry of Health. The advantage of coordination of this program was that it when the medical officer was released to national government to proceed for postgraduate studies, their position was filled without leaving a void of the MO position. On completion the specialist doctor would be posted to an area of need within Kenya. That way the government gradually increased access of Kenyans to healthcare while allowing doctors from different regions to work in areas that were not necessarily of their origin.
The devolution era initially started with this natural progression being maintained, with many doctors in the counties agitating for and leaving for specialist training. This led to a tussle between County Governments and the doctors because the medical officer position that fell vacant, needed to be filled, as an MO a key position in running public health facilities. Many specialists indeed did return to their counties of origin, not as medical officers, but as specialists. The counties soon realized that they were paying for a doctor who was in school but not necessarily serving the county directly. Despite this early realization the county governments, insisted that health was devolved and did not want to let go of the payroll. Their dilemma was that they had to pay for the doctor in school for four to five years and still employ a medical officer to replace the doctor in post graduate. Finding themselves/ with budgetary constraints, the county governments, instead of letting go the doctors to national government and started denying doctors the opportunities to specialize. They also an inadequate number of medical officers employed leading to a shortage. This was the challenge of not operationalizing a health service commission.
The Kenya Medical Association has always averted that the establishment of a Health Service Commission (HSC) would alleviate some of these tensions that have developed between doctors and county governments. A HSC would allow for doctors to do inter county transfers. A HSC would reduce the nepotism and tribalism witnessed in the hiring of medical personnel by County Public Service Boards. A HSC would promote cultural integration and as was of old, doctors and other healthcare workers would be the promoters of national cohesion. As it is now whereas counties claim an improvement in the numbers of health workers, the deep-seated Human Resources for health in general, and for doctors in particular remain.
Devolution is good generally, but the management of Human Resources for health remains an issue that needs to be discussed with the following in mind:
- No county government can sustain a wage bill of Human Resources for Health
- Limitations in the inter county transfers for health workforce is a hindrance to patriotism and promotion of family values.
- The unequal treatment of health workforce of similar qualifications in different counties is a weakness that has contributed to a decrease in output of health workers in counties that are perceived to mistreat health workers.
- The victimization of health workers by some governors without the ability to change counties has led to serious mental and physical health challenges of some health workers who were punished for having a different opinion from governors and their teams.
This is a call that the newly appointed team at the Kenya Human Resources Advisory Council (KHRAC) should take up and fast track. Whereas KHRAC has been there from 2017 when it was established by the Health Act 2017 it’s advice has largely not been taken up. The lack of legal muscle of this body is the weakness of it.
The rallying call for the next ten years of devolution is that a Health Service Commission is a friend of health devolution. Whereas there were and are still are challenges about Human Resources for health doctors they should take their place in the health system of the devolved health system. A doctor is a highly trained medical professional whose curriculum also encompasses some form of managerial training. Members of the noble profession should not be cry-babies about failures of a health system. They should take up their place in devolution as governors and deputy governors, County Executives of Health in the County Governments and Chief Officers of Health, MCAs, medical superintendents, Directors of Medical Services in the counties, Heads of Departments of Health, and most important service delivery providers at the counties, leading from the front.