PUBLIC HEALTH EMERGENCY OF CONTINENTAL SECURITY
The time has come again when we will be having very many discussions, debates and controversies on how to approach the management of MPOX, a disease that has been declared a Public Health Emergency of Continental Security. In Kenya this will definitely reignite the COVID-19 controversies of primary prevention via vaccination, secondary prevention via social distancing and lock-downs and treatment. There will also be all sorts of allegations, misinformations and personal opinions, all of which will require tempering by professional associations. The suspicion of ill motive by WHO, pharmaceutical companies and other bodies related to health management will definitely spring up.
DEVOLUTION OF HEALTH AND DISEASE SURVEILLANCE
In 2010 Kenya enacted a new constitution, devolving the country into 48 counties. In 2013 a hard devolution of health was done that attracted several court cases. The health workforce disputed the manner and spirit with which health devolution was done. This has resulted in many challenges of health service provision in the counties even with the report of successes in some aspects of health service delivery.
DISEASE SURVEILLANCE AS ORIGINALLY ENVISAGED IN DEVOLUTION
It is my opinion that if devolution of health was done as originally as envisaged ,Kenya today would be having a very robust disease surveillance system in place at the county Levels supported by a well coordinated national surveillance system at The Ministry of Health (MOH) under the Disease Monitoring Unit of the health ministry. If this proposed devolution was done correctly, COVID would not have been the big problem it turned out to be because there would have been in place localized detection and management at the county levels and containment would have been much easier as it would have been local and not dependent on MOH. In the same vein with the reported threat of MPOX, identification & isolation would be very easy locally.
COMMUNITY HEALTH PROMOTERS (CHP)
If the county surveillance had been strengthened as envisaged by health devolution the so called CHPs would be well managed & well paid by County Governments and there would be no tussle as to a 50-50 payment arrangement between county and national government where we occasionally find that the national government has paid its share but the county government has not allocated its share. County Government are literally next to the people and therefore are in a position to do outbreak identification and prevention. To strengthen disease surveillance County Governments would by now have engaged battalions of epidemiologists at various levels of the counties to monitor disease outbreaks and recommend prevention way before these get out of hand.
HEALTH SERVICE COMMISSION
In the original intent of devolution of Health the Human Resources for Health would be well managed & coordinated centrally by a Health Service Commission. Many people often confuse the notion of a HSC with MOH, which is wrong. The HSC would act like the Public Service Commission had acted prior to devolution to ensure a smooth, equitable, fair management of critical HRH to enhance efficiencies. It is also good to note also that the presence of a HSC does not stop County Public Service Boards (CPSBs) from budgeting for and engaging their own additional health workers to cover gaps that a HSC may not cover depending on county priority health areas.
MANAGED EQUIPMENT SCHEME (MES)
In the original intent of devolution of Health MES was to act as a source of medical equipment that was needed in various counties as per service need. It was envisaged that medicine being standard various counties would need similar equipment at the same time depending on needs and that these equipment could be acquired using economies of scale and directed to the counties on a need basis. Eg if 10 Counties needed CT Scans, these would be requisitioned and acquired centrally by MOH or KEMSA using the principle economies of scale and distributed where needed to save the tax payer from exhorbitant costs accrued from purchasing equipment one by one.
That was the vision of devolution of health which was eventually politicized and executed differently from the original intentions.
DISEASES AS SOURCES OF COUNTY REVENUE IN HEALTH FACILITIES
The push by County Governments to look at, and control hospitals as income sources overode the overall goal of disease prevention as the major health input of County Governments. County governments were to investing very heavily in addressing the social determinants of health with the goal of saving 16 Kenya Shillings for every 1 KSh invested in prevention. A simple illustration purely for illustrative purposes is as follows: For Cholera a County Government would invest in disease surveillance to ensure that there is no defecation upstream, there is good sewerage system within housing units and there is availability of water in public places for hand washing. Many county governments collect hospital fees from diarrhoeal illnesses of their constituents who get admitted to hospitals for treatment.
REVERSED ROLES OF NATIONAL VERSUS COUNTY GOVERNMENTS
Some of the health challenges we are having now are as a result of a reversal of the roles that were envisaged as to be managed by devolved units for better health outcomes.
HOUSING A SOCIAL DETERMINANT OF HEALTH
Good housing is a social determinant of health. County governments were supposed to improve housing, elimination health problems that result of poor housing conditions such as poor water and sewerage systems, poor lighting, poor ventilation and a lack of adequate spacing among housing units. The national government is competing to control housing.
FRAGMENTATION OF HEALTH RESPONSES
National government was to manage the national health referral system which constituted the whole health continuum from dispensary to level 6 hospitals, but this were distributed to counties. The HRH was dispersed to 48 Public Service Boards.
The fragmentation of health responses is a major setback in a coordinated health response and is always evident when there are threats of disease outbreaks where those who have invested heavily in health are affected more by the lack of health investment in other regions.
HEALTH AS A NATIONAL SECURITY ITEM
So even as we think about a possible strategy towards trying to detect, contain and prevent disease outbreaks we must revisit our vision of healthcare in a devolved system. Health should be treated as a national security issue and should be approached in a uniform way. We should not be having some counties being disease ready & others not ready as assessed using the usual six pillars of health systems.
CALL TO A UNIFIED HEALTH APPROACH
My call today, in the wake of threats of disease outbreaks such as MPOX, is a unified national approach to healthcare, and a localized approach (read Couties) to disease prevention as envisaged in the original vision of health devolution. The principle of subsidiarity is key in disease outbreak prevention and County Governments should utilize these uncertain health times to strengthen their disease surveillance and response more.
Dr Simon Kigondu is an Obstetrician Gynaecologist & President of Kenya Medical Association
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