One month ago, the Government of Kenya released four new health bills to accelerate progress towards the goal of universal health coverage. If passed, the bills will set in motion far-reaching reforms to how health services are financed and delivered in Kenya. Among these bills is the Social Health Insurance Bill, which proposes extending health insurance to all Kenyans based on member contributions, with government-subsidized coverage for the poor. It also mandates the creation of three funds to cover different types of services and a new government agency to manage it all.

To unpack what the Social Health Insurance Bill aims to do, why, and how, ThinkWell will host a Counterpoint webinar with the bill’s primary architects, county stakeholders, as well as leading health financing experts on October 3, 4-5:30 PM-EAT (9-10:30 AM-ET).

Register here

Counterpoint is ThinkWell’s signature series of webinars, which offers a platform for free and frank debate about questions related to health system strengthening. In this edition, ThinkWell’s Regional Director for East and Southern Africa, Dr. Anne Musuva, will host a discussion about Kenya’s new Social Health Insurance Bill featuring four panelists:

• Dr. Elizabeth Wangia, Director, Healthcare Financing, Kenya Ministry of Health
• Dr. Daniel Mwai, President’s Advisor on Health and Standards, Office of the President, Kenya
• Mr. Felix Murira, Country Program Manager, ThinkWell Kenya
• Dr. Joy Mugambi, County Director of Health Administration and Planning, Nakuru County, Kenya

Some of the questions the panel will explore include the following:

1. What overarching objectives is the Social Health Insurance Bill trying to achieve?
2. What drove the specific design choices (e.g., three separate funds, means-testing for everyone not employed in the formal sector, and a new health authority)?
3. How do the reforms envisioned by this bill align with the service delivery reforms set out in the other bills, especially the reorganization of all primary and secondary care facilities into networks?
4. What is the role of counties in implementing these reforms?
5. What are the biggest hurdles we can expect on the way to implementing the bill successfully?

We are looking forward to welcoming our peers and partners from around the world for this discussion. In the meantime, please contact our team with any questions or concerns.

By Kristan Jela Tambio, Helena Lagon Alvior, Pura Angela Co, Maria Eufemia Yap, Mary Camille Samson, and Rosario Dizon

As the Philippines continues its progress towards fully implementing its Universal Health Care (UHC) Law (RA 11223), it is crucial to harness ground-level insights and best practices that can be shared across the different provinces and municipalities in the country. ThinkWell Philippines and the Asian Development Bank (ADB) recently supported the Department of Health (DOH) Western Visayas Regional Office to organize and facilitate the first regional UHC Summit on July 12, 2023. It was followed by the two-day Learning Forum, which fostered further learning exchange on the progress of the technical, managerial, and financial integration across the province-wide and city-wide health systems in the Western Visayas Region.

The Western Visayas Region is currently the first region in the country where all six provinces and two highly urbanized cities have committed to restructuring their health systems according to the mandates in the law. This ensures that there is a region-wide effort on local health systems integration. In his opening statement, Regional Director Dr. Adriano P. Suba-an said, “Your presence here is a testament that we are on the right track towards the achievement of the UHC with inclusivity, creativity, and purposive expansion of medical coverage and reach.”

The summit was designed to celebrate gains and acknowledge and address the challenges the different local government units have faced during the past three years of implementation. The first panel focused on the accomplishments achieved by individuals within the local health offices and government units. In contrast, the second panel, composed of a different set of local chief executives (LCEs), provincial health officers, and municipal health officers, recounted significant milestones and hurdles on several topics, such as the stewardship of province-wide health systems, comprehensiveness of the primary care package and health care provider networks, human resources for health, and health financing (particularly the special health fund and frontload support mechanisms). The provinces also showcased their achievements in the Key Result Areas of the UHC Local Health Systems Maturity Level via a gallery walk during the event. Summit participants had the chance to ask provincial representatives how they progressed in their Key Result Areas and share their insights and experiences.

Several stakeholders shared key insights and ideas to strengthen the implementation of the UHC Law. Mayor Irene Montilla of Isabela, Negros Occidental advocated for allocating a minimum of 15% of the budget of local government units for health care as a tangible commitment of local chief executives towards health and health equity within the community. Furthermore, she underscored the necessity of working as a cohesive local health system, as the rural health unit cannot operate in isolation. Dr. Leslie Anne Luces-Sedillo of Aklan highlighted the significance of a transdisciplinary approach, the pivotal roles played by organizations like the Association of Municipal Health Officers of the Philippines, the LCE’s ownership of the UHC principles, and the importance of fostering collaboration at the grassroots level. Dr. Luces-Sedillo emphasized the finance team’s indispensable involvement in ensuring the local health care system’s financial sustainability. Dr. Sheila Gumabong of Guimaras reiterated how creating legal instruments fostered trust and collaboration by providing clarity of shared responsibility among key stakeholders such as local health offices, LCEs, hospital and facility heads, and private sector stakeholders.

The speakers also called for improvements and efficiency in the system. Current guidelines in the special health fund sandbox require an escrow or buffer fund to secure frontloading of funds from PhilHealth. This may tie up and render a significant portion of the local government units’ funds unusable especially for provinces with very limited fiscal space, prompting Governor Joaquin Carlos Rahman Nava of the Province of Guimaras to call for a more streamlined and cost-effective way of acquiring and utilizing the frontloaded money in the special health fund.  Additionally, Dr. Maria Socorro Quiñon from Iloilo Province encouraged service providers to place prime importance on their financial sustainability and the integrity of their services by clarifying standards of care at each level, especially the primary care level.

The event ended with a ceremony celebrating the commitments of health teams and stakeholders, such as the local government units, civil society organizations, and non-governmental organizations, to work towards UHC, focusing on essential lessons and implementation advancements. In the words of Regional Director Suba-an, “Indeed, we have shown and proved to the rest of the regions in the country that here in Western Visayas, walang maiiwan (no one gets left behind). In our pursuit of UHC, everyone is on board, and no one will ever be left behind. Padayon kita sa paghugpong agud ang UHC nga handum, aton maagom (Let’s continue to unite so that we can achieve the UHC that we want).”

In the two-day Learning Forum that followed, ThinkWell’s partner provinces, Antique and Guimaras, provided significant contributions on technical and financial integration as they discussed the unification of care pathways design within a province-wide health system and health care provider networks, the development of a referral manual within the care system, analysis of referral form data, setting up the special health fund, and the KONSULTA sandbox experience. ThinkWell and ADB will publish learning from the Learning Forum to provide insights to the DOH and other regions as efforts toward full UHC implementation continue.

We want to extend our deepest gratitude to the following individuals who were also present at the UHC Summit:

• DOH Western Visayas Regional Office: Dr. Mary Pauline Angelique C. Gestosani, Chief of RLED, and Dr. Mary Joy D. Castroverde, Head of HSIMEC
• Provincial Health Officers: Dr. Leoncio Abiera, Jr. from Antique Province, and Dr. Ramon Alex Nolasco from Capiz Province
• Municipal Health Officers: Dr. Christian Earvin Bondoc from Igbaras, Iloilo; Dr. Melba Billones from San Jose, Antique; and Dr. Uldarico Babayen-on, Jr. from Sebaste, Antique
• Development Partners: ReachHealth and the World Health Organization

By Anne Musuva, Country Director, ThinkWell Kenya

Much has been written about the inadequate or delayed flow of funds to frontline providers and its contribution to poor service delivery. The Lancet Global Health Commission on financing primary health care notes that because of insufficient public spending in many places, primary health care is not fully meeting the needs of people.

I gained a new, more grounded appreciation for this problem when I recently visited a series of dispensaries and health centers in a western county of Kenya. At many of these health facilities, casual staff like cleaners and clerks had not been paid for months because the funds received from the county were inadequate and often delayed.

Other facilities I found understaffed—some staffed by a single nurse—and it is not rare to find these facilities closed because the managing nurse is on leave or away for training. When the nurse is available, patients are often sent away to buy drugs from private pharmacies because the dispensary is out of essential medicines. These circumstances are common in many other parts of the country and point to significant under-resourcing of primary health care (PHC) in Kenya as well as poor fund flow to frontline providers.

The importance of PHC

In 1978, the International Conference on Primary Health Care signed the Declaration of Alma-Ata and called for strengthening of PHC, particularly in low- and middle-income countries. PHC is a whole-of-society approach to health that puts people and communities at the center of their health, focuses on patient needs, and shifts focus away from hospitals and specialist care. Equitable and high-quality PHC is the foundation of a strong health system and is essential for achieving universal health coverage (UHC).

What Kenya has gotten right

Kenya has made significant progress in expanding equitable access to PHC. Inspired by the Declaration of Alma-Ata, in the 1990s, the nation introduced user fee exemptions in public primary health care facilities to expand access to PHC. In 2006, Kenya launched a community health strategy that outlined services to be offered at the community level.

In 2013, Kenya adopted a devolved system of government which made the delivery of health services a county responsibility. Since then, county governments have expanded geographical access to health care by constructing health facilities, particularly dispensaries and health centers, referred to as PHC facilities. Access to PHC services was further improved through the free maternity program, Linda Mama, launched in 2013. The national government later introduced the “user fee forgone” grant to compensate PHCs for revenue lost from user fee exemptions. These funds were used for facility operations, including filling supply gaps and paying casual workers.

In 2015, the National Health Insurance Fund (NHIF) shifted from a focus on hospitalization to an expanded benefit package that includes outpatient care. The NHIF introduced capitation, a population-based provider payment mechanism that can improve equity and strengthen primary health care. Additionally, DANIDA, Denmark’s Development Corporation provides funds to PHC facilities for their operations and maintenance.

Currently, the Ministry of Health (MOH) is pursuing a number of reforms to strengthen PHC. The government is rolling out primary care networks which seek to improve PHC through reorganizing service delivery around a network of community units and PHC facilities. The MOH has also announced plans to recruit community health promoters across all counties and the establishment of a PHC fund to further improve PHC.

The glass half empty

Despite Kenya’s recognition of PHC as the backbone of UHC and the country’s immense milestones, we continue to face challenges in advancing the PHC vision. These include inadequate financing for PHC and lack of financial autonomy which lead to compromised quality, inadequate human resources, and drug stock-outs. Secondary and tertiary facilities receive the lion’s share of resources, including direct financing, human resources, and drug supplies. ThinkWell conducted preliminary analyses of several counties which show that PHC facilities on average receive less than 20% of a county’s health allocation yet constitute over 90% of the facilities and provide at least 60% of the services in a given county. Financing of the community health strategy and  paying stipends for community health volunteers has been inconsistent.

Several recent developments have jeopardized nationwide PHC financing. In 2021, the national government discontinued the user fee forgone grant for PHC facilities and converted the conditional grant to an equitable share grant for counties. The counties have full discretion over these funds, many of which have not been channeled to PHC facilities. DANIDA, which remained a main source of direct financing for PHC facilities, announced plans to phase out this funding by 2025.

Following the loss of two primary funding sources, PHC facilities are left with limited options, including the NHIF and county grants in the few counties that provide them. A facility’s access to NHIF revenue depends largely on whether its county has enacted legislation allowing facilities to retain and use funds generated from the NHIF, including from Linda Mama and from capitation payments. 21 counties have not allowed facilities to do this. Providers in these counties have little incentive to submit claims to the NHIF, leading to loss of NHIF revenue. As a result, mothers coming to deliver at PHC facilities in these counties are often sent away for drugs and supplies, defeating the purpose of Linda Mama, a program premised on free care to vulnerable women at point of use.

So, what should be done?

As Kenya rolls out its ambitious UHC program, we must strengthen PHC to deliver on the UHC promise. The government will need to prioritize the following:

Review resource allocation to prioritize PHC.

This will involve not only increasing allocation to the health sector, particularly PHC, but also reviewing how resources are allocated between PHC, secondary care, and tertiary health care. These allocations should be commensurate with the health care demands at each level. This is at the heart of strategic purchasing, a health financing function which seeks to allocate resources based on information about population needs and provider behavior.

Enact legislation to grant facilities financial autonomy.

The national government or counties should enact legislation that allows all health facilities, including primary health facilities , the autonomy to raise, retain and use funds at facility level. This will mean that facilities can retain NHIF revenue for the services they provide and would be incentivized to make claims to NHIF.

Instate direct facility financing.

As the main sources of direct facility funding dry up, counties should consider directly funding PHC facilities for their operations to improve service delivery. Facility managers are best placed to determine their priorities and manage their funds to meet the needs of the communities they serve. This should be accompanied by support to ensure adherence to the public financial management rules to ensure funds are well used and facility managers are accountable.

Prioritize service delivery.

Investing in additional facilities should be preceded by careful consideration of the need for a facility and the availability of resources to maintain it. Preliminary analysis suggests that counties should shift their priority from building new facilities to resourcing existing facilities and improving quality of care. The focus should be on ensuring existing facilities are well equipped, are stocked with medicines, and have adequate and well-trained health workers.

Conduct further research.

There is a clear need for further evidence on how best to finance and incentivize PHC to deliver high-quality, cost-effective, and equitable care. We need to track financing levels, sources, and expenditure for PHC, and measure what funding levels, strategies, and incentives are associated with better outcomes.

As Kenya continues to deal with the effects of the Covid-19 pandemic and face a triple burden of disease, financing PHC is even more important and should be a key priority for government, at both the national level and county level. The government’s plans to roll out primary care networks and improve PHC financing are a great opportunity for strengthening primary health care. The implementation of these reforms and their outcomes should be tracked closely to inform policy.

Stefan Nachuk takes a look back at lessons learned from the Joint Learning Network for Universal Health Coverage (JLN). Learn why facilitators are the “secret sauce” and see what’s next for JLN.

Read the full post at The Lancet Global Health Blog.

Yogesh Rajkotia, ThinkWell’s Founder and CEO, spoke at the 2014 Africa Forum on Universal Health Coverage (UHC) in December in Addis Ababa. The event was hosted by the Korean International Cooperation Agency.

Over 90 countries have endorsed the United Nations resolution on UHC. Dr. Rajkotia’s presentation discussed health financing trends that have emerged from countries’ drive toward UHC. Over 55 countries have implemented or plan to implement health insurance programs. Over 50 countries have implemented or plan to implement results-based financing. Dr. Rajkotia explained the steep increases in such programs, “Countries are seeking more effective ways to use available funding. Increasingly, health financing mechanisms are being used to drive the efficiency of programs, thus financing is serving to reshape the health sector.” His advice to countries? “Think big and plan ahead.”

Dr. Rajkotia went on to describe the importance of developing specific solutions that work for each country’s context. Traditional, standard models no longer apply. Increasingly, experienced experts are emerging from low and middle income countries, thus making south-to-south information exchange and collaboration an effective way to access advice on adapting customized solutions.

Dr. Rajkotia acknowledged that “Power and politics remain critical factors in developing local solutions. Politics drives progress.” Health financing mechanisms, like providing health cards to each citizen, have increased awareness among citizens, and brought on calls for increased information and involvement. Another way in which health financing has influenced the dynamic is by the defining and strengthening of the purchaser’s role in health services. Purchasing agents — which in a sound design are independent entities, separate from a Ministry of Health — are gaining more purchasing power and more autonomy from Ministries of Health, and are also invested in the benefits offered and the quality of the health services delivered. Dr. Rajkotia points to positive examples of health financing reforms driving improvements to health access and quality, such as Ghana’s successful national health insurance scheme, and the opportunity created for Morocco by its Arab Spring neighbors.

Dr. Rajkotia’s presentation is available on www.thinkwell.global/publications/.

This past December, I spoke at the Korea Foundation for International Healthcare’s (KOFIH’s) 2014 International Forum on Universal Health Coverage (UHC) in Addis Ababa. I also had the opportunity to deliver a keynote speech at KOFIH’s 7 year anniversary celebration in Seoul in 2013. I spend a lot of time at various international conferences and knowledge sharing events, but I was particularly inspired to witness the interactions between Korean health systems practitioners and their counterparts across Asia and Africa. The Korean approach is different: in the way they bring people together to exchange information, in the way they approach development. This synergized well with my observations about what is needed to help countries achieve UHC.

The Evolving State of Health Systems in LMICs

In my speech in Addis Ababa, I spoke of the evolution of health financing in low- and middle-income countries (LMICs). I discussed how international partners, mostly from Europe and North America, drew from their own experiences to support this evolution in its early stages. They introduced concepts found in Bismarkian, Beveridge and market-driven models of health systems. But the growing global chorus to achieve UHC has created the impetus for countries to develop unique health systems models tailored to the LMIC context. And these models look very different than the traditional models from upper income countries – just look at the mixed models in Rwanda, Ghana, and Philippines.

So who is best suited to support LMICs as they continue their journey towards UHC? I believe that it’s LMICs themselves. Rooted in practicality, their thinking goes beyond the standard models and transcends conventional wisdom. And, with over 55 countries having introduced or planning to introduce insurance, and 50 having introduced or planning to introduce results-based financing, the pool of health systems practioners from LMICs is growing every day.

KOFIH seems to have embraced this reality into their approach, while at the same time offering lessons from their own bumpy journey towards UHC.

The Difference from Korea

The South Koreans’ approach to foreign assistance is undoubtedly influenced by their own remarkable transformation – from a country devastated by the Korean War in the 1950s to becoming the 12^th largest economy in the world today. Since the end of the war until the late 1990s, Korea received $12 billion in foreign assistance, while today Korea is providing $1.7 billion in foreign assistance annually as an OECD Development Assistance Committee member.

At the same time, they project an unbiased and agnostic approach to assistance. In examining KOFIH’s work, it is clear that they do not push particular models, methodologies, or agendas. Their role is largely informative and facilitative – bringing peer countries together to share knowledge, exchange experiences, and generate solutions. They pair Korea’s innovative health agencies, such as Health Insurance Review and Assessment Service (HIRA) and National Health Insurance Service (NHIS) with budding counterpart agencies in LMICs. They understand that development is a process, and naturally, every process is unique. Most importantly, they do not expect any individual country’s development to look like South Korea’s.

The Koreans are still finding their feet in how to best engage in foreign assistance. Their strategies will surely evolve as they continue to learn about the dynamics in LMICs, narrow their focus, and harmonize their various foreign assistance agencies. But they are on to something. And it is a refreshing message for low- and middle-income countries, one I believe should be emulated by other providers of foreign assistance.