The Hidden Truth About Devolved Healthcare; Choose Who to Trust.

Our Swahili forefathers rightly said "majuto ni mjukuu" The statements indicates the spatial relationship between our actions and related consequences or outcomes.
There are decisions we have made collectively and individually in the last few years that have left sore tastes in our mouths.
The case in Kenya today comes to fore in every aspect. While a small percent, say once percent is content with status quo, the larger majority are writhing from effects of indifference, condescending and careless leadership that has become our national government
Yes, the same government that we lined up to elect on March the 4th 2013.
 In the part 6moths, there have been key happenings in the political circles in Kenya that have demonstrated out government as aloof and detached from the suffering of the poor.
For a start, the first order of the day was to increase the salaries and allowances of the political class. Many a Kenyan will not mind having more pay. That is granted. The only issue is that the sky rocketing prices of commodities has greatly affected the purchasing power of the majority poor. 
It is in this same period that we have seen an unprecedented increase in prices of commodities from increased taxation. The government thought it prudent to increase VAT on essential commodities, further making life more difficult. Amid intense protests, the government chose to turn a blind eye.
The government has pushed through very unpopular and dictatorial laws. The much talked about Media Bill is geared towards strict control of what the media transmits to the public. Indeed its encroachment on the constitutionally provided freedom of information. For any progressive society such liberties as freedom of information must be jealously guarded. Also in the process is the law on NGO. By limiting the maximum amount one can solicit to carry out programs to 15%, the neglected groups who have benefited and continue to benefit from NGO stand to lose.  
In regard to the current impasse between the country's health professionals and the government, this is an unfortunate situation. While the government purports to support full implementation they are very economical with the truth. What they are not telling Kenyans and the world is that up to now the relevant laws have not been passed to oversee this important exercise.
In their wisdom they have cut the period of 3yrs to 6months guided by other considerations other than the common good. They are not also stating that the true custodians of health care are the health professionals. They have in turn chosen to incite emotions into unsuspecting poor population who entirely rely on public sector for healthcare provision.
Its a fallacy that the public has bought this concocted untruths; they have said unsavory things against the healthcare professionals. They are the same time please for consideration of Hipocratic Oath. Dear friends. The said oath regardless of its outdated nature does not prescribe social and economic oppression to those who practice medicine and paramedic professions. Its not an authority to exploit, mistreat and fleece these selfless men and women who risk their own lives to save human kind from disease and pestilence.

A great write said "when the centre cannot hold any further, things fall apart". We are witnessing evident lack of leadership on the part of the central government. These men and women have decided to play into the tune of the already dysfunctional county government. They have ignored well intended input from the providers of healthcare in the country. They have decided to play a game of musical chairs with lives of the public. They have veered off from addressing the core issues raised by the healthcare professionals. They have concentrated on side shows and smokescreen
Its not long from now that the Kenyans will 'enjoy' the fruits of devolved healthcare.
It is expected that incessant interference from political class, overbearing and exploitative work environment, insensitive administration, poor pay and low motivation will cause healthcare to plummet a great deal.
Some of the immediate outcomes of this thoughtless process will include but not limited to
1. Chaos in training, licensing, regulation, accreditation of health professionals
2. Increased counterfeits in public facilities
3. Stock outs
4. A denuded workforce barely capable of handling healthcare provision
5. Unimaginable alienation of certain counties, imbalance in staffing and quality of care
6. Increase cronyism, corruption, NEPOTISM in recruitment, promotion, development of staff. These cannot co-exist with quality.
7. Ethnic zoning of healthcare.
As we continue to live with all these consequences, we must ask ourselves: How does delay in devolving personal emoluments of healthcare workers until relevant laws are passed negate the spirit of devolution?
The health professionals have rightly read a sinister motive for this accelerated attempt to transfer personal emoluments to the counties. It is no longer about service delivery or quality. It’s about the individual governors' self aggrandizement.

Finally, as Kenyans suffer, the political class access healthcare from private facilities and even abroad. We are still fighting one of the enemies identified by our founding fathers at independent. Ill-health.

THE TRAGEDY OF HURRIED DEVOLVED HEALTHCARE IN KENYA

It is argued that it is in the times of turmoil when people reason prompted by the need to restore order. This approach has a sadistic angle since some disorders are preventable. The intended devolution is ultimately a great thing but the care givers have faulted the process being followed in doing so.

In this article I discuss the top most expected problems with hurried and unstructured devolution of public health care in Kenya. It Is worth noting that should the anticipated challenges affect the health sector negatively, it’s the poor who will bear the brunt. Public health sector provides care to 87% of Kenyan population. The middle class who are decision makers receive care from elsewhere; the private sector and overseas facilities.

What is at stake with hurried devolution of healthcare?

It is envisioned in the constitution that healthcare being essential its devolution must be systematic and guided by clear structures. In addition, the Devolution to County Act of 2012 sets presence of relevant laws as foremost prerequisite in assessing if a function is to be devolved or not.

The proposed Health Bill was introduced by the previous government but did not see the light of the day owing to fundamental flaws therein. Overally, this bill proposes certain changes to ensure that the health sector remains professionally managed and preserves its essential nature in spite of prevailing political circumstances of the day. The functions below will be irreparably negatively affected by devolution devoid of relevant structures and policies.

Training of health personnel

Kenya is credited with provision of impeccable training if healthcare workers in all cadres in the region. As a matter of fact the neighboring countries have viewed Kenya as a role model in this aspect. There is standardization of training for nurses, clinical officers, medical, dental and pharmacy officers. This has been entrenched in the well defined centrally supervised training.

In absence of centrally structured supervisory bodies to inspect and accredit training, the quality training received will be eroded. Even in the developed nations like USA, there is one central body to ensure the quality of training is safeguarded.  As a direct consequence of hurried devolution, we are likely to see mushrooming of dubious training institutions. Due to the sensitivity of services the health professionals will provide to the public, this must never be allowed to happen.  There must be defined and supervised training of all cadres. This is effectively rendered impossible by the hurried devolution of health sector.

Registration of health care providers

The health Bill recommends formation of centralized registration body to ensure only those duly trained and qualified are registered to offer health services in Kenya and indeed other nations where Kenyan credentials are recognized. It has been practice to ensure that persons trained outside the country are tested and approved before they can practice in the country. This also helps in authenticating the certificate presented. This function must never be taken to the 47 ill-equipped counties since the repercussions will be costly. In the proposed and hurried devolution, there is no clear indication as to who registers health workers.

Supervision of Health care providers

Like any function, supervision is vital to ensure accountability by all healthcare providers. In the devolved healthcare, much as the county administration argues they are capable of supervising healthcare workers, this must be distanced from political patronage and interference. The delicate nature of healthcare requires clearly defined and unambiguous separation of functions. What may appear as supervision by politicians may eventually cripple operations in public health facilities.

Specialization and sub-specialization training

A weak economy as Kenya must take heed to invest in human capital development. The role played by specialists and subspecialist in the public sector cannot be overemphasized. The determination of priority areas of training and who is to be trained must be preserved. The rationalization for this must not be subjected to the political whims of county government. Some counties have argued that they don’t even need doctors in the first place. Incidentally the proponents of this thinking are not care seekers in these facilities.

Similarly, the trained consultants must be equitably distributed in all the 47 counties to ensure that some Kenyans are not starved of these services while other places are overstaffed. The current system of identification of trainees and redistribution of qualified specialist has been variously faulted. But this is better than no system at all. There is need to involve all stakeholder in crafting policies to achieve adequate and equitable coverage by consultants.  It is anticipate that the unplanned devolution being fronted and not backed by any policy or legal guidelines will irreparably dent the attempts of attaining better coverage as enshrined in the Kenya Vision 2030

Retention of workforce in the Public health sector

The jitters seen among the health workers owing to the anticipated political interferences, proposed reduction of pay and allowances is likely to push health workers out of employment. As it is, there a reports of resignations daily, stretching the already understaffed workforce in the lower units of healthcare system. It is worth noting that this may be viewed differently depending on which side one considers. To the Salaries and Remuneration Commission (SRC), they may laud this since they have constantly complained that the wage bill is bloated. But should they jubilate while an essential sector is crumbling? My opinion is no. To the employees, this is a very worrying development.  As with all other professions, it’s the hope of majority to have conducive and supportive environment to ensure services are discharged efficiently. A very thing workforce, de-motivated souls and poorly remunerated personnel inevitably affects their output. The public health sector is better improved through reduced exodus of staff to private sector, abroad and other unrelated engagements. The question is, does the devolved structure promote retention of staff in the public health sector? Simply no

What must be done to ensure smooth transition?

It is foolhardiness to presuppose that coercion and intimidation shall achieve results. If truly the relevance of devolution is to improve service provision, then dialogue must prevail. The Fourth Schedule of the constitution of Kenya has set the transitional period to three years to give room for adequate preparation before functions are handed over to the counties. But the usual practice of shifting goal posts has culminated to the standoff between the central government, the county governments on one hand and the healthcare providers of the other hand.

It must not be forgotten that no single group desires and longs for improved healthcare than the the healthcare providers themselves. The citizens must not allow other consideration but political class such as control of procurement, tendering and rewarding of cronies and sycophants to mar the process of devolved healthcare. Finally, in the event that the public health sector collapses, it is the poor citizens who will suffer and the elites continue enjoying uninterrupted services in private facilities and overseas institutions.

It is collective suicide to devolve healthcare in Kenya

In the recent past, there has been heated argument for and against devolved healthcare in Kenya. The process has received support and condemnation in somewhat equal measure. While this process in anchored on the constitution of Kenya, it must be noted that there have been issues raised that need consideration.

The medical fraternity has come out to unequivocally fault the haphazard and hasty manner in which health care is being proposed. The constant unheeded caution by the deliverers of healthcare has resulted into the current standoff and imminent strike that will erode gains made so far in restoring the image of public health sector in Kenya.

What are the issues?

The Transition to County government act of 2012 stipulates that the most important aspect before devolution is presence of relevant law(s) to spell out roles, responsibilities, obligations, and processes. As we speak today. The Health Bill has not been passed. This is the bill that will govern healthcare and the relationship between national and county government in matters of healthcare. In the absence of this bill, devolved health will cause confusion, anarchy, endless tussles and politicization of health sector.

The bill speaks of regulation of training, standards, quality, recruitment and licensing of health care workers to guarantee Kenyans quality of care. The bill envisages reorganization of administration of health sector, proposes centralized recruitment, posting and development of healthcare workers to ensure that all the 47 counties are equitably served.

The rushed devolution portends to cause undue political interference at the county level. It must be noted that county governments have now officially entrenched tribalism going by the composition of officers serving at the County Public Service Boards. These boards are composed of tribe mates and cronies and as expected, there will be little objectivity in their judgments.

Immediate effects of devolution in absence of legal framework

The process will affect the entire spectrum of health care. Supervision of training at both undergraduate and postgraduate levels remains in jeopardy. Kenyans must be assured that the worker churned out are properly trained and equipped to attend to them. Equally important, those trained must be absorbed into the already strained system. In Kenya today, there are 4000 doctors serving a population of 42million Kenyans (1:10500); very few dentists and even fewer pharmacists. There is a deficit of 40,000 nurses in the Kenya. This will only be worse with expected resignations.  Training of consultants also remains uncertain. With a country pegging the Vision 2030 on a health workforce and improved health indicators, training of specialist must never be relegated. There must be a clear structure to determine training needs, numbers and streamline the processes

Healthcare is a highly technical aspect of development. Some quarters have termed it as essential service. There must be clear depoliticization of healthcare processes. With creation of small empires in the counties and impunity exhibited by the county authorities, it is clear that the sector is headed for total collapse unless urgent measures are put in place

What is the proposed course of action?

A well thought out strategy must be worked out to retain professionalism and quality regardless of devolution. Stakeholder participation on defining processes is very critical to ensure success; the relevant legal and policy mechanisms must be put in place to govern the devolution process. Structures must be developed to foster accountability in this highly sensitive sector. Thus a complete reversal of devolution of healthcare providers and their personal emoluments will ameliorate the situation at the law makers are urged to debate and pass the pending Health Bill. The bill must entrench a (central) Health Service Commission (HSC), a licensing Board, and an organ to check on Quality of care.

In conclusion, the policy makers should remember it is very difficult if not impossible to force a process onto people (implementers) whether backed by constitution clause of not. Let sanity and reason prevail.