By Hayley Elszasz
Over the last three months, a nationwide strike in Kenya has brought public health care to a standstill. Doctors and nurses throughout the country are protesting the central government’s failure to implement a 2013 agreement to raise wages, improve equipment, and provide better training for medical professionals. This mass strike has highlighted the issues surrounding Kenya’s struggle to decentralize its health care system to its counties, as many local governments lack the resources they need to provide care.
This problem requires immediate attention, as the ongoing strike has left many of Kenya’s most vulnerable populations trapped with the choice between foregoing care or paying the high costs of turning to private facilities. With over 5,000 of the nations doctors actively protesting, public health care no longer functions properly. In some cases, tragically, cancer patients are being left without access to life-saving treatment. This is not the first time that health workers have gone on strike in Kenya; there have been more than 24 strikes since health care became a decentralized function of government in 2013. These strikes have continued to occur because the hurried and flawed nature of the decentralization process left the governments of the country’s 47 counties in charge of a sector that they were not yet capable of running effectively. County governments are now responsible for regulating, financing, and maintaining all primary and secondary health facilities. The challenge is daunting, but it is not insurmountable. It will take time and resources for the counties to build up their health infrastructure, but the central government can aid this process by increasing the funding to counties and altering the calculations used to determine county-by-county allocation.
While some central government officials blame the striking doctors and nurses for their seemingly self-interested demands for higher wages, others attribute the strike to the central government’s unwillingness to provide the county governments with funds to pay the doctors the wages they are due. Under the current system, only 15 percent of total revenues are allocated to the county governments; this funding is divided between them based on population, poverty index, and land area.
Although using population and area to determine the distribution of funding is meant to approximate the cost of delivering services in a particular county, there is a need for more precise calculations to ensure that counties have the funding they need to provide health services. Mwangi Kimenyi, a senior fellow at the Africa Growth Initiative at the Brookings Institution, correctly calls for an itemized approach to county financing that is “informed by good research.” This approach would take into account the cost of delivering each key health service to each specific county. The current formula used to determine the distribution of resources, while notable for its simplicity, is not informed by the differing cost of administering immunizations, treating malaria, and other common functions of the health system.
Kimenyi noted that the cost of treatment varies widely between larger and smaller counties as well as between counties on the periphery versus the center of the country. An example of this inequity can be found in the disproportionate number of doctors who work in Nairobi. A third of the approximately 10,000 doctors in Kenya are in the capital city, which is home to only about a tenth of the population. Counties on the periphery should be allocated additional funds to attract more health professionals. While there has been much debate about the division of resources to counties post-decentralization, and about the census numbers used to inform this distribution, there has been no progress towards reformulating the decentralization of funds from the central government to the county governments. As a result, counties are not financially able to pay their doctors and support the health system.
Despite the numerous benefits of decentralization—such as bringing services closer to the people, granting more autonomy over local matters, and providing closer links of accountability—when it is enacted without necessary resources and structures on the county level, it can result in devastating outcomes for the population. The health workers’ strike in Kenya provides a vivid example of the dangers of decentralizing functions without the requisite funding or ability to collect revenue to support the decentralized activities. Although the central government has agreed to pay the salaries of nurses from January to June 2017, this is not a long-term solution.
The key failures of decentralization have yet to be addressed. The central government of Kenya must provide resources to counties proportionate to their responsibilities, and they should consider the true cost of delivering life-saving services to local populations. The ongoing health workers’ strike has added urgency to these calls. Short-term agreements over salaries will not suffice; an overhaul of the funding mechanisms for counties is necessary to prevent future strikes in the health sector.
Hayley Elszasz is an Africa Fellow at Young Professionals in Foreign Policy (YPFP). She is also a Program Associate at World Learning. Hayley earned her BA in Political Science and Global Studies from Williams College in 2016. The views and opinions expressed in this article are the author’s own and do not necessarily reflect the views of any of the organizations with which the author is affiliated.