Quality universal healthcare is considered a fundamental human right and a key indicator of a flourishing nation, according to the World Health Organization (WHO). The provision of healthcare is viewed as a public good, aligning with a nation's interest in maintaining the well-being of its citizens.
The 2010 Constitution of Kenya (COK) decentralised healthcare services to counties, leading to a restructuring of the healthcare system and its administration nationwide. Under this arrangement, the national government oversees all Level 4 hospitals, providing specialised care, while county governments are responsible for managing Level 3, 2, and 1 healthcare centres in their respective regions.
Regarding access to quality and affordable healthcare, Kenya faces major challenges in ensuring equitable access to healthcare for her citizens. There is a high level of poverty and inequality among citizens, and this continues to impact access to healthcare heavily.
Kenya's doctor-to-patient ratio is 1:5,725, well above the WHO-recommended ratio of 1:1,000, according to a fact-check by PesaCheck. This is an indication of an insufficient number of doctors to meet the population's needs. An Oxfam report highlighted the vast inequality in Kenya, with the top 0.1% (8,300 people) being wealthier than the remaining 99.9% (over 50 million people). This wealth gap is expanding, with the country experiencing one of the fastest growth in super-rich individuals globally.
Access to healthcare is a life-and-death struggle for many poor Kenyans. A 2021 United Nations Development Programme (UNDP) report on Kenya's Multidimensional Poverty Index (MPI) showed that 37.5% of the population (19.8 million) is multi-dimensionally poor, while an additional 35.8% (18.9 million) are vulnerable to multi-dimensional poverty in a country with a population of 51 million (2019).
What are the issues facing healthcare systems in Kenya?
Major issues impacting Kenya's healthcare system include an uneven distribution of professionals, facilities, and resources, with a concentration in urban areas over rural ones. Counties like Mandera and Wajir have notably fewer health professionals per person compared to Nairobi and Kiambu. While nurses are distributed more evenly than doctors, their numbers still fall short of the WHO's recommended ratio of 25 healthcare professionals per 10,000 people.
Notably, a Ministry of Health (MoH) health facilities census from December 2023, spanning three months, indicated that 93% of Kenya's health facilities cannot provide basic outpatient services. The census, which covered over 12,000 facilities, revealed that a majority lack the necessary equipment for basic services. For maternity services, 84% of around 5,000 facilities lack essential equipment.
The report further reveals that 78% of health facilities are unable to offer critical care, with public facilities posting a mere 2,304 critical functional beds in the Intensive Care Unit (ICU) and High Dependence Unit (HDU). Moreover, 68% of health facilities do not have access to oxygen sources, while 69% have no advanced life support ambulances. This discrepancy has emerged despite the Kenya Kwanza government running on an ambitious healthcare manifesto.
In the same report, only 12 counties have satisfied the minimum requirement of the recommended manpower in the provision of health services. Narok County is ranked lowest, with only six workers serving an average of 10,000 people, with Wajir and West Pokot counties posting 12 workers to serve a population average of 10,000 people. Nairobi County has 37 workers for the same population set, with Vihiga and Laikipia counties posting 31 and 27 workers, respectively, for an average population of 10,000.
Indeed, the impact of these challenges is already visible, considering that the number of Kenyans losing their lives due to poor healthcare systems is rising. A report by the Civil Societies Organisation Centre for Reproductive Rights, for instance, pointed to a rise in the number of maternal injuries and deaths due to medical negligence.
The 2023 report highlighted cases of medical negligence, including the death of Rebecca Wangari at Naivasha Level 4 Hospital due to excessive blood loss during delivery. Medical staff allegedly neglected her for over 24 hours despite her critical condition. Two other cases involved Velma Anita Ochieng, a 19-year-old Kenya Certificate of Secondary Education candidate, who died after giving birth at Homa Bay County Teaching and Referral Hospital in November 2022, and Maureen Anyango, a patient at Mama Lucy Hospital, who died in September 2022 shortly after giving birth to twins.
Additionally, there is a shortage of training institutions and graduates, further compounding the country's healthcare needs. Public health facilities in rural areas, where most people live often lack the necessary funding and resources, while the allure of higher salaries and better facilities in urban areas pulls healthcare professionals away, creating a further disadvantage for rural regions.
The consequences of this imbalance include reduced access to healthcare for rural and underserved populations, resulting in challenges in obtaining basic healthcare services. Furthermore, the unequal distribution contributes to elevated rates of preventable diseases and a high maternal mortality rate in these areas.
A 2022 report by the World Bank found that Kenya’s maternal mortality rate is one of the highest in the world, with 510 women dying for every 100,000 live births. The report also found that rural women are twice as likely to die from childbirth compared to urban women.
The few cases are an indication that much hasn't changed at the county level to ensure that citizens have access to quality healthcare despite devolution. The unequal distribution of healthcare resources in Kenya is also evident in the distribution of health facilities, with over half located in urban areas. Notably, only 30% of the population lives in such areas.
One direct impact of this unequal distribution of health facilities is that the rate of preventable deaths can also be attributed to the unequal distribution of healthcare resources. The country is still dealing with cases of high maternal mortality rate, especially in rural areas where many women have inadequate access to skilled birth attendants. Furthermore, the high mortality rate issue is not confined to rural areas alone. Several urban centre facilities have been in the news for alleged medical negligence, resulting in death.
While the Kenyan Government has taken steps to tackle the unequal distribution of healthcare resources by introducing programmes to boost the number of healthcare workers in rural areas, further action is required. This includes hiring more healthcare workers, enhancing working conditions and salaries, and increasing funding for the construction of additional health facilities in rural areas.
Government response to healthcare disparity
As part of its initiatives to address healthcare sector challenges, a WHO report highlighted that the Kenyan Government implemented a pilot programme for universal health coverage (UHC), offering healthcare insurance and substantially improving access to services. Key achievements of this programme encompassed over 1.6 million additional hospital visits within its inaugural year, expansion to encompass all 47 counties, the establishment of more than 200 community health units, recruitment of 7,700 volunteers and 700 health workers, and government funding for health insurance for one million households.
Recommendations to address existing equity challenges
The health census report recommends the scaling up of investments in basic equipment and appropriate infrastructure to support basic services in outpatient, maternity and newborn care. The MoH also underscores the need to prioritise the improvement of pharmaceutical availability, medical personnel, and overall health infrastructure to achieve universal health coverage (UHC).
At the same time, the Kenya Kwanza government has taken various steps in a bid to address the provision of quality healthcare in the journey towards the attainment of UHC.
Since assuming office, significant reforms have been implemented, including the approval of crucial bills aimed at advancing healthcare. These bills encompass the Primary Healthcare Bill, the Digital Health Bill, the Facility Improvement Financing Bill, and the Social Health Insurance Bill of 2023.
Human resources for health is a critical component in the delivery of basic healthcare, according to Prof. Gilbert Kokwaro, the Director of the Institute of Healthcare Management.
“Kenya has got two doctors serving approximately 10,000 Kenyans; this gives you an idea of how critical the shortage is,” he said.
Prof. Kokwaro intimates that Kenya cannot afford to train doctors for other countries, as more than half of the doctors trained in Kenya hardly stay in the country beyond five years.
“We need a complete change in mindset. We need strategies to not only retain what we have but start increasing the numbers,” he added.
The professor discourages the classification of healthcare workers according to job groups and lumping everyone into a set. He proposes that workers should be classified into professional clusters and to produce a scheme that balances the resources available with people's qualifications.
In Prof. Kokwaro’s assessment, the work environment for training healthcare workers should have the necessary resources for them to work with while paying the available doctors enough wages that will incentivise them to stay in Kenya. His conclusion is that a central body that looks after the welfare of all health workers should be created. That body should be able to negotiate attractive packages for all cadres workers.
In reality, solving the unequal distribution of healthcare resources in Kenya requires a proactive approach that prioritises rural areas and impoverished counties. There should be investments in training healthcare workers, hospital infrastructure and labour incentives. These measures are some of the ways to make strides toward achieving fair access to healthcare for all Kenyans.
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