OPINION: Effective leadership is vital for working healthcare systems
By Doris Kathia
The enactment of Kenya’s new Constitution in 2010 devolved most functions previously held by the central government including health sector functions to 47 newly established counties.
Implementation of the new Constitution, however, did not begin until March 2013, after the general elections took place.
Rapid reforms and transfer of responsibilities to county level was due to pressure from actors within the devolved units, although structures were not yet established and capacity not in place to manage such functions at that time.
Devolution was motivated by the need to have a new Constitution that ensures equality in the distribution of wealth across the country.
In Kenya, the cooperative system of devolution was adopted such that the national and county governments consult and cooperate on various matters in their operations.
Devolution in Kenya is guided by three distinct principles: oversight – dealing with the supervision of how the devolved units are run and manage resources; interdependence – which emphasises the interdependence that exists between the national and county governments since they both serve same people, and some 5 of their roles overlap since the national government normally does policy formulation work while county governments are ones that are involved with implementation part; and lastly, distinction – meaning that every government level such as national and county have distinct boundaries, resource and roles.
County governments hold responsibility for planning, management and budgeting. They make decisions by drafting county integrated development plans; annual planning and budgeting; service delivery for public health, disease surveillance, community health services, primary health services, ambulance, county hospital services; recruitment and human resource management including facility and community health workers and partner coordination.
Governance is widely recognised as central to improving health sector performance and achieving universal health coverage (UHC).
However, it is political, the result of interactions, coordination and decision-making among different actors in the face of multiple views and interest.
Article 53 of the new Constitution provides the right to basic nutrition, healthcare and shelter for every Kenyan; Article 56 provides that the State should formulate and put in place frameworks that will make sure that the marginalised and minorities can access health services, infrastructure and water.
For these rights to be actualised, devolution divided health provision responsibilities between county and national government: it provided particular guidelines on which services both levels are to offer.
Primary healthcare provision was the role of the county administrations while national government retained management of national referrals and health policy formulation.
Promoting citizens’ understanding of health or their decision-making role is essential however, across the country; we have a host of barriers to effective citizen participation.
While avenues for citizen participation are described in policy in Kenya, in practice, a lack of funding and tokenistic implementation hinder opportunity for genuine involvement of the community in identifying priorities.
These have led to failure in addressing local patriarchal norms that limit women and youth’s active participation in the presence of men/elders.
Setting of priorities is often strongly influenced by power play and local politics, in keeping with influence of social hierarchies, social, cultural and religious norms, economic and political divisions and power asymmetries on participation in health facility management committees.
Redirection of funds reduced the ability of health facilities to purchase supplies or hire auxiliary staff. The Council Health Management Team (CHMT) convinced the county assemblies to keep user fees within the health system by establishing a dedicated bank account for user fee revenue.
Because the CHMT in County A wanted to maintain control of its own revenues, it identified a way to sustain a steady source of revenue for county health activities.
Failure to address pre-existing negative contextual norms and practices varied decision-maker values, such as patronage or nepotism, leads to their embedment and continuation at subnational levels, potentially leading to diversion of funds and priorities to more ‘politically influential’ individuals and groups.
This means that the neglect of historically marginalised groups persists and priority-setting capacity as well as genuine community accountability is further limited.
Unless the need for and benefit of public health services is understood by community members and politicians, this is likely to exacerbate neglect of public health interventions, impeding progress towards UHC. Poor leadership, or rather, non-political will highlights the nature of this problem.
But both the structure and openness of the political systems can drastically change. When a new government is formed after elections, or there are peace settlements after civil wars, they open up windows of opportunity. Moreover, resources can be made available as a consequence of an economic boom or donor promises.
Hence my recommendation for the national governments is to come up with appropriate mechanisms that will help counter the challenges associated with release of funds to counties.
Additionally, both county government leaders and hospital management should be comprised of people who are up to the task, focused and performance oriented.
County governments should come up with measures to counter corruption by reporting suspected individuals to the relevant authorities such as the Ethics and Anti-Corruption Commission (EACC). Consequently, prosecuting authorities should ensure that the cases are dealt with expeditiously.
Effective leadership is a vital component of healthcare systems and has an extensive range of functions in improving organisational effectiveness and efficiency.
Ms. Kathia is a youth advocate at Network for adolescents and youths of Africa (NAYA) Kenya