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Questionable assumptions - why health sector reforms have failed to deliver in Kenya
2004-02-25

he Kenyan government is committed to providing health services to all its citizens. But despite major health sector reforms, the population’s health status is falling. Researchers from the Tropical Institute of Community Health and Development, Kisumu, Kenya, explore the reasons for this lack of success.

The Kenyan government is committed to providing health services to all its citizens. But despite major health sector reforms, the population’s health status is falling. Researchers from the Tropical Institute of Community Health and Development, Kisumu, Kenya, explore the reasons for this lack of success.

Since independence in 1963, the Kenyan government has been committed to improving the health of its people but has struggled to supply health services to a rapidly growing and increasingly poor population. The health sector has seen a steady fall in resources to address an increase in the burden of disease. It has poor institutional and organisational capacity. The Health Policy Framework of 1994 focused on devolving government support to the district level and strengthening the district as the point of delivery and development of healthcare. This involves decentralising decision making by setting up district health management teams and transferring funds from the central Ministry of Health (MoH). This policy was based on four assumptions:

* Problems stem from mismanagement rather than a lack of resources. 
* Government and non-governmental health stakeholders have the capacity to implement the policy successfully. 
* Moving from needs-based to demand-driven planning will make healthcare more cost-effective and accessible. 
* Decentralisation will make healthcare services more responsive to local needs. 

However, the researchers’ analysis questions the validity of these assumptions, showing that:

* Government and donor funding for healthcare has decreased over the last decade. 
* 70 per cent of funding is allocated to staff salaries leaving few resources for service delivery. 
* The MoH cannot fully control all available healthcare resources, such as those in religious and private organisations. 
* The public sector at the district level lacks the capacity to regulate the system, enforce standards and enable effective participation of non-governmental stakeholders. 
* The services of non-governmental providers are too unevenly distributed and uncoordinated to be a useful alternative to government services. 
* The majority of the population faces not only falling quality and an increasingly restricted range of services but also a lack of purchasing power to ‘demand’ health services. 
* There are major concerns about governance and accountability in the health system at provincial and district levels. 
* Decentralisation has been donor-driven and so lacks responsiveness to the needs of local communities, particularly the poor. 
* The realities of market forces and poor governance make it difficult for the government to fulfil its commitment to improve the health of all Kenyans.

The researchers conclude that it needs to address four main challenges:

* closing the gap between central policy-makers and implementers at the district level 
* maintaining credibility as the protector of its citizens’ health rights while also responding to the demands of a market economy 
* sustaining the health sector reform process through collaboration with multiple stakeholders 
* overcoming poor governance and management of the health sector. 

(Source: id21 Research Highlight: 10 October 2003 ‘Health sector reforms in Kenya: an examination of district level planning’, Health Policy 64: 113-127, by C. Oyaya and S. Rifkin, 2003) 

Further Information: Susan Rifkin Tel: +44 (0)7946 842266
Email: sbr44@columbia.edu

Link \//\

Tropical Institute of Community Health and Development, Kisumu, Kenya
http://www.tichinafrica.org/

Other related links: 
'Swimming against the tide - health reform in South Africa and Zambia' 
http://www.id21.org/health/h1lg1g7.html

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