By Vincent R. Okungu, KEMRI-Wellcome Trust & HEU, University of Cape Town
DIVERSITY, it is said, underlies American greatness. How Americans harnessed the power of diversity is a question for another day. Contrary to the American story, (ethnic) diversity is a source of divisions and conflict in many parts of Africa, Kenya in particular. Ethnicity has been used to leverage national resources, acquire political power and fuel corruption. The commoditisation of ethnic identity has made ethnicity supreme such that it is not the quality of aspiring leaders but their ethnic affiliation that matters to the largely ignorant and heavily manipulated electorate. A common line in the Kenyan social media has it that a prominent politician promised to build under-water roads for his constituents. Forget about the cost of such a venture, the constituency is a desert. He got elected!
In the just concluded shambolic general elections in Kenya, ethnic blocks ganged up to elect a president and his deputy. Both are suspects charged with crimes against humanity at the International Criminal court in the Hague. Lack of moral integrity is an understatement. In the event that Kenya becomes a pariah or rogue state, international sanctions could quickly erode the gains made in the health sector and destabilize the fragile food situation. Food security and health are two-sides of a coin.
In more progressive societies, a general election is an important window of opportunity to effect social changes. Electoral windows of opportunity are often used to force politicians to commit to implement gainful changes in the health sector in exchange for popular support. Thailand is a classic example where a political party, seeking to win elections, committed to implement universal health coverage. President Fidel Castro promised free health care to all Cubans as a way of consolidating his 1958 revolution. A number of progressive developing countries are making progress to UHC. Unfortunately, health or any other social good cannot be a bargain issue with Kenyan leaders seeking political offices. Any bargains begin and end with ethnic identities and those elected see their positions as their “turn to eat”.
Kenya has neither political will nor clear plans for health sector reforms. Universal coverage remains just a phrase. Although politicians promised “free” health care for all Kenyans, such promises are often only for the ear but can never attract any votes. Plans by various presidential candidates on how they would finance free health care were as ridiculous as they were dumb. One candidate said he’ll privatise the coastal port to finance (purchase?) universal coverage. Another argued that he’ll make sure that Kenyans “eat only when hungry” and to leave space in the stomach for water and air so that people can save on food and the savings used to finance UHC. Brilliant! The Kenyan politician has no clue of what universal health coverage entails.
Add to the fact that those elected are non-reformist ethnic ‘kings’ and political children of former dictator, Daniel arap Moi. The election of these tribal kings has further polarised the country along ethnic lines. Such polarisation erodes solidarity, which is a key ingredient of universal health coverage. There are very heavy group grievances in Kenya. The future of the health sector has never looked so bleak!
Health policymakers are not helpful either. The current policy path to UHC encourages fragmentation in pooled health funds. Furthermore, there is no clarity on how the policy will be operationalised and how people in the informal sector, who are the majority, would be involved. The quality of public provision is also very poor and it would be extremely difficult for most Kenyans to prepay for health care with such quality of services. Improved quality of health services should precede universal coverage.
There have been piecemeal reforms in the Kenyan health sector aimed at financial risk protection. Waivers and exemptions, direct facility grants and drastic reduction in user-fees in primary health facilities are some of the reforms. There is no conclusive evidence that these initiatives have benefited the poorest groups and improved population health.
Reforms in the Kenyan health system are in dire need of direction and political leadership to provide clear and implementable policies for universal coverage. Leadership that inspires national solidarity will have an added advantage.