Strengthening PHC – Lessons from Kenya’s MakueniCare

In 2016, the Joint Learning Network for UHC under the Primary Health Care (PHC) Technical Initiative brought together practitioners that formed the Health Benefits Policy (HBP) Collaborative. This collaborative consisted of experience sharing and compilation of practical advice among six low-and-middle-income countries: Indonesia, Kenya, Malaysia, Mali, Morocco, and Vietnam. Each of them conducted an assessment to evaluate their efforts in implementing new or revised benefit packages using the PHC Health Benefit Framework (HBF), a knowledge product that was developed from the collaborative.

Kenya participated by sharing experience from a sub-national level, namely Makueni County, which is one of the 47 sub-national governments of the country. Makueni County established the MakueniCare UHC Programme in 2016 with an effort to provide coverage for the county residents. To access the programme, the registration fee per household was Ksh 1000 (USD 8.60) annually to cover the principal, spouse and five dependents below 18 years of age. The members can access services at level 5 and 4 county health facilities. The programme runs complementary to other health programs such as the program for free PHC implemented by the national government and the National Health Insurance Fund (NHIF), which is to be accessed as a last resort. The benefit package consists of the extent of the services available at the county health facilities and services covered/not covered in the complementary programmes. The services include inpatient, outpatient, and mortuary service with exemption of auxiliary devices and cost of surgical implants; forensic services; specialized services e.g., CT scanning, surgical implants, intensive care unit services, dialysis, non-routines medical reports, professional fees for autopsies/postmortems, medical reports and other related services, and referrals to outside the County.

Five years later in 2022, the JLN Kenya Country Core Group (CCG) with support from JICA and working with Makueni County Department for Health in the course of 3 months used the HBF to assess MakueniCare Programme, to check on the progress towards providing UHC to the residents of the County, and to inform the Kenya country JLN chapter on key areas on which to focus as the team plans to launch a sub-national JLN chapter. See the table below for the outcomes of the programme assessment based on the six policy domains from the HBF:

Policy Domain	Domain Definition	Findings
Financing: Mobilizing and Pooling Resources	The strategy for pooling resources that finance service delivery.	Sources of health financing: County Government – budgetary allocation to health (28 -33% of Total County Budget) and MakueniCare reimbursement User fees collected at facility (FIF)- cash payments, NHIF reimbursement, MakueniCare registration. Public health department levies Donor funding Conditional allocations and other loans and grants.
Financing: Payment Mechanisms	Provider payment mechanisms set up to incentivize providers to offer package services.	Fee-for-service (FFS) – MakueniCare reimbursement but not shilling-for-shilling, as this depends on resource basket and the FIF retained at facility level. FFS for cash payment in out-of-pocket payments Capitation – NHIF reimbursements from various programs In-put based financing- staff salaries, procurement of commodities & general administrative costs. Staff incentives portion of the budget (15%).
Supply Side Strengthening	Government’s spending to improve provider capacity to deliver prioritized PHC services.	Increase in health facilities from 109 in 2013 to 237 in 2022. Allocated 30% of its UHC budget to invest in facility infrastructure and staff training to deliver the full list of MakueniCare services. Additional 358 staff were hired through the national UHC program with contracting at facility level to meet their HRH needs. Investment in essential and specialized medical equipment and health infrastructure. Strengthening PHC through establishment of Primary Care Network (PCN) model. Upgrading of facilities to ensure access to services promised in the benefit package Plans for end-to-end hospital automation Development of a telecentre still pending due to funding. Supervisory support for facilities with low caseloads.
Generating Demand	The health system steward’s strategy for educating the public about services within the package and beneficiary enrollment.	Voluntary enrollment at the point of service -Level 5 and 4 facilities with plans to decentralize to lower levels. Annual registration fee increased to Ksh. 1,000 (USD 8.59) (from Ksh 500 (USD 4.30)). Introduction of 14-days waiting period to address adverse selection. Increase in the workload of up to three time over Challenges of renewal rates- campaigns to commence aggressively beyond the health facilities.
Protocols and Pathways	The treatment protocols and referral pathways that are put in place to improve quality and efficiency of service delivery.	The referral protocol in place for patient and specimen referral guided by the Kenya Health Sector Referral Implementation Guidelines, 2014. Centralized ambulance referral systems with call centre. Reverse referral for medical officers to busy health centres Challenge of patients bypassing PHC facilities to come to higher levels resulting in increased cost of service delivery, overload/underutilization of facilities and delayed care. Referral outside County facilities not covered by MakueniCare. There is a Citizen Service Charter that outlines guidelines for service delivery at the health facilities
Accountability Mechanisms	The regulatory framework for monitoring and evaluation systems that accompany the PHC benefits package	UHC Policy has an implementation matrix and M&E framework with M&E done by the County M&E Directorate in collaboration with the Health Departmental M&E and also external M&E consultants. Within the Department of Health is the Directorate of Health Planning in charge of quarterly and annual M&E reports on implementation of the UHC Policy. At facility level, M&E function is assigned to the UHC committee that reports to the Hospital Management Team that reports to the County Steering Committee. Applies the Kenya Quality Model for Health: Checklist for Assessing Quality of Healthcare (KQMH)/ An established quarterly budgeting and reimbursement process with checks and balances at every stage. County & facility level Health Administrative Units have oversight on operations to ensure efficiency, quality, access, equity and affordability of services. Stakeholder participation in budgeting and development in the county. Program guided and monitored by the County Integrated Development Plan, Annual Progress Report, County Health Policy, and County UHC Policy. 100% banking of all cash collected at facility and also subject to the approval even in emergency cases. Monthly facility reporting – workload and financial reports.

The assessment noted significant positive impact on the side of the policy objectives that drive a responsive PHC-oriented reform ass identified in the HBF – health outcomes, financial protection, quality, efficiency, equity, and sustainability. However, some areas still required investment and effort to improve the programme’s delivery as outlined in the recommendations below.

1. Costing of the devolved county health services so that health funding is evidence based as opposed to blind allocation of resources.
2. Establishing performance-based financing to encourage all facilities to increase their share revenue from the different sources such as NHIF capitation, rebates, inpatient reimbursement and have targets captured in performance contracts for facility heads. This goes a long way in increasing the health funding for facilities hance better service delivery.
3. Developing and strengthening innovative healthcare financing for communities’ by periodically reviewing the criteria for resource allocation and purchasing mechanisms to improve efficiency and utilization of resources;
4. Enhance prepayment mechanisms towards UHC. The introduction of the 14 days waiting period is positive but proposals from Health Administrators to increase the period will help with better planning based on the resources collected for UHC registration that contributes to the hospital funds retained by the facilities budgeted quarterly.
5. Promoting private sector participation in financing of healthcare through public private partnerships and other mechanisms.
6. Automation- involve the user department and also enhance access by hosting the servers at the health department for ease of access and efficient service delivery.
7. Developing and implementing a health information systems (HIS) policy; Facilitating access to information to the public while protecting privacy and confidentiality.

 

The MakueniCare assessment led to many lessons learned that can be used by other counties, the  Kenyan government, and even other low- and middle-income countries looking at implementing responsive PHC-oriented reform, in areas such as making a case for healthcare funding, ring-fencing and retaining health revenues by health facilities, health investment to improve access and quality of care, performance-based budgeting, legislation, governance and public participation. With this assessment, Makueni County can chart the way in addressing  challenges while leveraging on its strengths on the journey to ensuring  UHC for all in the county. With the resources available from JLN and other partners, this is possible.

Special thanks to JICA for the financial support and JLN for the technical support