Empowering Policy Reform through Shared Wisdom Beyond Borders: Kenya’s JLN Experience

Authors: Isabella Maina, Rahul S Reddy Kadarpeta, and James Soki

Joint Learning Network for Universal Health Coverage – JLN’s 14-year odyssey stands as a remarkable testament, fueled by the compelling narratives exchanged among fervent policymakers and practitioners steering health systems transformation in their respective nations, all in the relentless pursuit of universal health coverage (UHC). These narratives encapsulated the tacit knowledge acquired within their unique contexts, as they grappled with practical challenges that transcended the support of any ‘consultant’ or ‘technical assistance’. When these stories were shared among peers, a collective recognition of shared problems and challenges emerged, motivating them to collaboratively seek solutions. These stories, a potent force in themselves, became the driving impetus behind these leaders as they passionately championed the cause of UHC and achieved significant milestones along the way.

In the case of Kenya, its association with JLN since 2009, proved to be transformative. Actively engaging with the JLN community, Kenyan policymakers/ practitioners gained invaluable insights from their counterparts in different countries. Participation in various JLN learning collaboratives enriched our knowledge base and co-produced innovative solutions in health financing, service delivery, and system efficiency. These shared efforts became a catalyst for innovation and informed decision-making significantly contributing to strengthening Kenya’s healthcare system.

Kenya’s journey towards UHC began with the constitutional recognition of health as a fundamental human right in 2010. This guided the formulation of the Kenya Health Policy 2012-2030 and subsequent Health Sector Strategic Plans (HSSPs). The policy aimed at enhancing health outcomes and reducing disparities is supported by increased budgetary allocations to the health sector, reflecting a commitment to improve health infrastructure and explore innovative financing mechanisms. The establishment of the Social Health Insurance Fund (SHIF) replaced the National Health Insurance Fund (NHIF). Steps were taken to strengthen strategic purchasing alongside community-based primary healthcare underscoring Kenya’s comprehensive approach to achieving UHC. Responsive monitoring and continual adjustment of strategies through evaluation are ensuring the evolving health needs of its population are met.

The lessons learned and solutions adapted from the network’s collective knowledge became instrumental in shaping some of these policies. We present here four highlights drawing from Isabel Maina’s learning experiences with JLN where Kenya was able to tailor and implement strategies that resonated with its specific context, resulting in advancements in UHC goals – improving healthcare delivery, and ultimately enhancing the well-being of the population.

JLN PHC financing collaborative and country pairing with Ghana to advance Primary Healthcare Reforms in Kenya

The UHC agenda in Kenya is premised on Primary Health Care – an approach that is considered from existing evidence as more efficient and cost-effective in the long run. The Government policy commits to PHC reforms through the establishment of Primary care Networks (PCNs) across all counties in Kenya. PCN is a network of primary care facilities (health centres and dispensaries) that are linked to a county primary hospital and the community units in their area of jurisdiction in the form of a hub and spoke model. The PCN aims to strengthen service delivery and create a seamless connection between PHC level and hospitals. For this ambitious reform agenda to be translated into implementation, the main question in the policy circles was “How to go about it? Where do we start?”  Actively engaged with the JLN, there was an awareness that Ghana – a JLN member country was experienced in the formation and use of preferred primary care provider (PPP) networks as an innovative approach to catalyze providers with enhanced capacity to deliver essential primary health care (PHC) services and to use resources more efficiently.

The JLN PHC financing and payment collaborative in which Kenya and Ghana policy makers/ practitioners were participating created an opportunity for more learning between the two countries.  This collaborative, practitioner-to-practitioner learning and exchange was organized through virtual meetings in June 2020 between the Kenya team (Ministry of Health PHC team, health financing team, NHIF and selected County teams) and the Ghana PHC team. The Kenyan team learnt the nuances of how PCNs could be operationalized – the process of setting up functional PCNs, governance structures, the referral networks within and outside the PCN, the purchasing arrangements, management/ supervision, monitoring and evaluation of quality service delivery. Armed with this information, Kenyan policymakers developed guidelines for National implementation of the PCNs. Additionally, the best practices learnt from Ghana and other key learnings from the JLN PHC financing collaborative informed the PCNs implementation then in 12 counties – a journey that has currently culminated in the establishment of close to 120 networks across 39 counties.

Kenya National Benefits Package design and Co-developing the JLN Benefits Package Revision Guide

The moral question in Kenya, just like in many other countries on the UHC journey was ‘what to pay for’ in Kenya’s health system and how to arrive at the decision. Hence the journey towards the benefit package reforms was born, with the need to design an affordable, equitable, good-quality package of care for Kenyans in line with the Kenya constitutional guarantee of the right to health care services, and the right to the highest attainable standard of health. In 2018, the Ministry of Health, Kenya established a Health Benefits Package Advisory Panel with the mandate of defining a unified comprehensive and costed benefit package for Kenyans. The panel of experts included JLN practitioners from Kenya and practitioners with expertise from JLN member countries.

Further, the Kenyan technical staff used this experience to inform the development of the JLN Health Benefits Package Revision Guide in 2022 (Making explicit choices on the path to UHC – the JLN Health Benefits Package Revision Guide). During this, Kenyan practitioners participated alongside those of   Ethiopia, Ghana, Nigeria, South Africa, Sudan, Bangladesh, and India in contributing to the product that would hence guide nations in the revision of the benefits package, demonstrating the symbiotic relationship between JLN and Kenya.

JLN Knowledge Products Adaptation and Implementation

Kenya adopted and implemented JLN knowledge products to support its UHC journey. In 2018, the UHC-PHC Self-assessment Tool, Costing of Health Services for Provider Payment: A Practical Manual, and Toolkit for Medical Audit Systems were shared with the Ministry of Health and launched at the Kenya Health Forum. Pilot implementation of the self-assessment tool and the costing tool were conducted in four counties (Kisumu, Nyeri, Isiolo and Machakos), aligning with the pilot UHC program in Kenya.  The JLN’s manual for costing provider payments was customized to collect data at the county referral hospital in Makueni County. The team found that the reimbursement model used in the county was not sustainable and lobbied to change the county-wide reimbursement model. This shift was adopted by the Makueni County Department of Health in the 2019/2020 fiscal year impacting the reimbursement model for all 333 health facilities with a catchment population of just under 1 million Kenyan people. From piloting in select counties to national-scale implementations, these resources have guided policy and operational decisions, ensuring they are grounded in evidence and best practices.

Navigating the COVID-19 pandemic with the shared wisdom of various JLN member countries

The pandemic tested Kenya’s health system’s resilience and adaptability.  Leveraging the JLN’s collective wisdom and resources, Kenya successfully maintained essential health services across counties, ensuring continuous care amidst unprecedented challenges. During the COVID-19 pandemic, JLN provided virtual experience-sharing forums on COVID-19 topical issues (contact tracing, community mobilization, and maintaining essential health services among others) providing an opportunity for learning across countries. Borrowing from this experience, JLN Kenya held a series of webinars with Kenya policymakers and practitioners drawn from the National Government, County Government, and partners working in health. The motivation of the webinars was to provide an opportunity for learning and experience sharing from both levels of Government (The national and counties) on various topical issues including preparedness and response, community mobilisation and contact tracing, risk communication as well as sustaining essential health services during the pandemic period. These virtual fora provided an opportunity for encouragement and learning from one another to better respond to COVID-19 throughout the entire health system.

Kenya’s success story as a member of the JLN serves as a testament to the network’s capacity to drive positive change on a national scale through the power of shared experiences and collaborative problem-solving. JLN provides a secure environment conducive to openly addressing challenges and identifying solutions through collective thinking, drawing insights from the experiences of other countries. The adaptation of these solutions holds promise for effective implementation within one’s contextual framework. This ‘JLN way’ has emerged strong over the years, establishing robust institutional structures and processes towards harnessing the power of peer-to-peer and cross-country learning, fostering a collective effort to tackle the myriad challenges within our health systems. At the heart of this endeavour lies the synthesis of new knowledge, primarily stemming from the rich tapestry of country experiences. It is this unique approach that distinguishes the JLN from other knowledge generation modalities, propelling us forward on a journey of discovery and innovation in the pursuit of better health outcomes for all.