The Challenges of Achieving Universal Health Coverage by 2030 in a Sub-Saharan African Country (Kenya)

Introduction

The World Health Organization (WHO) recommends a minimum of 2 Physicians per 10,000 population. Thirty of the 47 sub-Saharan African (SSA) countries are below this level, 7 just qualify and only 10 are above this figure. The physician population ratio for SSA countries is currently 13 per 100.000 compared to 164 per 100,000 for United Kingdom and 279 per 100,000 for United States of America (USA). SSA countries have 12% of the world’s population, 25% of the world’s burden of disease but only 1.7% of the world health physicians and 1% of the global economic resources [1]. The Sustainable Development Goals (SDG’s), otherwise known as Global Goals, are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. These seventeen goals build on the successes of the Millennium Development Goals, while including new areas such as climate change, economic inequality, innovation, sustainable consumption, peace and justice, among other priorities. The goals are interconnected and often the key to success on one will involve tackling issues more commonly associated with another. The SDG’s work in the spirit of partnership and pragmatism to make the right choices now to improve life, in a sustainable way, for future generations. They provide clear guidelines and targets for all countries to adopt in accordance with their own priorities and the environmental challenges of the world at large. The SDGs are an inclusive agenda that tackle the root cause of poverty to make a positive change for both people and planet [2]. The third SDG aims to ensure healthy lives and promote well-being for all at all ages by 2030 by achieving universal health coverage including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines [3]. The targets for the 3SDG are to reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being by 2030. To achieve these targets it is necessary to increase health financing and the recruitment, development, training and retention of the health workforce in developing countries. This should include strengthening the capacity for early warning, risk reduction and management of national and global health risks. There is a great need to create resilient health systems in sub-Saharan African countries. Health system resilience can be defined as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises, maintain core functions when a crisis hits, and informed by lessons learned during the crisis, reorganize if conditions require it [4]. A review of the annual volume of major surgeries performed globally from 56 selected countries in 2004 revealed that there were as many  as 187-281 million operations done during that period, significantly higher than the 136 million childbirths reported in 2006. This highlights the importance of surgery in healthcare delivery and the role of complications associated with surgery may play in patient safety matters [5]. The Lancet Commission on Global Surgery, Obstetrics and Anesthesia (LCOGS) guidelines for surgical delivery in Universal Health Coverage include access to timely and safe surgery, increasing surgical workforce density, increasing surgical volume in low and middle income countries (LMICs), reducing perioperative mortality rates, and protecting against impoverishing and catastrophic health expenditures (CHE) Alkire, et al [6]. It has been observed that if the health agenda for SDG by 2030 is to be met, each country must increase its spending on Primary Health Care by at least 1% of its GDP, a far cry for LMICs [7]. In LMICs, direct out of pocket payments contribute more than 30% of the health care services and are a major cause of financial hardships and in some situations this is at least 10% of the household  income  [8]. The World Health Organization recommended that financial strategies for achieving Universal Health Coverage for all should be a part of the national health policy plan for each country [9]. The Kenya public sector accounts for approximately 34% of the Total Health Expenditure (THE), the private sector 40%, development partners 26%. One third of the THE is met directly by individuals and households paying for health services and products. Government health spending in health in Kenya is 4.5% (2019) of GDP and accounts for 6-8% of total government expenditure which is lower than the 15% recommended by the Abuja Declaration [10]. The National Hospital Insurance Fund (NHIF) is a state corporation in Kenya established in 1966 mandated to provide accessible, affordable, sustainable, and quality social health insurance to the Kenyan population. Through an act of Parliament (2021). It has now been renamed The National Health Insurance Fund with the mandate to implement Universal Health Coverage in Kenya. It provides 18% coverage of the population while private, microfinance, and community based health insurance provides 2% coverage [11]. In September 2019 the United Nations made a Political Declaration on Universal health coverage. It reaffirmed that health is a precondition for and an outcome and indicator of the social, economic and environmental dimensions of sustainable development and emphasized the importance of implementation of the 2030 Agenda for Sustainable Development [12]. This led to the establishment of a Global Action Plan for healthy lives and well-being for all. The plan laid emphasis on the following 7 strategies; primary health care, sustainable financing for health, community and civil society engagement, addressing the determinants of health, strengthening of health systems and work force to respond effectively to disease outbreaks, research and innovation to improve the quality and efficiency of health services, adoption of digital technology to assist in collection of health data for purposes of planning and evaluation of primary health care. The Global action plan enlisted 13 multilateral health, development and humanitarian agencies to accelerate the progress of the 3SDGs and collectively they account for about one third of the development assistance for health annually. These 13 agencies are Gavi (the vaccine alliance); the Global Financing Facility for Women, Children and Adolescents (GFF); the International Labor Organization; the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); the Joint United Nations Programme on HIV/ AIDS (UNAIDS); United Nations Development Fund (UNDP); United Nations Population Fund (UNFPA); United Nations Children’s Fund (UNICEF); United Nations Entity for Gender Equality and the Empowerment of Women; the World Bank Group; World Food Programme; and the World Health Organization [13]. Covid-19 has had a major impact on health financing in SSA countries and has affected the implementation of the 2001 Abuja Declaration target of allocating at least 15% of public revenue to health. According to WHO Africa’s young population may account for the relatively low number of people dying from COVID-19. However the impact of Covid-19 in Africa is bound to be significant for two reasons, one, the high levels of comorbidities such as diabetes, hypertension, HIV/AIDS, tuberculosis and chronic kidney disease and secondly the lower capacity of health systems in Africa compared to elsewhere. All these factors will have a major impact on meeting the targets of Universal Health Coverage for all by 2030 in SSA. This will be worsened by the increase in the number of Africans in the severe poverty bracket due to the impact of the Covid-19 pan endemic, Benson D, et al. [14]. Ultimately, more emphasis should be placed on the creation of resilient health systems and implementation of the Global Action Plan in SSA countries if they are to achieve Universal Health Coverage for all by 2030.