Dr. Zakayo Kariuki is the County Executive Committee (CEC) member for health in the County Government of Nyandarua. Having previously served in the same role in the County Government of Nakuru, Dr. Kariuki has great experience on how to turn around positively the quality of care at public health facilities, collect and retain funds at source and increasing own source revenue for county governments.
Meshack Acholla, the USAID Health Equity and Resource Optimization (USAID HERO) project Communications Specialist, speaks to Dr. Kariuki on Facility Improvement Financing (FIF), looking at what opportunities it can unlock for sub-national level governments
Meshack: Would you describe how the health financing landscape has been for Kenya and how has it changed with devolution?
Dr. Kariuki: You know, right before devolution we had the national system where funds for use in provision of health care was shared from Afya House. That is our national headquarters for the Ministry of Health and it wasn’t based on very good parameters.
It was also not very well distributed within the whole country, some districts then which are counties now, were a bit marginalized, especially in the north or some in the south where the majority of the population resides were also not getting enough funding.
After devolution, a lot of implementation functions were passed over to counties. Although it is true that not all the money followed, but you can see a definite change in the way we offer services given the fact that, a bit of the money was taken to infrastructure. Health service delivery has also improved in the few counties that have worked in.
With devolving health care services, decision making is near home. The County Assembly is around here to make decisions on budgets. Oversight is very near and complaints are sorted, very fast.
Meshack: Would you highlight how county governments have been able to introduce policy and mobilize domestic resources to finance healthcare in the past few years?
Dr. Kariuki: In 2013 I was working in the County Government of Nakuru and we made progress on own source revenue and domestic resource mobilization which is actually FIF. The clients assist you to serve them by paying subsidized fees for services rendered. That, that is the biggest.
The counties are at different level, some of them are doing very well and others even don’t have the FIF Act, but at least at the national level we have the FIF Act which anchors all the counties.
Meshack: Tell us about the work in Nakuru County which is seen as a trailblazer on FIF related policy. What are some of the lessons that could have picked working in Nakuru and informed the national conversation? And now we have an FIF Act for the country. Would you highlight how it was to get that policy?
Dr Kariuki: For the time I was in Nakuru as the CEC for Health, there wasn’t even an FIF Act.
Regulations were taken to the County Assembly on how we want to retain funds within the facilities as they are generated. And also make the facilities procurement entities, so that they are able to procure whatever they would wish to procure as long as it is a based on authoritative expenditure which has been issued and approved by the hospital boards or the facility committee and it worked like magic.
In 2017 Nakuru County was collecting around KES. 500 million for the whole County on FIF. By 2022 some four or five years later the collection was KES. 1.6 billion. So you can see it’s tripled within a very short time. And what is the reason? Charges were not increased; it is because service delivery improved.
When it comes to health care, people vote with their feet. I’ll tell you a very interesting statistics. That in 2017 money coming to Nakuru County from the NHIF. The faith based and private health facilities were taking 70% of that money, yet they were seeing fewer patients. County hospitals were taking 30% and seeing very many patients.
We improved service deliver and offered a bigger range of services, in 2022 the situation changed, the County government was now taking 69 percent while the private sector and the faith-based were taking 31% literally turning it from its head. That tell you that public hospitals can make money and health has money and that is a fact.
And the way we manage the way we offer our clients services improves everything.
What I also observed in that in the public sector is that people view health differently from the way we view it as experts. You know, when our clients come, they want to find a gate which looks polished, it’s nicely painted, the directions, they want clear direction, the washrooms, they are clean. You can have a cue management system like the one we put where people just sit and just like, in a bank. If you’re called to go to and see the next step, then you are directed once so that if you had come ANC, you don’t go to where people are doing orthopedic. People want convenience.
Also, I noted that word of mouth enough in our community is very is very trusted. So if people say:
‘That hospital is good. The next few days, you see people coming. That place, you don’t miss medicine, the people will come. So those are the some of the tricks that us as health providers don’t look at, but the people who come look at it.’
Investing in IT systems is important. People want that when you go to the lab if the doctor has prescribed what kind of investigations will be done and the people the lab people are waiting for you and can know you by name and they know what is to be investigated and it takes a shorter time and then of course it reduces pilferage because you can track everything from the services to the money and also the time taken.
Meshack: Now let’s discuss the context after 2023 when the UHC laws were passed at national level. Based on your experience and now your tenure in Nyandarua, what lessons will you now carry forward from Nakuru and how has the FIF journey been like?
Dr. Kariuki: First and foremost, I want say that the UHC journey is actually a game changer because for the first time as a country in health provision we are putting our money where our mouth is.
And now on FIF in Nyandarua, we are actually doing extremely well. We can see that even our patients’ numbers are increasing because the services are improving because we are improving those things I told you the hotel aspects of service provision.
So like currently we are seeing about 110,000 people who pass through our doors. Every month, which is a good idea. We are doing about a thousand deliveries. And as we speak, now, the latest population based survey showed that 98% of women in Nyandarua County have a skilled delivery in our facilities, which is a very good thing.
We are immunizing 95% of our under five, which is also very good. Our uptake of FP is increasing. We are among the top three counties in giving a vaccination for to prevent cervical cancer in our girls, which is also very good.
And now with FIF and these other acts that have also come as part of UHC, the Digital Act, Primary Health Care Act, the FIF Act itself, we are going to provide funding to the level 2 and 3 which have perennially been underfunded.
Because initially level two and three were only getting money, maybe from Linda Mama or from Edu Afya. Now for every services rendered at that level, we are the government is going to pay for it under the Primary Health Care (PHC) fund, which is going to be a game changer because most of our clients actually visit those facilities.
Meshack: How did Nyandarua get to have a FIF law? The Council of Governors provided different pathways for counties, would you highlight the decision that your county took, highlighting that process getting other stakeholders until now you operationalizing the law?
Dr. Kariuki: We actually didn’t have an FIF law until recently, like two weeks ago. And even now, it has not gotten the Governor’s accent because there is still some duration that it goes through the wordings of the Act.
But we have been trying to retain some of the funds within the facilities as we used to call it facility transfers. So that the money they collect, although it goes to the county revenue fund, it is rewired back in total. Okay, once in a while you didn’t manage it but generally it hasn’t been so bad.
And we were assisted by very many good friends like the Council of Governors and USAID HERO itself, and especially at the formulation levels and also at the level of engaging the community. They supported us at the level of engaging, the members of the County Assembly who are critical in passing any law.
Meshack: Do you foresee any challenges and how will they be mitigated so that this FIF Act delivers the best promise for the people of Nyandarua?
Dr. Kariuki: The kind of challenge that we have had, is that people imagining there is some sinister agenda in wanting to retain money in health. So we have had a lot of difficulties in convincing people and we still don’t think people are fully convinced at some levels at the political level that this is a good thing to do.
But we have taken them to places like Nakuru, which have been doing very well and they can see the difference from infrastructure, to health products and technologies, the way they are able to buy in time and how the human resource is managed.
Meshack: I know you’ve mentioned this, but let’s revisit how you collaborated with the USAID HERO project and what value did they add?
Dr. Kariuki: Very well. A lot of value addition. We had the pleasure of having lawyers of repute to come to assist us in crafting FIF law. We had them sponsoring our members of the County Assembly so that we go and train them, even our own staff especially the County Health Management Team.
So we have had some good assistance and even as we speak now our staff have been trained on Program Based Budgeting so that the resources we get don’t slip through the fingers. They are going to the right use and we make sure that we don’t leave anything so that we can trace a coin to where it was supposed to do.
Meshack: Thank you, as we conclude, in your own words, what is it that you can say, on FIF and the partnership with the USAID HERO?
On FIF what I would say is that county governments should know that FIF funds have not come to replace the responsibility that the county has in terms of the shareable revenue, the FIF is supposed to come and assist in areas where the shareable revenue sometimes does not quite reach.
So the counties should not imagine that the FIF is coming to replace their responsibility.
Our people know, quality, any good services, you don’t need to preach to them if they see good quality services, they will come. And if they come, we have a real opportunity now for the Social Health Authority (SHA) of making sure that we increase our domestic revenue sources by utilizing SHA.
Because now, SHA is going to remove the trouble of dispensaries and health centers through the PHC fund. And now at the hospital levels, the Social Health Insurance Fund (SHIF) will just do like what the former NHIF has been doing taking care of people who fall sick and then at the other end, we have the Emergency and Chronic Illness Fund. Because for a very long time, counties were having a problem in managing those areas because they are very expensive.
So we have one chance that we can’t let go as the counties because we are the biggest providers of healthcare. We should just take it and run away with it and the clients will follow us if we offer good quality services.
On cooperation, we still need a lot of cooperation, especially from USAID and in this relationship, I will talk about money because there’s a real chance that most counties might double their FIF if they manage well. So, it will be a waste of a good thing, if we make money, then we don’t transform that money into good services. And that is why we need more training with our staff. Because most of our health workers are not good in financial matters. They are not accountants. So that they can manage those funds.
Thank you.