By Gatonye Gathura
Strikes by health workers and politics are holding up a Sh275 billion extended free maternity project even as the clock continue ticking on a $191 million loan.
Key to the mega project, are health workers but whom between nurses and doctors have been on strike for almost seven months this year.
The five-year project: Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) or Universal Care Project launched last year takes over the struggling free maternity initiative introduced in 2013.
Already loans and grants totaling $191 million through the World Bank have been secured since last year and some of the money released to the national government.
To access the World Bank loans, county governments were supposed to apply for grants by the end of last month (31st August).
“Whereas implementation of the project did not kick off as fast as was expected in 2016, steps have been taken to accelerate the process,” says Jacqueline Mogeni the CEO at the Council of Governors.
But industry players say it will be impossible to get the project off the ground with the current health workers strike and the re-constitution of new county governments and a brand new Council of Governors.
Workers, the project document says are a crucial component of the initiative taking 28 per cent of the budget, second only to drugs and commodities which take 55 per cent of the resources.
In its loan document, the World Bank says a lot of efforts will go into the contracting, training and retaining of health workers especially in rural and remote areas.
In a project appraisal document the World Bank says apart from a shortage of health workers, public hospitals are dogged will incredibly poorly performing workers.
The situation, the bank says is exacerbated by high absenteeism, insufficient competency, and low productivity of health workers.
“For example, the absence rate of health workers during unannounced visits to health facilities was high at 27 per cent,” says the bank.
The situation has been worsened by persistent health workers strikes which this year have seen doctors and nurses boycott work for more than 200 days, almost seven months.
In a new twist, which could further complicate the nurses’ strike, some counties including Kiambu and Kirinyaga have started the process of replacing the boycotting workers.
“The industrial dispute and prolonged presidential elections are not ideal environments for this project,” says unionist Jeremiah Maina, director Kenya Health Providers Association of Kenya.
The initiative which has the hallmarks of the still controversial Sh38 billion hospital equipment project initiated by the national government in 2015 is yet to be introduced to the incoming governors.
Some counties had opposed the equipment project on the grounds that procurement remained the responsibility of counties and not central government.
In the current project, medical commodity procurement running into billions of shillings has been almost exclusively assigned to the Kenya Medical Supplies Authority (KEMSA).
Clarifying this move the World Bank document sites lack of clarity in the past on who was responsible for planning, purchasing and paying for medical supplies sometimes leading to inconveniencing stock outs.
For example the bank says although in 2016 counties had agreed to shift the responsibility of procuring vaccines to the national government the matter still has problems including the purchasing of family planning commodities.
However the crucial views of the governors over the project will be known next month during a scheduled induction retreat for the country chiefs and their deputies where the matter may be tabled.
But to forestall possible fallout, Mogeni while recently receiving some project vehicles and equipment from the Ministry of Health said the initiative has being discussed and modalities agreed upon between the two governments.
A senior health economist at the Ministry of Health argued that governors in the past have shown very strong instinct to defend their turf and there is no evidence they are about to cede any ground on this matter.
But more important to the project, the economist who requested anonymity says is which political party eventually takes over the government.
If Jubilee, he says it will be more of continuation of the enhanced free maternity and a shared medical cost between the two governments, donors and households as spelt out in its manifesto.
In the current arrangement the national government will pay about Sh27 billion, donors Sh14 billion, counties 67 billion, households Sh50 billion with a funding gap of about Sh59 billion in the five year period.
“But in case of a NASA government which has promised a fully government funded health care the project may have to be renegotiated to free household from any financial burdens,” said the economist.
But whoever takes over, Maina suggests they quickly and decisively restore industrial harmony in the sector by addressing workers grievances including staff shortages, equipment and supplies.
“Any policy which brings more patients to the hospital without addressing capacity will only worsen an already bad situation,” says the economist.
For example a recent study comparing the quality of care for women presenting with delivery complications at Kenyatta National Hospital before and after the introduction of the free maternity initiative showed things have got worse than before.
The study by Dr Diana Marion, of the University of Nairobi says the introduction of free maternity services without corresponding workers and resources had increased the number of patients with delivery complications.
Dr Marion reported a rise in the number of patients but also an increase of after delivery bleeding, uterine rupture and post caesarian section complications directly linked to the free maternity care initiative.