County Assemblies in Kenya, like other legislative bodies, carry out some of their work through committees. The committees of the County Assembly are provided for in the Kenyan Constitution and the County Governments Act. They have the following functions:
- Conduct oversight on the Executive to ensure that the Executive exercises fiscal prudence and good governance in the health sector;
- Initiate and scrutinize legislative and regulatory proposals on matters touching the health sector;
- Review and recommend budgetary allocations to the departments of the county;
- Investigate, inquire into, and report on all matters relating to the health department management, activities, administration, and operations;
- Study the program and policy objectives of the health department and the effectiveness of the implementation;
- Vet and report on appointments in the departments where the Constitution or any law requires the assembly to approve.
We spoke to the Makueni County Assembly Health Committee Chair, Mr. Jackson Mbalu, to learn about his experience serving in this capacity for the last five years.
Please introduce yourself briefly?
I hold a post-basic Diploma in Anesthesia and a Diploma in Clinical Medicine and Surgery; I practiced as a Clinician for over 15 years. My story was spurred by limited access to health services among marginalized communities. After my basic training, my medical career began in earnest. I was posted to Isiolo county in the North-Eastern part of Kenya. The counties in this region referred their patients to Meru County for emergency services (including theatre services). The referral hospital was more than 350 kilometers from some counties, e.g., Mandera. This motivated me to pursue my post-basic Anesthesia training to improve access to theatre services in hard-to-reach areas.
After my post-basic training, I served as an Anesthetist. Afterward, I joined the University of Nairobi to manage the institution’s staff clinic in Kibwezi sub-county in Makueni County. I was ecstatic; this was a moment to give back to my community. As I worked with the institution, I noted that the community had limited access to health services. They brought ill community members for treatment at the staff clinic.
The management of the institution had reservations about serving the community members. And while still in full-time employment, I set up a private outpatient clinic and recruited some staff to manage it. The clinic was a pivotal time in my life as I knew I wanted to share my experience and make a difference to people. Working with anyone who came through the doors wanting assistance, I often attended to the community at a very subsidized fee or even for free, which was magical.
The memories are still very fresh in my mind of how the community members would bring in patients with severe anemia, pneumonia, diarrhea, or convulsions and decline referral to government health facilities. Yet, my private clinic could not admit them. They attributed their refusal to the high cost of health services and the negative attitude of service providers. Every day was a gift to have the opportunity to care for patients in their most vulnerable times. The experience has proved invaluable throughout my career.
I developed an interest in engaging with the community members during this period. It was an introduction to the needs of people across the social spectrum, which planted me firmly in the community. I was able to identify many orphans and took the responsibility to volunteer services to the community.
The county government of Makueni has achieved significant milestones in the health sector. I served as a service provider in a rural part of this county, and devolution has significantly improved access to health services. In my ward, we already have two fully functional dispensaries. The county has almost doubled up health facilities since devolution. I would also say the committee oversight role has also improved social accountability.
I never had any political aspirations until 2017, when the community approached me to represent them at the County Assembly. I have served as County Assembly Minority Leader and Health Committee Chair for 5 years.
What changes have you seen in the health department since you began your County Assembly Health Committee role?
Universal Health Coverage is vital for any population. Before devolution, health care was costly since it was cost-shared by the government and individuals through out-of-pocket payments. The high poverty index, food insecurity, and perennial droughts aggravated the affordability of healthcare for most of the population. The county poverty index is over 60%. A weak social protection system makes people less resilient to health shocks and less able to seek care when needed. The economically disadvantaged are unlikely to follow the advice and are more prone to economic hardship related to health care. The county government engaged the public in need identification and resource allocation exercises between 2014 and 2016, and the persistent theme of affordable healthcare was evident (public participation reports 2014-2016).
Good governance in the health sector involves making pro-health legislation and framework for implementing strategic policies combined with effective regulation, monitoring, system design, and social accountability. Governance shapes the likelihood of attaining universal health care coverage. It is a political victory that universal health coverage is discussed since it is a highly political concept that is very expensive. During my tenure, the health committee has spearheaded several policies, including the county universal health coverage and reproductive health care policy, and is preparing to present the community health policy to the county assembly. These documents are crucial in ring-fencing the gains made in health, especially with subsequent governance changes.
Makueni’s universal health care model is a success and great relief, especially for the economically disadvantaged. The UHC model took two years to design. It was piloted by offering free health care to residents over 65 years for six months. The county learned crucial lessons that helped the government design population-wide universal health coverage. This enabled the Makueni residents to access care without incurring out-of-pocket expenditure at the point of care in all public hospitals in the county since the financial year 2016/2017. Since then, the project has recorded an upward trend in the number of beneficiaries enrolled in the program.
Despite the outstanding achievements, the project has faced multiple challenges. At the beginning of the project, beneficiaries were supposed to contribute an annual premium of KES 500 (or approximately $xx?). Following a policy review, the yearly premium was adjusted to KES 1,000 (or approximately $xx?) to make the model more sustainable. However, this is still very little. Currently, the premiums contribute less than 25% to the UHC model.
| Financial year | Beneficiaries enrolled(households) | County government contribution | Premiums | Total | % government contribution |
| 2016/2017 | 49,766 | 168,731,706 | 24,883,000 | 193,619,706 | 87% |
| 2017/2018 | 90,422 | 151,165,533 | 45,211,000 | 196,376,533 | 77% |
| 2018/2019 | 110,982 | 166,000,000 | 55,491,000 | 221,491,000 | 75% |
| 125,585,000 | 485,897,239 | 611,487,239 |
Access is a crucial component and contributor to achieving universal health coverage. All public hospitals automatically qualify to offer services under this program except for primary health care facilities since they usually offer services for free. The county only has eight level 4 and one level 5 health facilities; more than 90% of the health facilities are dispensaries and health centers.
Patients with non-communicable diseases travel long distances to access care or re-fill their prescriptions. We look forward to ensuring the primary health care facilities can monitor patients whose conditions are controlled and re-fill their prescriptions. Such patients should only visit level 4 or 5 facilities during regular checkups or in case of complications. The bottom-up referrals will go a long way in decongesting the referral health facilities and improving their emergency preparedness, reducing the cost of transport and time spent by patients while seeking services. This is also likely to improve adherence since I have seen several clients coming to me to request funds to buy drugs.
This conversation on adherence to drugs by patients should be discussed beyond considering the availability or accessibility of medications, knowledge of the patient’s condition, and the importance of adherence. The health committee is aware that the county is experiencing transition, and non-communicable diseases are increasing significantly. The importance of investing in preventive and promotive health cannot be overemphasized.
Commodity security is another challenge affecting the county UHC. The government legislation to procure medical supplies from KEMSA has its limitations. The county health sector has experienced stock-outs for some commodities and no supplies for crucial ones. The county assembly will try to advocate for a pool system where counties only receive what they require at the right time, quantity and quality. Another limitation of the county UHC program is that it is limited to Makueni County; if a patient is referred for advanced care, they have to explore alternative means of payment.
What do you think about the state of Primary Health Care in Makueni county?
In the world of health, there is no such thing as a quick fix. The provision of primary health care is a high priority in the county because access to these services has shown a high return on investment. In the context of limited resources (infrastructure, commodity insecurity, understaffing), community health volunteers contribute to community development and, more specifically, improve community access to and coverage of essential health services. Community health workers’ programs are vulnerable unless driven, owned by, and firmly embedded in the community. The programs are neither panacea for weak health systems nor a cheap option to provide access to health care for the underserved population.
The county health policy recommends strengthening our community health system by restructuring community health units, capacity-building community health workers, and providing stipends to minimize attrition. The community health policy and costed-implementation plan have come at the right time. The documents will enable the county health committee to advocate for an increased budget allocation for community health services.
What is your opinion on advocating for a budget line for community health in-line departments and county ward development fund?
In our county, I know that the agriculture department has community volunteers. I think this is high time our policies integrate.
Meanwhile, we need an interdepartmental engagement framework. Makueni county resource allocation involves a lot of community participation; what is required is creating awareness and generating demand for health services for the community to prioritize health as part of the community development agenda.
What challenges do you face as a health committee chair?
Now that my term is ending, it was a great privilege to serve as health committee chair in the county for the last five years. I have had both incredible highs and deep lows. Sometimes, we have had to make tough decisions guided by law as a committee. I remember there was a time we had to dismiss a nurse from service for gross misconduct. This is a very complex process, and you have to be very impartial and shelve all your interests for the benefit of the community. If this is what it calls for, I would still do it again as long as justice is served to both the community and healthcare workers.