Why looming donor pullout could lead to a health crisis

The recent shortage of medical commodities, including condoms, TB drugs and ARVs for the control of HIV, could escalate as donors plan to leave Kenya in 2027.

This is after Kenya recently graduated from being a low-income to a middle-income country.

A country is perceived to be capable of financing its health system when it moves from being a low-income to a middle-income. As a result, donors often reduce support bringing significant challenges to the affected country. 

But questions remain as to whether Kenya is ready for the transition. And lives are at stake as uncertainty prevails. 

Ezekiel Muchiri has been living with HIV for 30 years. In an interiew, he told the Star ARVs are important in his everyday life.

“When my immune system is weak, I need a booster. Taking ARVs in the morning and in the evening covers my white blood cells so the virus in the body will be able to sleep,” Muchiri said.    

He said the moment one stops taking the medication, they become vulnerable to other diseases that are likely to kill them.

“Once you stop giving them medication, then you are putting them at risk of being attacked by other diseases, like malaria, cholera and TB, because the immune system is weak,” Muchiri added.   

This explains why a continuous supply of drugs and medical commodities to such patients is critical to keep their lives going.

“The person who is HIV positive is not as strong as the person who is HIV negative, who has nothing interfering with their white blood cells. This is why the availability of the drugs is crucial,” Muchiri said.     

SHRINKING FUNDING

The Ministry of Health has called for a scaling up of domestic resource mobilisation to bridge the gap due to shrinking donor funding.

The resources are mainly for HIV, TB, malaria, vaccines and nutrition.

They will also help with reproductive, maternal, neonatal, child and adolescent health and blood transfusion services.

The ministry outlined this plan in the Medium-Term Expenditure Framework  for the period 2023-24 to 2025-26.

Kenya experienced an acute shortage of TB drugs in November last year before the normal supply was restored towards the end of December.

Stop TB Partnership national coordinator Evelyn Kibuchi asked the government to ensure it takes full responsibility for procuring drug commodities.

“The government should allocate adequate resources to the health sector in line with the Abuja Declaration of 15 per cent GDP to health. Counties must also allocate adequate resources for health at the county level,” she said.

Kemsa CEO Andrew Mulwa said the shortage of drugs is not a local issue.  

“The problem is that we had a global challenge with the supply of TB drugs despite us having a contract with suppliers, who were unable to get the drugs here,” he said.

The government is increasingly exploring strategies for eventual transition away from external funding and programmatic support for health and ongoing sustainable progress.

Without proper preparation, the progress of a transitioning country may slow or even reverse as a result of the loss of donor aid. 

According to the National Syndemic Disease Control Council (NSDCC), HIV, TB and malaria interventions heavily depend on donor funding, raising fears of a possible crisis. 

Donors mainly invest in treatment and prevention programmes, including commodities and programmes for priority and vulnerable populations. 

The NSDCC says the Global Fund, US Government and other donors invest Sh77 billion per year in the three diseases, meeting 92 per cent of that need.

The HIV response has been attracting more than 80 per cent of external funding, and it is predominantly supplied by the US Government.

One of the most critical challenges faced by health systems is to generate efficient, fair and sustainable financing mechanisms, which guarantee universal coverage of good quality health services to the entire population.

WORRY FOR PATIENTS

National HIV Youth Prevention Ambassador Bernard Baridi says donors moving out of the country could spell doom for HIV patients as major HIV programmes rely heavily on donor funding.

“I will tell you for free that we cannot be able to manage HIV. We have Global Fund, which is giving us huge money. We have Pepfar doing the same but still it is not enough,” he said.

Kenya Union of Clinical Officers national chairperson Peterson Wachira, many life sustaining programmes under the Ministry of Health are purely funded by donors.       

“The cost of medicines such as blood pressure is going to be high because Kenyans are becoming poorer day by day,” he said. 

“It will be impossible for Kenya to sustain these programmes if donors were to pull out.”

Wachira said Kenya is heavily dependent on donors, who fund some of the policy development programmes at the Ministry of Health.

In April 2001, African Union member states met in Abuja, Nigeria and committed to allocating 15 per cent of their government budgets to health.

This is because more resources were required to address the pressing health challenges, including HIV-Aids, malaria and tuberculosis.   

The commitment is referred to as the Abuja Declaration, which became a rallying call to mobilise more resources from government coffers to the health sector.

However, Wachira thinks allocating more resources to the health sector has become a politically convenient narrative.

“You cannot be talking about moving from primary health coverage to primary healthcare, while you are not funding the same programmes to ensure that you achieve the same,” he said.

BURDEN OF NCDs

Non-Communicable Diseases (NCDs), which also depend on donor funding, are burdening the country’s healthcare system.

Statistics from the National Council for Population and Development show that NCDs account for more than 50 per cent of the total hospital admissions, and more than 55 per cent of hospital deaths.

John Gikonyo, chairperson of the Caucus of People Living with NCDs, said the diseases are projected to increase by another 17 per cent by 2025 due to state inaction.

"NCDs are a pandemic in slow motion. It has been going on, it is going on, things will get worse and that is why we are saying, let us make sure that NCDs are properly controlled," he said.

Gikonyo urged the government to put more funding into preventing NCDs and invest in primary healthcare.

In 2022, the Council of Governors started seeking a recalibrated approach to healthcare financing to address funding hitches presented by a decline in donor interventions on key programmes, such as those related to HIV, tuberculosis (TB) and malaria.

The council’s caucus, bringing together Health and Finance executives, noted the donor landscape was fast changing, necessitating measures to address the funding gap.

Through their treasuries, counties agreed to seek more independence from donor funding through domestic resource mobilisation, progressively increasing county allocation towards the health sector, and the planned takeover of donor-paid staff.

The Constitution of Kenya and other policy documents, including Vision 2030, the Kenya Health Policy (2014-30), county integrated development plans (CIDPs), and county health sectoral plans (CHSPs), recognise health as a fundamental right and an important driver in spurring the country’s economic growth. 

Despite having 14 devolved functions, most counties invest about 30 per cent of their budgets in health.

In 2014, the Ministry of Health developed the Kenya Health Policy (2014-2030)2, whose goal is attaining the highest possible standard of health. The goal will be achieved by supporting equitable, affordable and high-quality health and related services of the highest attainable standards for all Kenyans.

According to the National Council for Population and Development (NCPD), the proportion of the combined discretionary public budget allocated to health by national and county governments during FY 2016-17 decreased to 7.6 percent from 7.7 percent the preceding year.

This is below the pre-devolution level of 7.8 per cent and below the Abuja declaration target of 15 per cent.

The Kenya Kwanza administration now seeks to turn around this situation and make health the primary healthcare centrepiece of his plans to attain the dream of Universal Health Coverage.

On October 19 last year, President William Ruto signed into law four health bills. These are: the Social Health Insurance Bill, the Digital Health Bill, the Primary Healthcare Bill and the Facility Improvement Financing Bill.

Under the new system, which will be anchored on the four new laws, primary healthcare will be offered free of charge at the community and facility levels.

IMPROVING HEALTHCARE FINANCING

The Health Act 2015 clause 54 singles out UHC as a top priority, stating that the “Ministry of Health shall ensure progressive financial access to universal health coverage” through various measures.

One of the measures outlined in the act is developing a mechanism for an integrated national health insurance system, including making provisions for social health protection.

The country’s health insurance coverage stands at 20 per cent, according to data from the Ministry of Health. This is unacceptably low as many Kenyans lack financial protection in the event of huge medical costs.

The World Bank estimates that one million Kenyans fall into poverty annually due to healthcare-related expenditure.

Evidence from the World Health Organisation (WHO) shows that if all women had access to antenatal care in pregnancy, skilled care during childbirth and support in the weeks after childbirth, countries can achieve the goal of universal health coverage.

WHO has calculated that in order to attain UHC in low and middle-income countries by 2030, more than 50 per cent of the additional health care spending in the coming years should be allocated to primary care, particularly to human resources, infrastructure and equipment.