Dr. Custodia Mandlhate, Former World Health Organization (WHO) Country Representative,Kenya
Director of ceremonies Dr Peter Kimuu, Ministry of Health
The Permanent Secretary of Ministry of Health (MOH), Dr Nicholas Muraguri
Mr Hendrik Linneweber, Country Director, GIZ Kenya
Mr Klaus Peter Jacoby, Head of the Evaluation mission
Ladies and Gentlemen,
Good morning; ‘Hamjambo’.
Let me join the previous speakers in welcoming you all to this important gathering. It is a great pleasure for me to be here on behalf of the United Nations Family in Kenya / “Jumuia ya Mataifa”, and share some of our ideas in our contribution to Universal Health Coverage ( UHC) in the context of the Sustainable Development Goals ( SDGs).
The World Health Organization that I represent , recognizes the critical role played by the people and the Government of Germany in providing important health and development services globally, in the African Region and in particular in Kenya. Please receive the World Health Organization’s appreciation! As part of the United Nations Family in Kenya allow me to convey the appreciations from the rest of the United Nations (UN) Agencies, especially the ones in the Health Cooperation, and I want to mention them for your records: Word Health Organization (WHO), United Nations International Children’s Fund ( UNICEF), United Nations Population Fund (UNFPA), United Nations Programme on HIV/AIDS (UNAIDS), the World Bank, United Nations Entity for Gender Equality and the Empowerment of Women (UN WOMEN), now known as H6 , and the United Nations Country Team (UNCT) as a group largely contributes for Health and United Nations Development Programme (UNDP), in governance; United Nations Office for the Coordination of Humanitarian Affairs ( OCHA) as Secretariat for Emergencies and Humanitarian Actions, among others – United Nations Office on Drugs and Crime (UNODC) , United Nations Environment Programme (UNEP), United Nations Human Settlement Programme (UN HABITAT),United Nations Educational,Scientific and Cultural Organization (UNESCO), Food and Agriculture Organization ( FAO) , World Food Progamme (WFP)).
Let me commend the partnership between the GIZ and the Government of Kenya and the importance it brings to the health sector as part of the Health Systems Strengthening.
Ladies and gentlemen,
Let me use this opportunity to remind ourselves about the current health perspectives relating to Global Health Strategies, particularly in relation to how they have guided Countries in terms of defining its health agenda and the move to the Universal Health Coverage (UHC), including in Kenya.
I am sure that most of you should be aware that WHO has been strongly advocating for a move to attain Universal Health Coverage (UHC) as the anchor agenda around which the health sector needs to be built in the post Millenium Development Goals (MDGs) global development field.’ The Sustainable Development Agenda – the SDGs.
We are fully aware that many countries in the African Region , including Kenya, the health targets (MDG 4, 5 and 6) were not fully achieved, hence the need to deal with them as unfinished business.
I think that it is important at this forum, to remind ourselves of the historical background of the Universal Health Coverage Agenda.
The health services in many of our countries in Africa have evolved through different phases since we attained independence – each phases characterized by some successes, but also some failures in attainment of the desired health goals. Kenya 50 falls in these analyzes.
The health focus has evolved significantly, since independence in line with global paradigms/phases in health. WHO have characterized the evolution of the health services in many countries of the African Region, into five (5) distinct phases:
The First Phase, which we call an ‘expansionist phase’ corresponded with similar reforms globally from 1962 – 1970 the post-independence phase. Health care was relatively free and easily accessible, but relied strongly on extensive investment in the health sector by the Governments.
It is easy to understand that facility based health care delivery is not holistic. We cannot ignore that health starts at home, at community level and not at the facility. This phase ended with the global recession as a result of the oil shocks in the 1970s.
As a result of the global economic crisis during the 1970s, access to capital decreased making the health system design unsustainable. As a result of reduced or stagnant investments in the health system, health services deteriorated, with most public health programmes collapsing and health facilities facing shortages of human resources and medicines. During this second phase – the quality of health services declined – under the table payments became prominent, and there was a resurgence of use of traditional medicine. During this time, the global focus on health shifted from the hospital focus to a ‘Primary Health Care’ (PHC) approach, encapsulated in the well-known ‘Alma Ata’ declaration of 1978 that promoted combining medical and social goals being addressed as close to the client as is feasible.
The countries health services therefore were in a third phase, of ‘PHC adoption’. Community involvement and participation plus better sustainability of health services were further championed by African Ministers of Health through the Bamako initiative agreed upon in Bamako, Mali in 1987. This phase was therefore characterized by targeted focus on key interventions that were deemed as most important or cost effective – such as Growth monitoring, Oral rehydration therapy, Breastfeeding, Immunization ,Family spacing, Food supplements and Female education ( GOBIFFF) through a focus on community participation, and inter- sectoral collaboration efforts. During this phase, the country underwent extreme financial stress by the end of the 1980s and through 1990s as a result of the clamor for reforms. This was characterized by a reduction of foreign support. User charges became a mainstay in service provision with a strong focus on cost-recovery. Health of populations still wasn’t being improved, due to a narrow focus of services, plus cost barriers to access, and limited local stewardship.
The health sector entered a fourth reform phase, which we call a PHC re-engineering. This was characterized by a significant increase in external support ( United States Government (USG), Global Fund,Japan International Cooperation Agency (JICA), Deutsche Gesellschaft für Internationale Zusammenarbeit (GTZ/GIZ),United Kingdom Aid Match International Development Funding ( UKAID), Canadian International Development Agency (CIDA), among others) , focusing on emergency and targeted disease programs like Human Immunodeficiency Virus (HIV),Tuberculosis (TB) and Malaria. This coincided with the Millennium Development Goals (MDGs), plus the Aid Harmonization efforts at global level that were aimed at improving development, and Aid Effectiveness (Paris Declaration for AID effectiveness). However, the system was still too costly, and heavily donor reliant. In addition, local priorities were not adequately taken care of, as focus and investments were largely determined centrally by the national government. A stronger emphasis on the role of good and coordinated health systems was missing during this phase.
In the case of Kenya, the promulgation of the 2010 Constitution marked the beginning of the fifth and current phase of the system – a PHC and health systems phase.This is being driven by the need to better involve the population, the communities, in determining health priorities through devolution, and implementation of a rights based approach that looks at health as a right, not a luxury. The phase is also characterised by a Government that is increasingly taking charge of the health agenda. Regionally we had the Ouagadougou Declaration, and Globally this phase has been driven by an increased emphasis on a health systems approach to implementing PHC, and a move towards Universal Health Coverage (UHC) with defined health services.
The current phase of the health sector is therefore in line with the overall Global Focus for health. This is best encapsulated by the proposed overall health goal of ‘Ensuring Healthy lives and Universal Health Coverage at all ages’.
The global health strategic approach is built around the following goals:
This focus of the global health strategies is innovative in a number of ways:
First, it is shifting the focus away from diseases to the individual. Ensuring health of the individual is quite noble, as it places the individual at the centre of all efforts of the health sector, and makes sure their health needs are holistically addressed. Let me give an example: It doesn’t help us if we have a perfect vaccination program and are able to provide immunization for all children, only for the same children to die of diarrhoeal diseases, drug abuse, or road traffic accidents……
Second, the strategic approach places emphasis on healthy life, and aims to address all physical, mental and social components as per definition of “health” by WHO Constitution .It is only when we can maximise the amount of healthy life that we can maximise the capacity of our labour force to participate in development of the county. Let me emphasize that “here is no development without health”.
Third, a focus on Universal Health Coverage (UHC) with required services is central to the current health strategy. By focusing on Universal Health Coverage, we are trying to ensure individuals have access to all available services that will assure their health needs, and are able to use these services in a manner that doesn’t lead to financial catastrophes.
Fourth, a social determinants (housing, water and sanitation, agriculture, labour, etc.) approach ensures that health is looked at from all dimensions and is embedded in all government policies.
The World Health Organization together with other UN Agencies and Development partners have been engaged with Kenya Government to ensure that the health agenda takes this current global health focus in mind, while defining their health priorities and embrace as part of the post 2015 Agenda, the Sustainable Development Agenda translated in Health through the Universal Health Coverage.
Using the WHO Country Cooperation Strategy from the period 2014-2019; the United Nations Development Assistance Framework UNDAF 2014-2018 and in the context of evolving partnerships ( Development Partners in Health Kenya (DPHK), Civil Society, Global Fund etc.), we have pledged support in a number of areas in line with the health priorities as defined in the National Health Strategy 2014-2018, namely:
Ladies and gentlemen
It is important to mention in this forum that WHO has developed, and maintained a trusted partnership with GIZ for many years (now we are even located in the same building!). This support has been unique, and has largely been in a collaborative manner, where GIZ consults with, and ensures its program design and implementation is aligned to international best practice as defined by WHO, in the given area of focus. It has over the years spanned across many areas of the health sector, including but not limited to programs of:
– The reproductive and maternal health services looking at ways to support improved access to services particularly for populations with real financial and cultural barriers hindering their access.
– Social health protection, looking at policy framework and institutional design for comprehensive risk pooling mechanisms.
– Health financing, putting in place a useful costing process that complements the one-health, and development of the health financing strategy for Kenya within the context of the P4H global initiative.
– Support to quality of care initiatives, with a specific focus on supervision, design and roll out of Kenya Quality Model for Health (KQMH) and the ongoing process of elaboration of an accreditation framework for Kenya.
This partnership with GIZ is built on a solid global foundation of WHO/GIZ collaboration, mainly through the Social Health Protection Network (P4H) initiative. Let me appreciate that the German Chancellor was the keynote speaker at the last World Health Assembly, the 68th World Health Assembly (WHA) in May 2015 where she highlighted in more detail the close working relationships that WHO and GIZ possess, in supporting countries to build resilient health systems.
At this juncture, on behalf of WHO and the UN Family let me commend this Programme evaluation mission. I am hoping that at the end of your mission you have interacted with Ministry of Health at National and County levels; you have interacted with the major health players in the country, and you will be in a better position to advise the Government and the people of German how to continue to engage with Kenya through an informed decision on: Moving towards Universal health Coverage, with a guiding principle: Quality health is a right.
As I conclude, let me reiterate the commitment of the World Health Organization and the entire United Nations Family, in making Kenya a healthier Country.
January 15, 2018
September 15, 2017
May 5, 2017
May 2, 2017