Nakhumicha's short, troubled stint at Afya House

Dr. Debra Mlongo Barasa is stepping into the health portfolio after the dismissal of her predecessor, Susan Nakhumicha Wafula.

But before celebrating this new appointment, Dr Barasa must brace herself for the daunting challenges ahead, which could define her legacy at Afya House. If she can navigate these turbulent waters, she has the chance to leave an indelible mark on a public health sector now mired in uncertainty.

Health is a key pillar to Kenya Kwanza’s Bottom Up Economic Transformation Agenda (BETA) whose delivery rested on Nakhumicha’s shoulders, until her abrupt departure.

Nakhumicha is applauded for establishing key policies at the ministry.

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Kisumu Governor Prof Peter Anyang' Nyong’o who once ran the ministry, acknowledges Ms Nakhumicha’s push for key health policies to transform the sector. “That is not an easy feat,”  Nyong’o said

Nakhumicha spearheaded the enactment of the National Health Insurance Fund (NHIF) bills; Social Health Insurance Fund Bill, Facility Improvement Financing Bill, Primary Health Care Bill 2023, and Digital Health Bill 2023.

The bills would later be assented into Acts by President William Ruto on October 19, 2023, birthing the Social Health Authority (SHA) that replaced the National Health Insurance Fund (NHIF).

The new scheme is the vehicle for actualisation of Universal Health Coverage (UHC) and is meant to ease the burden of healthcare that many Kenyans are currently shouldering.

XN Iraki, an economist, and lecturer at the University of Nairobi, says Nakhumicha’s legacy on the scheme remains conflicted.

“Do we retain NHIF or go for SHIF?” Poses Prof Iraki.

The court recently nullified the SHA Act due to insufficient public participation, days after Nakhumicha departed from the portfolio.

A three-judge bench comprising Justices Alfred Mabeya, Robert Limo, and Fredrick Mugambi gave Parliament 120 days to make the necessary changes.

In the scheme, deduction to SHA is capped at 2.75 per cent for the salaried, while those in informal sectors and the unemployed are expected to pay from their earnings.

Before being fired like the rest of the cabinet secretaries, Nakhumicha was always waxing lyrical about the new health scheme, emphatically stating that it is meant to ease the strain on healthcare.

The scheme has a Primary Healthcare Fund that is fully government-financed, providing care at Level 2 and 3 hospitals.

Deductions of 2.75 per cent will go to the Social Health Insurance Fund (SHIF), which will offer services at Level 4, 5, and 6 facilities.

Individuals who deplete their SHIF cover will access care using the Emergency, Chronic, and Critical Illness Fund, at Level 6 hospitals.

Services have also been standardised devoid of the amount contributed to the scheme. For example, those paying Sh300 and those paying more than Sh1 million will be able to access equal services under SHA.

Meanwhile, the pricing of health services across all private and public hospitals under the new scheme has also been harmonised. 

As the implementation of these laws and policies now lies in limbo, Prof Nyong’o attributes this to a lack of mutual working relationships with key stakeholders in the ministry, particularly county governments.

“She (Nakhumicha), left them (counties) out when drafting the bills and ignored them again during public participation.

Failure to include counties in the establishment of the laws saw the Council of Governors’ (CoG) Health Chairperson, Muthomi Njuki, confront Nakhumicha during the National Validation of Social Health Insurance (General) Regulations, 2024, at the Kenyatta International Convention Centre (KICC) in February this year.

Njuki was categorical that county governments were sidelined in the initial process of formulating laws and regulations, warning that this would affect the implementation in the devolved units.

 “I will not belabour the fact that health is primarily a devolved function and therefore in legislating we must draft laws that are county responsive,” he said during a validation exercise.

But in an interview with media, Ms Nakhumicha maintained that the laws were to actualise UHC; and ease the cost of healthcare that is forcing Kenyans to dig deeper into their pockets.

During her tenure, at least 107,000 Community Health Promoters were flagged off to deliver preventive and promotive health across the country.

The promoters are using the Community Health Information System (e-CHIS) for routine household visits, with each entitled to a Sh5,000 pay, in a shared role between counties and national governments.

But Prof Nyong’o, a former Medical Services Minister, observes that the implementation of UHC was done hurriedly.

“The CS thought that Universal Health Coverage (UHC) could be achieved in one go and failed to create a gradual plan with milestones towards achieving UHC,” he says.

In a previous interview, the CS defended the move, saying SHA laws are a vehicle for realisation of UHC. “Former governments failed to actualise UHC because of lack of laws,” said Nakhumicha.

Dr Christine Sadia, a Global Health Policy expert, acknowledged that reforms could have easily been realised with more engagement with key stakeholders.

Nakhumicha, according to the expert, came at a time when several reforms were happening at the ministry - including at NHIF - where more Kenyans had started appreciating the scheme that was paying for dialysis, radiotherapy, and chemotherapy services.

“People had started gaining confidence in NHIF. I do not know the policy shifts she picked. She came too quickly. She did not settle to understand the ministry totally,” she stated.

“She started introducing policy reforms too soon and shifted without settling. She did not bond as it were with health workers,” asserted Dr Sadia.

The expert added that working with technical people at the ministry would help in articulating policies.

Previously, Nakhumicha said there were plans to rebrand NHIF to National Social Health Insurance Fund, only that the government had planned a complete overhaul of the NHIF.

Complaints with outpatient capitation care, in particular, had seen many physician-staffed facilities pull out, leaving less than three per cent offering doctor consultations in the out-of-patient department.

Nakhumicha established the Kenya Health Human Resource Advisory Council to handle human resources which has seen employees hold numerous strikes.

Health workers' unions, the council and the ministry committed to work together through the Kericho Declaration signed in the presence of the Head of Public Service Felix Koskei on October 18, 2023.

Doctors through the Kenya Medical Practitioners, Pharmacist and Dentist Union (KMPDU) demanded implementation of the 2017 CBA, with the posting of interns having been among the contentious issues.

The issue of the workers remains complex.

However, according to Sadia, the issue of human resources can best be managed by the Health Service Commission.

Sadia takes an issue with the exportation of human resources to developed countries, saying Kenya does not have adequate health providers.

Amid her roles in changes in laws and policies, Nakhumicha admitted that corruption at the ministry from top to bottom has hampered the provision of efficient services to Kenyans.

Among agencies that have reported damning scandals include the National Health Insurance Fund (NHIF) and Kenya Medical Supplies Authority (KEMSA).

Irregularities witnessed in the procurement of long-lasting mosquito nets at KEMSA worth Sh3.7 billion saw President William Ruto sack Health PS Josephine Mburu.

Mburu became the first high-ranking government official to be shown the door, barely months after being sworn into office.

Ruto later appointed Dr Andrew Mulwa as the acting CEO for KEMSA, and Irungu Nyakera as the chairperson.

Nakhumicha also suspended managers at NHIF in Nairobi and Meru offices over alleged involvement in dirty dealings with some private hospitals.

Dr Sadia, also chair of the Kenya Medical Women Association, noted that the incoming CS should be an experienced professional who can strike a balance between technical and political space at the ministry.
“This time, the president should just listen, maybe look for a Kenyan who understands how health policy is driven, delivering service, and have a rapport with everybody,” said Dr Sadia.