De-facto privatization of health in Kenya limits access, says report

The Kenyan government and international development actors, such as the Bill & Melinda Gates Foundation and World Bank, have pushed for the de-facto privatization of the health care sector.

It has had devastating impacts on access to quality, affordable services in the country, leaving the public sector ill-equipped to meet the needs of the population, according to a report from Kenyan human rights organization Hakijamii and New York University’s Center for Human Rights and Global Justice. The report argues that increased private sector involvement has set the country back on its goal of achieving universal health coverage.

“More and more people have been priced out of health care because of their socioeconomic situation and inability to access private care either because of the expenses involved or because the type of help they are looking for is not available, because it's not profitable,” Nicholas Orago, director of Hakijamii, told Devex. He said about 41% of the country’s health care system is for-profit.

According to the report, there is “chronic underinvestment” in public health care, leading frequently to poor quality health services, often in health facilities that are long distances from where people live and not stocked with critical medicines, forcing many to seek out private health care.

And while good health care is available in the private sector in Kenya, many cannot afford it, leaving them to poor-quality private actors.

“The haves and the have-nots experience entirely different private sectors. Private health care is often disastrous for poor and vulnerable community members who are left with low-quality, low-cost private providers that are too often unsafe and even illegal,” said Rebecca Riddell, lead author of the report, and co-director of the Human Rights and Privatization Project at NYU Law, during a press briefing Wednesday.

Since the private sector relies on making profits and is subject to higher borrowing costs than the public sector, private sector health care spending by patients can be up to 12 times more than the public sector, having risen by 53% between 2013 and 2018, according to the report. People on a low budget might be turned away if they don’t have the money — or drawn into mountains of debt. Authors spoke to Kenyans who sold livestock, land, and vehicles — as well as sacrificed educational opportunities — to pay for private care.

The private sector also often focuses on services that are most profitable, the report said, neglecting others, such as preventative care and family planning.

The Kenyan government has enacted reforms and put initiatives in place to encourage the private sector to bolster its presence in the health care sector, making its participation grow rapidly in the past decade.

The Kenyan government’s National Hospital Insurance Fund contracts with the private sector; it subsidizes access to private care; offers private providers higher reimbursement rates; sends most of its claims money to the private sector; and engages in public-private partnerships with international companies at a high expense to the government, according to the report’s authors. NHIF is considered the signature vehicle for the government to achieve universal health coverage.

“An uncritical ideological commitment to privatization and a determined push to engage the private sector have trumped the health needs and rights of the Kenyan people,” according to the report.

Increasing the private sector’s role is at the “urging and encouragement of key actors in the development sector, including international financial institutions, private foundations, and wealthy countries looking for new markets,” the report said.

“Many of these actors have provided financial and technical support for, and even conditioned aid on, pro-private sector reforms, without acknowledging or paying adequate heed to the harms being caused,” it said.

The Gates Foundation, for example, funded a six-year project supporting the provision of private sector primary health care in Kenya and Ghana.

“While some, such as international organizations like the World Bank, must at least make routine disclosures, others, like the Gates Foundation, offer exceedingly little information about their activities and certainly no meaningful opportunities for Kenyans—whose rights are at stake—to raise their concerns or seek to influence policy,” according to the report.

The World Bank has supported user fees in the health sector and pushed for reduced government spending on health care, as well as supported the private sector through loans and expertise, authors said.

One key bank-endorsed public-private partnership in Kenya, the Managed Equipment Services project, “has resulted in poor value for money and is embroiled in controversy,” according to the report.

The authors said the public sector is better equipped to deliver on universal health care but given the private sector-focus of the NHIF, its expansion will “divert more public money to private actors without eliminating high costs, aligning private interests with public health goals, or addressing exclusion in the private sector.”

They advised that the regulatory framework around private providers “be significantly strengthened and far better enforced.”