The Context
Internationally, following the global recession of the 1980s, there was a shift in developmental concepts away from the satisfaction of basic needs as a universal human right towards a market orientation in the provision of social services, including health. The World Health Organization continued to urge countries to formulate mental health policies and to provide mental health care along the principles of Primary Health Care [
3,
29], but the World Bank and the International Monetary Fund played an increasing role in determining the direction of the development policies of developing nations.
Critical of developing countries' attempts to treat health care as a right for their citizens and their attempts to provide free services to everyone [
30], the World Bank advocated instead that these countries shift some of the health care costs from the state to the consumers. To this end, the World Bank and IMF exerted pressure on these governments, including Kenya, to introduce Structural Adjustment Programmes based on the market model. Locally, various factors such as the attempted coup d'etat of 1982, the drought of 1984, the suspension of donor aid in 1991 and the ever rising health demands of the population contributed to a decline in Kenya's economy.
Documentary analysis
The key policy documents of this period were the 6
th Development Plan [
31], the 7
th Development Plan [
32], the 8
th Development Plan [
33], the Health Policy Framework of 1994 [
34], the National Guidelines for the implementation of Primary Health Care [
35], the Mental Health Act of 1989 [
36] and the Mental Health Programme of Action of 1994 [
37].
The key features of the development plans of this period were the increasing responsibility of the public and non-governmental agencies for health care, coupled with a decrease in the state's provision of health care. Market terms like "creating an enabling environment", "contracting", "budget rationalization", "cost-sharing" (ref 1989) crept into the policy documents. The 1989 development plan introduced Structural Adjustment [
31]. Contrary to the government's previous commitment to bearing the cost of health care, cost sharing was introduced in public hospitals in 1989.
It was during this era that explicit mental health policies were formulated. The National Guidelines for the implementation of Primary Health Care of 1986 included a section detailing how mental health care could be incorporated into Primary Health Care. The Mental Health Act of 1989 legislated the decentralization of mental health services to the district level and their integration with general health services and also established a multi-sectoral Board of Mental Health to oversee the services, protect patient interests and advise the government on mental health matters. Following the passage of the Mental Health Act, work started in 1990 on formulating a national mental health programme of action. According to the national mental health programme of action, the objectives of the Mental Health Act of decentralization of mental health services and the demystification and de-stigmatization of mental illness were to be achieved through the integration of mental health with general health care, community participation in mental health care programmes and rehabilitation, and prevention of mental illness through early intervention by addressing precursors of mental illness as well as public mental health education. This policy was based on the principles of Primary Health Care.
Although work on the national programme of action had started in 1990, it was not published till 1994, by which time a new, overall health policy, the
Health Policy Framework of 1994, [
34] had also been published. This document Health Policy Framework was the over-riding health policy under which all health policies, including the mental health policy, had to be implemented.
The Health Policy Framework was a direct result of the Structural Adjustment process which had demanded Civil Service Reform, including Health Sector Reform. The main objectives of the Health Policy Framework were the reorganization of the Ministry of Health structure; the re-definition of the role of the Ministry of Health as creator of an enabling environment with a reduction in direct provision of health care, especially curative care' an increase in the role of other non-governmental health providers; an increased emphasis on alternative sources of health funding including insurance schemes and cost-sharing' the decentralization of health services and the re-orientation and deployment of personnel in line with the new policy.
Although the government's commitment to the Primary Health Care strategy was repeated, in reality the Health Policy Framework sounded like an echo of the 1987 World Bank Report,
Financing Health Services in Developing Countries: an Agenda for Reform [
30]. Table
1 compares some features of the two documents.
Table 1
Comparison between the World Bank policy document and the Kenyan policy document.
Year Published | 1987 | 1994 |
Problems identified in the health sector | inefficient spending on cost-effective health activities Internal inefficiency of public programmes "lower-level facilities are underused, while. hospitals are overcrowded (p.3)" Inequity in the distribution of benefits from health services |
"The Ministry of Health is seriously underfunded" (p.1)
"unnecessary congestion of hospitals by patients who should be treated at lower cost in health centres and dispensaries"(p.1)
"geographical disparities, which need to be addressed in order to achieve some equity" (p.4)
|
4 Proposed policy reforms | | |
(Title/Catchphrase) | "Agenda for reform" | "Agenda for Reform" |
Reform 1: | Charge user fees (p.3)
"The apparent willingness of households to pay at least some of the costs of health care" (p.3)
|
"raising of additional resources through widely accepted cost-sharing initiatives" (p.39)
|
Reform 2: | Provide insurance or other risk coverage (p.4) | shift part of financial burden to insurance schemes (p.40) |
Reform 3: | Use non-government resources effectively - government to focus on community/public health measures, rather than individuals (p.5) temporary government subsidies to NGO health providers (p.5) | Strengthening of NGOs, local authority, private and mission health service providers (p.37) enabling environment, which may include subsidies (p.37) |
Reform 4: | Decentralize government health services - planning, budgeting and purchasing: allow revenue to be collected and retained close to the point of service delivery (p.6) | "Further decentralization of planning, management and resource creation, control and use to the districts" (p.36) |
The model followed by the generic health policy during this period was the Market model espoused by the World Bank, as shown the similarities between the two documents above, and by the health policy document's emphasis on cost-effectiveness, budget rationalization and payment for health as a commodity.
The
telephone interviews with the policy makers confirmed that the generic health policy was no longer based on the Primary Health Care model [
38] that it had been influenced by the Structural Adjustment Programme and Health Sector Reform [
38], that the mental health policy was still based on the Primary Health Care model but was facing pressure from donors and international agencies to conform to a market model [
39] and that there was conflict between the generic health policy and the mental health policy [
39].