Political Engagement of Counties for Sustainable Health Programs

Introduction

Tegemeza is a five-year project funded by PEPFAR through CDC to implement and expand high quality HIV prevention, care and treatment services in Central Kenya. This project is implemented in five counties of Central Kenya (Kiambu, Murang’a, Nyeri, Nyandarua and Laikipia), in the former Central Province. The project period is October 2011 September 2016 plus a cost-extension to March 2017. Tegemeza implements these services in collaboration with the Ministry of Health and the counties at 105 health facilities. This work entails technical support, supervision, support for human resources for health, laboratory sample referral, and peer education, among others. This model requires significant collaboration with Ministry of Health/County Departments of Health. CHS uses sub-grants to support efficient implementation of this work.

 

The Constitution of Kenya (2010) occasioned devolution of power to 47 counties; health was among the key sectors devolved. After the 2013 elections, county governments came into being. This was mid-way through the Tegemeza project, which was implemented in Central Kenya. Several functions that had been supported through sub-grants to the Provincial and District Health Management Teams and hospitals needed to be grounded within the new structures. The county governments wield significant influence and power, and getting their support was critical for achievement of project goals and targets. Obtaining political support requires multiple strategies owing to the unique nature of counties.

Description of the Best Practise

While meaningful engagement of county leadership is critical in fostering a conducive environment for county ownership and support, it is often not given the emphasis it requires. CHS acknowledged the need for this and developed a system to engage counties to gain political support and ensure smooth and successful implementation. The project reached out to a broad array of parties that could potentially affect the work including County Health Management Teams (CHMTs), county executives, members of the county assemblies and public service boards. Specific officers within CHS have a mandate to build strategic relationships and partnerships with these offices.

Goal

To increase ownership and sustainability of the project activities and enhance collaboration between county governments and CHS.

Specific Objectives

1. To cultivate a collaborative relationship with counties and improve ownership of the project activities
2. To ensure absorption of health care workers and uptake of other project-funded activities upon completion of the project
3. To increase health financing for health and HIV
4. To strengthen the leadership and advocacy function of the county health management team

Key Elements of the Best Practise

1. Entry meetings with counties to describe our work and obtain their support
2. High-level negotiations with County Executive Committee Members of Health, Chief Officers of Health and County Directors of Health to advocate for absorption of health care workers and uptake of other project-supported costs
3. Signing of MoUs with County Governors
4. Engagement of county public service boards to ground human resource engagement in the county system
5. Working with the Murang’a County Department of Health to engage the Members of the County Assembly (MCAs) to secure support for the health bill and increase health financing
6. Training of county health management team and other health managers in Nyeri to conduct advocacy for health
7. Quarterly review and planning meetings with the county health management teams

Innovations of the Best Practise

1. Engagement of the county assembly, the legislative arm, to prioritize and increase allocations for health
2. Capacity building of health managers in advocacy
3. Advocacy with County Public Service Boards for human resources for health
4. MoUs with county executive for political commitment
5. Supporting identified county priorities to build partnerships

Lessons Learnt

1. It is important to formalize engagements with counties at the outset of engagement by clearly defining working relationships and expectations. If possible, MoUs should be signed at the outset.
2. The end should be borne in mind even at the outset of the engagement. E.g. discussions on staffing, support for services beyond the life of the project (or during, should donor terms and conditions change)
3. It is important to hold regular (e.g. quarterly) planning and review meeting with the county health management team to ensure shared understanding and goals, and to share and track performance
4. The County Public Service Boards should be engaged early to understand the project and to support with recruitment and other HR matters
5. There is need to build capacity of county health management teams and the Departments of Health in areas beyond health service delivery e.g. advocacy, leadership and governance, HR management, etc. to support their leadership role and ensure sustainability
6. Counties are a reliable partner for health services support. Considerations should be made to have staff supporting HIV services at other institutions (e.g. universities) seconded from the host county, as county systems are more flexible.
7. Diverse counties present diverse priorities and needs hence their uniqueness should be considered when developing the support strategies.
8. Working with counties to address their identified priorities fosters a mutually beneficial partnership.

Potential for Scale-Up

This is a model that can be applied in similar settings where implementation of health services requires county or national government support, particularly where human resources of heath and health financing are concerned.

Case Studies

Laikipia County – Ownership and Sustainability The Laikipia County Government was one of the newest teams that CHS worked with upon devolution. The leadership had previously been in the Rift Valley Province, whereas those of the other supported counties had been in Central Province and had extensively interacted with CHS. Initial discussions with the Laikipia County Executive were challenging as there was resistance to the proposed sub-granting model. However, through continued engagement, a working arrangement was arrived at that paved the way for a mutually beneficial and collaborative working relationship. CHS also engaged the Laikipia County Public Service Board to ensure ownership of the human resource for health function. Laikipia was the first county to sign a Memorandum of Understanding (MoU) with CHS to guide the working relationship. The MoU was signed by the Governor. The county has also embraced absorption of health care workers supported by the project; all HCWs in two consecutive years were absorbed and retained at HIV service points. This points to ownership and has ensured sustainability of services; towards the end of the project, the county requested not to receive support for HRH!

 

Muranga Members of County Assembly (MCAs) Engagement CHS has continued to engage the Muranga county leadership to ensure ownership and sustainability of supported services, particularly health care workers. The Muranga executive faced some challenges in their plan to absorb staff. The county assembly did not allocate requested funds for this. Further, there was a general under-funding of health services. CHS approached the County Chief Officer of Health to explore ways to help address this issue. It was proposed to meet the MCAs and highlight the gaps in health financing and attributable gaps in health service delivery. MCAs could understand the complexities of health financing and pledged to support the health bill that ring-fences health resources, and to improve allocations to health.