Amref’s Insights: Strengthening Primary Healthcare Financing for the Health Workforce – Lessons from Kenya, South-Sudan and Zambia

Introduction

The foundation of any nation’s healthcare infrastructure rests on a well-funded primary healthcare (PHC) system. This system is the initial point of contact for individuals seeking medical assistance and preventive care. Adequate financing guarantees the availability of essential services and plays a pivotal role in attracting, retaining, and motivating a skilled and committed healthcare workforce. By investing in PHC, countries can achieve improved health outcomes, reduce healthcare disparities, and fortify the resilience of their health systems. To shed light on the existing mechanisms, challenges, and potential solutions in financing the PHC workforce, the Health Financing and Human Resources for Health Communities of Practice recently convened experts from Kenya, Zambia, and South Sudan for a comprehensive discussion.

Current Health Workforce Financing Mechanisms

Kenya manages healthcare financing through a decentralized approach, where funding flows from the national government to county governments. This system grants counties the authority to allocate resources based on their specific healthcare requirements. In recent years, Kenya has exhibited a heightened commitment to health financing, with a substantial portion of resources directed towards strengthening the primary health workforce to meet the escalating demands of its population. Nevertheless, Kenya has encountered hurdles due to declining government and donor funding. To counteract this, Kenya has embraced community health policies, a strategy designed to ensure that healthcare strategies are developed and implemented at the grassroots level, thereby enhancing healthcare accessibility, especially in remote areas.

On the other hand, Zambia relies on a national healthcare financing strategy to fund its primary healthcare services. This approach emphasizes adequate funding and incentives for healthcare professionals, particularly those serving in rural and underserved areas. Like many other countries, Zambia grapples with migrating healthcare workers, notably nurses, to neighbouring countries such as South Africa and Botswana, or even beyond the continent. To counter this trend, Zambia has implemented incentives like better pay and improved working conditions, aiming to retain and attract healthcare professionals to provide essential services in areas of greatest need.

South Sudan, in contrast, heavily depends on a multi-donor trust fund as its primary source of funding for primary healthcare. While this approach has enabled the delivery of healthcare services, it also carries the risk of systemic collapse should donors decide to withdraw their support. The current incentive-based system, primarily facilitated by non-governmental organizations (NGOs) and development partners, may hinder the country’s transition towards achieving systemic autonomy in healthcare financing. Additionally, South Sudan grapples with the challenge of generating sufficient domestic healthcare resources, given the national government’s limited financial capacity. Currently, health receives less than 3% of the budget allocation.

Key Challenges in Financing the PHC Workforce

Establishing robust information systems for community health units remains a significant challenge across all three countries— Kenya, Zambia, and South Sudan. These systems are essential for the timely and accurate collection of data, a crucial component for making evidence-based decisions and efficiently allocating healthcare resources. Enhancing data infrastructure and focusing on capacity-building efforts could greatly enhance the effectiveness of primary healthcare financing strategies.

One overarching concern affecting many low- and middle-income countries is their high dependency on donor funding, which creates instability and uncertainty in healthcare financing. As these nations transition toward domestic funding mechanisms, the negotiation process with donors can be complex and carries implications for the stability of their healthcare systems and overall economies. Countries like Kenya, Zambia, and South Sudan must explore diverse funding sources to address this challenge. This includes increasing domestic investments in healthcare, seeking opportunities for public-private partnerships to supplement external funding, and actively engaging in resource mobilization through strategic lobbying and budgetary allocation. Decision-makers must recognize that investing in healthcare benefits the population’s well-being and is crucial for long-term economic growth and prosperity. Governments and development partners must collaborate to design sustainable and locally driven incentive mechanisms that encourage long-term commitment from healthcare professionals.

South Sudan faces a unique challenge—ensuring the safety and security of implementing partners. In regions marred by conflict and instability, implementing partners have encountered security challenges that hinder the effective delivery of healthcare services. Therefore, ensuring the safety and security of healthcare workers is paramount to maintaining uninterrupted healthcare access and addressing the needs of vulnerable populations.

Strategies for Ensuring Sustainability and Retention

In Zambia, addressing the issue of healthcare worker migration has taken a proactive turn. The country has hired 11,000 nurses to strengthen its primary healthcare system. Recognizing that nurses are particularly susceptible to seeking employment abroad, Zambia has improved opportunities for employment and proper remuneration, critical elements in retaining and attracting skilled healthcare professionals, especially in remote areas.

In South Sudan, the focus is on increasing funding for the health sector to provide better working conditions and competitive salaries for healthcare workers. A strong and well-funded healthcare sector retains skilled professionals and attracts new talent, ensuring a sustainable healthcare workforce. Furthermore, strategies are being developed to address the future needs of the health workforce, anticipating and adapting to evolving healthcare demands.

Best Practices and Lessons from Amref’s Work

Amref Health Africa has significantly addressed healthcare workforce financing challenges, particularly in South Sudan. Their efforts include upgrading nurses to diploma level, providing technical assistance in collaboration with the government, and adopting advisory and cooperating roles. By supporting 67 hospitals across the country at the primary healthcare level and implementing family planning projects using a top-down model due to community stigma, Amref has demonstrated the importance of flexibility and innovation in healthcare financing.

Key Takeaways

The discussion on financing primary healthcare workforces in Kenya, Zambia, and South Sudan has yielded several key takeaways:

• There is a pressing need for a more sustainable strategy for financing primary healthcare to ensure consistent and equitable access to healthcare services.
• Incentives for healthcare workers play a critical role in retaining and attracting skilled professionals, particularly in underserved areas.
• Using technology and innovative solutions can significantly improve the efficiency and effectiveness of primary healthcare service provision by reducing the administrative burdens of health workers.
• Enhanced collaboration and coordination among stakeholders, including governments, donors, and NGOs, are essential to addressing primary healthcare financing challenges.

Conclusion

The challenges and strategies discussed in this article underscore the critical role of financing mechanisms in ensuring the availability, accessibility, and quality of primary healthcare services. The experiences of Kenya, Zambia, and South Sudan provide valuable lessons for other countries facing similar healthcare financing challenges. By implementing sustainable financing strategies, prioritizing the retention of healthcare professionals, embracing technology and innovation, and fostering collaboration, nations can build robust primary healthcare systems that benefit their populations and contribute to overall health system resilience. In doing so, we can pave the way for healthier and more prosperous societies in Africa and beyond.

Authors:

1. Dr. Cynthia Waliaula, Policy Analyst, UHC Delivery Lab Health Systems Strengthening Directorate, Amref Health Africa

2. Ebubechi Nwaononiwu, Technical Officer Evidence Generation and Learning (EGAL), Strategic Purchasing Africa Resource Center (SPARC) – Amref Health Africa.