INEQUALITIES

Rights groups warn private healthcare is failing many, draining public resources

Government-backed expansion of the private healthcare sector in Kenya is leading to exclusion and setting back the goal of universal health coverage, said two rights groups in a report released today. National policies intended to increase private sector participation in healthcare, alongside chronic underinvestment in the public system, have contributed to an explosion of for-profit private actors who often provide poor value for money, neglect public health priorities, and push Kenyans into poverty and crushing debt.

The 49-page report, “Wrong Prescription: The Impact of Privatizing Healthcare in Kenya,” is authored by Hakijamii and the Center for Human Rights and Global Justice at New York University. It finds that privatization has proven costly for individuals and the government, has shut people out of access to healthcare, and is undermining the right to health. The government’s signature policy for achieving universal health coverage—the planned expansion of private-sector friendly social insurance through the National Hospital Insurance Fund (NHIF)—risks exacerbating these problems.

“Privatization is the wrong prescription for achieving universal health coverage,” said Philip Alston, former United Nations Special Rapporteur and co-author of the report. “Proponents of private healthcare make all sorts of promises about how it will lower costs and improve access, but our research finds private actors have really failed to deliver.”

“Promoters of private care have gravely misdiagnosed the situation,” said Nicholas Orago, Executive Director of Hakijamii and co-author of the report. “While many associate private care with high-quality facilities, the ‘haves’ and ‘have nots’ experience entirely different private sectors. Private healthcare has been disastrous for poor and vulnerable communities, who are left with low-quality, low-cost providers pedaling services that are too often unsafe or even illegal.”

Privatizing care has proven costly for both individuals and the government. The private health sector relies heavily on government funding, including tens of billions of shillings each year to contract with private facilities, subsidize access to private care, and pay for secretive public-private partnerships. Individuals face excessively high fees at private facilities, where treatment can cost in excess of twelve times more than the public sector.

“Healthcare is a big business, with global corporations and private equity firms lining up to profit off the sector in Kenya,” said Rebecca Riddell, Co-director of the Human Rights and Privatization Project at the Center and co-author of the report. “These companies expect returns on their investments, leading to overwhelmingly higher prices in the private sector while scarce public resources prop up private profits.”

The report draws from more than 180 interviews with healthcare users and providers, government officials, and experts. Researchers spoke with community members from informal settlements in Mombasa and Nairobi as well as rural areas in Isiolo. Many described being excluded from private care or facing hardships to afford treatment, such as selling important assets like land or forgoing educational and livelihood opportunities. Others described tragic consequences of low-quality care at private providers, including unnecessary deaths and disabilities. The impact has been particularly severe for people who are poor or low income, women, people with disabilities, and those in rural areas.

Researchers also found that the private sector in Kenya is concentrated in more profitable forms of care, and has neglected less commercially viable areas, patients, and services. Private sector healthcare workers described having to meet patient “targets” as well as working in conditions significantly inferior to those in the public sector.

“The disconnect between profits and public health goals should cause policymakers to rethink their reliance on the private sector,” said Bassam Khawaja, Co-director of the Human Rights and Privatization Project and report co-author. “Many essential health services are incredibly valuable or even lifesaving but may not be profitable as one-off transactions.”

The anticipated nationwide rollout of mandatory NHIF coverage will divert more public money to private actors without preventing exclusion and high costs. Though the NHIF is a public insurer, it contracts extensively with private facilities, offers private providers higher reimbursement rates, and sends most of its claims money to private actors. “Expanding coverage through the NHIF instead of investing in a strong public health system is a major step backwards,” Orago said.

Much of the pressure to privatize has come from external actors in the global North. Key development actors have urged Kenya to increase the private sector’s role in health, including international financial institutions, private foundations, and wealthy countries looking for new markets.

“An ideological commitment to the private sector has trumped the rights of the Kenyan people, as development actors promote private care and financing without accountability,” Alston said. “The extreme secrecy around many arrangements with the private health sector opens the door to corruption and self-dealing.”

The report concludes that the government should rethink its support for the private sector and prioritize the public healthcare system, which still delivers the majority of inpatient and outpatient care in Kenya despite being starved of resources. “While the government should address serious shortcomings in the public system, popular recent investments illustrate an enduring appetite for public care,” said Alston.

“With sufficient political will and resources, the public healthcare system is best positioned to provide all Kenyans with the accessible, affordable, and quality healthcare that they have a right to,” said Orago.

This post was originally published as a press release on November 16, 2021.

INEQUALITIES

Makundi ya haki yaonya kuwa huduma ya afya ya kibinafsi inaathiri wengi, kufuja rasli mali za umma

Hatua ya serikali kuunga mkono upanuzi wa huduma ya afya ya kibinafsi nchini Kenya imesababisha kutengwa na kurudisha nyuma hatua za kutimiza malengo ya afya kwa wote, makundi mawili ya haki yamesema kwenye ripoti iliyotolewa leo. Sera za kitaifa zilizokusudiwa kuongeza ushiriki wa sekta ya kibinafsi katika utoaji wa huduma ya afya, pamoja na uwekezaji duni katika mfumo wa umma, zimechangia kuenea kwa wahudumu wa kibinafsi ambao mara nyingi hutoa huduma duni, hupuuza vipaumbele vya afya ya umma, na kuwasukuma wakenya wengi katika umasikini na malimbikizi ya madeni.

Ripoti hiyo ya kurasa 52, “Tiba Tatanishi: Athari ya ubinafsishaji wa Huduma ya Afya nchini Kenya,” imeandikwa na Hakijamii kwa pamoja na Kituo cha Haki za Kibinadamu na Haki za Kimataifa katika Chuo Kikuu cha New York (CHRGJ). Ripoti hiyo inabaini kwamba ubinafsishaji umewekea watu binafsi na serikali mzigo mkubwa wa gharama, umewazuia watu wengi kupata huduma ya afya, na unahujumu haki ya afya. Sera kuu ya serikali ya kutimiza mpango wa afya kwa wote—mpango wa kupanua bima ya jamii inayoegemea sekta ya kibinafsi kupitia Hazina ya Kitaifa ya Bima ya Afya (NHIF)—unatishia kuzidisha matatizo haya.

“Ubinafsishaji si suluhisho tosha kwa kutimiza mpango wa afya kwa wote,” alisema Philip Alston, aliyekuwa Mjumbe Maalum wa Umoja wa Mataifa na mwandishi mwenza wa ripoti hii. “Watetezi wa ubinafsishaji wa huduma ya afya hutoa ahadi za kila aina kuhusu jinsi hatua hiyo itapunguza gharama za matibabu na kuimarisha upatikanaji wa huduma ya afya, lakini utafiti wetu umepata kwamba wahudumu wa kibinafsi wameshindwa kabisa kutimiza ahadi zao.”

“Watetezi wa huduma ya afya ya kibinafsi wameshindwa kutoa ufafanuzi halisi wa hali ilivyo,” alisema Nicholas Orago, Mkurugenzi Mtendaji wa Hakijamii na mwandishi mwenza wa ripoti hii. “Huku wengi wakihusisha huduma ya kibinafsi na vituo vya kiwango cha juu, ‘mabwanyenye’ na ‘wachochole’ hukumbana na aina tofauti za sekta ya kibinafsi. Huduma ya afya ya kibinafsi imekuwa na madhara makubwa kwa watu maskini na jamii zilizoko hatarini, ambazo hulazimika kutumia wahudumu nafuu wa kiwango cha chini, ambao hutoa huduma ambazo mara nyingi ni hatari au hata kinyume cha sheria.”

Ubinafsishaji umedhibitishwa kuwa wa gharama kubwa kwa watu binafsi na serikali. Sekta ya afya ya kibinafsi hutegemea zaidi ufadhili wa serikali, ikiwemo matumizi ya mabilioni ya pesa kila mwaka kutoa kandarasi kwa vituo vya kibinafsi, ruzuku kwa huduma ya kibinafsi, na malipo kwa miradi ya kisiri ya ushirikiano wa sekta za umma na kibinafsi. Watu binafsi hukabiliwa na ada za juu zaidi katika vituo vya kibinafsi, ambako matibabu wakati mwingine yanagharimu mara kumi na mbili zaidi ya gharama katika sekta ya umma.

“Huduma ya afya ni biashara kubwa, huku mashirika ya kimataifa na kampuni za ufadhili wa kibinafsi zikilenga kujinufaisha kutoka sekta hiyo nchini Kenya,” alisema Rebecca Riddell, Mkurugenzi mwenza wa mradi wa Haki za kibinadamu na  Ubinafsishaji katika kituo cha CHRGJ na mwandishi mwenza wa ripoti hii. “Kampuni hizi zinatarajia faida kutoka uwekezaji wao, hatua ambayo husababisha bei za juu zaidi katika sekta ya kibinafsi huku rasli mali haba za umma zikitumika kuimarisha faida za sekta ya kibinafsi.”

Ripoti hii imeandikwa kutokana na mahojiano yaliyofanyiwa watu zaidi ya mia moja themanini wakiwemo wagonjwa na watoaji wa huduma ya afya, maafisa wa serikali na wataalamu. Watafiti walizungumza na wanajamii kutoka mitaa ya mabanda katika miji ya Mombasa na Nairobi na vile vile maeneo ya mashambani katika kaunti ya Isiolo. Wengi walieleza jinsi walivyotengwa kutoka huduma ya kibinafsi au kukabiliwa na matatizo kugharamia matibabu, kama vile kulazimika kuuza mali muhimu kama shamba ama kukatiza masomo ya watoto na fursa nyingine za kutafuta riziki. Wengine walielezea matokeo ya kusikitisha ya huduma ya kiwango cha chini katika vituo vya kibinafsi, ikiwemo vifo ambavyo vingeepukika na ulemavu. Athari zake ni kubwa zaidi kwa watu maskini au wenye mapato ya chini, wanawake, walemavu, na wale wanaoishi sehemu za mashambani.

Watafiti pia walipata kwamba sekta ya kibinafsi nchini Kenya imejilimbikiza zaidi katika huduma zenye faida kubwa,na kupuuza maeneo yenye faida duni, wagonjwa, na huduma. Wafanyikazi wa huduma ya afya katika sekta ya kibinafsi walieleza jinsi walivyohitajika kutimiza “malengo” ya kuhudumia idadi fulani ya wagonjwa na vile vile kufanya kazi katika mazingira duni ikilinganishwa na sekta ya umma.

“Mkinzano kati ya faida na malengo ya afya ya umma unafaa kuwachochea watungaji sera kufikiria upya utegemeaji wa sekta ya kibinafsi,” alisema Bassam Khawaja, Mkurugenzi mwenza wa mradi wa Haki za kibinadamu na Ubinafsishaji na mwandishi mwenza wa ripoti hii. “Huduma nyingi muhimu za afya zina thamani kubwa au ni muhimu kwa kuokoa maisha licha ya kwamba hazina faida kubwa kibiashara.”

Mpango unaotarajiwa wa kusambaza kote nchini huduma ya bima ya afya ya lazima utachangia kuelekezwa kwa pesa zaidi za umma kwa wahudumu wa kibinafsi bila kusitisha kutengwa na gharama za juu. Ingawa NHIF inatoa bima ya umma, hazina hiyo hutoa kandarasi nyingi kwa vituo vya kibinafsi, hulipa wahudumu wa kibinafsi kwa viwango vya juu, na hulipa kiwango kikubwa  cha madai kwa wahudumu wa kibinafsi. “Kupanua huduma kupitia NHIF badala ya kuwekeza katika mfumo dhabiti wa huduma ya afya ya umma ni hatua kubwa kurudi nyuma,” Orago alisema.

Msukumo mkubwa wa ubinafsishaji umetoka kwa washirika wa kigeni. Washirika wakuu wa maendeleo wamehimiza Serikali ya Kenya kuongeza jukumu la sekta ya kibinafsi katika utoaji wa huduma ya afya, ikiwemo  mashirika ya kifedha ya kimataifa, wakfu za kibinafsi, na mataifa tajiri yanayotafuta masoko mapya kwa bidhaa zao.

“Dhamira ya kiitikadi kwa sekta ya kibinafsi imekiuka haki za wakenya, huku washirika wa maendeleo wakieneza na kufadhili huduma ya kibinafsi bila kuwajibika,” Alston alisema. “Usiri mkubwa juu ya makubaliano mengi na sekta ya afya ya kibinafsi unatoa mwanya kwa ufisadi na maslahi ya kibinafsi.”

Ripoti hii inabainisha kwamba serikali inapaswa kufikiria upya msaada wake kwa sekta ya kibinafsi na kutoa kipaumbele kwa mfumo wa huduma ya afya ya umma, ambao bado unatoa huduma nyingi kwa wagonjwa wanaoruhusiwa kwenda nyumba na wale wa kulazwa nchini Kenya licha ya uhaba wa fedha. “Ingawa serikali inafaa kushughulikia mapungufu makubwa katika mfumo wa afya wa umma, uwekezaji maarufu wa hivi karibuni unaonyesha hamu kubwa ya matumizi ya huduma ya afya ya umma,” alisema Alston.

“Kukiwepo na nia njema ya kisiasa na rasli mali, mfumo wa huduma ya afya wa umma una nafasi bora kutoa kwa wakenya wote huduma iliyo rahisi kupatikana, yenye gharama nafuu, na ya kiwango cha juu ambao wanastahili kupata,” alisema Orago.

This post was originally published as a press release on November 16, 2021.

INEQUALITIES

Government’s new strategy grossly inadequate, says former UN Rapporteur Philip Alston

Privatization of the bus sector in England outside London, Scotland, and Wales has delivered a service that is expensive, unreliable, and dysfunctional, said New York University human rights expert, Philip Alston, in a new report. The former UN Special Rapporteur criticized the government’s new national bus strategy for England, which he said merely tinkers with the existing system, offering ineffective half measures that fail to address the structural cause of the country’s bus crisis.

The 38-page report finds that many people have lost jobs and benefits, faced barriers to healthcare, been forced to give up on education, sacrificed food and utilities, and been cut off from friends and family because of a costly, fragmented, and inadequate privatized bus service that has failed them.

“Over the past 35 years, deregulation has provided a master class in how not to run an essential public service, leaving residents at the mercy of private actors who have total discretion over how to run a bus route, or whether to run one at all,” said Philip Alston, who authored the report with Bassam Khawaja and Rebecca Riddell, Co-directors of the Human Rights and Privatization Project at NYU’s Center for Human Rights and Global Justice. “In case after case, service that was once dependable, convenient, and widely-used has been scaled back dramatically or made unaffordable.”

The UK government imposed an extreme form of privatization and deregulation on the bus sector in England outside of London, Scotland, and Wales in 1985, arguing a year earlier that competition would deliver “a better service to the passenger at less cost.” More than three decades later, the promised benefits have not materialized and the current service is grossly inadequate.

Researchers spoke to passengers in England, Scotland, and Wales who described a broken system of fragmented services, disappearing routes, reduced frequency, poor reliability, falling ridership, limited coverage, inefficient competition, and poor information. Average fares have skyrocketed, rising 403 percent in England since 1987, while ridership has plummeted, falling an estimated 38 percent in England outside of London between 1982 and 2016/17.

“Private companies understandably prioritize profits rather than the public good, extracting money from the system while cutting unprofitable but necessary routes,” said Khawaja. “The public has effectively become an insurer of operator profits, propping up private services with considerable subsidies.” Despite privatization, the government provides billions of pounds in funding for bus services annually, accounting for more than 40 percent of funding for bus services in England, and has allocated hundreds of millions more to support private operators during the COVID-19 pandemic.

Bus service failures have restricted access to work, education, healthcare, and food. This has been especially severe for low-income people or those in poverty, as well as those in rural areas, older people, women, and people with disabilities. Inadequate transport systems also jeopardize individuals’ ability to take part in society and cultural life. And because bus services are operated by effectively unaccountable private companies, those impacted often have little meaningful recourse.

“The absence of a strong public bus system affects a great many people’s economic opportunities, but also their means to participate in their communities, travel to football matches or libraries, and visit family and friends,” Alston said.

Buses provide an essential service and account for some 4.5 billion journeys per year in England, Scotland, and Wales—the majority of all journeys on public transportation. More people commute to work by bus than all other forms of public transportation combined. They also boost economic growth, enable access to basic rights, alleviate poverty, and reduce congestion and greenhouse gasses.

The United Kingdom has international human rights obligations directly related to transportation. Physical accessibility is an essential component of many economic and social rights, but also civil and political rights such as the right to vote, to freedom of religion, and to assembly. Many residents’ ability to exercise these rights is directly contingent on access to a reliable and affordable bus service. Parliament should legislate minimum standards of transportation that UK residents can depend on, instead of leaving it up to the vagaries and predations of the market, Alston said.

Alston and his co-authors called on the governments of England, Scotland, and Wales to cease relying on private actors and market forces to determine access to such a vital service, adopt public control of bus transport as the default system, and provide the necessary financial and political support to local authorities pursuing public control or ownership of bus services.

“Unlike the current system, public control or ownership would allow for reinvestment of profits, integrated networks, more efficient coverage, simpler fares, consistency with climate goals, and public accountability,” said Riddell. “It’s also a more cost effective approach.”

“The United Kingdom is one of the wealthiest countries in the world, and can afford a world-class bus system if it chooses to prioritize and fund it,” Alston said. “Instead, the government has outsourced responsibility for a vital public service, propping up an arrangement that prioritizes private profits and denying the public a decent bus.”

This story was originally published as a press release on July 19, 2021.