How Kenya doubled its health budget
Minister Charity Ngilu puts the politics in health
The Ministry of Health and health services in Kenya received a refreshing boost from the departing Minister of Health, past Presidential candidate Charity Ngilu. But it hasn't been easy. Here she puts health, and research for health, into its full political context.
When researchers or disease specialists become frustrated that they can’t press their results and ideas directly into action, through a willing minister and ministry of health, they sometimes forget that the minister has very many difficulties to face before their concepts become reality.
Nothing illustrates this better than the story of Charity Ngilu, Minister of Health in Kenya until her dismissal on 6 October, which tells vividly of the political challenges that can face a minister quite outside her brief in health (see Box 1).
An active, committed politician who bravely stood as the first woman candidate for President of her country ten years ago, Ngilu also claims to have beaten back corruption in her health ministry (see Box 2).
But now the ministry is clean – or at least cleaner – and drugs are reaching the dispensaries, she tells RealHealthNews, and she can concentrate on tackling real health problems (see Box 3). “But no research was done on what I had to do” she says.
Ngilu, who also champions the role of women in Kenyan society, and sometimes goes incognito to inspect the operation of health centres and hospitals, spoke to RealHealthNews in her office at the ministry in July.
>RHN: You stood for the Presidency in 1997, in very difficult circumstances against Daniel arap Moi. I read that at one point you and your supporters were actually tear-gassed. Why did you do that? What was your vision?
CN: What really drove me into leadership right from 1992, first of all run for parliament, was the belief that we could change this country.
I believed we could change the way we were being managed, being governed and being led by our previous government run by KANU, headed by President Moi. I thought they really were missing the point and not working as servants of the people, but much more as masters of the people. I could not stand, like many other people, those dictatorial ways of doing business.
I used to run a business, and my late husband also was in business. Every time we needed services from public offices, we had to go through bureaucracy after bureaucracy, coughing up money here and there to get any action.
And when Kenyans started agitating for change, I said this is now an opportunity for me to join in, to support a very worthy cause, with our resources, and with ourselves as people. So in 1992 when I had an opportunity to be elected in my constituency, I stood, and I beat a cabinet minister who came very, very close.
>RHN: Where was that?
CN: In Kitui central constituency. So I became a member of parliament. Unfortunately, of course, I was in opposition, but I knew that the struggles and the fighting for real change in this country were not over. In 1997, I realised that we were not united as opposition and I said unless we get united, we are not going to defeat the incumbent. So I found myself in parliament heading a party with about 17 MPs, the Social Democratic Party.
>RHN: What was your business?
CN: Then I had a bakery. And a manufacturing plant that was producing PVC water pipes and electrical conduits and fittings. It was doing very well.
>RHN: May I ask you briefly about your background, your education, how you came to this position?
CN: Yes. I went to local schools and I did a Diploma in Administration after I completed my O-Levels. And then I went to do Business Administration, strictly just business.
>RHN: Was your family middle class?
CN: No. My father was a local preacher, and my mother supported his work. She’s still today alive. She’s about 94 years old. But we were just poor, not middle class, very poor indeed.
>RHN: Goodness, but it’s good for a family to educate a girl so highly.
CN: Yes, but I did not get a very high education. I would have loved that, but the education that I got has served me well, and I like to continue reading, even today.
>RHN: But how did you get the capital to set up a business? Or were you just a good businesswoman and you built up the capital?
CN: I got a loan. When I left school, I was reading as I was working. First I got a job with the Central Bank of Kenya and I started saving. Then I worked with the Chase Manhattan Bank, here in Nairobi.
They paid me well. So I kept on saving money, saving money and I also got married to a person who was very ambitious and hard working. He was an electrical engineer and he also started his own consulting company. And he was also making money. So we somehow were blessed, myself and my husband, and he supported me very much.
And when I said I wanted to go into politics, my husband also wanted to support change. He wanted to support change through me and others, but he himself, did not want to go into politics. So that’s how were able to make some money to start the business, and get me into politics.
>RHN: A special couple.
CN: Yes. But unfortunately our businesses were not doing well when I got into politics, because then government decided to hit it my husband’s business as well as my business.
>RHN: As a political act?
CN: Yes. In actual fact at one time, I went to my office just to find that they had broken into my building, and smashed all the machines.
>RHN: Is that so! That was when?
CN: That was 1997, when I was running for President. And they said will you stop this or will you go on? I said have you done this to stop me? They said yes, you will have to be taught a lesson. And I said you might as well close this place, because I have made such a resolve that we must go all the way. So we’ll close the businesses if need be, until we sort this problem out. So that’s how we went on.
>RHN: Well, that’s very strong.
CN: But also I wanted to bring more women into leadership, because it was clear that government then, like government today, were not interested in giving women an opportunity to be in office.
>RHN: Like government today?
CN: Yes, even the government today.
>RHN: Isn’t the women’s movement getting stronger and stronger in Kenya?
CN: I don’t think so, because what is important is for women, first and foremost, to sit down and define themselves – to say what they want, what role they want to play in the management of public affairs.
Women need to understand their own strengths – and from their strength to say now, we will sit down and negotiate with you, those who are going to run for political office.
I have been pushing with other women for affirmative action, because there cannot be meaningful change and development when ideas of women are not put on the tables where decisions are being made.
>RHN: So you’re saying women are not politically well-organised at the moment?
CN: Compared with how it was in 2002, right now six months before general elections I am not seeing a very strong women’s movement or an organised, united women’s movement.
>RHN: It’s gone back a little bit?
CN: It’s gone back a little bit - and the donors who supported women’s causes have not quite put money into our women’s activities.
>RHN: There was talk that you would stand as President again.
CN: This year, my Party has nominated me so that I can run on our Party. Now we realise in this country, no single Party will win Presidency on its own. So we have got to now work in alliances and in coalitions like we did in the year 2002. Those elections put President Kibaki in office. He came through a Party called the Democratic Party. I came through National Party of Kenya. And another late Vice President came through a Party called Ford Kenya. And together all those parties were able to win.
>RHN: So the Social Democratic Party became part of the National Party of Kenya?
CN: What happened after I built the Social Democratic Party… I was not the registered as the Chairperson. So the person who was registered came and just said I’m not going to give you what you want. So he denied the opportunity to build the Party and the Party then just died.
>RHN: That was too bad.
CN: That was very bad. I suppose that’s what happens. People always short-change women and I felt I was short-changed by that Party. After we put the president in office, we feel that he did not strictly follow what we had agreed with him.
>RHN: So the possibility, if you’re standing again, is to form a coalition, then to be selected?
CN: Yes, the coalitions are going to be put in place. In fact, this is going to be a very, very busy month.
>RHN: I don’t know whether you can be candid about this at this point, but do you think President Kibaki has made a difference?
CN: We are growing. I believe together we have created this democratic space, a much more open society than it was before - including opening up the media, including that as a Minister here I can make decisions sometimes without having to ask the President - because he has given us that opportunity to do so.
But I still believe that we could have done much more with him. What went wrong with those of us who came together, was that as soon as we got into office, people who did not understand the struggle and the need to build a very strong political foundation and a strong democracy, came in very quickly. There were those who did not believe in change. And they have become the gatekeepers.
>RHN: To block change?
CN: Yes. So if President Kibaki had continued working with us very, very closely, without getting influenced by other people who did not necessarily believe in what we wanted to do, we would have done much better.
>RHN: But do you think that Kenya is moving slowly towards your goal?
CN: We’re moving.
>RHN: That’s good. But we should talk now about your work in health itself. What is your motivation here at the Ministry of Health?
CN: When I got here I realised that there were such great challenges of disease, of an under-funded ministry, and of de-motivated workers, including health workers, simply because of the conditions.
>RHN: In the ministry and outside?
CN: In the ministry and outside, in the sense that there was no proper infrastructure in the ministry. The running of the ministry was very, very bad. In fact, in Kenya ‘afya’ means ‘health’, and this is Afya House. But in the past people called this ‘Mafia House’.
CN: Instead of calling it Afya House, health house, they called it Mafia House because of the corruption and the bad things that went on in this ministry. You went to our health facilities outside there and you could just see some of them were closed, covered in cobwebs. Health workers did not come, because even if they came, they were sitting there, there were no drugs.
We have a medical supplies agency called the Kenya Medical Supply Agency, a big warehouse and a place where all our drugs, when we buy them, are stored, and they are distributed from there. But unfortunately the KMSA was also very badly run. So the monies that came to the ministry here for the procuring and the distribution of drugs never went out.
>RHN: Is that so?
CN: It never went out, so health workers had no drugs. So I said stop, now things have got to work here. We know the needs of the people. We do not have to do research to know that when people are sick they need medicine.
So I said that the first thing we need to do is to show me the resources of the ministry. How much do we have? What can we do with that? Once I realised that although we were actually under-funded we were at least getting some legal money, I said put this money in primary health care. Let us ensure, first and foremost, that we can take care of diseases at the village level, and take drugs to the dispensaries and to health centres, because that is where the poor live.
>RHN: And in the slums, of course?
CN: And in the slums. In actual fact, the whole of Nairobi city, all the facilities were closed. I opened all of them up.
>RHN: They were closed? Completely?
CN: There were no drugs. There were no health workers. They were being run by the ministry of local government, so I said, open up! I went round the whole city personally inspecting them and there were no health workers, no drugs, nothing.
>RHN: I hear that sometimes you went incognito?
CN: I did! Then I could see what was happening. And when they realised that somebody’s looking, they woke up. I said I understood that even if I come and I find you, but you have no drugs, there’s nothing you can do.
So I opened up. I gave them doctors in the city, first of all. I gave them health workers. I got ambulances for them. We had maternity wards where women used to die every day, but today we have streamlined it and people are very happy to deliver there. The same with other facilities in the city. Kenyatta National Hospital used to be crowded, congested. We have now decongested it.
>RHN: I understand some people used to carry cards saying ‘don’t take me to Kenyatta Hospital’?
CN: Absolutely! So now it’s better. The health sector today is better. Then we also opened up our health facilities, dispensaries, health centres. No research was done on what I had to do.
>RHN: No research was done on the management of the health system?
CN: It was something I just had to do. I visited, one day, a dispensary called Makhonge in the Western Province, to check on what was happening. I found this child outside, very sick. She was bleeding, with high fever, and many of the children had died in her village.
So when we were flying back in the evening, I was very stressed because when I asked to take the child inside to be treated, the mother said ‘I don’t have money, I’ve been inside there and I was told to take my child back home’. So they were sitting outside and the child was dying.
The child was called Nafula, nine years old. And I said, let’s take the child inside. So I took the child inside and the clinical officer looked at me and said the mother has no money I cannot treat this child. I said but the child is going to die. He told me yes, but the mother has no money. What the clinical officer was telling me, was that the policy from your my office is that people must pay before they are treated.
>RHN: This is the user fee policy?
CN: The user fee policy. So I told him ‘you treat the child I’m going to pay’. He said you pay. I paid and he treated the child.
But when we were coming back in the evening very late, all very tired, we were in a small aircraft. And this small aircraft was going up and down with the turbulence. And everybody in that small aircraft was screaming.
We were carrying one young woman from the media called Pamela Asigi and Pamela was screaming and said to me Minister now we are going to die in this small aircraft. ‘Minister I’m so young, I’m not married. Minister I’m now going to die. You are better off because you are old. You have children. You have a husband.’ I said Pamela can you pray your own God, I’m also praying my own God.
And I said to God, do you remember Nafula was going to die and I was told I’m the policy maker. I’m the decision maker and Nafula was going to die because of the policy that I have made, give me one more chance.
God give me one more chance and I will change that policy. Nafula will not die because of a bad policy. So I was praying, it went on and on and then it stabilised after about fifteen minutes. So I said we might land. When we landed I came on my desk and I said I don’t need any evidence. I don’t need any research. I know user fee is a bad policy for the poor.
And I announced the following day that we are now going to remove the user fee from dispensary and health centre. That did not go well with the cabinet.
>RHN: That was when?
CN: That was June 2004, and I said that from 1st July, I will remove user fee.
>RHN: So you announced it without consulting the cabinet?
CN: Without consulting anybody. And when I was called in to the cabinet, I said do you know for how long I’ve been trying to get in a decision making position, so that I can make a decision? This is the one decision that I’ve made.
I was told you can’t do that, it involves money. Of course, the minister of finance called this special cabinet to talk about this policy. And I said, but surely all of us know that if people are poor they cannot be treated, they are not giving them drugs. What government is that, that cannot look after its own people, even the poor? So of course, there was a lot of fighting.
>RHN: You do have to balance the budget.
CN: Of course, but I said when it comes to us at our level, ministers, money will be found, but if it’s Nafula, there’s no money. So I said that’s a policy I cannot retract. They told me you must retract. I said no, I can’t. Any of you can do so but not me.
So the President realised that this one I was not going to let go. So he just said go and see that it works. I was very happy. Our dispensaries and health centres are working very well indeed with enough drugs now, with enough equipment, because we have increased our health budget.
>RHN: And the staff are happy? Because sometimes the staff used to take the user fees.
CN: They used to take the user fee, but now there’s no user fee, because children under five are treated for free.
>RHN: But doesn’t it mean that their own income has gone down?
CN: Yes, but now we are giving enough drugs and we are paying the staff.
>RHN: Oh, you’re paying the staff to cover what they were taking?
CN: Yes. We pay the staff. And in fact, some of the success that I have enjoyed in this ministry is to see the increased number of health workers that we have hired.
>RHN: So have you managed to increase the budget then?
CN: Yes. The Ministry of Health has its increased budget from initially US$300 000 000 to now close to US$ 650 000 000.
>RHN: In what period of time?
CN: From 2004 to 2007.
>RHN: You’ve more than doubled the budget?
CN: Yes. We have more than doubled the budget.
>RHN: So what’s the magic? How did you do this?
CN: We continued to put pressure. We have also shown our donors that we can spend money well, because that was also another problem. And generally there was no proper leadership. And to show where we need money.
>RHN: And you’ve brought in a very potent combination. You’ve brought in a political vision, which is a social democratic vision, and you’ve also brought in management skills.
>RHN: That’s a pretty strong combination isn’t it?
CN: And much more also there is something that I believe about in this ministry, that maybe only a woman can bring, the feelings, the heart to know what a mother feels. What would I do as a mother if I had a sick child? I would go to a health facility and I know there are drugs in there but I am poor, I have no money and my child is dying.
And I also told people that these are the women who have gone out there to vote for you to become the President of Kenya, to vote for me to become a member of parliament and therefore minister here. So you cannot forget the person who has put you in the office and start making policies that do not relate to her.
And for me that’s what I brought here. I’m working with technical people but I have got to understand whom we serve. Who do you serve? Who are you here for? When you sit at this desk, who are your clientèle?
>RHN: So that’s a really fundamental analysis, but let me come on to some of my other questions. What about the pressure that comes from donors and also from interest groups? HIV/AIDS, TB and malaria get plenty of money from the Global Fund, for example, but there are other things to think about as well. You were at a diabetes conference yesterday, but you could claim that the diabetes movement, for example, is just one interest group among others. You’ve got interest groups for lots of other components and diseases. How do you balance those?
CN: Each department has its own work that has got to be done. You talk about diabetes. Talk about epilepsy for instance. A young girl walked in here. She’s about 25 and she was in tears. And I said to her why are you crying? And she said you have put so much emphasis on HIV/AIDS. You have put so much emphasis on TB, and malaria and you have put money there. But I am epileptic since birth and I cannot afford the treatment. Why don’t you talk about epilepsy?
And I said what would you like me to do? And she said I would like to be treated like you are treating HIV/AIDS patients. And I said OK I’ll look into that. And then I called out my Director of Medical Services and I said what do you do about epilepsy? All we have there is the association. Do we put money there? No.
Why? Why does it look like nobody care about epileptics? And yet they are there. Diabetes also, treating diabetes is a very expensive affair.
>RHN: You mean for the insulin injections?
CN: The insulin and even the prevention measures. We have put so much emphasis now on TB, malaria, and HIV/AIDS, actually to the extent that we have almost forgotten other non-communicable diseases.
>RHN: I was going to bring that up because I was told that you have only one senior member of staff dealing with all the non-communicable diseases.
CN: Exactly, Dr William Maina, and he has a very thin department. It’s like the whole ministry zeroed in on HIV/AIDS, TB and malaria.
>RHN: The donors give extra funds for people who are working in these things.
CN: Donors did so. But in the past there was some kind of mismatch, in the sense that there was no proper coordination of broad human resources.
>RHN: The planning was missing?
CN: The planning was missing. Coordination was missing. Harmonisation of the programme was missing. But I now see that we have harmonised everything well. In fact we sat down with the donors and said let us know what each one of you is doing and where.
>RHN: If you take the figures that are coming out of WHO, they show the burden of non-communicable diseases to be almost equal to that of the communicable diseases. But of course, they affect a different group of people. They affect the older more than the younger to some extent. Do you consider that having Maina’s department being essentially one man, and the rest of the ministry dealing with communicable diseases, is right?
CN: Obviously it has been wrong for us not to look at the non-communicable diseases as a very important department of the Ministry of Health. And that’s why I have said that we cannot ignore non-communicable diseases.
We have got to put a lot of emphasis on that one - and once again look at the resources available in other diseases so that this one is not forgotten. Because I do not want to see ourselves as ministry depending on donors for some of the diseases, like non-communicable diseases.
By the way it is not just non-communicable diseases, as I said to you. Let me tell you one area I have now started putting my work and my time and efforts on, and that’s reproductive health. It never used to have one cent from the government. It only depended on donors. And I said this is a very important department, reproductive health is very important.
>RHN: Yes, and maternal mortality issues.
CN: Maternal and infant mortality. Safe motherhood if you like. So I said you just cannot ignore some of these things.
And now we are zeroing in, and thus this diabetes summit that took place last Friday and Saturday for me was an eye opener, showing that you cannot ignore this. This is important.
>RHN: There are many questions I could ask, though I know your time is limited. I wanted to ask you about evidence and science and how you use it. Do you think your connection with the scientific community, and those doing research on those issues, is strong enough? Or do you think it could be stronger? Not just between yourself and these people, but the ministry and these people.
CN: First of all, once you have done research on something, you can cut costs, in the sense that when you now go to implement a programme based on information that has been gathered then you know you can’t make mistakes. You are not wrong and therefore it cuts costs.
>RHN: So you don’t waste money.
CN: Don’t waste money, don’t waste time. It is reduces frustration because you know you are zeroing in on the problem and you are getting correct answers and correct solutions. So that is very, very important.
It also, of course, encourages researchers in this ministry. You know we have the Kenya Medical Research Institute here, which has done marvellous, great work and we connect that very well with the ministry. So anything that we also want to do we ask them to check.
That is on the medical side. But there is also research that needs to be done to get to hear what the people we serve are saying. Because you don’t make good policy simply because you think this is what they need. Sometimes what we sit here and think this is what they need isn’t what they need.
And therefore I encourage research. I think it’s very, very important to do research. We have done a lot of research now on malaria, HIV/AIDS and TB from a community perspective.
Traditional birth attenders have actually done a lot and given us a lot of information, for instance, when we think about home based care and the people who are doing it. Now they know how to tell other women to please go and get checked and to go and deliver in our facilities. And they say you may be HIV positive, but if you go to the facilities you will get a tablet that you will take and your baby will come out OK. So the traditional birth attenders now have themselves said we can also keep this nevirapine and also administer it.
>RHN: So there’s been research on that and you’re using that research to train them?
CN: Exactly, so where women are not coming to our facilities, they are doing it in their homes. That’s very good.
>RHN: Right, so research is important to you. Do you think you are well enough connected, that you know enough about the research?
>RHN: People talk about the need for ‘knowledge translation’.
CN: No, we are not very well connected, because this is new. This has just started. For example, as I said in the past there was very little connection between communities and the ministry. We have now built this community-ministry relationship and it’s getting strong.
>RHN: You’ve given me a fascinating interview and I really appreciate your time and commitment to this. Let me ask you briefly. I’m trying to communicate in this area amongst different countries about the problems, the issues and the solutions to dealing with the poorest for health in Latin America, in Africa, in Asia. And I’m trying to create a communications tool that is actually usable by ministries of health. Now what would be useful for you? You have some magazines out there in your office, but you probably don’t have time to read them yourself.
CN: FM stations.
>RHN: You think radio is the way? Radio to the community?
CN: Radio to the community.
>RHN: But what about you in the ministry as policy makers?
CN: We in the ministry need magazines. Small magazines. Something that’s very easy to carry around.
>RHN: On special subjects?
CN: Yes and everything really. Something like this [pointing to RealHealthNews] is very, very good.
>RHN: So if I delivered some magazines about these issues to you at the ministry, you would distribute them to who needed to see them?
CN: Yes, of course we’ll do that.