On March 13, Kenya reported its first case of COVID-19, and an additional 649 cases were reported in the following two months. As the pandemic spreads, Kenya’s policymakers are facing the first significant challenge to the country’s nascent intergovernmental system and will have to prioritize how to spend the country’s scarce resources amid existing fiscal constraints.
Established in 2013, Kenya’s decentralized government structure gives the country’s 47 counties the primary responsibility of delivering health care services to their citizens. But historical and geographical factors have led to substantial variation across counties in both health care capacity and risk of contracting the coronavirus.
To make critical decisions to control the pandemic, Kenya’s policymakers will need not only accurate data on the spread of the coronavirus but also county-specific data and analyses on health care capacity and population risk. With such county-level data, the national government can flatten the curve and better allocate the country’s limited resources in line with individual counties' circumstances.
To assist Kenyan policymakers in their decisionmaking, the Urban Institute, together with Kenya’s Institute of Economic Affairs, has developed two county-level indexes. One analyzes health care capacity through 14 measures, including the number of medical personnel and treatment and sanitation facilities per capita. The other analyzes population risk using 7 measures, including morbidity and mortality rates, share of population share of population 60 or over, and share urbanized.
We have plotted the results of these indexes according to scores on capacity and risk, with county population size represented by the size of the circle on the scatterplot.
What Kenya’s policymakers can learn from these indexes
Although each of Kenya’s counties has its own story, the totality of the data can provide policymakers with solid evidence for decisionmaking. For example, only five counties appear to have high risk and low capacity, but another four counties are right on the edge. All nine of these counties are large, with populations close to or more than one million, except Vihiga, which has a population of around 600,000. The counties most in need, Kwale and Kilifi, score poorly in the overall capacity index and require support in all personnel and facility areas. Both counties urgently need hospital beds and cots and public health workers. Kwale also needs doctors and medical labs, and Kilifi needs medical workers and nurses.
Of the 15 counties with low risk and low capacity, most are relatively small, although Kakamega has a population of more than 1.8 million. Mandera presents a special case of these 15 because its low risk stems from a low urban population, low HIV prevalence, its considerable distance from the major population centers of Nairobi and Mombasa, and its low capacity because of relatively low numbers for health workers and facilities. But Mandera borders Somalia, a country that has reported 671 COVID-19 cases as of May 4, which significantly increases the risk of infection despite the characteristics of Mandera’s population.
Kenya’s two major counties, Nairobi and Mombasa, have high risk and high capacity. Nairobi has a population of 4.4 million, Mombasa has a population of 1.8 million, and both urban centers host substantial numbers of travelers. Even with high capacity, it is unclear whether these counties can handle their current caseloads, which are likely to continue growing. As of May 4, these two counties accounted for around 90 percent of total reported cases. Other large counties in the same quadrant, including Nakuru, Kiambu, and Machakos, face similar trade-offs.
To meet counties’ needs to deal with this crisis, the national government and each county will have to coordinate closely as they confront trade-offs among health care capacity, population risks, and population size. To best allocate resources to counties in the long term, Kenya’s policymakers will need to decide how to build health care capacity for the future during the current budget allocation process, even as they maintain lockdown and protect the capacity of the existing health care system.