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What ails Kenya’s public healthcare


Three cures for a sick system

Despite all efforts to resuscitate Kenya's public healthcare, patients still cannot access quality primary care.

At the new-born unit at Kenyatta National Hospital, Judy Nelima can barely sleep as she has to wake up once every three hours to feed her baby. She would have delivered closer to her home at Pumwani Maternity Hospital, where she had been attending her antenatal check-ups, but nurses are on strike there.

Her little girl was born pre-term, setting the little one on a path of a rough start at life as now she is more vulnerable to medical problems than the average baby born on term. The nurse in charge, Anne Kioy, is worried for Nelima’s baby and the other 180 in this 60-bed unit. She is doing all she can to make the mothers and their babies here as comfortable as possible, but with nurses on strike, and the unit stretched way beyond capacity, overwork and burnout are beginning to set in on the skeletal staff here.

Nelima, her baby, and nurse Kioy have found themselves in this situation because of a series of errors in Kenya’s public healthcare system. The incoming administration could save them and the tens of other Kenyans in the same situation, or it could as well damn them to more anguish and suffering.

The problem started in 2013, when management of health services was devolved to the counties, giving the 47 units autonomy to make decisions on human resource management, emergency, and primary health care.

The idea was great — bring services closer to the people, and have teams close to those people managing the whole health enterprise — and as the first Cabinet Secretary for Health after devolution, James Macharia, indicated, health workers constituted the largest bulk of staff that left the national government to the counties. More than 44,000 of the 66,000 that joined the counties were in the medical sector.

Unfortunately, most county governments were not prepared for the additional staff, and, to make matters worse, did little to separate politics from the important matter that is public health management.

A year after the new devolution system kicked in, the World Bank, in a study titled Delivering Primary Health Services in Devolved Health System in Kenya, declared that a tenth of existing healthcare facilities in the country had become non-functional.

The report judged Kenyan hospitals on the availability of networked, motivated and competent staff; supply of essential medicines and funds for operation; and maintenance.

Health indicators at a glance

140/191

Position in health delivery, globally
52

Under-five mortality, per 1,000 live births

63.5

Life expectancy

362

Maternal mortality, per 100,000 pregnancies

5.7%

Percentage of total budget on health, way below the 15 per cent recommended in the Abuja Declaration
Sh17,600

Money spent on health per head, annually

So much has changed since then, but so much has also remained the same. Here, the three major problems ailing Kenya’s health sector, and what should be done to correct them, according to experts:

1. GOVERNANCE: POWERPLAY IN THE COUNTIES

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One of the many county health executives who found themselves lost in the conundrum of devolved healthcare was Kisumu’s Dr Elizabeth Ogaja. In 2015 and a greater part of 2016, Dr Ogaja said, she did not have money to ensure that hospitals were stocked with essential drugs and non-pharmaceutical supplies.

Kisumu District Hospital had its power supply cut over a Sh700,000 debt, and many suppliers refused to do business with the facility. While the hospital was collecting money from patients, sometimes raking in as much as Sh2 million monthly, it could not use the money to pay its bills because of a bureaucratic finance requirement to submit the monies to a common pool.

“I draw budgets for emergencies such as supplying of drugs but every time I go to the county finance departments I am told I have to wait for the finance and procurement processes to run their full course,” she said.

Dr Ogaja said that she loathed the “unnecessary irritation of begging and nagging over the phone for something that is rightfully supposed to be released without much hassle because of the consequences involved”.

She also decried the underfunding that health has suffered as it is often seen as an easy casualty when budgets have to be cut or money transferred to fund something else.
The pharmacist said that county governments had employed a lot of people who did not understand the needs of various departments, and so officials were often at loggerheads.
“It is not just for the sake of salaries that you are employed, but to be part of a process that would make the lives of people better,” she said.

Dr Ogaja said she was sad that the monies hospitals collect are not being reimbursed to the hospitals in full, as should be the case. Before devolution, as explained in the National

Health Strategic Plan II spanning 2005 to 2012, hospitals all over the country banked all the money they collected. After every three months, hospital management teams would draw budgets depending on the total amount of money they had collected, which they would send to the Provincial Director of Medical Services (PDMS) for approval.

The money they collected would then be sent back to their accounts, together with the government’s allocation. Should there be an emergency, the hospital would write to the PDMS again and receive the money.

The government also gave money to a special kitty, Facility Improvement Fund (FIF), to be used for development in hospitals.
But in the new system hospitals collect money which they bank in the county’s revenue account. The county government ought to reimburse the money to the hospitals with an additional amount, but the money is scarcely refunded and in the rare occasions that it happens, the funds are lesser than what the hospitals banked. Hospitals cannot spend the money they collect until an Authority to Incur Expenses (AIE) is issued to them.

Also, before devolution, hospitals operated in a “push” system, where drugs and any other medical kits were centrally determined and sent to the facilities. The current system is designed to work in a “pull” arrangement, where each facility should place orders for drugs depending on its needs, such as the disease burden of the catchment areas they serve.
The push system has not been working because of, among many other reasons, the fact that county governments have treated money collected from facilities as a source of revenue. Kisumu County Finance Executive George Ongaya said that the “strict financial laws that were put in place to curb corruption” are preventing counties from spending money on hospitals”.

“The National Treasury allocates money for any activity in the county,” he said. “Some allocations are more than the need, but I am not authorised to divert that money to any other account. I can only return it.”

When asked whether money from hospitals is treated the same way as, say, licensing fees for bars and restaurants, Mr Ongaya said that when the money is pooled in the county account, it is not specified to him where it is coming from and what it should be spent on. There is no alternative account for hospitals so that their money can be “ring-fenced” against consumption by the activities of the county government.

2. HUMAN RESOURCE:

Strikes on service, strikes on lives

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Kenya has experienced five national doctors’ strikes since independence. Two of those — with the last one considered the deadliest by health experts — took place in the first term of devolution. Experts cited ego and poor human resource practices that strained relationships between medics and county health departments for the industrial action.

In March 2016, the secretary general of the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU), Dr Ouma Oluga, lamented that close to 2,000 doctors had quit public service within a year because of poor treatment by county governments.

Nine months later, on December 5, 2016, doctors embarked on a strike that would last three months, causing unimaginable suffering to patients and undocumented, unverifiable deaths.

Now debate on the nurses strike, long into its second month, has been shelved as political noise takes centre stage. The body count, doctors fear, might in the end be higher than what was registered during the doctors’ strike because the nursing profession is essentially the backbone of any functional healthcare management system.

But, again, because no one is tracking it, no one will ever know how many people lost their lives because of the current nurses’ strike.

National facilities like Kenyatta National Hospital and mission facilities such as Kijabe have been forced to take in double, or even triple, the patients they ordinarily handle.

However, even without the strikes, the human resource in Kenya’s public hospitals is already strained, which compromises care for patients. The latest Kenya Healthcare Workforce

Report, launched in March this year, states that the country is still very far from meeting the 44.5 physicians, nurses and midwives per 10,000 people recommended by the World

Health Organisation, and remains at a low ratio of 13.8 per 10,000.

Dean of medicine at Moi University, Prof Lukoye Atwoli, told HealthyNation that the Kenyan government should apologise to Kenyans for the apathetic way it handled the doctors’ strike and now the nurses’ action.

“Apart from the constitutional demand that the state needs to take care of its people, it is callous how the president went around launching new facilities as people died, not caring that equipment cannot be run without medics,” Dr Atwoli said.

As a result, and as expected, there is a huge brain drain in the sector as professional medics seek greener pastures elsewhere, worsening an already bad situation. A 2013 survey by the Ministry of Health and the World Bank ranked Kenyan healthcare workers as more knowledgeable in the region, making them attractive to other countries.

3. MEGA EXPENDITURE:

Cart before the horse

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Bombarded by unpleasant headlines and the civil society for deaths arising from maternity complications and non-communicable diseases such as cancer, the government intervened by introducing a one-shoe-fits all approach: free maternity care and purchase of equipment for all county hospitals. The Managed Equipment Service (MES) cost Kenyan taxpayers Sh38 billion.

While free maternal healthcare in public hospitals may have reduced maternal deaths, hospitals whose resources are stretched by the upsurge of mothers seeking delivery services are beginning to question whether the Sh5,000 per mother is sufficient.

Without a feasibility study to see the needs of each county, there are hospitals that received equipment that they had already purchased instead of what they needed. Other counties got equipment to treat diseases that were not prevalent in their areas and they did not have the expertise to handle them.

Yet counties pay close to Sh1 million every year for the equipment, money that many feel would have solved other pressing health needs such as hiring more clinicians.

Senior surgeon Dr Elly Nyaim termed the approach as putting the cart before the horse.

“How do you bring a dialysis machine to a county facility that lacks water, has very few healthcare workers, and sometimes has stockouts of antibiotics?” he asked.

In 2016 Healthy Nation learnt that the renal department at Nakuru Provincial General Hospital (PGH) did not operate at night because of lack of staff to take over from the overworked daytime shift. And in April 2017 Makadara Health Centre in Nairobi did not have basic supplies needed for delivery such as oxytocin, a hormonal drug that stops post-partum bleeding.

Dr Peter Kimuu of the department of policy, planning and financing at the Ministry of Health raised the alarm on misappropriation of the maternity money at the county level.

“The county hospitals need to tell us where the monies, even in the years before, went to”, Dr Kimuu said.

Even in regions where MES was welcomed, there were concerns about some of the equipment that were brought.

After suffering years of neglect, Lamu County started building its healthcare from scratch.

The county only had four hospitals — King Fahad Referral, Mpeketoni, Witu and Lamu West — separated by large bodies of water and poor road networks.

The county executive for health in Lamu, Dr Mohamed Kombo said that while they were grateful for the equipment that MES brought, they did not have the personnel to run it.

Dr Kombo said that staff attrition in the county was really high.

“We can hardly ever retain the medics we attract for general health delivery, let alone the specialised care such as running the renal equipment,” he said.

THE ‘PROBLEM’ WITH DEVOLUTION

Everyone agrees that the transfer of power to the counties is the best thing that has ever happened to Kenya’s governance structures since independence. Key decisions on development, infrastructure, policy and legislation are no longer centralised in Nairobi as county assemblies not only have huge budgets to manage, but are also closer to people and, therefore, it is expected, understand development needs better. But there seems to be a problem with the way these devolved units are managing the health sector. While it is true that the national government has failed in some areas, including disbursement of funds, county governments appear clueless, and sometimes structurally handicapped, on the management of the crucial public health sector.

Here, voices on the mess outside Nairobi:

Since devolution, the national government expects counties to deliver quality healthcare as per the Constitution but it still holds the monies meant to facilitate counties in this endeavour.” Peter Munya, outgoing governor of Meru

Let’s revisit the Constitution and arbitrate on necessary amendments, including the devolved health system. Some governors cannot handle the health docket given the strikes that have rocked many counties across the country.” Francis Atwoli, Central Organisation of Trade Unions secretary-general

The government should lay off everyone and pay us our pension dues. Then whoever wants to work for the devolved systems can go ahead and apply.” Seth Panyako, secretary-general of Kenya National Union of Nurses

Healthcare services can’t be devolved at present. We first need proper systems and structures in place.” Moses Lerre,Kenya Health Professionals Society secretary-general

We support devolution 100 per cent but we are opposed to the sudden transfer of health functions to the counties, which has seen resignation of medical doctors. Healthcare professionals want a chance to consult.” Dr Sultani Matendechero, former secretary-general of the Kenya Medical Practitioners and Dentists Union.