New health CS has an uphill task as sector beset by myriad woes

Health Cabinet Secretary Cleopa Mailu addresses partakers during his visit to Kenya Medical Supplies Authority depot on January 12, 2016. Medics we spoke to were optimistic that the new Health Cabinet Secretary, Dr Cleopa Mailu, has what it takes to get things running smoothly, but whether that happens remains to be seen. PHOTO | FILE

What you need to know:

  • Poor human resource management, disgruntled workers, low salaries, poor working conditions and lack of funds are among the problems Dr Cleopa Mailu is expected to tackle, and it remains to be seen whether his promise to hold discussions to reach a consensus will pay off.
  • A month-long visit to a number of county hospitals in different parts of the country by DN2 revealed that healthcare workers were overworked, a situation that created room for medical malpractice, or “medmal”, due to fatigue. Experts have warned of the danger of the burn out.
  • There is also the problem of negligence. In June 2015, about 30 children in Bungoma County became paralysed after they were improperly injected.
  • Then Director of Medical services Dr Nicholas Muraguri had hinted that the quality of training in medical colleges was “not up to scratch” after a nurse trained at the Turkana Medical Training College was found “deficient in knowledge in certain basic areas”.

There couldn’t have been a better place for Dr Cleopa Mailu to start his official duties as Cabinet secretary for health than Kenyatta National Hospital, which epitomises all that is to be celebrated or criticised regarding the country’s public healthcare system.

During a tour of the hospital on January 5, Dr Mailu maintained a calm demeanour as he walked beside his colleague, Dr Nicholas Muraguri. He also showed a subtle sense of humour, cracking jokes that only his peers understood.

As he shook hands with employees in the different departments, one could not help noticing  the stark contrast between the medical geneticist’s soft-spoken nature and the murky waters in which he is about to set sail.

Asked what his agenda for the first 100 days in the office was, he replied, “Well I do not have a 100-day agenda, all I know is that I will work.”

Given the number of strikes and casualties that have occurred in the health sector, there is no doubt that it is the most controversial devolved function.

But that was to be expected.

Apart from the complex nature of the business, which needs proper systems to succeed, health workers accounted for more than two-thirds of the 66,000 civil servants moved to the counties by the national government.

The strikes, essential drug stockouts in hospitals, deplorable working conditions and poor human resource management practices, among other challenges, put the docket squarely under the spotlight, indicting the government for failing to provide quality healthcare for Kenyans.

But the healthcare workers who spoke to DN2 were optimistic that things would change, saying that since the CS is a medical doctor with a stellar curriculum vitae, he has what it takes.

But qualified though he might be, Dr Mailu faces an uphill task.

MEDICAL MALPRACTICE

First, there is human resource management. While healthcare remains critical to the achievement of Vision 2030 and is cited as the pillar of a stable economy, the government has consistently shown apathy towards its workers. And Dr Mailu acknowledged as much.

“I know they feel disenfranchised, there are complaints about payment, promotions, being placed in the field for which you were not trained, lack of a career path…I know and that is why we are planning to engage the county governments, have collective bargaining that can foster industrial harmony,” he said.

The basic salary for most young doctors, who sometimes work 16-hour shifts because of the workload, is below Sh50,000, according to  their  union.

This resulted in the first and worst nationwide doctors’ strike after devolution. Many patients suffered as the doctors stayed away from work, with some even dying.

It estimated that since then, there have been more than 40 strikes in parts of the country where health workers and the government disagree on what to give priority in expenditure.

Cabinet Secretary for Health, Dr Cleopa Mailu (centre) flanked by Kenya Medical Supplies Authority (KEMSA) CEO John Munyu (left) examine distribution logistics led by ICT manager Samuel Wataku on January 12, 2016 at the KEMSA plant in Nairobi. PHOTO | JAMES EKWAM

In June, the vocal Secretary-General of the Kenya Medical Practitioners and Dentists Union (KMPDU), Dr Ouma Oluga, claimed that 700 doctors posted to the counties had been rejected because they were from outside those counties.

Earlier, he had said that 2,000 doctors had left county hospitals due to, among other reasons, frustration and poor working relations with the county governments.

While Dr Oluga did not provide proof for his claims, a month-long visit to a number of county hospitals in different parts of the country by DN2 revealed that healthcare workers were overworked, a situation that created room for medical malpractice, or “medmal”, due to fatigue. Experts have warned of the danger of the burn out.

At the Siaya Level Four hospital, Dr Joanne Ahero was the only medic on duty in a facility that handled 41,215 patients in in 2013, with a daily outpatient traffic of about 200.

Speaking to the Nation at the 42nd Kenya Medical Association (KMA) annual scientist’s conference in 2013  in Mombasa, the association’s chair, Dr Elly Nyaim, said the medics’ poor working conditions create loopholes for malpractices that are sometimes fatal.

“Malpractice can occur out of deliberate negligence, but sometimes due to lack of equipment and doctors who have no choice but to work for long hours without a break might make mistakes that cost patients their lives,” he said.

The situation is aggravated by the fact that Kenya has inadequate resources.

The story was no different  regarding specialised care: Nyeri Level 5 Hospital had no cardiothoracic surgeon, so heart patients had to be referred to the already crowded KNH or to expensive private hospitals.

Consensus had not been reached by August 2015 as the KMPDU, backed by the Central Organisation of Trade Unions (Cotu) Secretary-General Francis Atwoli, called for a constitutional amendment to stop county governments from handling the health function.

MEDICAL NEGLIGENCE

Data in the Economic Survey 2014 from the Management Health Information System indicated that the country had  8,682 doctors shared between private and public institutions. Meanwhile, the doctor patient ratio was 1:5,000. This is five times the World Health Organisation’s recommended 1:1,000 ratio.

Notably, a 2013 survey by the Ministry of Health and the World Bank titled Health Service Delivery Indicators and Public Expenditure found Kenyan healthcare workers more knowledgeable than their counterparts in the region, making them attractive to other countries. For instance, 80 per cent of Kenyan healthcare workers can diagnose common health conditions and have the necessary knowledge to handle them.

Negligence

There is also the problem of negligence. In June 2015, about 30 children in Bungoma County became paralysed after they were improperly injected.

Then Director of Medical services Dr Nicholas Muraguri had hinted that the quality of training in medical colleges was “not up to scratch” after a nurse trained at the Turkana Medical Training College was found “deficient in knowledge in certain basic areas”.

In November 2015, Elizabeth Akala, 36 and pregnant, died at the Kakamega Provincial General Hospital after medical staff clocked out at the end of their shift, leaving her unattended in pain for 14 hours.

Two weeks later, Abigael Ng’asia died in the same hospital after waiting for medical attention for  12 hours, leaving a two-week old baby behind.

A report titled The Kenya Patient Safety Impact Evaluation Study (KePSIE), which was launched in Nairobi in November 2013, showed that 90 per cent of healthcare facilities and care-givers do not always follow regulations, and that some providers sometimes mistreat patients, with negative consequences.

Dr Mailu’s hope lies in “empowering regulatory bodies” such as the Kenya Medical Practitioners and Dentist Board so that they hold every player in the system accountable.

Then there was the death of Alex Madaga, who spent 18 hours in an ambulance waiting for intensive care services after  a road accident. Unable to breathe on his own, he had to be kept on the ambulance’s ventilators since KNH — the largest health facility in the country which has 21 ICU beds instead of the recommended 125 — did not have a bed for him.

Lack of, or shortage of equipment is a problem that plagues many cancer patients. At KNH, the only public medical facility in the country for cancer treatment, DN2 saw only radiotherapy machines.

To tackle the shortage of equipment, former health CS James Macharia had instituted the Managed Equipment Services (MES), an arrangement that saw the government sign a Sh38 billion deal with healthcare technology companies like General Electronic to equip hospitals countrywide with more than 95 high-tech machines to help manage diseases like cancer and diabetes.

However, some governors opposed the deal, citing lack of qualified personnel to handle the machines, and that  they were not consulted.

On the issue of equipment Dr Mailu said, “It would be imprudent to have them in boxes, not working at all, but it is also important to learn to utilise fully what is available before asking for more because you might buy equipment, but then who will run this equipment?”

More equipment is needed to stem the increase in non-communicable diseases, which is attributed to lack of diagnosis. For instance, government statistics show that there were 11,995 cancer deaths in 2010. The number rose to 12,574 in 2012 and to 13,720 in 2013. These figures could be higher due to poor capturing of data.

The Embu Provincial General Hospital, the biggest referral hospital in the region, serving the whole of Embu, Mbeere, Tharaka Nithi, Runyenjes, Kirinyaga and sometimes even Meru, did not have a casualty department.

The situation was no different  in most of the hospitals DN2 visited.

Financing

While the national government had used the managed equipment services as a way around finances,  county governments are stuck in a rut over money, a situation which county health executives have blamed for the poor state of health in the counties.

Dr Mailu said he was ready for discussion to reach a “unanimous decision” on every matter. But will openness alone solve the controversial money battles between the Treasury and the county government health departments?

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UPHILL TASK

Cabinet Secretary for Health, Cleopa Mailu. Medical laboratory technicians have issued a 14 day notice to the CS to reconstitute the Kenya Medical Laboratory Technicians and Technologists Board. FILE PHOTO | JAMES EKWAM | NATION MEDIA GROUP

Why financing still remains a tricky issue

IN JUNE 2015, during DN2’s visits to county-run facilities, hospital administrators cited lack of money as the major obstacle to the delivery of services.

County government health executives also cited lack of money  as a major problem.

Kisumu County health executive Dr Elizabeth Ogaja, for instance, said she had trouble explaining to healthcare workers why she cannot do what needs to be done thanks to the bureaucracy in the county’s finance department.

Dr Ogaja had said she loathed the “unnecessary irritation of being forced to beg and nag over the phone for something that should rightfully be released without much hassle.”

However, Kisumu County Finance Executive George Ongaya says they must play by the rule: “The strict financial laws that were enacted to curb corruption are what sometimes stop me from spending money on hospitals.”

“The money comes from the national Treasury, with allocations for specific activities. Some activities get more than they need but I am not authorised to divert the extra money to any other need; I can only return it.”

Yet these hospitals also collect money every month.

The problem is best understood by looking at the management of public hospitals before and after devolution.

Before devolution, as explained in the National Health Strategic Plan II that covers2005 to 2012, public hospitals all over the country banked all the money they collected at a central point.

PUSH AND PULL

Every quarter, the hospitals’ management teams would draw up 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.

It would take about three working days for the money they collected to be sent back to their account, with an additional amount, which was the government’s allocation for that particular hospital.

If the need arose to pay for, say power or water supply, the hospital would write to the PDMS again to have the money sent.

The government also put money in a special kitty, the Facility Improvement Fund (FIF), to be used for development in hospitals.

With devolution, hospitals bank the money they collect in the county’s revenue account.

The county government is expected to give them the money, plus some on top.

Hospitals cannot spend the money they collect until they receive an AIE (Authority to incur expenditure.

Previously, hospitals operated under the “push” system, where drugs and any other medical kits were centrally determined and sent to the facilities.

But they now work under the “pull” system, where each facility orders for drugs depending on its specific needs. 

The push system has not been working because of, among other reasons, the fact that county governments have treated money collected from hospitals as a source of revenue.

These financial challenges demonstrate that public hospitals are heavily dependent on donor funding and public private partnerships.

A large proportion of the little money that counties allocate to health is gobbled up by recurrent expenditure, leaving less than five per cent for development and training.

As he strives to tackle these challenges, Dr Mailu would do well is  to learn to get along with the Catholic Church to have smooth vaccination campaigns in 2016.