The Man, October 5, 2015
A 37-year-old man on his way home needs to cross Waiyaki Way.
It is a dangerous road to cross during the day, and even more so at night when visibility is low and drivers are speeding, but he has to do it.
What happens next is this: A speeding driver hits the man before he can make it to the other side. Probably just a second faster, or slower, and Alex Madaga would have made it home to his wife. But this was not a story with a happy ending.
When first responders took Alex Madaga to Kikuyu Mission Hospital, they knew they were in a tight race to save his life.
What he needed was immediate attention, and emergency surgery. He also needed a proper Intensive Care Unit (ICU), and probably would need one for a while before he could be up on his feet again ... if he survived his substantial injuries, that is.
What they didn’t know at that point, but would realise over the next 18 hours as Madaga lay dying in the ambulance, was that everything that was wrong with Kenya’s healthcare system, both public and private, would be working against the race to save the man’s life.
The medical staff at Kikuyu Mission referred him to Kenyatta National Hospital (KNH) for the specialised treatment he needed.
But the hospital turned them back, saying it had no ICU bed for him. As his family huddled to find a place that did have the facilities, and the space, to treat him, paramedics tried to keep him alive for just long enough.
At one point, just before daybreak on Tuesday, October 6, they raced back to the first hospital to replenish his oxygen supply.
The obvious option, since KNH did not have the space, was to seek emergency treatment at any of the dozens of big private hospitals in Nairobi.
The smaller ones were unlikely to have the facilities Madaga needed, so his family tried the big private ones.
Nairobi Women’s Hospital and Ladnan Hospital, both of which had no ICU bed, turned them away.
At Coptic Hospital, the staff who should have first saved Madaga’s life before thinking about money, “refused to admit the patient prior to payment of a deposit of Sh200,000”.
If this story reads familiar, it’s because it was extensively covered at the time.
Alex Madaga spent 18 hours on a stretcher in an ambulance, turned away by a healthcare system that was meant, at least on paper, to save his life.
As his family tried to find him urgent medical care, the paramedic who had first picked him up stayed on, trying his best to keep Madaga alive.
“All the 21 beds in the ICU were occupied and up until an hour before we admitted him, no one had been discharged,” KNH’s deputy director for clinical services, Dr Simeon Monda, explained at the time.
In subsequent investigations by the Medical Practitioners and Dentists Board, the regulator said Kikuyu Hospital did everything right to provide immediate care, but should have had a qualified clinician accompany him in the ambulance.
The board said Nairobi Women’s Hospital and Ladnan Hospital did not have vacant ICU beds and both made referrals.
KNH, on the other hand, did not treat Madaga’s condition as the emergency it was, and those who saw him did not inform the hospital’s leadership and other authorities to find an immediate solution.
No one at Coptic examined Madaga, or even followed the hospital’s own ICU admission policy.
The board dismissed the case against Nairobi Women’s and Ladnan Hospitals, admonished PCEA Kikuyu Hospital, and found merit in the cases against KNH and Coptic Hospital.
The latter’s witness admitted before the board that “the patient was not assessed by a doctor and the relatives were not guided appropriately on the issue of the required deposit”.
Still, Coptic Hospital got off easy, with just an official reprimand.
The investigating committee also outlined a rough structure to solve the gaps in healthcare that had led to a cruel and unnecessary death.
One of them was to bridge the gap between the law and how private hospitals work, because “there are no guidelines on payment for such services in the event affected patients are unable to pay”, Dr Bernard Muia, the chairman of the Professional Conduct Committee, wrote in the report on December 21, 2016.
The story of the man who was denied, both by omission and commission, and multiple other reasons, his constitutional right to emergency medical treatment was probably the most important story of 2015.
It was the subject of multiple headlines, investigations by police officers and the body that regulates healthcare, as well as a court process. It even inspired a movie, "18 Hours" (2017).
Beyond the headlines, there were efforts by different groups to demand a better structure that would have kept Madaga alive.
The case, taken up by the Kenya Legal & Ethical Issues Network (Kelin) Kenya and a legal firm on a pro-bono basis, was more than just about one man and an unkind healthcare system.
In 2017, two years after his unnecessary death, Madaga’s family was awarded Sh2.5 million as compensation.
It was about making sure it never happened again; that a Kenyan, in dire need of medical care, was not left to die because he couldn’t afford it.
But more had before, and more would after, and Madaga’s slow death would fade into history.
Just as Kenya was wading through the socio-political crisis of late 2007-2008, the global economy was reeling from an apocalyptic event.
Although the global financial crisis began in the US in 2007, its effects properly spread in 2008 as banks and investors outside the US had also bet on the continued, uncontrolled, rise of its mortgages.
On September 15 of that year, the fourth largest investment bank in the US filed for bankruptcy.
The bank, Lehman Brothers, was a beast within the US financial system, meaning its collapse had a roar that was heard, and felt, across the world, particularly in Europe.
The crisis itself had been years in the making, and it would be the new US President Barack Obama’s main focus at home for a significant part of his first term.
Both the US and European countries not only studied the reasons their economies had facilitated the uncontrolled lending, and rule-bending, but also saved some institutions and made laws to prevent it from happening again.
For private equity (PE) firms, the years right before the crisis had been great. Lehman Brothers, for example, had raised $5.5 billion (Sh554 billion) for four of its private equity funds in weeks in mid-2007.
That era, especially between 2005 and 2007, has been called the “Age of the mega-buyout” and the “Private Equity Boom”.
Flush with money, or at least the promise that they could get it, PE firms bought 654 companies worth $375 billion (Sh37.8 trillion) in 2006 alone. Then it all came crashing down.
The global financial crisis that began in the mortgage markets before pulling down with nearly everyone involved, many of who were not directly involved with the physical homes, just their rising value, required a new paradigm.
The resulting changes to regulations, particularly in the US and Europe, made it a hostile environment for PE funds, at least those that wanted a ''laissez faire'' system of rules.
In Europe, for example, they could no longer launch hostile takeovers, and/or just strip the assets of firms they bought without following new legal structures on notification and disclosure.
This might look like a small change, but PE funds have a 10-year life cycle, meaning, they need to run fast, break things, build new ones, and exit at a profit to both themselves and their investors.
While this was happening in the West, Africa had crossed into the new millennium with the raw materials to be the next destination for PE funding and global attention.
In Kenya, systematic liberalisation that had begun in the 1980s was hastened, with the government selling part of its ownership in multiple sectors, including Kenya Airways, Safaricom, and other assets to private investors.
More often than not, the new buyers were European mega-firms. By the new millennium, whose beginning was Kenya’s most optimistic, several things happened.
One, the incredible rise of profitable companies such as Safaricom and the rapid expansion of Kenya Airways offered the idea that Kenya’s economy was the place to invest.
Most of this expansion was funded by private investors, eager to build on the optimism with which Kenyans spent the early to mid 2000s.
Two, after the 2007/8 elections, the new and expanded government tried to do its best to keep the economic pace going.
This fitted right into the “Africa Rising” narrative, at least among eager investors, because Kenya’s promise included further liberalising key cogs of the economy.
Private investment would, if the success of the country’s most profitable companies at the time was a pointer, not only solve critical social problems and gaps, but would make everyone incredibly rich. Key among the sectors now on the table was healthcare.
After I first shared the leaked screenshots from the Nairobi Women’s work group, hundreds of Kenyans on Twitter shared stories of similar events in just about every big, private, hospital of note in Kenya.
The stories sent in included unnecessary admissions, tests, procedures and medications.
Seen together, they describe a pipeline structure where a patient is seen as a customer, and the hospitals’ structures work together to make sure that when a patient walks through their doors, they pay up as much as possible.
“In 2014, I got constipated,” a former patient wrote. “I freaked out and went to Nairobi Women’s Hurlingham. Thank goodness I called my sister.”
The doctor who examined her, the former patient says, instilled the fear of the Lord in her by telling her she needed emergency surgery to close a minor cut that had resulted from her constipation.