A distraught health worker in a sub-county hospital in Siaya County narrated to a colleague an incident where he requested for an ambulance from the county referral hospital for a child he had operated on and the matter had deteriorated. When the ambulance came, it did not have oxygen, the very thing that the baby needed to survive until it reached the more equipped Level 5 hospital. Expectedly and tragically, the baby died minutes later.
These are common stories among gagged healthcare workers.
A study of 24 hospitals in Kenya found that children deaths in hospitals seven days after surgery are 200 times more than in the developed world. This is caused by lack of basic surgery equipment and an acute shortage of paediatric surgeons and anaesthesia.
A spot check conducted by the Sunday Nation in children’s wards in 13 lower level facilities in Embakasi and Lang'ata in Nairobi County and K’ombewa in Kisumu County, revealed not only a lack of crucial equipment such as surgery lights, but also burnout among health workers.
The study published in the Anesthesiology journal showed that 0.8 per cent of the children died 24 hours, 1.1 per cent died in 48 hours, and another 1.7 per cent died seven days after surgery. These figures may look negligible, until they are calculated against the number of surgeries that hospitals conduct in just 24 hours, let alone a week or a year.
Referral facilities such as Kenyatta National Hospital (KNH), which take the severest cases from within and from other facilities, conduct as many as 200 surgeries a day. The World Health Organisation (WHO) estimates that children account for an average of 10 per cent of hospital admissions for surgery. Therefore, for public hospitals with the traffic of KNH, there are more than 2,000 paediatric medical operations in just one hospital in a year.
The researchers – Prof Zipporah Ngumi and Prof Susane Nabulindo from the University of Nairobi and KNH, and lead author Prof Mark Newtown from Kijabe Hospital — also showed that about 4 per cent of the mortality occurred in primary hospitals. These are health centres and dispensaries, the bulk of which are usually the first point of contact most patients have with the health system. The majority end up receiving all the care there.
The deaths were fewer in secondary and tertiary facilities, which are obviously better equipped and staffed.
Prof Newton said they attributed the high mortality to a number of factors, many of which continually point to the entrenched inequity in the health system.
The professor of anaesthesiology expressed immense concern over the lack of trained paediatric surgeons and anaesthesiology experts in Kenya, and even more so in lower-level health facilities.
“Due to the size of the children, medical equipment such oxygen monitors have to be specifically designed for them and the same applies to the specialists,” he said.
Infection control was also found to be poor, with very few of the hospitals using a safe surgery checklist that would ensure those participating in the surgery are properly clad.
Infections kill tens of thousands of children categorised as severely sick, such as those born prematurely and have to be kept in the newborn unit.
Prof Newton spoke to the Sunday Nation barely a week after the Kenya Health Facility Assessment conducted by the Ministry of Health revealed that a meagre one in five facilities (24 per cent) of all the health facilities in Kenya have all the equipment required to offer health services. Another 77 per cent have basic equipment such as thermometers, adult and child scales and a source of light. Also, none of the health facilities in Kenya have all of the WHO’s essential medicines.
Primary healthcare units were the most affected, with only 17 per cent of them having basic equipment, while 50 per cent of secondary and tertiary facilities had all the equipment. The study found that facilities in urban areas were more equipped (30 per cent) than those in rural areas (19 per cent) even though over 70 per cent of Kenyans live in rural areas. Only 17 per cent of government facilities had all the basic equipment as compared to a third (31 per cent) of private hospitals.
Besides the equipment, there is need to improve the “hardware” components of care. Prof Newton’s study raises the question of healthcare workers whose function the government has given to less qualified healthcare workers.
Kenya is already suffering from a chronic shortage of healthcare workers – 10 qualified medical personnel per 10,000 people against the recommended 22:10,000 – but there are even fewer neonatal paediatricians, nurses and anaesthetists. In the face of shortage of trained personnel, others that are present take up duties they are not trained to do.
Another study from the same research institute found that 20 per cent of the time, nurses overprescribed the antibiotic Gentamicin, which is toxic to babies’ kidneys.
It was noted that while there are around 50,000 nurses registered to practice in Kenya, fewer than 17,000 offer services in the public sector, which the poor rely on the most for inpatient newborn care.
In a study analysing how nurses for neonates (babies under one month old), Kenya Medical Research Institute (KEMRI)-Wellcome Trust researcher Jecinta Nzinga found that while international standards required that even in cases where babies do not require intensive care, there should be one nurse for every two to four sick babies.
In Kenya, Dr Nzinga observed, two to four nurses took care of between 20 and 40 sick babies, which is 10 times higher than in countries such as the United Kingdom. In night shifts, there were as few as one or two nurses looking after as many as 40 children.
The neonatal period contributes nearly 45 per cent of the deaths of children under five. Kenya’s child mortality currently stands at 22 deaths per 1,000 live births. According to exclusive data from the national health records in the Sunday Nation’s possession, Kenya loses about 850 children every month.
Neonates are very delicate and need extremely specialised care. In a previous interview with this reporter on this subject, Rachel Musoke, a professor of neonatal health at the University of Nairobi’s paediatric department, said neonates cannot regulate their own body temperature.
This is why they are kept in incubators that keep the temperature and humidity within survival range. For this reason, they lose all the water through the skin and can easily die of dehydration. They are also often fed through a pipe.
Cleanliness standards must also be high as neonates pick up diseases pretty fast. The babies also “forget to breathe” because their brains are not fully developed to co-ordinate these functions. They turn blue, start foaming and a nurse has to be there at that very moment to “remind them to breathe”.
“They are stimulated by touching, and sometimes resuscitated if they do not remember to breathe,” explained Prof Musoke.
Dr Nzinga noted in her research that to cope with the workload, neonatal nurses delegate some duties, like feeding the babies using tubes, to mothers, and cleaning the incubators to cleaners. This delegation, especially on feeding, may lead to deaths.
In feeding the babies, the milk is sucked using a syringe and injected into the tube in drops. Gravity then takes it down the baby’s throat. Some mothers, especially young ones, get tired and force the liquid down the tube to speed up the process. The baby ends up choking, and if a nurse is not around, it dies.