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.
Confused and scared, it was her sister who told the doctor they would go home and think about it.
“So I went to another doctor and he told me to sit in salt water and that it’s normal. I healed in five days.”
The procedure alone, which would have been unnecessary, would have cost her Sh120,000.
“Nairobi Women’s Hospital diagnosed me with fibroids and put me on medication, even recommended surgery. When I sought a second opinion I found out I don’t have them,” another said in a text.
“They even told me I had ovarian cysts and admitted me for two weeks just to get money from me,” she added.
Another man who took his nephew to Aga Khan Hospital’s Ruaka branch after the boy complained of headaches, fatigue, and general lethargy was told “he needs a CT scan”.
“I was immediately shocked and asked her what happened to procedural vital diagnosis including some basic lab tests,” the concerned uncle wrote.
After being given a list of planned lab tests, which would have cost Sh14,000, he paid for consultation and sought help elsewhere.
PRICE OF MEDICINE
The cause of the boy’s illness, the second doctor figured out, was a bacterial infection. Tests and treatment cost just Sh4,000.
“I once ended up spending 20k on tests in Nairobi Hospital simply because I was covered,” the same man wrote. “They don’t recommend unnecessary tests if you are paying from your pocket.”
Another uncle who took his nephew to Nyali Children’s Hospital in 2017 says that after paying Sh6,000 for consultation and a blood test, the doctor told him the boy had poison in his blood and needed immediate admission.
But first, he had to pay Sh45,000 before admission. When the uncle called one of his siblings to get money, he was told to take him to a public health facility.
“We queued but eventually we got to see the doctor,” he narrated. “He just put him on a nebuliser and prescribed antihistamines of Sh150 and we were good to leave.”
A woman who once worked in health insurance wrote that “hospitals even have targets for lab teams and pharmacy. The average cost of care at Nairobi Hospital for treating a flu, for example, is 7,000 bob.”
To close the gap, hospital staff recommend multiple tests, and then overdose patients by prescribing more medicine than necessary.
Many patients also described realising that the price of medicine from private hospitals’ pharmacies was incredibly high compared to other pharmacies and chemists.
But it is not even as easy as hospitals seeking to drain money from unsuspecting patients.
In some cases, they are willing partners in what appears to be other social, and psychological issues.
“My mum is a narc parent. Meaning she will seek admission at any time for attention,” a personal friend of mine wrote in a private message.
“Nairobi Women’s LOVE HER because she goes and never fights admission.” Every time she goes to the hospital, “they keep her on even going as far as giving her oxygen from tanks for her asthma, when it is easily solvable with a single injection and inhaler.”
Then, as the conversation spread to medical professionals, many wrote, saying that the problems patients face are because the system is broken.
Several said getting hired in public healthcare is a precarious game that involves bribes (of around Sh300,000), and employment can still be revoked if you’re not from the specific county, or the communities that live within it.
Young medical professionals, a doctor wrote, have no choice but to follow whatever corporate culture they find when they get a job.
“The government does not post us after internship anymore,” she said. “This means we tarmac and look for jobs, and we’ve no choice.” “Beggars are not choosers,” she adds.
The pressure to meet financial targets, she added, is placed on doctors who eventually do get employed because the hospital is a business.
“Medical students are trained in public hospitals,” another says, “so we’re taught to diagnose based on clinical acumen and not many tests because common mwananchi cannot afford and they deserve to be treated regardless.”
In the June 24, 2018 issue of the Business Daily, Anzetse Were wrote that the Africa rising narrative “was not us or our intelligence; it was population growth”.
“Lots of economic growth, growing middle class, maybe we can make money here after all,” it said.
Were said of her first thoughts when she heard of it. She added: “The subtle nature of this narrative, clothed in complimentary language, actually erases the agency of Africans in the growth of the continent.”
The points Were raised are clearest in Kenyan private healthcare, and the larger healthcare sector.
As part of the race to Vision 2030, the blueprint of the Kibaki-Odinga run post-2007 government, the government was going to progressively quit the healthcare sector and let the private sector thrive.
This meant looking for, allowing, and facilitating as many investors as wanted to invest in private healthcare.
PRIVATE HOSPITALS RISE
According to the latest economic survey, public healthcare system levels three-six have reduced significantly since 2014.
In 2014, for example, there were 394 public hospitals between levels four and six. By 2018, there 342.
Meanwhile, private hospitals have been growing exponentially, as millions of dollars have flowed into the sector since the late 2000s.
In 2014, there were only 168 private hospitals between levels four and six. By 2018, there were 313.
The growth has been even higher in level three, where the number of privately-owned health facilities nearly doubled — even with a slight dip in 2015 — more than doubled from 246 in 2014 to 574 in 2018.
This situation, where the public healthcare sector is receding while the private healthcare one is growing fast, is not accidental. It was, in fact, the plan all along.
A 2010 World Bank paper, which described Kenya’s private sector as “one of the most developed and dynamic in sub-Saharan Africa”, also noted that both Vision 2030 and Ministry of Health (then divided into two), planned to reduce the government’s role in providing healthcare.
“Some of the key features of those plans include social health insurance to increase access to healthcare, a reduced role for the Ministry of Health in service delivery, more delegation of authority to provincial and district levels, and promoting more public-private partnerships (PPPs)”, the researchers wrote.
What this meant was that whoever could afford to buy or start a private hospital in the country would not only have government support, but would also benefit from all the perks offered to international investors.
The Bretton Woods institution itself was not a neutral observer in this future, which is now our present.
Through its private equity fund, the International Finance Corporation, the World Bank is a direct player, and part owner, of several private healthcare facilities in the country.
It owns them both directly, according to a list on its website going back to 2000 and that mostly includes non-healthcare companies, or through other funds.
The Dutch-based PE firm, Investment Fund for Health in Africa (IFHA), not only counts the IFC as one of its investors, but also the Big Pharma company Pfizer, as well as Africa Development Bank and European Investment Bank.
By replicating this complicated structure, the World Bank, pharmaceuticals, and other global financiers effectively own a large chunk of the private healthcare sector in Kenya.
IFHA, for example, owns part of AAR Group, and CarePay Limited, the company that built M-Tiba.
It first invested $750 million in 2010 to buy a fifth of AAR Group; three years later, World Bank’s IFC directly bought its own stake for 340 million, of which its PE fund (IFHA) also bought another chunk.
Like many other similar structures, AAR has been on a massive expansion drive as a direct result.
To save costs on investing taxes in healthcare, amidst several corruption scandals and unanswered audit queries going back years, the Ministry of Health has encouraged private hospital funding and expansion.
Just last October, Health Cabinet Secretary Sicily Kariuki told an EAC gathering that Kenya is still open for more private healthcare providers.
“We recognise that our health systems are closely interlinked and the only way is to strengthen our governance systems for the health sector to realise efficiency and value for money,” she said.
“The healthcare [sector] is set to grow USD 65 billion & Kenya is open to private sector investment in healthcare,” Ms Kariuki said a month later at a diaspora event.
While investment in healthcare is a good thing, no one seems to be working to ensure that patients get affordable, necessary (and only necessary) care.
Instead, private hospitals have built their own ways of working, which are often about getting as much money as they can from each person who walks through their doors.
With corporate pressure to meet revenue targets, and the hospital as first a business before anything else, managers push clinical staff to do unethical and unsavoury things like admitting patients for whom a simple injection and good wishes would have been enough.
While Madaga lay dying in an ambulance, the system that should have huddled to save his life did not fail.
It worked exactly as it had been built, to see him not as a patient in need of critical care, but as a customer who did not have money to pay for the service of helping him.
He died on an ICU bed that was offered to him when, in retrospect, the damage was already done.
And not even on those long dark hours in October 2015, but long long before.
There have been many Madagas in Kenya, denied their human and constitutional rights to have a healthcare system that is pro-people before anything else. Something needs to give.