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The sad story of our public healthcare and lack of innovation

Monday June 23 2014

By BITANGE NDEMO
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Kenyatta National Hospital is the oldest and largest referral Hospital in East Africa, with a bed capacity of 1,800 and more than 6,000 staff members. 

It was founded in 1901 as the Native Civil Hospital (later renamed King George VI Hospital in 1952, and after independence it became Kenyatta National Hospital), with the neighbouring Nairobi Hospital serving the Europeans.   

Sitting on 45.7 hectares of land, it has the most qualified doctors in the region, and houses the University of Nairobi’s School of Medicine. There are also several other government agencies located there. But it is sinking into despair and hopelessness in the jungle of neglect. 

The floors cry for a broom to wipe the piling dust. The walls are hungry for paint as patients’ relatives saunter around aimlessly. Patients lie yearning for more beddings in crowded wards. Others lie outside on the grass hoping that a bed will be found for urgent surgery. 

Sophia sits on a ledge outside the hospital with her face down. Her surgery to remove pre-cancerous fibroids will not happen until after nine months. She is worried it may turn into full-blown cancer before the remedy comes. This is unnecessary, because in modern days lack of finance is not an excuse any more. Underneath all the despair lies an opportunity to build a hospital that we can all take pride in. 

With a little ingenuity, we can turn the problems at Kenyatta into a great opportunity. Here is why. You may have missed a news item in one of the dailies on India’s Apollo Group of Hospitals in which they said that they receive patients from 120 countries. More than 152,000 cardiothoracic surgeries, 1,000 joint transplants and 13,000 kidney transplants are performed each year and 20 per cent of these procedures are done on Kenyans. 

AFFORDABLE HEALTHCARE SYSTEM

They also receive other patients with several different diseases like cancer and other conditions. The story is the same with other Indian hospitals. This proves that we have the numbers to build an affordable healthcare system for all, and more from the African continent.

India benefits from economies of scale and as such, a patient can have a full-body examination with all the scans, X-rays and endoscopies at a cost that will only pay for a single scan in Kenya. Fees for a single doctor in Kenya are enough to pay seven to eight consultants in India. In Kenya, investment on capital expenditure has pushed the healthcare cost to levels that more than 70 per cent of the population cannot afford. 

Within a single block, doctors invest in similar capital expenditure and charge for a procedure. What sense does it make to have ultrasound equipment in every doctor’s office when they are used only 10 per cent of time? There is no justification for hospitals investing in expensive diagnostic equipment when their core competence is in patient care. Such services should be outsourced within the hospital, and equipment manufacturers have been doing this globally.   

Some of the changes needed at Kenyatta National Hospital do not require money. What is needed more than anything is discipline among employees and the public, common sense, and the courage to take responsibility. 

POOR WORKING CONDITIONS

Maintenance here is a foreign word since only three of the eight lifts at the main nine-floor building are functional. This forces people to act aggressively as they try to get into the lifts. If you attempt to use the stairs, as I did, you find the entrances into the wards padlocked (God knows if there were to be a fire), forcing the hikers to look for the lift used by both patients and the public. 

On every floor, there is a patient needing to be moved elsewhere, once again forcing people out of the lift. It takes at least 30 minutes to move from the ground floor to the ninth floor when you are aggressive. It can take longer if you are gentlemanly. Common sense dictates that you separate patients from the general public by dedicating at least one lift for utility.

In general, the work environment and working conditions are not conducive, not just to the workers, but for the public too. These are some of the issues striking doctors and nurses were raising. In their words, they feared for their safety within a poor work environment and working conditions. Wikimedia confirms that there is such a thing as hospital-acquired infection, also known as a HAI, whose development is favoured by a hospital environment, and may be acquired by a patient during a hospital visit or may develop among hospital staff.

HAI is a serious matter. Wikimedia says in the United States, the Centers for Disease Control and Prevention estimated roughly 1.7 million hospital-associated infections, from all types of microorganisms (including bacteria) combined, cause or contribute to 99,000 deaths each year.

PARTNERSHIPS WITH PRIVATE SECTOR

In Europe, where hospital surveys have been conducted, the category of Gram-negative infections is estimated to account for two-thirds of the 25,000 deaths each year. We complicate matters when the hospital environment is not clean. Yet there is water and people employed to do the same, with so many unemployed people who can do the cleaning. It is simply inexcusable to risk the lives of so many people.

It is possible to partner with the private sector to build more ward facilities for patients who can afford to raise enough money to subsidize those who cannot afford the care. There is a glaring opportunity to leverage technology to improve workflow within the hospital. This will free up the doctors to concentrate on their core activities. There should be a call centre manned by a general physician to screen patients, direct them to appropriate locations and leave only referral cases to consultants. A 2012 study on the workflow changes revealed that the hospital could save as much as 40 per cent of the healthcare cost. 

Since more than 80 per cent emergency room cases are accident-related, there is need to create trauma centers at strategic locations, such as Mombasa, Muranga, Waiyaki and Limuru roads and train first responders. The same can be used for other emergencies, with complex cases being referred to Kenyatta. This is what will free up Kenyatta Hospital to undertake its core mandate and ease the congestion. To finance such changes, we need legislation to force insurers to pay for the cost of caring for accident victims upfront. 

INCUBATE START-UPS

There is need to leverage the university students as labour to create industrial production of some of the bulky essential materials, such as infusions, which cost more in transportation than the content. Most universities globally incubate start-ups that eventually become big companies that boost university endowment funds. Sections of Kenyatta National Hospitals should be used to set up these incubators. They can even start with the manufacture of generic drugs that we now import from India. 

Chances are that when the students graduate, they will replicate what they have learnt and create jobs. It is inexcusable to have knowledge, labour and resources and become a net importer of generic drugs. Without making the generics, we may never have the confidence to innovate new drugs.

The story of our healthcare is similar throughout the country, but we now have the opportunity to correct at least one facility that can become the centre of excellence for others to follow. It requires a county government that can take the risk to build a public-private partnership around equipment and capacity building. 

On equipment, you do not even have to lease it, as it is not a core competence for the hospital. It is possible to rent space to equipment manufacturers and give them targets on pricing and number of patients. After sometime, and as throughput improves, the price will significantly drop to the extent that the majority of Kenyans will begin to afford healthcare. We did it in the telecommunications sector and it can be done in the healthcare sector too.

William Pollard said, “Without change there is no innovation, creativity, or incentive for improvement. Those who initiate change will have a better opportunity to manage the change that is inevitable.” 

Let’s change things so the poor can afford healthcare.

Dr Ndemo is a Senior Lecturer at the University of Nairobi, Business School, Lower Kabete Campus. He is a former Permanent Secretary, Ministry of Information and Communication. Twitter:@bantigito