Our healthcare is sinking - and we are drowning

Now that the dust is settling over the major distractions being orchestrated by our Parliament, is it time to get back to what really matters? Our healthcare is falling apart and we don’t seem to be able to stem the tide. 

In reference to the World Health Organization’s (WHO) ‘Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies’, a health system consists of all the organisations, institutions, resources and people whose primary purpose is to improve health. This means delivering preventive, promotive, curative and rehabilitative interventions delivered through both public health actions and healthcare facilities that provide personal health by state and non-state actors. 

The WHO guides that the actions of the health system should be responsive and financially fair, while treating people respectably. A functional health system needs a working service delivery system; a skilled health workforce; an effective health information system; access to essential medicines; adequate financing; and an effective leadership and governance structure. 

The goal of a functional health system is to achieve improved health outcomes for all; responsiveness; social and financial risk protection; and improved efficiency. This is achieved through improving access, coverage, safety and quality. 

When a country leadership speaks of achieving healthcare for all, I imagine that all the above parameters are up for consideration. Overall health systems strengthening means addressing the key challenges afflicting each and every pillar progressively to achieve the desired goals. 

So, where are we as a country? Let us look at it pillar by pillar. With regard to service delivery, our biggest challenge has been maintaining standards. The service delivery variance between multiple health facilities is too big to assure quality healthcare for all. Why is this the case? While the Ministry of Health (MoH) provides guidelines and standards for service delivery, it seems to focus on standards guided by the most affordable options, not necessarily the best available ones. 

This creates an immediate discrepancy, categorising patients into those who cannot afford better; and those who can. The automatic response is that private health facilities then disregard these guidelines because they do not speak to their circumstances. 

An example of this would be care of women with miscarriages, where MoH provides for manual vacuum aspiration under local anaesthesia, disregarding sedation anaesthesia as an option that is more comfortable and less traumatic to the women. For private hospital care, the patient is offered sedation as routine, yet this is not captured as an option in the MoH guidelines. 

To standardise care, guidelines must speak to all facilities equally. Otherwise, service delivery in public health facilities will continue to be regarded as inferior, even when this is not always the case. Further, MoH has consistently ignored the development of guidelines that speak to key features of patient comfort. The matter of patients sharing beds, congested wards, lack of privacy for the patients, dirty and unmaintained toilets and showers, the dismal food served, and patient feedback mechanisms. The assumption is that the patients patronising public health facilities are too poor to complain; an absolute failure to uphold patient rights. 

The government’s idea of a skilled workforce seems to be churning out large numbers of health workers from universities and colleges mushrooming everywhere across the country without a proper plan of their future absorption and staff establishment. The one MoH policy that has completely failed in implementation is the staffing norms. 

The focus seems to be on setting up technical committees to make recommendations that are never implemented; yet there is a whole body in place to address this - the Kenya Human Resource Advisory Council (KHRAC). This cannot be. All the relevant sectors must sit and address this issue. We must strengthen the quality of pre-service training so as to produce health workers of unparalleled quality. We have lost this, and it is going to cost us. We must ensure the internship training policies programmes are not threatened as they are a quality assurance step in producing a skilled health workforce. 

The lack of quality data is a stumbling block to decision-making in any sector. Our health information system must be strengthened and made accessible to all decision-makers, whether in the public sector or the private one, because all of them do contribute to the health system. The data collected must address the information needed; hence a routine review of the system by all players is essential to ensure data capture makes sense. 

In the past year, we have had an exodus of multinational pharmaceutical industries from Kenya. Many have cited the difficulty in doing business as a key challenge. Unfortunately, this is happening against a background of failure to expand local manufacturing of essential medicines, biologicals and other essential non-pharmaceutical products and technologies necessary for healthcare. This means we shall keep importing these products at prices we have no control over, creating a handicap and strengthening a key pillar in delivery of healthcare. 

The only factor the government seems to be focusing on is the health financing pillar. The challenge here is the failure to demonstrate how the other pillars are being appropriately supported so that the health financing pillar plugs into a functional system. 

It is absolute double-speak for the government to tell its hardworking citizens to commit 2.75 per cent of their earnings to funding healthcare, and then ask the same citizenry to ask their employer to further spend an equivalent sum to provide them additional private insurance. What this tells us is that government has no intention of improving the quality of care in our public health facilities to standards that we as a people feel comfortable with! 

One key conflict of interest that is not being addressed is the fact that the Social Health Authority is the one responsible for determining what the care packages are supposed to look like, for purposes of costing. The payer cannot get to determine what treatment the patient needs. This must be done by an independent body comprising health professionals. 

This body should determine what the quality standard of care for a condition looks like, based on evidence; and then derive the protocols that are then used to determine the tariffs. The payer will always go for the cheapest option, which may not be the most effective. For this reason, the provision that the Cabinet Secretary has the leeway to revise the tariffs is in itself inappropriate. 

The component in health systems strengthening that has inadvertently suffered the greatest drawback for years is the leadership and governance pillar. The greatest difficulty in healthcare is that the most important decisions regarding healthcare are made by persons with no commitment to the sector. 

The health sector is a service industry. It is not a profit-making industry. Until the mindset of our executive and political decision-makers changes regarding the importance of the health sector, they will continue to use this highly important sector as a political bargaining-chip with the electorate, instead of understanding that it is the foundation for economic development for any country!

Dr Bosire is a gynaecologist/ obstetrician