A decade of mixed fortunes for healthcare system

Perhaps we should celebrate the promulgation of the Constitution as the enabler that set up 2011-2020 as a decade of hope for Kenya. For healthcare, it has been a mixed bag of fortunes.

1. Formation of doctors’ union

The decade began with the formation of the doctor’s union in 2011 after years of failed attempts. The ease of having essential service providers belong to a trade union, though unfathomable to others was a right enshrined in the Constitution. As fate would have it, doctors drew first blood as soon as they had the chance. It came in the form of the 2011 doctors’ strike dubbed Linda Afya 1. A lot of the things working in the public sector can be indirectly linked to the lobbying the union has done for her members. There is a lot of health advocacy going on in health courtesy of the doctors’ union.

2. Devolution of health and the descent into chaos

It still remains a hot potato in the country. Kenyans, including doctors, remain divided on whether devolution of health was the right thing. There are county governments that hit the ground running and have brought health services closer to their people. There are others that moved their health services out of the frying pan into the fire. The one area on which most people seem to have a consensus is having human resources for health managed from a centralised body at the national level. The devolution of health was hurriedly done despite the existence of the relevant schedule. The other ugly side is the political influence that came along. Every other MCA wants to tell the medical superintendent what to do just because the hospital is domiciled in his ward. The haemorrhaging of doctors to foreign countries and the private sector that seemed to have been checked by the gains of the 2011 doctors’ strike is roaring back. Our doctors are preferring the private sector to the public sector. The net result is exposing an already stretched public health system.

3. The World Health Assembly Resolution  68.15

Those of us in surgery have famously likened surgery to the neglected step child of the global public health. It is so because surgery has suffered neglect in funding and policy fronts. Even where evidence has showed injury (a small branch of surgery) to contribute to death and disability more that Aids, TB and malaria combined, it has remained in the periphery. It was against this backdrop that Zambian delegates led by a surgeon and diplomat, Dr Emmanuel Makasa, successfully lobbied other health delegates to adopt the resolution WHA 68.15 during the World Health Assembly in 2015. The resolution recognised essential surgery, obstetric and anaesthesia care as core components of primary health care. It has been less than five years now since the resolution and there is great movement from various health players to ensure this. It is sorry that the launch of the Kenyan National Surgery, Obstetric, Trauma and Anaesthesia strategy did not get the expected grand launch. I hope the Cabinet Secretary will fish out that document and re-focus his energy in launching it and effecting the strategy. As Prof Meara writes: “We do not need a moon shot. We need a functional infrastructure, a trained work force, supplies that arrive on time and processes necessary to assure a mother is saved from postpartum haemorrhage, a child from a perforated appendix or her father from a broken thigh bone.”

4. The 100-day strike (2016/17)

We were not used to this. But we saw it as doctors staged street demos and court appearances. Their leaders were jailed, then released. The stage shifted from boardrooms to streets, courts then prison cells, back to the streets and television studios. It finally ended where it had all began- the boardroom. Was the 100 days worth it? How do you sustain hospital closure for 100 days? It was such a debacle it got published in the World Health Journal. We hope that we never get to such a level in future. Was the strike a union success or a failure in goodwill, leadership and consensus? You be the judge.

5. Cholera outbreak in a city hotel

Have you ever suffered from a sore toe? One that keeps coming back?  Sometimes because you wore a tight shoe, or just because you hit your foot on the door frame? This has been our dalliance with communicable diseases. When we go for a long spell without one, we celebrate that we have finally got our act together. Then, whether because of letting down the guard or some other reason, another outbreak occurs and we are in the news for the wrong reason. Cholera has treated us like this in the past. The 2017 outbreak in a city hotel was special in two ways. First, it affected healthcare staff who had congregated there for a conference. It was hitting us where it hurt most. Secondly, even when all the tell-tale signs spoke to the unmistakable nature of the diagnosis, health authorities denied the diagnosis. It was not until July 2019, two years later, that the ministry confirmed that indeed the outbreak was cholera. It should not take that long to establish a diagnosis.

6. The UHC pilot

Universal Health Coverage became one among the top four agenda of the President upon his re-election in 2017. It was a welcome gesture for me as a medic to have something relating to health at the apex of the political administration. We all welcomed the pilot in Machakos, Nyeri, Isiolo and Kisumu counties each of which was chosen because of a specific target health challenge. As a surgeon, I rejoiced at the recognition of trauma as a health burden and hence the inclusion of Machakos as a pilot county. The confusion that marred the place of NHIF in the grand scheme of funding was the Achilles heel. Patients defaulted their NHIF premiums and brandished the UHC cards. It was free care. And that was the catch. People do not value what is free. It is better to pay something affordable and get more than they have bargained for. That way they will value it. I am sure the policy experts concerned have gained a great deal of experience from the pilot and I still hope we can roll out universal health coverage for all the counties successfully.

7. The Cuban doctors

Doctors were up in arms again when they heard the government was to bring foreign doctors to lend a hand where we had a sizeable number of unemployed local doctors. The salary scale shared with the public was obnoxious so much so that one Kenyan doctor went to court. The court of course ruled in the government’s favour citing public interest. There were mixed reviews from those who work with the Cubans. There could be more that we do not know about the deal. Could this example herald a future of exchanges of other professionals by the government without regarding the existence of equally qualified Kenyans? Only time will tell.

8. Wrong patient surgery and death of Walibora

These events of 2018 and 2020 show a challenge in dealing with trauma patients. The news of a trauma patients undergoing unneeded surgery due to identification problems took the country by surprise. It was the case of a patient who could not speak, therefore could not identify himself. Many such cases occur on a typical busy day in a referral facility. The case very well raised a goldmine for system improvement. In my view, a computer-generated code would sort out the problem. Ensuring that every unknown person would have a different identifier. Ken Walibora did not suffer the fortune of getting brain surgery, whether wrong or not. Having been taken to hospital by a police ambulance from downtown Nairobi, it was too late.
His case speaks of how far we still have to go as a country in establishing a well-functioning ambulance system. A proper ambulance system should be able to make calls to all the hospitals with surgeons within a certain kilometre radius and determine where the patient can be operated from. All we know is Kenyatta National Hospital even when it is full to capacity.

9. The Beyond Zero Campaign

Launched by the First Lady, this charity initiative got very good reviews. The initiative is a wake-up call for those of us privileged enough to reach out and give. And there are many who can do that. There are so many others who are endowed and can give in their own special ways towards a course. If a million people in Kenya ran some charity in their own small ways, we would bequeath our country a crop of givers and carers in the next generation. And we are in dire need of that.

10. The pandemic that united the world, in doom

It finally landed on Kenyan soil on March 13, 2020. Its name is Covid-19. It has turned everything upside down. As we hope for a solution through a vaccine, I hope we can learn lessons on letting go of some unnecessary pleasures and observing health precautions even when there is no life and death moment. At least we can start the new decade on a premise that with internet, you do not need to travel. Remote working is here. And that malls and restaurants can provide handwashing and temperature check gadgets for their customers.