Hospitals crumble under weight of heavy expectations on lean budgets

On the shores of Indian Ocean, in Pate Island, Lamu County, is a genetic wonder: men and women with dark skin, but their eyes blue and have epicanthic folds, a signature look among East Asians. The people of the island speak Bajuni.

The stories they tell are not about how they ended up resembling the Chinese, but their struggle to get pregnant women across the ocean to the main referral hospital in the county, King Fahad Level 5 hospital.

Usually, this involves taking a speed boat from Mtangawanda, which would cost between Sh6,000 and Sh15,000 in certain occasions.

This was the trouble until the Health ministry renovated Faza Health Centre, a level three hospital that is closer to the people that can now offer caesarean operations, X-rays and some surgeries.

But, such rural and lower level hospitals are closing down at an alarming rate despite their importance. Their closure has been blamed on getting little or no support from the government yet they offer health services to two in every three Kenyans.

Little action

Data from the Kenya Medical Practitioners and Dentists Council sent to HealthyNation, but not yet publicly available, showed two in five of the shut hospitals (80 facilities) were in Nairobi, while 17 per cent (33) were in Coast. A total of 27 were in the former Eastern region, 26 in Rift Valley, 17 in Western and nine in Nyanza.

The facilities were closed between July 2018 to May 2019 for operating without a licence, lack of qualified personnel for the labs and pharmacy as well as nurse aides attending to patients instead of qualified nurses.

Other deficiencies that led to the closure included a lack of infection control mechanisms such as handwashing points and poor collection of medical waste.

The council’s chief executive officer Daniel Yumbya said the number of health centres that could have been closed this year doubled, but they were not closed.

“It is important that hospitals remain open during this pandemic, and so we supported them in areas where they were deficient instead of closing them,” he told HealthyNation.

That their closure has been met with little action from the government, casts doubt on the country’s commitment to Universal Health Coverage.

Open sewers

HealthyNation established that some hospitals, especially those run by faith-based organisations were almost closing due to financial pressure even though they serve all patients.

Ruben Health Centre in Mukuru slums is one of these. To reach the centre from any direction, one drives or walks through the slums, a sojourn that gives a peep at what could contribute to the illnesses of those who visit the health centre: the pungent smell of open sewers and uncollected garbage; jerricans of water on carts, a sign of water shortage.

Nurse and public health specialist Zipporah Mwangi, in charge of Ruben Health Centre, makes these trips every day.

Ruben Health Centre is the only one that the locals can afford before they are forced to snake their way around traffic to Kenyatta National Hospital, Mbagathi or Mama Lucy. Too many times, the patients forced to make that journey never survive as they are often pregnant women in need of urgent medical care.

Like many lower level hospitals, Ruben centre has borne its fair share of the brunt of Covid-19. In April at the peak of Covid-19, a patient collapsed at the gate. “The patients took off due to fear, and the healthcare workers also became afraid because they did not have adequate personal protective equipment,” Zipporah told HealthyNation.

Eventually, the hospital closed for a week because a health worker tested positive for Covid-19. The people who spoke to HealthyNation at the facility talked of the long arduous journey to Mama Lucy Hospital fto have their children vaccinated, and the pain of being in labour without money for a taxi to the nearest hospital.

Teenage girls

Millicent Kamau, the lead clinical officer in the facility, told HealthyNation the closure was particularly worrying because of the level of teenage girls who delivered in the facility. According to the hospital logs, on average, 103 women give birth monthly. Eleven per cent are teenagers as young as 13, whose management calls for more than clinical work.

“We follow up on young mothers after they leave the hospital to educate them on the need of and how to breastfeed, eat and immunisation,”  she said.

Failure to do so, she said, will result in malnutrition of the children and the mother, and in some cases, the death of the baby even before they are six months old.

According to the Health ministry, level 4 and 5 hospitals remain the main drivers of curative expenditure in Kenya, accounting for about 33 per cent of the total public health expenditure as they offer costly specialist services such as complex surgeries. They also experience higher patient flows.

Level 1 and 2 are community clinics and dispensaries, which offer outpatient and extremely critical preventive services such as vaccination and health education.

In 10 months in 2019, the medical board closed 192, all of which were dispensaries and health centres, the facilities that not only predominantly serve rural and poorer communities in Kenya, but also play the biggest role in preventive medicine such as vaccination.

It is not a walk in the park for private hospitals either. The National Health Insurance Fund (NHIF) has not accredited more than 3,000 lower-level hospitals in the past three years, despite being given the green light by the medical council and the Health ministry to do so.
In a letter to Health Cabinet Secretary Mutahi Kagwe, officials of the Kenya Associations of Private Hospitals, the Rural Private Hospitals Associations and Christian Health Association of Kenya demanded fairness in the process of NHIF accreditation..

“Patients in rural areas and informal settlements are sometimes unable to pay Sh3,000 for very crucial care. So, when they pay their premiums for NHIF, it is only fair that they are able to get medical services in the hospitals near them,” he said.

However, there is a renewed interest in Level 3 hospitals and this is why. Level 3 health centres and nursing homes are a sweet blend of curative and preventive medicine because they are not only fully involved in preventing the causes of diseases through immunisation, but they also offer surgeries such as like Caesarean operations.

They were established in 1970 as part of the Comprehensive Rural Health System which was instituted by the government to utilise primary health centres as points of promotive, preventive and partial curative services.

94 per cent

According to the hospitals master roll, there are 2,313 health centres in Kenya, representing 17 per cent of all the 13,790 facilities in the country. Combined with the 10,671 level 2 facilities, with which they work closely for preventive and promotive health services, they account for 94 per cent of all hospitals in Kenya. Yet they get the lowest budgetary allocation.

In 2015, the Commission for Revenue Allocation found that health centres served a catchment area of 30,000 people and required, at the bare minimum, Sh91 million per year with about 150 staff to run.

If they are lucky, these facilities get a tenth of that amount. For faith based hospitals such as Ruben, the government does not reimburse the money the facility uses to treat patients from public level 2 hospitals.

However, the past couple months have not been ordinary, forcing the government to rethink the strategy of these facilities, especially in urban areas which hold more than half of the country’s health facilities, but more than 60 of residents cannot afford treatment there.

Buoyed by the mantra ‘if patients won’t come to the hospital, the hospital will come to the patients’, Kagwe told HealthyNation the ministry and the Nairobi Metropolitan Services will construct 15 health centres, and nine level 2s in Nairobi slums.

Kagwe said they would pave the roads to the facilities to enable ease of access using ambulances. The CS said apart from the usual health services, the hospitals would help curb the spread of the virus.