THE HEALTH SECTOR IS THE GREATEST TRAGEDY IN POST INDEPENDENCE KENYA BUT WE COULD CHANGE IT TODAY

9th May 2011

Of the documented Kenyan disasters - the Wagalla massacre, the Sachangwan fire tragedy, the US embassy bombing, and yes the 2008 post election violence – none of these come close neither by magnitude nor by number of lives needlessly lost, individually or collectively, to the horrific tragedy that  is public healthcare provision. Thousands of Kenyans lose their lives every year for reasons that could be easily corrected if our health system worked better.

On Friday 6th May 2011, a patient passed away while in transit from Kiambu District hospital to Kenyatta National Hospital to receive dialysis. He worked in Busia DH and had gone to Kiambu to visit his parents. During this break he developed severe malaria and two days later he had developed acute kidney failure because of which he was referred to KNH for dialysis - this he never got. This patient was Dr. Henry Gatune Medical Officer Busia DH who finished internship last year and he died because Kiambu DH does not have dialysis facilities. No, let’s put that more accurately, he died because the only places in a country of 40million people and 47 counties that the government has bothered to put dialysis equipment are KNH, Moi Teaching and Referral Hospital, Coast General and Nakuru DH.

Acute kidney failure is often easily reversible. All one would have to do is dialyse the patients for the two weeks or so that the kidneys would be dysfunctional as the precipitating factors are dealt with, and they get back to perfect health - this young doctor who has literally saved lives couldn't get this. It also begs the question, if this is what happens to the doctor, what happens to the ordinary citizen patient? This incident, one of thousands, emphasizes the points the doctor’s union has been trying to highlight albeit to a deaf and uncaring government –

1. That public sector healthcare provision is a horrific tragedy and  

2. That doctors can’t even afford the healthcare they provide – not even when their lives depend on it (and the public so much less so). For instance, if Dr. Gatune had been in a position to afford treatment at the Karen Hospital he would have began dialysis in an hour latest. Better yet, if he were a more important or useful member of society, perhaps we would have flown him to America on day one, the sarcasm in this statement being deliberate. Instead, this government pays him just enough to seek treatment in Kiambu district hospital and KNH – both of which it has severely underfunded, underequipped and understaffed with poorly paid unmotivated staff. 

Yet this kind of needless death of young people is not an exceptional event. Sadly, it is the norm. In the last two weeks, this is the 3rd death of young and middle aged people I know personally who died for lack of effective healthcare services. In fact, hundreds of people die every month of conditions that would be perfectly treatable if our health systems were marginally better.

Kenya’s life expectancy of 57years makes her one of only 41 countries with life expectancies of  less than 60years and is ranked number 186 out of 221. Compare this to the violence laden Palestine lands of Gaza and the West bank at 73 and 74 years respectively, or Libya at 77years. How does it sound that you would be expected to live considerably longer in Eritrea(!) as compared to Kenya?

The problem has been that the health sector of all sectors has been neglected and treated with disregard, flippantly, and as an afterthought. This, tragically, has not changed. The universal order of priorities for humans is 1. Food 2. Good health. Everything else comes later. It is pointless to argue that one knows what he is doing in government or leadership when they do not have similar priorities. Similarly it is delusional to imagine that our leaders have our interests at heart when they demonstrate little or no regard for our lives – yes, food and health are life.

Only 10% of Kenya’s population can afford the better and meaningful care provided in private institutions that are almost exclusively in the three cities and perhaps three other major towns. As I write this, Kenya has less than 3000 doctors in public service. The WHO recommends that each country have a doctor for every 1000 citizens. This means that Kenya is in fact short of 37,000 doctors! There are only 300 specialists in Public service and most of these are in the capital city. The queues in our hospitals need not be that long and factually, most of these are to see clinical officers.

Cancer is a disease that needs to be diagnosed early and treated aggressively to give the patient a fair chance at survival. Diagnostic tools include MRI machines. This country of 40 million people has only one in KNH. Suppose one is lucky enough to be diagnosed, most are not, one of the treatment modalities is radiotherapy. The only radiotherapy machine catering for a population of forty million people is in KNH and it is so obsolete that it was last seen in the western countries two decades ago. The few who use it therefore suffer worse radiation effects for less medical advantages while they easily could do much better. Most die.

Kidney failure is a devastating disease especially if it is chronic. Fortunately, dialysis is so far advanced that one could live for decades as long as he has access to timely, appropriate dialysis. Acute kidney failure is very common, life threatening but often reversible as long as appropriate and timely dialysis is instituted, often for a short duration of time. These patients would then resume their normal lives and perhaps live to old age. Sadly, its absence, as was the case for Dr. Gatune, and I am sure many others this week and every week, would signify the end of life in a matter of days. About 4700 people need dialysis in the country today. Each person needs up to three sessions a week sometimes more. Each session lasts four hours on average. There are a total of fourteen dialysis machines (artificial kidneys) in KNH, but only about eleven are functional at any given time. There are an average of four functional machines at Coast General hospital, Nakuru PGH, and MTRH – that is it as far as our government is concerned. Apart from machines, one needs kidney specialists. The whole country has about twenty two. Most of these are in the private sector. There is one in each of the following towns: Eldoret, Nakuru and Mombasa. The rest are in Nairobi. One also needs dialysis nurses to operate these machines and suffice to say that these are so few that some hospitals have had machines donated but these remain in storage as they lack personnel to operate them. In addition, each dialysis session costs 5000 shillings which equals 60,000 Shillings monthly. With these severe shortages, the government last year stopped training specialists and in spite of the best efforts of people who know quite a lot more about healthcare, our politicians have refused to budge. Compare this situation to the world leader in inflation, Zimbabwe, or even war torn Southern Sudan. In both of these countries, dialysis is free and readily available.

For some reasons that may be as reversible and manageable as inadvertent poisoning, or convulsions or moderate trauma to the head (while some are less so such as severe strokes) people find their relatives in need of life support machines which are largely the artificial lung machines primarily in ICUs. Here also, the presence of this kind of equipment and the personnel to handle it makes a literal difference between life and death. In its presence, one could walk home in a few weeks, in its absence one could die in a matter of minutes. If our politicians knew that these conditions are often emergencies that rarely give people time to be flown to Nairobi, South Africa or America, if they realised that they themselves could easily suffer these emergencies while in their rural constituencies, they would hasten to equip their local hospitals with these necessary lifesaving facilities. As it stands, only KNH and MTRH have meaningful ICUs. Kenyatta’s has a capacity of thirty beds while MTRH has an eight bed ICU – for forty million Kenyans whose lives, for this reason, obviously mean nothing to their leaders.

There is probably nothing worse than a patient dying of correctable bleeding. My sister became a widow at 23 when her husband died of a bleeding ulcer. The sadness in all this is evident to any doctor who knows that all it would have taken was to open his abdomen, put a few stitches, add him some blood and he would have lived to die of a totally unrelated cause, but there was no theatre available for him.

The hospital in Bute serves one hundred and forty seven thousand people yet it has one doctor and five nurses. To have a simple haemogram done at the Mbita District hospital requires the sample to be transported to Sindu to be received two days later. The transport costs themselves are twice as expensive as the test itself, and the two days it takes is immeasurably longer than the 5 minutes it takes to do the actual test with even not so modern machines. Every day, relatives are given prescriptions to buy medicines elsewhere for relatives admitted in government hospitals despite having NHIF cover.

When we talk of raising the minimum wage to 7,607 in the urban areas, is any one aware that this is 7,607 more than half of the doctors in KNH who are specialists in training, with mouths to feed, children to educate and rent to pay,  earn for work done in KNH? Nearly 200 years after the abolition of slavery, and 56 years after Rosa Parks and Claudette Colvin refused to stand choosing freedom instead, self-sponsored registrars who constitute half of the 400 or so doctors in KNH, are forced to work long hours for no pay all this in the dishonest guise that the hospital is doing them a favour in their studies. The reverse is true. While these doctors pay full fees of about 214,000 per year, they do most of the surgeries, run most of the clinics and treat most of the patients. Contrast this with the Agha Khan University Hospital (and indeed almost anywhere else in the world) where not only are these doctors paid but they also don’t pay any fees. The truth is, registrars are some of the most important, knowledgeable and useful doctors in any institution lucky enough to have them. In KNH, they are all there is, save for a few consultants, interns, and limited contract medical officers.

Watching news while editing this article a few days after initially writing it, a local TV station showed a young girl who had missed school because of a massive cancerous growth on the right arm. More importantly, she was literally crying in pain with each slight movement. As a bare minimum – a lot more can be done and could have been done a long time ago with better facilities – Why must we accept this? If she were the daughter of a more important Kenyan...

These deficiencies are only a few selected examples of what is to be found in each and every speciality of medicine and institution in the public sector. Because of these deficiencies, hundreds, maybe thousands of people die every month needlessly. They may not be our relatives or always people known to us but they are other people’s mothers, fathers, children and siblings. Some of these are breadwinners and guardians and they are often voiceless. Whose problem is the noisy hornbill? If any Kenyan, because of medical insurance that will end when one retires (incidentally this happens to be the time health becomes a major issue) or when the current job ends, should think that it is the hornbill’s problem, it is only a matter of time before we find ourselves being the hornbill.

Three of the eight Millennium Development Goals are health related. This alone should serve as a not so subtle hint to any inadequately appraised National policy maker just how important health is. However, the question as to whether Kenya will achieve MDGs 4, 5 and 6 by the set target year 2015 does not need expensive conferences to arrive at the answer. We will achieve none of these goals for as long as the public health system remains close to what it is today.

A major part of this problem is that healthcare provision has neither been a priority for past governments nor is it one for our current one. To train the 97 specialists who had qualified to join public institutions but whose sponsorship was stopped for lack of funds would have cost 35million Shillings for the whole year. In one year, in spite of our best efforts, this has not been availed the main reason being budgetary constraints. Contrast this with the Vice president’s recent globetrotting. In the name of shuttle diplomacy, he and all those involved in the process spent as much as 100million shillings. Now, I can guarantee that the last year’s budget made no mention of shuttle missions, but in this situation clearly of greater importance to our government and Treasury than the health of forty million citizens, budgetary constraints was not a limitation to releasing money that would have been enough to train all the 97 doctors for the entire three year duration of their courses. This disorder in priorities is in part because, unlike in other countries, in Kenya, health is not an electoral issue. For example, in some countries, no one would dare reduce the budgetary allocation to health knowing that such action would guarantee that they would never be elected for anything more than the chief of an imaginary village – ever. Contrast this with Kenya where in the last budget which was itself of record size, the recurrent expenditure allocation to the ministry of medical services was reduced from 22billion in the preceding budget to 21billion.

In 2001, African governments, Kenya being among them, met in Abuja and committed to the allocation of 15% of their budgets to health. In the 2009/2010 budget, health allocation constituted 7.0%. In 2010/2011 budget, the health sector percentage allocation was reduced to 6.5%. Compare this to countries like Malawi, Burkina Faso, and would you imagine Rwanda among others, that have surpassed the 15% target.

The WHO recommends that each country budgets at least $40 (KSh 3,360) per person per year for health. This is a very modest figure given that the average per capita health expenditure in Europe and North America is $1,300 (KSh 109,200). While countries other African countries like Equatorial Guinea allocate $353 (KSh 29,652) per person to health, Kenya’s health budget amounts to $12.35 (KSh 1,037) per person! The two referral hospitals received 100 million shillings in total to go towards development while all the remaining curative health facilities in the whole country received a combined total of 100million! This same budget bore a 17% reduction in the curative services (medical treatments) sub-vote!

This gross and impunitus underfunding of the health sector is largely responsible for most of the ills in this sector. The other negatively significant factor is the retention of past regime era policy makers at the two ministries of health under whom this dilapidated health system has remained so for years - people who give advice that a country that needs fifty times the number of specialists it has can afford to stop training them – people who believe in oppression and suppression of dissenting voices through intimidation, sackings and illegal, unfair transfers and postings as happened in the case of Dr. A. K. Onyimbo among others.

That most of the population is poor and would not afford healthcare even if it was to be improved does not help much either.

There is no point in highlighting deficiencies without offering solutions. Fortunately, this sad situation need not continue. Today, we could rewrite the course of history and begin to reverse this costly manmade tragedy. We need to address some key components:

1) improving quality through the establishment of adequate high level health facilities, the purchase and commissioning of serviceable state of the art equipment in these facilities for the sake of all Kenyans, promoting improvement in the welfare of doctors, nurses clinical officers and other paramedics to voluntarily retain them in public service and in the most adverse regions, equipping the hospitals to provide meaning to the presence of the doctors and other specialists, and guaranteeing the availability of timely, appropriate and quality medication and

2) improving access to these much improved services through the establishment of a meaningful insurance scheme that guarantees all Kenyans medical services, but more importantly, an insurance scheme that works the way it was meant to when it was conceived.

WHAT WE CAN ACHIEVE IN ONE YEAR 

In just a year, we can transform the public health sector from, in the words of Public Service Minister Hon. Otieno, the shame that it is to an example of African success and victory. The key to doing is through prioritization of health by our politicians, either willingly which would be a rare sensibility or otherwise, improving budgetary allocation to health, repopulating health policymaking bodies with people with a track record of excellent performance rather than the current trend of employing the longest serving, line toeing loyalists, and very importantly to have a change in the mindset of the general populace from wherever it is now to appreciating the fact that healthcare provision is a right and that the public health sector could be as good as anywhere else on can think of.

We need to allocate 15% of our budget to health. Calculating using last year’s budget, this will amount to 148 billion shillings. As an example let us see what we could do with this money in the space of 1 year:

1) Build and equip 47 new hospitals, one in every county.

The new hospital that has been built in Eastlands Nairobi cost 800million to build and equip. Factoring in inflation, we can reasonably expect to build a new well equipped hospital in every county, at 1billion each for a total of 47billion. An additional 940million shillings would, by converting all these 47 new county hospitals into dialysis centres, increase the total number of dialysis centres from the current 4 to 51! Very importantly, the Dr. Gatune of next year and many others would live.

2) Employ more medical personnel and pay them better

The current wage bill for medical staff providing curative services on the ground is approximately 19billion per year. Investing 57billion more would allow us to employ twice as many doctors, nurses and paramedics, and pay them all twice as much!

3) Upgrade former provincial general hospitals to referral centres

At the cost of 700million per institution totalling 4.2Billion Shillings (MTRH and KNH excluded) each of these centres could receive an MRI machine, a CT scan machine, a modern radiotherapy machine and a host of other diagnostic and therapeutic equipment

4) Train more specialists and personnel

The cost of training the 97 doctors whose sponsorship was halted for lack of money was 35million per year. Fairly accurately assuming that there are on average four classes (388 specialists in training) per year, 280million would train twice as many doctors (776) per year!

5) Stock hospital pharmacies with appropriate medicines and establish an effective monitoring unit.

The current team charged with surveillance of medicines in circulation to weed out counterfeits is a joke. In today’s Kenya, counterfeits - which are look alikes of vital, life sustaining drugs that instead of the true curative agents contain medically inactive substances such as blackboard chalk - can be found in the shelves of many pharmacies. This improved funding will ensure that this team is better equipped, better staffed and is itself better monitored. Reforming KEMSA will go a long way in addressing the problems of medical supplies almost as much as improved funding.

6) End slavery

That the specialists in training at KNH and MTRH are forced to work for long hours for absolutely no pay is an unacceptable colonial era like relic that has no place in a civilized society.

The beautiful thing is that we will neither build county hospitals nor have such massive investments in equipment every year, meaning that the actual cost of maintaining such high standards will be much less than what we would use in the first year. In addition, many people are today willing to invest in a working health system; look at the free primary education project for example. The Appropriations in aid could be immense, yet even if none is availed, we would be able to do enough on our own.

Proposed NHIF changes and access to health

In isolation, the proposed NHIF changes would go a long way in improving access to health and should therefore be highly desirable. However, it is foolhardy to make such an exclusive assessment. Let us for the sake of explanation equate quality healthcare to a well full of clean, refreshing cold water in a desert. NHIF, meant to address issues of access, would be like a wide smooth, tarmac road leading to a well. If it is implemented with the current state of public health facilities unchanged, at the end of this beautiful tarmac road, one would find a dry well and perhaps at best and very occasionally dirty water. This would mean that despite having paid for the tarmac road, when one really needs water, he would have to get off it, use an expensive and rugged road to find acceptable water. I agree with the current minister of medical services that we need to start somewhere, but that somewhere has to be digging the well first and ensuring it has water, then building the roads leading to it. Should this happen, we should all do away with blindness and politics and support the proposals. Without these necessary changes, this pleasant sounding scheme is, in terms of effect, meaningless.

Our mindset as the public

At least three factors perhaps more are hindrances to better public healthcare quite attributable to the general public: Inadequate information about health, a lack of a sense of entitlement and a sense of ill advised comfort in the part of the few who are lucky enough to have medical insurance that guarantees access to the better private institutions.

The general public especially those in the rural areas remain very poorly informed on health matters. The result of this includes the following factors;

  • An inability to recognise deficiencies. How would one understand the significance of absent radiotherapy and dialysis machines when they don’t know what these are? How does one explain to the resident of Holugho the significance of an MRI when he does not even know what an x-ray is? Today the expectation remains that the doctor should just by seeing the patient, know exactly what is wrong and institute remedial treatment not knowing that there are crucial aids to diagnosis and treatment.
  • Inability to recognise and classify medical personnel appropriately. We still live in a society where all the males who wear white in health institution referred to as a doctor. In fact, it is quite possible that out of every six people referred to as doctors outside the cities only one is a legitimate doctor. Growing up in a rural area, our local doctor turned out to be someone who had worked for several years as sub-ordinate staff in a health institution. His medical prescriptions contained a large dose of pain killers – his fame needless to say rose. Recently, a caller on a radio show in which the doctor’s union was participating complained that the doctors in Makadara begin work past 11a.m. not knowing that there has never been a government doctor in that division and unless the changes we recommend are implemented there will be none in the next decade. It also explains the disparity between the high number of complaints of callous, uncaring “doctors” vis a vis the fact that such doctors are in fact a rarity and are by far exceptions.
  • A lack of understanding of diseases. Amazingly, in this era of free information, the number of learned people who still believe in only two diseases – malaria and typhoid -  remains amazingly high. It is why a patient with a brain tumour can be treated for malaria and typhoid for an entire month (definitely by the “doctors”) so that by the time they arrive at a meaningful facility with real doctors, they already have irreversible brain damage.
  • Misdirection of blame for the torrid state of affairs. The most blamed group of people for the pathetic state of medical care has been the medical staff especially doctors. These have been blamed for the long queues, lack of medicines, faulty equipment, detention of patients for non-payment of bills, and many other things not knowing that the doctors are in no way involved in the purchase of medicines or equipment, have nothing to do with public hospital bills, and that the long queues are mostly occasioned by a shortage of facilities which are themselves understaffed. The net result of this has been that the truly culpable people are spared from the blame they deserve and have more than earned and therefore continue to have peaceful nights, wake up, and continue to make nonchalant decisions that keep this mess a mess.
  • The other significant case of lack of knowledge is the group that have read a few paragraphs of a few parts of a few diseases and suddenly believe that they have learnt the practice of medicine. This is the group of people that will scream malpractice when a child is given Viagra not knowing that this drug was initially used for and remains one of the very few drugs available to treat life threatening pulmonary hypertension in children and it was when it was noted that these children developed pronounced penile tumescence that it acquired its rather more famous adult role.

I have to say this here; we have great doctors in our country. Every year, local doctors at the Mater and Karen hospitals do numerous open heart surgeries to correct complicated heart defects including in one child barely two weeks old. If we had any idea how tiny such a heart is we would appreciate how miraculous it is to close a hole in it and the baby lives. The Karen Hospital operates their cardiac unit in a manner that, in some aspects, rivals western units. When our colleagues leave for other countries with better systems, they immediately stand out for their excellence. There is a possible reason for this. The Kenyan education system is so skewed that those who become doctors were the brightest in our classes, themselves full of Kenyans who are some of the brightest people in the world, demonstrating great understanding and deep knowledge in both primary and secondary schools. These select few then spend five or six years often more in medical school studying medicine – if it were as easy as reading a web page or two, these medics could be done with their studies in months not years. I hope that this begins to explain why while it is not impossible, it is highly unlikely that one would know more about any given sector of medicine than his or her doctors, so let us trust our doctors. While there are indeed some cases of malpractice, a majority would take no less than a doctor to identify. It may be unwise to shout out how right we are when our view differs from that of the local doctor while at the same time it is congruent with the medical of opinion of the local matatu conductor. Medicine is simply not that simple.

We often blame ourselves whenever our loved ones suffer because the public institutions are not good enough while the private institutions are too expensive. It is important that all taxpaying citizens realise that it is the responsibility of government to provide affordable quality health to its citizens. We must therefore demand this. Similarly, when we choose who our leaders are through the vote, let us not vote for our tribesmen and parties, rather let us vote for our children and for our spouses and for our parents and for our brothers and sisters. Let us ask each candidate vying for whichever elected post, “What will you do for the health of my family?” and we should rest assured that anyone with an unsatisfactory response doesn’t have the slightest idea what it means to be a good leader, does not intend to be one and does not care the least about us or our families irrespective of their words, bribes, tribes, parties or social standing. A vote for such people would therefore be a betrayal of our children, our families and ourselves, a vote opting to remain poor and uncared for, a vote opting to perpetuate the needless deaths not realising that tomorrow it could be our own deaths. These are the kinds of demands that will thrust health into the faces of the politicians, into their priorities, and therefore directly translate into a better health system.

Yet a lot of us with insurance from our places of work and therefore access to private institutions couldn’t care less what happens in the public sector and are regrettably oblivious of the hornbill phenomenon – the story is told of the noisy hornbill crying of pain in the forest. When its neighbours were asked what the problem was, they replied with carelessness saying that hornbill’s problem was hornbill’s problem. None of them lived long enough to regret that decision because when the hunter, attracted by the incessant wailing of the bird, shot it down, he killed all the neighbours finding them fitting garnishes of hornbill soup. When these jobs end or retirement arrives, these insurance covers will evaporate. They are too expensive for us to afford individually. Incidentally this occurs in late middle age when expensive diseases begin to set in. Pretty soon, we discover that we are in fact the hornbill.  This is the hornbill phenomenon and it is inevitable. Let us therefore do something for today’s hornbills knowing that when we become them, we will reap the fruits of our basic wisdom today. 

The policymakers

We need to rid ourselves of the so called technocrats who have overseen this failure of a system both at Treasury and at the two Ministries of Health. Let us be honest and fair. Let us judge our trees by their fruits, and the fruit that is the public health system is at best horrific. It is illusionary to do the same things the same way with the same people and not expect the same outcome – I do not know who said this but it is rather obvious. Let us for once exercise the much needed responsibility in the public sector: the margin for error in healthcare provision is minimal.

To the two principals, is this dilapidated health system the legacy you would like to leave as a testimony of the impact of five to ten years of your leadership? I have alleged that your government is deaf, uncaring, and unmoved by the needless deaths of its people – as long as it is ordinary people. It would be my pleasure to be proven wrong.

To treasury and the parliamentary budget committee, you have the power to today put an end to this disaster and stake claim to the titles of true leaders. Health should only cede ground to food and nothing else.

To external partners and friends of Kenya, these are the issues our country is facing and while some are common to many countries, many are unique and require unique solutions. Let us tailor Kenya’s solutions to her needs and target our support to where it makes the most difference.

In conclusion, we are in a tragic place, but we have the choice and the power to make a change today. I suggest that for the sake of the families who will, if we choose to do nothing, continue to lose loved ones needlessly, for the sake of this country whose life expectancy, depending on our choice today, could remain in the 50s or rise by 10years, and in practice of what we preach, we do whatever it takes, pay whatever it costs to ensure that this kind of occurrence will not happen again in our country. Not while we live.

DR. VICTOR NG’ANI

Chairman, KMPDU

(Kenya Medical Practitioners, Pharmacists and Dentists Union)

This article was delivered to the President, Prime minister, ministers of finance, medical services and public health, the parliamentary budget and health committees as well as hons Ababu and Karua. History and our short experience however tell us that our government understands no other language apart from mass action. Neither the budget nor the health committee has honored the pledge to have us meet them. Let us wait and see what happens at the budget reading.



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