Why Striking Doctors Are The Least Of Kenya's Health Problems

This week, the news has understandably been dominated by the countrywide strike by the nation’s health workers. On Monday, doctors and nurses across the land stayed at home in protest at the government’s failure to implement a collective bargaining agreement signed in 2013 that was meant to govern their pay and conditions of service. The strike has thrown an already rickety health system into chaos and contributed to the deaths of several patients and heartbreaking scenes of desperate suffering at health centres.

It is not the first time public health workers have walked off the job. In recent years, the health sector has been plagued by strikes. In December 2011, hundreds of doctors marched through Nairobi streets to demand a larger stock of drugs in hospitals, better equipment and better pay. Three months later, in March 2012, and again in September 2012, they again laid down their tools to demand government spend more money on health services. Similar strikes followed in December 2013, August 2014 and August 2015.

Throughout, the main focus of media reporting has been on the demands for better pay. Little attention has been paid to the complaints over working conditions and the terrible state of the health system in general. Yet the situation is dire despite, total per capita expenditure on health (both public and private) doubling between 2010 and 2014 and government share of that spending growing from 36% to 61% in that period. Kenyans and their government are increasingly spending more on healthcare. So what have we got to show for our money?

The short answer is: not very much. As I noted more than two years ago, according to the 2013 Kenya Service Availability and Readiness Assessment Mapping report, the country’s first attempt to get a comprehensive picture of the health sector, less than 6 in 10 of all health facilities in the country are ready to provide the Kenya Essential Package for Health –a sort of standardized comprehensive package of health services. Less than half have basic amenities and while two-thirds have half the basic equipment required, 59% do not have essential medicines. Only 2% of facilities are providing all KEPH services required to eliminate communicable diseases.

Further, as reported by The Star last year, the WHO Global Atlas of Health Workforce identifies Kenya as having a “critical shortage” of healthcare workers since independence. While the World Health Organization has set a minimum threshold of 23 doctors, nurses and midwives per population of 10,000. Kenya’s current ratio stands at a mere 13. Yet, according to one 2008 paper, the irony is that there is a large pool of trained, unemployed health workers available, but the process of recruitment is cumbersome.

Despite the government trumpeting its free maternity program, maternal health is still in the doldrums. In fact, Kenya is still one most dangerous countries to be pregnant and to give birth.  Nearly 8,000 women die every year due to pregnancy-related complications, while a fifth of babies don’t live to see their fifth birthday. And then there are the scams, such as the recently exposed Mafya House scandal where fraudsters have siphoned off up to Sh5 billion via questionable deals or the prevalence of fake doctors.

Devolution has undoubtedly brought health services closer to many who were previously left out, but even here, problems abound. These range from allegations of tribe-based hiring of doctors and questions over the efficacy of county spending plans to the national government foisting medical equipment on reluctant counties lacking the capacity to utilize it. There are also massive inequalities in access to healthcare facilities and in staffing which manifest in statistics such as a third of counties being responsible for 97 percent of all maternal deaths.  

But perhaps no other area is as neglected as care for the mentally ill. When about 100 patients reportedly “escaped” from the Mathari Mental Hospital on Monday, the media dutifully reported it as a consequence of the health workers’ strike. Yet earlier this year, a report in the Daily Nation indicated that the country’s sole referral hospital for psychiatric care was packed to the brim with patients, some of whom had been sent there by the courts for “failing to understand English, or Kiswahili … or for domestic issues that had nothing to do with mental illnesses.”

Worse, the conditions inside the hospital are appalling, with patients drugged into a stupor, abused, denied food and other basic necessities. In 2013 when 40 patients again “escaped” following a riot at the facility, the Nation reported “it was a case of hunger, abuse, lack of basic services and a fight for survival.” This deplorable state of affairs is perhaps not surprising when one considers that only 0.5% of funds earmarked for health is spent on mental health. This is despite the fact that, according to a 2011 CNN report, “the government’s own figures show that one-quarter of all patients going to hospitals or clinics complain of mental health issues.”

The fact is, even before the current strike, Kenya’s health sector was already in a state of crisis. It will not be cures by appeals to patriotism and fellow feeling or even solely by paying our doctors better. Rather than merely addressing the symptoms of decay, Kenya needs a sober examination and diagnosis of the underlying systemic and structural illness afflicting its health system. Then a similarly credible set of proposals to cure it. The campaigns that are underway for next year’s elections provide the perfect opportunity for Kenyan media and society to force the political class to do both. The question is: Will we take that opportunity? Or will we continue acquiescing to management of health by crisis?