Why The Doctors' Strike Is A Missed Opportunity

It is now nearly three months since Kenya’s doctors went on strike. The dispute centers on the Comprehensive Bargaining Agreement the national government and the Kenya Medical Practitioners and Dentists Union signed in June 2013 and which the latter is insisting must be implemented.

The Executive has been at pains to disavow the very agreement it signed and the doctors have had to defend the legality of their strike. The quarrel has caused untold misery in hospitals and drawn in the other arms of government as well as the Central Organisation of Trade Unions and the Kenya National Human Rights Commission. However, for all the sound, fury and chest-thumping, the sick and dying in Kenyan hospitals have little explanation for their calamity. Both sides have privileged spin over substance and confusion over clarity.

The government first claimed the CBA would be too expensive to implement, then argued that the document was not a legitimate agreement anyway since it had not been registered, then that the doctors were not its employees but those of the county governments and it was only playing a “facilitation” role; and finally that the CBA was illegally signed by an illegitimate official on behalf of a Ministry that did not exist.

On its part, the KMPDU has ignored court rulings and orders regarding the legitimacy of the CBA and the legality of the strike it has called; and courted public sympathy by seeking to portray the CBA as the solution to Kenya’s health problems and themselves as warriors for the common good not just for improvements in doctors’ welfare.

These mental gymnastics merit some attention. It is not the first time the government is making offers to its workers to avert industrial action that it later claims are too expensive to implement. Far from it. In fact, it is a tactic the state has developed into something of an art. The same ruse was pulled on teachers in 1997 and again in 2015. The country’s university lecturers are today on strike claiming the government has reneged on a similar promise for a 300 per cent pay rise.

Further, it is strange, to say the least, that the government was unaware that the doctors were not its employees when it signed an agreement with them. The CBA many times refers to the Ministry of Health as the employer, not the county governments. Further, in interviews with this writer, doctors themselves have claimed that their contracts, despite the devolution of health, are still with the Public Service Commission, not with county governments, to whom they say they are seconded. That when, in January, President Uhuru Kenyatta tried his hand at brokering a deal, he left the county governments out of the talks is an indicator of the government’s attempted sleight of hand, as is the idea that it took nearly 4 years to realize the document it had signed and that has been the subject of a dispute in the courts, was fraudulent. In any case, the courts have already declared the signature on the document, if not the document itself, is valid.

Some of the claims advanced by the KMPDU are similarly disingenuous. That the legitimacy of the CBA is problematic cannot be gainsaid. The Labour Court last October ruled that it must be negotiated afresh. A judge has already declared“there is no CBA.” While one can sympathize with the doctors as victims of a government confidence trick, that still does not render it a legally enforceable document. 

If anything, by calling the strike, the KMPDU spurned an opportunity offered by the courts to apply to get the CBA registered in January if talks with government had failed to generate an agreement. In so doing, they put themselves in their current predicament, where their officials have a one-month jail sentence hanging over their heads. Further, even a cursory reading of the CBA will reveal that, contrary to the spin being put out by the union, it is primarily about enhancing the welfare of doctors, not that of their patients. In an interview with Citizen TV in December last year, Secretary General Ouma Oluga stated “categorically” that the strike was about doctors’ suffering, not that of patients.

It is of course obvious that improving the welfare and training of medics as demanded by the CBA will have beneficial effects for Kenyans in general, including in helping to stem the hemorrhage of skilled workers out of the public health system. However, the KMPDU has blown these benefits out of al proportion, with claims such as that implementation of the CBA would end shortages personnel in the hospitals. By Oluga's own numbers, the country has about 8,000 doctors and trains just 600 annually against a requirement of 83,000. That means, even if each and every doctor, including those currently in private hospitals, were employed in the public service, it would still take over a century just to cater for the needs of our current population. The CBA thus does not even begin to scratch the surface.

More than anything, the lies and distortions by both the doctors’ union and the government have denied Kenyans an opportunity to deal the failures in the health system. The problems therein stretch beyond the welfare of doctors and encompass the motives behind the decisions that policymakers in the government have taken. Only by moving beyond the empty spin and honestly addressing the real issues can Kenyans begin to craft a system that works for both our long-suffering doctors and their even more traumatized patients.

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?