Devolved healthcare turns sour as doctors quit service

In Elgeyo Marakwet, mothers held the lifeless bodies of their children minutes after they were vaccinated. In Teso, the limbs of young children turned wobbly after an injection. In Nairobi, a man succumbed to death after awaiting admission at a hospital for 18 hours.

These incidents depict the growing pain of Kenyans as county executives sack hundreds of the few health workers that Kenya has trained while nurses and doctors go on strike over salaries.

Are counties ill-prepared to take over the health function?

Dr Ouma Oluga, secretary-general of the Kenya Medical Practitioners Pharmacists and Dentist Union (KMPDU) says that the public health sector challenges have become more pronounced with devolution of healthcare.

“It was a good idea. But its implementation has been chaotic,” Dr Nyaim Opot, the chair of the Kenya Medical Association (KMA) said.

He reckoned that most county governments which took over management of health functions from the national government seem ill-prepared to execute the role.

Since healthcare system was devolved in 2013, media have been awash with reports of health workers’ unrest in counties. Salary delays, poor working conditions, low remuneration, and segregation based on ethnicity.

“It’s obvious that most county governments still don’t get the significance of health care to the country. They don’t accord it the seriousness it deserves. And this is killing the morale of health care workers,” says Dr Oluga.

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This has consequently contributed to extensive brain drain, with many doctors opting to resign and work in local private hospitals or other health-related fields like medical research and advocacy for behaviour change.

Many health workers are also leaving the country for greener pastures abroad, thus rendering useless investment Kenya has made in training them.

“This year alone, I have signed recommendation letters for 60 of my medical students going to work in Europe. And I know it as I am their referee,” says a senior doctor at KNH and lecturer at the University of Nairobi School of Medicine who did not want to be named.

“This trend deeply saddens me. These were some of my best students who could have greatly contributed to the growth of our health care sector. But now that change will happen in other countries,” he added during an interview with the Business Daily.

This brain drain is piling pressure on a health sector that already suffers from a chronic insufficient work force.

The doctor-patient ratio in Kenya now stands at 17 doctors for every 100,000 people, below the World Health Organisation (WHO) recommendation of 100 doctors for every 100,000 people.

Yet, most of these doctors practise in urban centres mainly in private facilities hence making access to healthcare difficult for Kenyans living in rural areas.

In areas such as Lamu, Marsabit, Mandera and Siaya, the ratio goes as low as just one doctor for every 100,000 people.

Dr Oluga stated that when devolution of health care began in 2013, the public health sector had approximately 4,000 doctors.

But this figure has since been halved to about 2,000. Yet, the government doctors are often the ones posted to work in remote settings. Nursing care is also wanting in the country.

In Kenya, a nurse takes care of at least 13 patients in a general hospital ward against the WHO ratio of one nurse for every six patients in a general ward.

As the health care crisis prevails, Kenyans are also falling prey to quack doctors keen on exploiting human resource gaps for selfish gains.

Various propositions have been brought forward to address these challenges. James Macharia, the Cabinet Secretary for Health, recently announced that the Ministry of Health (MOH) would establish a special administrative unit within the Public Service Commission that will address issues affecting the health sector.

The unit, set to act as an intermediary between the county and national government, is expected to ease conflicts between the factions that have often blamed each other for failures in the health sector.

Since it will comprise of representatives from both levels of government as well as other stakeholders, the special unit is expected to enjoy the good will of all players in the industry.

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It will thus provide counties with the much needed support in health care management. This unit will centrally manage a broad range of healthcare matters including staffing, remuneration, promotions, staff professional development, career progression, improvement of health infrastructure, supply of medical equipment and others.

Dr Opot says that as much as health care is a devolved function, activities need to be centrally co-ordinated to ensure that the country is moving in one direction.

“For instance we need to look at the distribution of human resource so that we don’t have more health workers in one area and very few in another,” he says.

As counties now control health funds allocated to them, Dr Daphne Ngunjiri noted that this offers them a unique opportunity to put in place innovative staff motivation packages that can eventually address the challenge of brain drain.

“Most doctors want to make a difference in people’s lives and wouldn’t mind working anywhere so long as their needs are well catered for.”

The KMPDU is proposing a 300 per cent salary increment that will see the lowest paid doctor earn a basic salary of about Sh120,000 up from the current Sh40,000.

This figure will, however, still be lower than that of their counterparts in countries with a lower GDP than Kenya such as Mozambique and Botswana where doctors earn more than Sh250,000.

In slightly advanced economies like South Africa, doctors take home about Sh400,000. But in Europe and America where most Kenyan doctors emigrate to, the pay is approximately Sh600,000 up to over Sh1 million.

“The salary we are getting in Kenya now is by no means proportionate to the amount of work we do, the special nature of the service we offer and training required in the medical profession,” Dr Oluga stated.

He adds: “Doctors are overworked and often have to attend to more than the required number of patients daily due to congestion in most public hospitals.” Dr Opot says that the government should improve working conditions and strive to retain health workers in the country.

“When doctors go abroad, all the money incurred by the country to train them will go to waste. And this is not good.”

Indeed, a previous study, published in the BMC Health Research Journal, indicated that for every single doctor that emigrates, Kenya loses about Sh53 million ($517,931) worth of returns from investment.

If it is a nurse that emigrates, the country will lose Sh35 million ($338,868).

Another challenge is the ill-equipped hospitals. Healthcare workers who despite having necessary skills and knowledge on management of various conditions, watch helplessly as patients suffer because they lack required tools and supplies for treatment.

“It’s frustrating to watch patients suffer from an illness that can easily be treated yet there’s nothing you can do due to lack of equipment,” said Dr Ngunjiri who previously worked as a medical doctor in Baringo County but now manages a group of low-cost private health clinics in Nairobi.

She added that procurement challenges also compromise timely delivery of medical supplies thereby causing treatment delays. “Sometimes they would come when it was already too late.”

Dr Ngunjiri says that counties also need to look for innovative ways of offering incentives to doctors working in far-flung areas such as providing training opportunities, hardship allowances and performance based payment increments.

Dr Pratap Kumar, a healthcare management expert at Strathmore Business School, said that the government can also tap technological innovations to address health care access gaps in remote areas through telemedicine or m-health.

Remote hospitals

“With accurate and detailed patient information, a doctor in a different location can make a diagnosis and send the feedback to the hospital through e-mail.”

The medical equipment — such as ultrasounds, X-ray units and ICU tools — being supplies to county hospitals through the government’s Sh38 billion leasing deal already has provisions for telemedicine.

To address the perennial shortage of specialists in remote hospitals, the government is promoting the uptake of a master’s programme in Family Medicine.

The course covers surgery, paediatrics, orthopaedic and trauma care. They also get training on health care management.

This specialised training prepares doctors to adequately deal with a myriad of conditions affecting people at the counties as opposed to their counterparts who specialise in just one area of medicine.

“It’s not always easy to get specialists in rural hospitals. So doctors going there should be prepared to handle most conditions,” said Dr Bruce Dahlman, an expert in Family Medicine and Community Care.