Doctors’ strike is perfect chance to redesign Kenya’s healthcare system

Workers’ strikes aren’t always about the money. The 5,000 doctors, who walked off the job in December 2016, in fact sought to save lives, and their leaders were jailed for demanding high quality healthcare that citizens deserve.

Last week, negotiations broke down again and doctors were given an ultimatum to resume work or face dismissal.

The controversial collective bargaining agreement (CBA) signed in 2013 between the Kenyan Medical Practitioners Pharmacists and Dentists Union (KMPDU) and the government proposes more than just a pay increase. It proposes a series of improvements which would lead to better health services for all Kenyans.

The government, however, says it does not have the money to implement the CBA — leading to the worst strike by doctors Kenya has witnessed in decades.

The KMPDU took this drastic action to force the government to honour the agreement guaranteeing more equipment, more health workers and better working conditions in our public health facilities.

As a doctor who previously worked in the public sector, I know these realities too well. Every day, doctors are forced to send patients to private facilities for medicines and laboratory testing.

And too often, doctors watch helplessly as Kenyans die of conditions they could easily treat, if only they had the right resources.

The devolution of health services to the counties in line with the 2010 Constitution has registered mixed results, and many people have called for these services to be recentralised. But that system faced challenges too. 

Under the centralised system, most health workers preferred to work in urban areas, leaving rural communities severely underserved. Budget decisions that did not consider the unique needs of each county led to unequal distribution of resources.

This resulted in uneven health outcomes, with disadvantaged districts recording much higher deaths among women and children compared to the national average.

At least in theory, devolution seeks to address these inequalities by bringing resources and decision-making closer to each county.

But the results from the first four years of devolution have been disappointing. As health budgets are not ring-fenced, many counties have diverted resources meant for health to other needs.

Recruitment, retention and remuneration of health workers across the board have suffered, and more health facilities are going without medicines and supplies than ever before.

This is the time for the government and health sector partners to come together to redesign Kenya’s healthcare system.

Many of the problems exposed by the doctors’ strike can be tackled with the establishment of a national health services commission, the expansion of social health insurance and improved access to primary health care.

Poor management of human resources for health remains one of the weakest links in the current system. A national health services commission would set standards for the recruitment, deployment, retention and continuous medical education for all health workers, while at the same redefining the roles of different levels of government.

This could include the adoption of models that link payment to performance and move away from the old “permanent and pensionable” model that no longer serves anyone’s needs.

And it would allow hospitals in remote counties to hire specialist doctors on a short-term basis — a win-win situation for doctors and for the hospitals and citizens that need their services. Such a model has successfully been implemented in several states in India and Ghana.

Every year many Kenyan families fall into poverty when forced to pay high out-of-pocket expenditures for a sick family member. Expanding the registration of more Kenyans to the National Hospital Insurance Fund (NHIF) will help prevent this.

It will also shift the role of government away from service provider to that of a strategic purchaser, thereby also giving hospitals more autonomy and resources.

Health facilities — both public and private — should be contracted by the NHIF to deliver high quality services to citizens at pre-negotiated prices.

Ultimately, the Kenyan public using NHIF cards would be able to access treatment and medication for cancer, heart disease and other diseases without any payment.

Meanwhile, the county governments are best suited to provide primary health care services from the community up to health centre level.

With support from the national government and other donor programmes, the counties have an opportunity to advance health education and address cross-cutting issues that impact healthcare like water, sanitation and nutrition.

Performing these functions optimally will prevent many diseases and lead to a healthier Kenya.

With negotiations once again at a standstill, now more than ever we must use this strike to stimulate real and meaningful change in our healthcare system. Only then can we ensure that the high cost of this strike brings real benefits to all Kenyans.