Sorry state of Kenya’s mental health system

The number of mental disorder cases has risen exponentially in Kenya with official data indicating that that approximately 20-25 percent of outpatients seeking primary healthcare present symptoms of mental illness at any one time.

But more shocking is that there are no sufficient qualified medical personnel and facilities to take care of this lot of patients.

A review of the Health ministry records by the Office of the Auditor-General (OAG) reveals that as at 2015, there were only 92 psychiatrists in the country instead of the 1,533 required. Similarly there were 327 psychiatrist nurses instead of 7,666.

“Going by the estimated population of 46 million in 2017, the current staffing for the different professionals thus drastically falls short of the ideal ratio,” the OAG says in a new report.

“For example, while it’s expected that a psychiatrist should serve 30,000 citizens, currently a psychiatrist is serving about half a million citizens.”

The situation is even worse when it comes to psychology services in Kenya when one worker is faced with a ratio of 4.6 million patients instead of a recommended 15,000.

“This in turn means that the referral system in place cannot work for provision on mental healthcare services since most of this staff are unavailable in almost all institutions in level 1 to 4 of the referral chain, while others are thinly distributed between level 5 and 6 facilities,” the OAG says.

The country’s present reliance on dysfunctional referral system for the provision of mental healthcare services is attributed to the fact that the government has not taken sufficient steps to roll out such services in more health centres despite the increasing number of patients with mental disorders.

“The effect is that patients with mental disorders face difficulties in accessing mental healthcare services. Their families in turn must bear the burden of living with their untreated sick persons who remain unproductive, dependent and sometimes a risk to themselves, the family and the society depending on the nature and extent of illness,” noted the report.

By December 2014, there were 3,956 government-owned health centres providing general health services across the country. However, besides Mathari National Referral Hospital, mental healthcare services are only available in 29 of the 284 hospitals in Level 4 and above of the referral chain representing just 10 percent of the total facilities in Level 4 and above and 0.7 percent of the 3,956 government-owned health centres.

But even at Mathari Hospital all is not well. At level 6 of the referral chain, the hospital is expected to provide the highest level of specialised care for patients with mental illnesses.

According to the Kenya Health Sector Referral Strategy, national referral hospitals provide specialised healthcare services and should operate with a defined level of autonomy.

The hospital has nonetheless failed to operate optimally, partly due to bureaucratic systems of management that have hindered financial planning.

“As a national referral hospital, Mathari Hospital should have a charter and operate as a semi-autonomous government agency managed by a board of directors and headed by a chief executive officer. This would mean that budgetary provisions are appropriated directly to the hospital whose management is then able to secure all the required resources and run the hospital independently” the OAG points out.

However, the hospital operates under the Curative and Rehabilitative Health department under the Ministry of Health. The hospital thus is headed by a Medical Superintendent who reports to about five different offices. It lacks a defined level of autonomy thereby missing out on the benefits that other semi-autonomous referral hospitals have.

This situation has financially burdened this key hospital, which is also a training centre and the only healthcare centre in the country with a Maximum Security Unit (MSU), despite the huge inflow of patients that continue to flock its gate for medical assistance.

An audit revealed that Mathari Hospital offered services to an average 906 psychiatric inpatients per day, translating to 330,690 patients per year. About 320 of these patients were in the MSU while 586 were in the civil wards. Further, the hospital receives approximately 400-500 students per quarter across the different courses.

“To maintain an inpatient at the hospital, the actuarial estimate given by National Hospital Insurance Fund (NHIF) is Sh3,500 per day per patient. The hospital would therefore need Sh3,171,000 per day translating to about Sh1,157,415,000 per year for maintaining inpatients alone,” points out the OAG.

In addition, the hospital is mandated to receive mentally ill law offenders from prisons and police department across the country for assessment and forensic mental health services, for both outpatient and inpatient care. These patients are in the MSU and are in three categories; remandees, special category and those convicted of crimes. Most of these patients have a long stay.

The hospital also offers teaching and training facilities to psychiatry students from government’s medical training centres, public universities as well as private hospitals and universities. It receives about 500 students per quarter resulting to about 2,000 students annually. The management estimates that it costs the hospital about Sh2,000 per month, per student which translates to Sh48 million per annum.

The workload therefore means the hospital would require Sh1.15 billion and Sh48 million for inpatients and students’ upkeep respectively per year adding up to Sh1.2 billion. The figure will even be higher when outpatients’ needs are included.

Documentary review of financial records by the OAG indicate that the hospital received approximately Sh280 million, Sh220 million and Sh215 million in financial years 2013/14, 2014/15 and 2015/16 respectively for recurrent expenditure.

“The funding appears to be reducing each subsequent year. In comparison with the daily costs related to patients and students, the funds provided were only 23 percent, 18 percent and 18 percent of the estimated service cost in the three years respectively representing a shortfall of up to 82 percent in 2015/16 financial year,” The OAG notes

“This also means that in 2015/16 financial year, with an amount of Sh215 million, to cater for the 330,690 inpatient days, the hospital allocated less seven than Sh650 to each patient per day, which is only 19 percent of the NHIF actuarial cost of Sh3,500 per patient per day,” it added.

Though the hospital is mandated to provide training and research facilities, it does not get any funding for training from the ministry. At the Ministry, the budget for training is allocated to the Department of Research and Development under programme-based budgeting.

“No evidence was provided to show that any of these funding was disbursed to Mathari Hospital,” the OAG says.

“Further, the hospital lacks a Memorandum of Understanding (MOU) with all the public institutions that take their students to it and as such these students do not pay for the services rendered. The private institutions, despite having an MOU with the hospital, remit only Sh 1,500 per student per month, which is less than the estimated cost of Sh2,000. This means there is lack of effective enforcement of the MOU with regards to training and attachment fees chargeable”

Mathari records also indicate low disbursements for recurrent and lack of disbursements for development expenditure. A review of the government’s printed estimates for the three financial years 2013/14 to 2015/16 indicate that the hospital was allocated Sh1.15 billion and Sh 96.5 Million under the recurrent and development votes respectively.

However, financial records at both the ministry and the hospital indicate that the hospital actually received a total of Sh447.5 million for recurrent vote and nothing for the development vote.

The variance is as high as 72 percent for recurrent and 100 percent for development in 2015/16 financial year and no explanation was provided for the variance. The hospital management estimates that it would require about Sh 20 million to refurbish a ward and Sh50 million to construct a new 40-bed ward. Had the development funds been disbursed, the hospital would’ve constructed a 40-bed ward and refurbished two others while better services would have been provided to the patients had all the recurrent funds been released.

Further, the recurrent allocation from the MoH for operations for the 3 years since Mathari Hospital was elevated to a national teaching and referral hospital has been reducing despite an increase in the workload and cost of living.