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Underfunding, staff poaching put Mathari Hospital on sick bed

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Nurses (left) at Mathari Mental Hospital administer drugs to patients at the hospital. FILE PHOTO | NMG

Massive poaching of staff and underfunding have left Mathari National Referral Hospital in a wretched state, shows a new audit report, dealing a blow to mental healthcare in the country.

At level 6 of the referral chain, the Nairobi-based hospital is expected to provide the highest degree of specialised care.

A review by the Office of the Auditor-General (OAG), however, revelled rot amid congestion and shortage of staff, medicines and key equipment.

Mathari Hospital does not have adequate qualified personnel to handle the number of patients seeking mental healthcare.

Of the 17 psychiatrists and 179 psychiatric nurses in public hospitals in Kenya, seven psychiatrists and 104 psychiatric nurses are deployed at Mathari.

Ideally the hospital requires 18 psychiatric consultants — meaning it is short of 11 such officers. The situation is even worse for psychiatric nurses because it has shortage of 191 nurses.

Ideal staff ratio

The World Health Organisation (WHO) recommends a ratio of 1 psychiatric nurse to every six mentally ill patients.

A review of patient and staff records at the referral hospital indicate that the ratio is below WHO recommended ratio. For example, a psychiatric nurse in Ward 5F at Mathari takes care of 54 patients. In wards 6F and 9M such a nurse handles 68 and 70 patients respectively.

The situation is worse in the Maximum Security Unit (MSU) that has one nurse attending to 152 patients who have been booked in as law offenders.

“Mathari Hospital management and staff attribute the inadequate personnel to its inability to retain them as compared to the private institutions that provide better pay and working conditions,” the OAG said in the report.

This is compounded by the fact that there are few psychiatrists in the country and their demand is on the increase, yet the hospital provides no incentives to retain these critical staff.

A review of the Health ministry records by the OAG reveals that as at 2015, there were only 92 psychiatrists in the country instead of the 1,533 required and 327 psychiatrist nurses instead of 7,666. In addition, the hospital deals with some patients who have violent tendencies and may pose a big risk to fellow patients and staff, further serving to disentivise personnel.

“Lack of adequate skilled personnel negatively affects mental healthcare service delivery at the hospital and increases the risk of violence and threat to life especially in the MSU since the few staff available are not able to handle the large number of patients,” the OAG observed.

Mathari Hospital’s woes are compounded by inadequate diagnostic and treatment equipment.

Though the hospital has ElectroconvulsiveTherapy (ECT) and Electroencephalogram (EEG) machines, it lacks other crucial equipment such as CAT scan and Magnetic Resonance Imaging machine (MRI), which assist in diagnosis and treatment of mental illnesses and related ailments.

This means that patients who need the CAT scan and the MRI, and can afford to pay, are sent to Kenyatta National Referral Hospital (KNH), about eight kilometres away, for the procedure.

According to the KNH Service Charter, the minimum cost of a CAT scan and MRI examination is Sh 8,500 and Sh17,000, respectively.

“The patients who cannot afford to pay have to wait indefinitely for availability of funds from relatives or the hospital, as they take drugs to manage their condition. Lack of CAT scan and MRI also means that patients only receive basic treatment of undiagnosed condition thereby prolonging treatment and denying them a right to proper treatment,” the OAG said.

Mathari also has a shortage of beds to accommodate patients. A review of patient records indicated that although the actual number of beds increased from 574 in the 2011/2012 financial year (FY) to 768 beds in 2015/16 FY, representing an increase of 34 percent, there has also been an increase in the average number of patients in the wards from 596 in 2011/12 FY to 906 in 2015/16 FY, a 52 percent increase.

Further analysis of patient records for the five financial years indicated that on average, there were 106 patients showing a 15.5 percent excess admission.

“In addition to congestion, most of the wards are in deplorable conditions and do not provide conducive living conditions for the patients. Physical observations at MSU in Mathari Hospital show that the ward is in a deplorable condition, which has reduced the bed capacity from 347 to 320,” the OAG said.

“The unit lacked toilets and instead the patients used buckets to relieve themselves while one of the wards had a hole on the roof, which would obviously cause leaks during rainy seasons. The patients must in turn suffer under these conditions and this could worsen their current conditions and/or breed more ailments” it added.

Eratic drugs supply

The audit further revealed that Mathari Hospital lacked sufficient medicine. Drugs used in treatment of mental illnesses are categorised into first and second generation drugs. The second generation drugs are preferred by medics for mental health treatment since they have a shorter curative period compared to the first generation drugs.

“As at the time of the audit, Mathari Hospital was using both first and second generation drugs for treatment of mental illnesses. Interview with hospital officials revealed that of the drugs available, 80 percent were first generation while only 20 percent were second generation,” the audit report said.

A review of drug records showed that the hospital experiences stock outs for as long as a month and this was attributed to low funding, delayed funding and the long procurement process at the ministry.

“The effect of insufficient supply of drugs is that patients stay longer in hospital awaiting availability of these drugs, which means delayed treatment and more psychological effects on the patients, higher operational costs to the hospital and related undesirable effects on the patient’s family,” the OAG said.

Lack of finances is a big factor that exercebetes it condition. The audit revealed that the hospital offered services to an average 906 psychiatric inpatients per day, translating to 330,690 patient per year and further received 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,” the OAG pointed out.

In addition, the hospital is required 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 mostly are long-stay individuals.

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 per year. 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 Sh1.2billion. The figure is 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 FY,” The OAG noted.

“This also means that in 2015/16 FY, with an amount of Sh 215 million, to cater for the 330,690 inpatient days, the hospital allocated less 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 in mental health, it does not get any funding for training from the Health ministry. At the Ministry, the budget for training is allocated to the Department of Research and Development under programme-based budgeting.