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Public Health System: Designing Kenya’s Health System-Lessons From South Africa

With promulgation of  Constitution of Kenya 2010, observers expected Kenya’s new national covenant- hailed as the most progressive North of  the Cape of Good Hope in Southern Africa and South of  the Mediterranean-  to be a boon to Kenya’s public health system. We explore how this new, liberal, social contract sets the stage for revolutionizing Kenya’s public health sector, drawing our comparisons form the workings of  South Africa’s public health system, a system bed-rocked on another of Africa’s more progressive constitutional dispensations.

[dropcap]T[/dropcap]he highest attainable standard of health, is the ideal spelt out in Chapter 4 enshrining human rights in the supreme law of the land. This wasn’t empty rhetoric too, a Kenyan could seek redress in court if they had sufficient reason to believe the government was reneging on its end of the contract.

Besides, with introduction of the county governments services, money and the power to make decisions was now in the hand of the people in the devolved units. But it’s been everything but smooth sailing. Kenya’s public health system has intermittently coughed and ground to a halt  There has been a 100 day doctor’s strike. A nurses strike and skirmishes from other health cadres like clinical officers and medical laboratory technicians. Donor organizations like USAID have withheld funding over corruption and lack of funding.

But as Dr. Erick Wekesa Bunyasi, offers, the task is enormous, but necessary and achievable. A robust public health system remains our only hope he prays. In a November 2016 interview with the Financial Times ‘It was defiance’: an interview with Ngugi wa Thiongo, the good prof retorts:

I’ve always made a distinction between what we ought to do and what we have to do.Ngugi wa Thiongo

With this piece, Dr Erick Wekesa Bunyasi -Kenyan doctor studying, living and excelling in South Africa does what he has to do: his civic duty. What we all ought to. Daktari argues that the Kenyan government ‘ have to’ implement the CBA of 2013. A document that is a negotiated road map towards a public health system that will realize Universal Healthcare in Kenya.

Kenyan public doctors’ strike: a brief comparison of the Kenyan and the South African public health systems

Are Kenyan doctor’s strike demands unreasonable? Why would extremely intelligent, highly skilled,hardworking individuals risk income and imprisonment if not for a worthy course?

In South Africa (SA) it is called ‘Black Tax’. Simply put, this refers to the financial demands placed on individuals, usually Africans from constrained family backgrounds, when they finally ‘make it’ or obtain gainful employment and have to support relatives e.g. fundraising for astronomical or catastrophic medical costs or remittances to support relatives.

After my medical training at the University of Nairobi and internship I was posted to an ill-equipped district hospital; with limited lab capability, insufficient and often late supply of drugs and consumables, and was on a meagre salary of Kshs. 55,000 (in 2008). My work was reduced to referring patients for the most basic of tests and procedures that could be competently performed by a newly qualified doctor.

These factors, among others, led me to resign from public service within a year of completion of internship, a fate that many young Kenyan doctors resort to, and joined the Kenya Medical Research Institute (KEMRI).

Fast forward, I look forward to completing my PhD in about 18 months. I have been in SA for 5 years to pursue a master’s degree and then a PhD degree. The PhD is mostly funded by the South African government’s National Research Foundation (NRF) and the Department of Science and Technology (DST).

Despite being away from Kenya for more than five years now, my heart and mind never really left Kenya. I want my relatives and fellow citizens to have access to a functional, efficient and sufficiently staffed and resourced public health system.

I would also love to bring my skills back home, albeit in a functional set up where systems work, and additionally enjoy favorable terms of service. It is for this reason that I have not only closely followed and fervently supported the Kenyan doctors’ strike, but  also conducted  a brief comparison of key aspects of the South African and the Kenyan public health systems relevant to KMPDU’s Collective Bargaining Agreement (CBA) of 23rd June 2013. In summary, the doctor’s strike seeks to improve;

  • Working conditions, access,to equipment and quality of services in public hospitals.
  • Training, professional development and research by doctors.
  • Improve handling of human resource for health
  • Remuneration/terms of service of medical doctors

Other items of relevance to the Kenyan public health system;

  • Universal Health Coverage (UHC).
  • Health Service Commission (HSC). This was covered in the Musyimi task-force report.

What is in the doctors’ Collective Bargaining Agreement (CBA) for any Kenyan citizen or Wanjiku’

There has never been a better reason for mass action by Kenyan citizens than an 85-day doctor’s strike that has been mishandled by the government. Besides denial of access to constitutionally mandated highest attainable level of health care, Kenyans have been denied access to quality public health care via long-standing, systematic under-investment in the public health sector that has resulted in a poorly resourced and dysfunctional public health system.

Inforgraphic simplfying the demands of striking Kenyan doctors who assert that implementing the 2013 CBA guarantees appropriately equipped hospitals adequately manned by well trained, motivated and disciplined health professionals whose skills were equitably distributed across the country.Who can find fault with such a public health system?

This Inforgraphic simplifies the 2013 doctors CBA whilst drawing attention to the struggle it has been to get it operational as evident in the hashtags #CBAforKenyans #ImplementCBA #Lipakamatender #GovernmentOnStrike

If, God forbid, you or any Kenyan were involved in an accident in Lamu while on holiday, the immediate point of resort will be the local public hospital; long before transfer to ‘5-star hospitals’ that your limited insurance cover entitles you access to.

Therefore, my heart bleeds for my family and relatives back home with every passing day that the doctors’ strike remains unresolved.

Being a key constitutionally mandated service, failure to provide highest attainable level of healthcare for almost three months calls for resignation of concerned cabinet secretaries, principal secretaries and even the president.

The following are reasons why the current doctors’ strike is of relevance to you as a Kenyan. You stand to benefit both directly (better quality, cheaper healthcare), and indirectly (e.g. via reduction in ‘black tax’, ‘harambees’ for health care in foreign countries for family, relatives and friends), from a better resourced public health system if the government agrees to provide more resources for health such as drugs, equipment and other medical commodities.

Alma Ata Declaration

The government currently spends a measly less than 5% of its national budget or less than 6% of its GDP on healthcare against a recommended minimum of 15% for the former. Agitation for better public healthcare should be a struggle and concern of all Kenyan citizens, not just doctors. Kenyans need to stand out and be heard in constitutionally permissible protests &/or picketing.

You, and fellow Kenyans, will pay less in public hospitals, than private hospitals, for quality services if the government allocates more resources to the health sector.

Increase in number of doctors in public service will increase access to these key professionals by you and all other Kenyans. This will reduce waiting time for health consultation and procedures. It pains me that the government procured equipment worth Kshs 40 billion that lie idle in some facilities due to lack of expertise to use them yet it’s not keen to commit to training such personnel. The CBA fronted by doctors will cost roughly 8-12 billion, and will serve as a stimulus package to jump-start an abominably and chronically underfunded public health system.

Further training of medical professionals and research will increase access to their expertise in public facilities at a pittance of charges in private hospitals. Further training of doctors, as happens in internship, is done on apprenticeship basis and is fully paid in progressive health and education systems, including SA.

Increase in remuneration of Kenyan doctors will encourage more doctors to stick in Kenyan public service, unlike those like me, and roughly 4000 others, who moved South or North for better career progression and terms of service. Kenya is one of top six African countries in ‘exporting’ doctors: an unfortunate eventuality given dire shortage of this expensive human resource in Kenya.

A Brief Comparison of the South African and the Kenyan Healthcare Systems

  • Training, professional development and research

Research is heavily funded by the South African government e.g. it was easier for me to obtain a PhD scholarship from the SA government than the Kenya government. My PhD studies are largely funded by the South African government’s DST through the NRF.

The NRF gives close to 5000 new scholarships every year for PhD and Master’s Programs through various calls . These are targeted to projects that are of strategic interest to SA. This funding is separate from loans to students administered via ‘NaSFAS’  a body similar to HELB in Kenya.

Additionally,a dedicated body, The Medical Research Council  provides enormous funding to address the top 10 causes of ill health. The latter provides both career development awards and scholarships largely to doctors. In Kenya, KEMRI receives little funding from the Kenyan government. Most funding is investigator (PI)-obtained from Europe and US-based funders such as CDC, NIH, Wellcome Trust, and the Bill and Melinda Gates Foundation. For example, out of roughly 800 staff at KEMRI Kilifi in 2010 only a handful (<5%) were funded from funds obtained directly from the Kenyan government.

Healthcare, Security and Education are among the key services that need to be steered by any given government. As stated by Prof. Geoffrey Rose, and widely accepted in public health, the chief cause of ill health is social and political and so is the solution. Thus President Uhuru Kenyatta needs to provide direction and demonstrate leadership in this three-month-old health crisis. Strong health systems are not built by courts of law but by focused, concerned and visionary political leadership.

Unlike many professions, advanced training of doctors occurs by apprenticeship and is fully funded in most progressive health systems given consultants-in-training provide a service in excess of 160 hours per month and are a backbone of healthcare provision in teaching hospitals. SA most consultants-in-training or residents receive Kshs 400,000 unlike in Kenya where most do not receive anything, including a stipend. The Kenyan medics’ CBA proposes research funds, and paid residency positions, which is a norm in progressive health and education systems.

  • Remuneration

Poor remuneration that forces Kenyan doctors to ‘moonlight’ or do locums aggravates output of an insufficient human resource for health. Such doctors have to work many hours, endure burn out and have little time to rest, have more profound social life and pursue other interests, research and continuous education which is key in the practice of medicine.

Kenyan medics’ CBA does not call for a 300% payrise of gross salary as erroneously and widely reported in media. An increase of a salary from Kshs 127,910 to Kshs 325,730 cannot be a 300% increment by any economics, especially after adjusting for inflation.

A medical officer intern in SA public service receives a monthly starting salary of an equivalent of Kshs 235,000-300,000, as compared to Kshs127,910-149,880 in Kenya currently and the union’s proposed Kshs 325,730-342,770 pm. In SA, this increases to Kshs 350,000 to 400,000 on promotion to an entry-level medical doctor, against Kshs135,590-168,840 in Kenya currently and the union’s proposed Kshs. 369,770-389,570.

Out of public service, medical doctors [general practitioners] enjoy a starting salary of between Kshs. 400,000-600,000 depending on employer e.g. the University of Cape Town just advertised such a position for Kshs 441533 per month.

Senior consultants and professors on joint University of Cape Town/SA Department of Health tenure earn roughly Kshs 800,000-1,200,000 pm, excluding other income from leadership roles or undocumented consultancy. Kenyan medics of equivalent training and experience earn between a third and a half as much. The union’s proposal is a salary of Kshs. 402,570-946,000pm.

Currently SA loses its doctors to UK, Canada, Australia and the USA. For example in Canada and UK a consultant doctor earns up to 3-5 times and 2-3 times as much as in SA, respectively. Thus, the demands by Kenyan doctors’ union compare well to the practice in SA, barring comparison of the two economies.

Underpaid

Given the lower doctor-to-patient ratio in Kenya and worse maldistribution of doctors across Kenya, Kenyan doctors no doubt work more hours, are underpaid, and are exposed to extraordinary risks in chronically and severely under-resourced environments. When dealing with a scarce critical resource, effort should be made to keep rather than to let go of the resource, some of which is trained at tax-payers expense. Retention is required more so in public hospitals that serve 99% of the population, than private hospitals that serve 1% of the population. I therefore beg to disagree with CS Rotich on this.

The Kenyan government has capacity to honor the CBA given this will require roughly Kshs 8-12 billion commitment in a country with an annual budget of Kshs. 2.6 trillion and given Kenya spends <5% of its national budget on healthcare [this is 11%for SA] against a recommended 15% as committed by Kenya, which is as a signatory to the 2001 Abuja declaration Parochial business interests particularly linked to the health private sector hospitals’ monumental profits and insurance given the longstanding neglect of Kenya’s public health sector and may be barring progress in current negotiations. For example, NHIF pays Kshs 33 billion to private hospitals serving 1% of Kenyans and only Kshs 5 billion to government hospitals that serve 99% of Kenyans.

  • Universal Health coverage

Universal health care refers to a health care system that provides equitable, highest possible quality, sustainable health care that confers financial protection to all citizens and households in a country. Countries that have made significant strides towards UHC such as Thailand and Cuba are not the richest.

Achievement of greater strides towards UHC is possible in Kenya but this will require strengthening of the NHIF, the public health system and a carefully designed and aptly managed healthcare financing mechanism. This will inevitably require efficiency in use of current resources dedicated to health, generation of fiscal space for health and, inevitably, progressive increase in healthcare financing.

South Africa is yet to achieve UHC, but the legislation and debate is ongoing and at an advanced stage. Nonetheless, health facilities are better equipped. This is hardly surprising given SA in 2012 spent 8.8% of its GDP on healthcare, against Kenya’s <6%. The Musyimi taskforce report proposes increased funding and better management of health workers. Increased funding will jump start a fledgling health system that has been chronically neglected and underfunded.

  • Human Resources (read medical doctors for this review) for Health

Kenya has roughly 3,956 medical doctors in public service and roughly 8,000 overall [against SA’s 38,236 medics]. Kenya and SA doctor/patient ratio is 1 doctor/6250 and 1 doctor/1300 individuals respectively. Kenya would require at least 34 years to meet the recommended doctor-to-patient ratio of 1-1.5 doctors/1000 individuals or a total of 44,350 doctors. This assumes a continuation of the current annual training output of 600 medical doctors, that all graduating doctors are employed in Kenya, and that all of them are equitably distributed and none either emigrates/resigns to pursue non-clinical interests. Only 5 countries – Seychelles, Tunisia, Libya, Algeria and Mauritius- have the recommended doctor/patient ratio in Africa.

  • Health Service Commission (HSC) and National Laboratory Service (NLS).

Given the outcry of tribalism, nepotism and cronyism in management of doctors by some counties, a body equivalent to the Teachers Service Commission or the Judicial Service Commission will greatly improve management of human resource for health.

Counties could continue providing drugs, commodities and health infrastructure but have the financial burden of paying health workers and their management conducted by a HSC. If the HSC is funded by treasury, this will free fiscal space in counties to which could be dedicated to provision of drugs and other supplies.

Governors should support doctors’ demands and compel treasury to provide additional funds for healthcare. This will, most importantly, enable counties to provide better quality health services. At a personal level, this will give governors a higher political rating/appeal that will enhance their re-election. South Africa doesn’t have a central body that manages health workers.

However, given the above misgivings, it will be profoundly useful to have professionalism seen in management of teachers or judges, emulated in health resource management via establishment of a HSC as recommended in the Musyimi Task Force report. A dedicated central body focused on lab services, like SA’s National Health Laboratory Service, could prove pivotal in improving laboratory services that are key in health practice.

About the author: Dr. Erick Wekesa Bunyasi is a Kenyan-trained Medical Doctor and now a PhD student at the University of Cape Town’s Institute of Infectious Diseases and Molecular Medicine. His PhD studies are largely funded by the South African Government.

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