Evolution of humans and role of Coronavirus

The reality of the Coronavirus is with us and it’s only fair to periodically look at aspects of our lives that are being challenged and changed by the virus.

Type of health systems in a country

As the coronavirus is showing us, your private health insurance won’t help you at times of pandemics. Insurances are set up as profit-making entities and will seek to opt out of high-risk exposures that would drain their returns though claim payouts. Your best bet should be your government. Any move to make governments only regulatory bodies who watch from the sidelines as private health service provision takes center stage is mistaken and myopic. Governments should strengthen both their pooling of resources for the common good in the form of a tax-based universal health system and also service provision in the context of their populace needs and research and development of both vaccines and technologies.

Best outcomes so far in the handling of coronavirus pandemics has been in countries with more government control over service delivery and funding. In the context of low and middle income countries this augers well as it would also act as a safety net against exploitation of the poor and marginalized who would face an extra to access barrier through privatization of services.

Population health management:

As a component of a national health system, we need to prioritize preventive and community-based heath approaches to reduce transmission of diseases, be they air-borne or even water-borne. Without proper investment by governments in public goods like access to safe drinking water, sanitation and immunization the cost of handling outbreaks of diseases are all the more increased. As we look at setting up ICUs and isolation wards we should also seek to promote population health management strategies.

Armchair experts on health policy,infection control and all medical issues

A time of pandemic is a time of fear for the general public but the most disturbing thing are the range of opinions by medical practitioners that can easily be mistaken for the only truth. This leaves room for many people who many not have expertise on the subject offering half-baked and even spurious claims that may result in spreading the disease instead of controlling it. So, seek advice from only trusted and validated opinions of Ministry of Health and WHO and key opinion leaders in the health profession whose advice is backed by scientific basis.

Social space.

Ever thought how some people are always in your face and never giving you space at the Mpesa agent or while queing for matatus at Nyama Kima , at the banking hall queue of the bank or at the supermarket checkout counters. Guess what, all you have to do is have a slight sniffle and the social distance is restored. The happiness that an introvert feels in the quiet of the house with a good book or movie is now though shared with company of family members forced to stop their kutangatanga  and instead be at home in a lockdown.

Lack of civility and tissue paper as an essential supply

In a scene out of an apocalyptic movie, the middle class have been busy stocking up on tissue paper and hand sanitisers in the mistake belief they will disinfect themselves and wipe their behinds so well that the virus will slide away from them. The shortages of essential hygiene commodities created by such irrationality in a time of pandemic increases the chances of infection spread as other would be unable to access the sanitisers and will readily spread the virus to the tissue-hoarding members of society.

Lack of ethics in entrepreneurship

The above scenes of greed and insecurities are but an extension of the society’s values. The thought that in a time of scarcity a group of entrepreneurs emerge, with a pursuit to buy out all the essentials and resell them at mind-boggling markups is a reminder of what ails capitalism. Recently a man in Tennessee,USA bought thousands of hand sanitizers and was reselling them on Amazon at inflated prices only for karma to come back and bite him in the behind.

It’s all good to create availability of commodities that are in scarcity through innovative manufacturing or sourcing and charging a profit, but to put up 1000% markup is immoral but won’t be uncommon if the current pattern of the spread of the virus continues.

Greed of investors and vultures

At times like this of utmost hardship, there will be greater incidents of the 1% of the society trying to buy-out distressed firms and family owned businesses at a fraction of their worth, only because they can. I would like to see how this unfolds given it’s not a case of if , but when it happens.

After all has been said and done, all that matters is the kindness we show those unable to access the essentials while they are sold at inflated costs or what we communicate to the government to institute measures to mitigate against the extra strain on the distressed bottom 10% of the population. Our humanity is not in how good we are in our prayers but in how well we take care of each other in times of need.

Come to think of it God still exists even though the ornate mosques and cathedrals may be closed for public use. So, after all, remembrance of God should be in our hearts and not in buildings.

Peace be upon you all.

*edited version

Coronavirus and the future of Kenyan health system

Coronavirus outbreak could be the time to reset our health system as a country. The spread of the virus that has put a great strain on many economic,political,sporting and religious events is a testament to the challenge that the world faces due to mass movements across borders and seas.

Coronavirus has put on hold Liverpool lifting the English Premier League till later (if ever), in golf Masters wont be held in April and Saudi Arabia and the Vatican City have stopped many peoples spiritual journeys by banning gatherings and pilgrims from out of country. However, in Kenya it is just but one of many issues we have to contend with and least of all a movement in nothingness called BBI and invasion by locusts of biblical proportions (things for which I have no opinion of 😉).

On matters health care however, I would like to beg your indulgence as I explain how this is the best time to click Alt+Ctrl Del for our health system. 

 First of all,I had in a way foreseen impact of a virus of the same corona class way back in 2013 and briefly talked about its potential. So hear me as I give my take on the benefit of Coronavirus in Kenya.

Looking at the bigger picture,as we are responding to the fire of the Corona and its impact on the economic growth of our country and the world and livehoods of many in the populace, we might as well  reclaim and rebuild a resilient health system or be doomed to pay for it with another cycle of unpreparedness next time another emerging virus appears.

The lessons we learn as we set to tackle the virus should be key in helping to put a new blueprint of an inclusive,equitable and affordable health system for all.

As it is, Kenyan health system has been almost on its deathbed with lack of investment by the state in improving the infrastructure or the capability in human resources and technological innovations without it becoming a scandal in the form of Medical Equipment Leasing or the Mobile Health Clinics. So whatever move the state makes in tackling the coronavirus would shape what to exect in the coming years and decade in health care in Kenya.

Currently the public facilities are hard pressed to ensure minimum working conditions and equipments in many places and so the only facilities to handle the Coronavirus patients who may be exhibit severe symptoms would be in the major cities of the country. As the Wards set up  at Infectious diseases section of Mbagathi-Kenyatta National Hospital fill up there would a need to look back and ask how we can ensure the same can be handled at far flung areas of the country. Given that the world is interconnected very much, the next outbreak of an epidemic proportion could easily start from those far-flung areas and without the facilites and know-how could easily spread to Nairobi and traansmitted toanywhare in the world.

Government investment in healthcare

So far, in the early phases of this outbreak, government systems and protocols have been a key pillar to ensuring a reduction in mass infections and in essence reducing the burden on the curative services of those countries. South Korea has been largely able to contain community transmission flattening the curve of transmission and once the cases are detected a great surveillance system ensured timely testing and treatment for the severely ill with good outcomes. (Least Mortality rates for the most affected countries so far.). Its not suprising to note that South Koreans enjoy a Universal health coverage that is run by the Ministry of health and dynamically funded through a mandatory national health insurance scheme.) This way the motivation for better care and improved outcome is assured through no profit motive for those running it. 

So we need to re-look at the current health system and the need to invest more in our public facilities. There has been an explosion of privatision of healthcare in this country and ever since it has taken the growth phase, even good people have started to lose their morals and become enmbedded with the vulture capitalists to create an American-modelled health system that seeks to put $$$$$ ahead of human life. The evils of neo-liberal capitalists out to reap off the country and the most vulnerable in our society should be the tiping point of the conversation on why you should demand better publicly funded and run health system.

When emergencies arise and you have a car accident on Mombasa Road,your private health insurance wont be of use. However  if the public hospital at Makindu had a Trauma Centre that is well equipped and with the right personnel you might just make it out alive. Also when a pandemic is declared,remember the insurances have bolted on you and you will pay out of pocket for the care that you so much wish for and need.What more do you require to ask for a better public health system.?

To those who think a publicly funded health system in the form of NHIF as presently constituted is the answer, eat my shorts. And to those who think pouring public money to PPPs is the answer, eat your caviar in peace and set up your private facility without involving the public to fund your business.

The government needs to rethink the devolution of health service and how to better create a seemless transition from one facility to another.

Other important aspects that the government  need handle once it rethinks how to improve public health system would include.

• Investment in preventive approach to health. ( Which is what the initial aspect of handwashing would be all about.)
• Better procurement systems that reduces the cost of care.
• Availability of quality testing kits. (So do we have coronavirus testing at more facilties?) 

#CoronavirusinKenya should be a turning point in our revival of public health system. If we fail to use this moment in history,we shall forever regret it. Lets do the right thing and seek improvement in publicly funded health system.

Culture Change Crucial for Better Health Services

One of the key pillars of a strong and resilient health system is a dedicated, competent and empowered health workforce. There are a lot of learning points from the private sector that can be applied to public service to improve both the systems, processes and outcomes. Private sector has adopted the principles and to good effect (and profits).

With a focus on health sector it’s worth noting that in as much as investment in the other pillars of health system are crucial, Human resources for Health #HRH deserves clear and strong focus. Without a competent and committed workforce all gains towards #UniversalHealthcareKE will prove to be transient and unsustainable. Taking an example of the two adjacent hospitals on Ngong Road, one a public, tertiary hospital and the other a privately run “not-for-profit” hospital. With the limited number of specialists in our country some of the doctors admitting at KNH also have admission rights in Nairobi Hospital. However the way they would treat patients in KNH is markedly different from across the road. You may attribute that to various factors including the money is king mantra. I beg to disagree as to the extent that contributes to the way they handle patients. It all boils down to organizational culture also.

In private institutions, there are a laid down structures of interactions between consultants and hospital based doctors and patients and that is adhered to very well. However in the public service ,there being either a lax oversight role by the management and/or lack of control on the conduct of what can or cannot be done in the facilities, the standards plummets. If public hospitals and public service in general could just adopt the implementation plans of private hospitals, there would be a world of difference.

Meritocracy

In the private sector there are some conduct that would not be tolerated but in public service form the norms. Promotions and increments are mostly after accomplishment of set targets. However in the public service there is the expectation that there is a continuous promotion ad infinitum as long as one has a pulse and clocks in for work. This breeds a laissez faire attitude that with time generates a systemwide breakdown of ethos as a subculture of minimalist job performance is adopted.

Performance contracts

Highly successfully used in the private sector, no individual should be above a performance contract. If a practitioner cannot meet certain standards expected of them as set by peers and with clear goals set at the start of a given term they should be reallocated to other areas where they might perform better rather than have a security of tenure of employment for mediocre staff who do not aid the achievement of any long term vision of better health outcomes.

The health system practitioners (who ideally would be technical health workers themselves) are not and should not be seen as just managers out to ensure budget preparation and operational supervision of the institutions. They should be given greater autonomy and oversight to improve their institutions and departments without a constant either political patronage that clips their wings and turns them out to be zombies, rubber stamping unrealistic programs without giving a contrary knowledgeable opinion.

Oversight and control

Another reason private-sector like structures would work in public service given the proper backing is that, with oversight of personnel transferred to the institutions, decision-making and performance standards can be locally formulated taking into consideration the areas health needs and outcomes to aspire for. The empowered health system managers are able to therefore implement more measures that would avoid the present great variability of patient experience and quality of care between two adjacent hospitals.

Distribution of health workers to counties

There are other factors too that contribute to variability of healthcare provision but public service culture needs to be reshaped and improved. I do admit that there are many honourable and dedicated health workers in public service but the organizational cultures and subcultures increase their burn-out rate and some even might be tempted to move over to the private sector where their handwork and initiatives will be appreciated.The devolution of  health services to the counties without a structure of addressing shortfalls in staffing in various areas resulting in lopsided distribution of health workers and lack of autonomy by the hospital heads because of local politics hindering their vision for better services has also constituted to the current chaos we have.

There are various ways in which such a debate could be pursued and a new, vibrant public health system culture redesigned from the models of private sector without the burden of pursuit of profit but instead greater efficiency and quality of care.

I hope I live to see the day when the Profs won’t have to cross the road to be humble and smile at the patients in equal measure.

Let's listen to the people on issues healthcare

Every single article on healthcare in Kenya currently starts and end with Universal Health Coverage as if it’s an event just like the World Cup with ribbon cutting and pomp and colour to mark the occasion. Players from various sectors have already weighed in on the issue to the extent that conversations has been reduced to a chorus of “Do this, do that” and a scramble to be on the table of policy formulation, such that it now looks more like a pie-eating contest than a visionary approach to better healthcare. For all intent and purposes UHC is a people process that requires careful planning, consultation and implementation. In my opinion, UHC is not about what the president wants in his BIG 4 agenda but what the common man needs in their day to day health seeking and wellness.

Already various bodies have forwarded their vision of how the UHC can be implemented and while some remain noble attempts at achieving results, most tend to be a hyena pack with kizungu mingi ready to focus on innovation, complex process costing approaches and very few seek to demystify the agenda.

In my opinion a logical approach would be to handle the UHC agenda as we would any social issue by involving the people and understanding their local needs before pushing for a top down approach of implementation.

Most of us have had to be involved in various Whatspp fundraising campaigns to fund medical bills for a family member, colleague, acquaintance and even random strangers who have access to your number and are pulling a moonshot hoping you will help in alleviating their problem. From interactions in those fundraisers, it’s easy to understand the challenge people face to get best care possible with limited resources. As healthcare management and policy experts, let’s take a backseat for a while and understand the drivers of burden on mwananchi.

Most of the anecdotal reports do point out to lack of available government or subsidized care, both primary and specialized closest to the people. In such scenarios, people are forced to seek care from profit motivated care facilities whose most important goal is better returns for shareholders. Thus the care will be provided, but at a cost that is astronomical, uneconomical and downright depriving.Like the shylocks they are,private facilities and even government ones now claim their pound of flesh by detaining already discharged patients or even dead bodies in order to claim their dues. The cause of such private based system is even more shocking bearing in mind the outcomes are often unsatisfactory and the payment system utilized an archaic, provider centric fee-for-service.

So let’s remember this, more than half of the people of this country live in abject poverty and the current state of healthcare is a perdition that they live here on earth. We have to come up with a people centric health system reform that ensures dignity, better care and sustainability of the system that is to be designed to achieve UHC. Let’s also remember that the middle class and working poor of this country may have a level of cushion against the drawback of the current health system since they may be members of a voluntary health insurance scheme or they may benefit from the NHIF as it presently constituted. So to expect NHIF to be the vehicle of choice in achieving UHC through contribution from a population who remain uninsured due to poverty is not a viable way to enhance the road to UHC. Furthermore the providers of NHIF services are currently mostly private providers (In monetary compensation) who would not care about reducing the charges to NHIF patients covered as indigents. Since the burden of the cost of NHIF would still go back to the state, it would prudent for the powers that be to ensure a functional government hospital system rather than just focus on increasing health insurance uptake as a path to UHC. Failure to strengthen the government health system will lead to a collapse of the Healthcare agenda of the president and a great loss for this country.

If we are to devise any system for attainment of UHC then the path to take is one of government led and subsidized public health system that is available closest to the people.

We already have the policies, regulations and structures for a referral system from the community level to the tertiary level. Now is the time reform them to achieve what they were intend for, better care for the poor of the country. But again we would need the personnel equitably distributed in the country to run the system and some Cuban doctors to boot. But that’s a story for another day.