OPEN LETTER TO KOFFI ANNAN TO HELP END #LIPAKAMATENDER

Dear Koffi,

I hope you been  well and traversing the world in your retirement trying to save the world from self-destructing.This is operative Nyangau whom you met briefly at the Serena,Nairobi last time you were around trying to broker a peace among our warring factions of the same party.I know you may think It’s a bother to hear from a Kenyan even after we failed to hoist a statue in your honour after you got us from the precipice and back to a semblance of national unity. You did good my fren and despite a few schools being grabbed here and there and a billion lost here and there it’s been ok. We have even managed to overhaul the old constitution and replaced it with a new one, launched with pomp and colour which you know we are used to. We even managed to hold an election under the new constitution and got in place a new vibrant digital team to run the affairs of the state. (Just an side, they seem to be doing very well if the IPSOS desktop surveys are to be trusted).

I am writing you this letter not to update you on the situation but to ask for your intervention yet again. You see, after the digital team came to power they came on a premise to right the wrongs and to give everyone their rightful dues. They launched roads, laptops for schools and even modern state of the art leased equipment for hospitals. The problem is, the doctors to man and ensure the hospital equipments get used have refused to work.

It is now the festive season and we are conducting auditions for the the band to play at the New Years Ball and the order of drinks seem not to have arrived on time and so we are unable to concentrate on this crucial activity while also dealing with the doctors. Since it’s the season to be jolly, I knew I could get you in a good mood to ask a small favour of negotiating a new deal with the doctors to resume duties and not ask for much from our government. The government has a lot of commitments to creditors who financed a modern train system, and other infrastructure projects. They have used most of the resources to do good for the country to pay suppliers like M/S Things of Desire and others for essential commodities supplied to our very vibrant national youth service involved in digging up trenches even where none existed. The doctors are unreasonably asking for the government to implement a signed and stamped bargain agreement which we thought they would forget about after the last time they absconded from duties. They want 300% pay hike but with your intervention we know we can get them to reduce their demands to maybe an extra lunch allowance here and there. Beside, other than saving lives in our hospitals what else do they do? They are just busy separating and rending asunder what God has joined together and even recently managed to separate a conjoined twin despite our best efforts to stop them from doing so. Now we have to issue to birth certificates and even identity cards depleting our expenditure of state. Furthermore, they were unable remove bandage from the face of one of our governors and we had to urgently evacuate him to South Africa to perform the intricate intervention.

Please pass by en route to Accra, and have tea with us and photo-op with the protocol team before meeting briefly with them and reassuring them to accept goodwill of your visit and am sure they will return to work after being hypnotized by your perfectly graying hair and monotonous voice that made us hide the hatchets in favour of peace last time you were around. Please assure them the government shall honour the commitment made in 2013 after they ensure we re-elect our dear leader for another term in 2017.Besides which government honours its commitment to a trade union of only 5,000 people most of them young, humble, polite, bright voters who do not wear bling-bling and do not have a booming voice to address workers without a microphone. They are led by this fellow called Oluga who is soft-spoken and even has the audacity and bravado to mesmerize everyone with his eloquence and clarity of thought and calmness of pose in the midst of all the obstacles placed in his path.

Just a heads up, I hear the government had earlier pleaded with them to stop their quest for emancipation and better terms of service and better health system and even assured them we would bring them colleagues from Cuba and India to assist them but they did not listen. Their other colleagues, nurses and clinical officers have accepted to go back to work and I hope that they too forget about the agreement promised to them. If you can just get the doctors to go back to work for lower than 300% hike I assure you my fren we shall be deeply in your debt and will even donate 1Billion cedes in your name to enhance national unity through more activities of digging trenches and clearing garbage where no one sees them.

We are looking forward to your acceptance of this new assignment as you have shown the desire to bring temporary peace that holds for some time all over the world.

Sincerely yours

Bwana Nyangau

PS:

This is a satire

THE EndGame After #LipaKamaTender: KILLING THE KENYAN HEALTH SYSTEM

The current impasse between doctors and the government over the implementation of the 2013 collective bargaining agreement (CBA) may seem like a normal industrial action that is taking longer to resolve. But at its core the lack of effort to stop the deterioration of services in government-health facilities due to the strike should have alarm bells ringing as to the potential for complete collapse of the public health system.

There has been a slow but steady investment in healthcare by several multinational companies and even investment by proxy by the IMF through the International Finance Corporation(IFC).The aim of the  investment  by the multinationals and venture capitalists is maximizing profits in the chosen ventures.  This investment can only have maximum returns if a greater proportion of the population utilize the services of the for-profit healthcare providers and a nudge towards this can only come from the inaction to solving an industrial dispute pitting doctors and government run facilities. The resulting vacuum generated by such inaction will result in an acceptability of greater privatization of even essential services that are currently available in public hospitals. Several private equity firms have in the recent past made in-roads in acquiring local stakes in local medical facilities such as Metropolitan Hospital, Goodlife pharmacy chains and health insurance companies. These investments and also in for-profit social franchising models targeted towards the low income communities of the slums and rural areas will be the greatest beneficiaries of a collapsed. non-welfare health system. The returns from greater private insurance coverage, greater uptake of private services and increased importation of pharmaceutical and medical equipments shall tilt the curve to benefit repatriation of profits.

The government will almost robotically be willing to go along with the experiment as it will be rid of the high payroll expense of doctors and specialists who would be expected to join the consortiums that will be formed to protect their interests. This will reduce the government expenditure on health as a percentage of GDP well below 3% and ensure absorption of the difference by more politically expedient causes. The government will even go to the extent of marketing a pro-poor medical insurance scheme under NHIF in the guise that it would reduce financial burden through pooling of resources and would allow the bottom of the pyramid (slum dwellers) to access care at the social health franchises after an enrolment fee and a few other jargon that will be added to confuse them. The new system will almost certainly be touted as a success based on a successful US or Indian model. What won’t be divulged is that, the US healthcare system has the worst per capita efficiency and quality of care among OECD countries. With this information all will proceed so fast that we will find ourselves with a predominantly private health system modeled on the US system. The system will however be a success to the shareholders and venture capitalists that will get maximum returns on investment. Already there are counties that have had initial contact and alliances with private healthcare entities to set up base in their areas, allocated huge chunks of land to the private healthcare providers and thus it’s only a matter of time before the process is full completed and the vision realized.

The desperation of the doctors and need to succeed in their chosen field will also force them to either join the growing private care provision or force them to seek greener pastures in foreign lands. Either ways its win-win for the private system and a great loss for the country.

My plea is that we reform our health system to have a more robust, resilient public health system with sustainable healthcare financing model that does not take us the United States way. Several studies including some from The Commonwealth Fund have found that public, tax-funded health systems have ensured greater access to care for the populace and better outcomes than other systems. Studies have also showed that a dollar spent on healthcare by the government has an impact in raising the GDP of that country. Therefore we need a re-think of leadership and governance of health system in the country and entrust it to individuals and structures that cater for the greater good and ensure equitable, sustainable, affordable and quality care to all. The British created the National Health Trust (NHS) from the ashes of World War II and it’s a model we could borrow a leaf from taking into consideration local variation and shortcomings of the NHS.

But what do I know? Am just a dreamer, a wishful thinker dreaming of a better health system and quality healthcare for all.

SOLVING THE DOCTORS STRIKE AND THE NATIONAL HEALTH ERROR:My Take

Currently doctors in public health facilities are on the fourth week of strike with no resolution in sight. At the start of the strike the government was in a much dire situation with doctors, clinical officers and nurses all on strike. With the resumption of duties by nurses and clinical officers the government thinks that it has saved face and gained public confidence that the government hospitals are back in full operation. In reality, only routine services are available to the public. More complex surgical and medical cases requiring the intervention of doctors and immediate cascade of care to specialists for prompt attention is lacking. This has resulted in untold (and sometimes told) suffering of the poor who rely on the government health facilities for all care. It is surprising that coming on the backdrop of festivities of Christmas and New Year no attempt has been made to end the strike and the media has lost its credibility through either churning out one sided propaganda pieces, turning a blind eye or featuring the story as a filler material between political parties news. The impact of the strike will be greater mortality rates and greater healthcare out of pocket spending by the poor who will be forced to seek care in private for-profit facilities. In the short-term the government may think it has won the battle but in the long run it has resulted in many deaths due to lack of diplomacy and arbitration engagement with the doctors.

I do not wish to delve into the ethical dilemma of the actions from both sides. Doctors will insist on the deontological principle of the government honouring its word while the government either through naivety or braggadocio insists there are no funds available and avoids its obligation to meet its commitment. In complex case like this an independent arbitrator with no link to either the employer or the doctors would be important to have. The Ministry of Labour despite the mandate to facilitate is a biased mediator since it draws its budget from The Treasury who is an interested party to the dispute. Therefore I do believe a prompt settlement can only be achieved if the Labour ministry withdraws its patronage of the talks and cedes to an authority agreed upon by both the doctors and the government. This way a foundation of trust can be set to start negotiation on implementation or viability of the collective bargain agreement (CBA).Since the government had already indicated that the CBA is a legitimate document its implementation only would be the most likely bone of contention. The government and doctors union however need to come to the new negotiation table with no preconditions and with an open mind to accept the verdict of the independent arbitrator. This will hopefully save the Kenyan masses compounded suffering. The arbitrator needs to be appointed soonest possible to stop more suffering both to the patients and doctors of Kenya.

All other sideshows of government of union officials commenting on evening news of TV stations with dwindling viewership (even of those with high viewership numbers) should be banned and all statements on the progress of the talks should be through the arbitrator only. In the meantime Kenyans need to start thinking wisely of how their future healthcare system and even leadership system should be governed given the facts of the doctors’ strike, the myriad others problems facing the nation and the lack of attention to problem solving by the current government.

The current healthcare crisis in Kenya has been simmering for years and has not been tackled well and to its conclusion. The evolution of the health system in Kenya has been one of trial and errors and the current one is just another phase of error. From the first Sessional paper No:10 on African socialism in 1965 to the introduction of cost-sharing in public hospitals in early 1990s as part of IMF/WB Structural adjustment programs(SAPs) and finally the devolution of health service provision to the counties in the new constitution systematic errors have been repeated. The situation is so dire and replete with errors that we should just call it the national health error.

I have written several times on this before and maybe it’s time we had a consultative forum of experts on health systems and stake holders to chart the way forward towards a more robust, resilient and responsive health system. But what do I know? I am just a wishful thinker dreaming of a better health system and quality healthcare for all.

Heartache of a dying health system

As we enter day 3 of the nationwide doctors strike in Kenya,I cant help but wonder do we really care?Does the government really care that thousands of Kenyans continue to be turned away from health facilities because of the strike and that the death count due to the strike continue to mount.

ACHIEVING UNIVERSAL HEALTHCARE COVERAGE IN AFRICA

A healthy nation is a wealthy nation. This statement has in its core a truth that any investment in the health of a nation is not a wasted, expensed cost but an investment in the economic gains of the nation. During the recently concluded 6th TICAD (Tokyo International Conference on African Development) conference in Nairobi, there was great focus on health and development and the need to improve the health of Africa to improve its economic outlook. It is with this in mind that the President of World Bank Jim Yong reaffirmed the commitment of the institution in strengthening African Health systems towards universal health coverage (UHC) by allocating $30 billion over the next five years for the strengthening of African health systems. This is a realization that health is crucial to economic development and wealth creation.

At the turn of the millennium, The UN millennium development goals (MDGs) were developed and sought to address poverty and other crucial health outcomes including reducing child mortality, improving maternal health and combating HIV/AIDS, Malaria and other diseases. Through various partnerships, The Global fund has been able to work with countries to reduce the burden of disease in Africa and other developing countries of the world. Further , in 2001 African countries made the Abuja declaration to increase government support to health sector to at least 15% of their budgets. More than a decade later only one country managed to reach this target with at least 11 countries reducing spending on health in the time period.

This background confronts the continent as we begin the implementation of the expanded Sustainable Development Goals- post 2015.With a focus on the Health goal of the SDGs I wish to state that while individual countries will have different paths to attainment of Universal health Coverage, commitment of leadership is the single most important factor that can contribute to success of this initiative. A challenge to all leaders gathered for TICAD is to reassess their health systems and define ways of improving it towards universal health coverage. The Ebola outbreak in West Africa was a wake-up call to strengthen the health systems of the region to be able to tackle epidemics in future. 

Good Governance and Leadership
The pursuit to have strong viable health systems can only be achieved if several key pillars are addressed. First, strong health systems are based on good governance and leadership but anchored on stewardship and support of visionary leaders who make it their legacy to support the achievement of Universal health coverage. Other than Tanzania, no other country on the continent has shown a consistent commitment by successive regimes towards health. This might be attributed to the almost singular leadership style and uniform party affiliation of all the presidents of that country to date. In most African countries, a regime change signals a change in focus priority areas such that it’s difficult to ensure continuity of any interventions.

Increased government healthcare expenditure
Secondly, governments in Africa need to make efforts to increase healthcare expenditure as a percentage of their GDP. Many African countries have an unsustainable level of out-of-pocket healthcare expenditure by the population. Innovative health financing systems should be encouraged without the governments shirking from their responsibility of providing health services to the people. While considering the health financing system to adopt its important to look at the outcomes of various health systems as opposed to the economic expediency of any measure that may be taken. Taking into consideration the market failure inherent in healthcare, we should be cautious in approaching health financing as market-forces driven economic sector but as a merit good that should drive towards the greater agenda of social welfare ideals. It’s important to note that better health outcomes are attained in countries with a greater percentage of health expenditure by the government as compared to privately provided health systems. This has been consistently shown in WHO reports and other studies. Therefore there is a need to frame our systems with this in mind while investing in strong resilient health systems.

Address deficiencies in human resources

Thirdly, there is need to address deficiencies in healthcare human resources on the continent. Africa bears 11 % of world population, 24% of the disease burden and only 2% of the health workforce. This net deficiency in health workers and the ever growing brain drain to western nations of highly qualified professions calls all of us to action towards looking for solution to this perennial, ever-growing problem. Greater private-public cooperation in training and investment in community health workers might be some of the way to alleviate the problem and reduce the gap in health workforce. Other capacity enhancement measures can be adopted with adequate use of technology to ameliorate this situation. Some of the useful innovative ways of ensuring success of community health have been spearheaded by non-government entities. www.amrefhealthafrica.com  has been involved in educational activities for community health workers in various areas of East Africa with commendable results in reduction of diseases and improvement of maternal and child health. AMREF has also been involved in e-learning program of nursing upgrading program that has seen an increase in the pool of available trained community health nurses in Kenya. This is just one among many initiatives, which if strengthened by the governments of the region could be replicated all over the continent with better results.

Therefore we need a re-assessment of our health systems, increase of government contribution to health sector financing and investment in human resources for health as priority areas to start a renaissance in African health and healthcare. This does not mean other pillars of health system are not important, but I would urge governments in the region to look at the above as the cornerstones towards universal health coverage.