WHAT PRECIPITATED THE NURSES STRIKE AND HOW TO END IT

Since the devolution of health service provision, we were assured of a better organized public health system responding to the needs of the citizens at the grassroots. But with untested and improperly structured measures of management the role of health service delivery was taken over by the county governments. This was the start of an unfortunate experiment in failure. Healthcare delivery requires a competent and innovative management of the limited resources allocated in the counties for that vital function. But most counties have had to cope with first -term governors who did not ensure proper focus on planning and thought all the resources in their counties were to be reallocated to other functions at their whim. They also surrounded themselves with yes-men who sung their praises and never once questioned any misadventures in allocation of resources. This myopia affected service delivery and can only be corrected through a better recruitment process in the second term of county governance in this country if we are not to witness the same.

One of the essential pillars to a smoothly working health system is a workforce that is competent, committed, content, confident, compassionate and united. This function of health system takes up over 50% of recurrent expenditure in both the private and public sectors. Healthcare human resources is also the single most important factor that affects all pillars of the health system including health service delivery, supply chain management and management and leadership. Therefore one would think ensuring proper staffing and continent of this important resource would have been the first order of business for any administration. But alas, we were mistaken.

Some of the problems affecting this component of health system include

LACK OF UNITY OF HEALTHWORKERS

Healthworkers cadres in Kenya have become disjoint, individual silos working almost to antagonistic goals and with mutual petty rivalries hindering their unity to ensure an improved health system. In the midst of all the doctors rights and #LipaKamaTender there was hope that the nurses and clinical officers would be on board to ensure a permanent resolution of the problem, but that was not to be. The nursing union officials and membership were mum and busy toiling in the overcrowded hospitals while doctors were busy agitating and holding demos and sit-ins to press for a negotiated settlement. Rumour mills not to be believed insinuated that there was a tiff in the different unions and it led to lack of support for the doctors strike hence the long 100day strike we witnessed. Now the roles have been reversed and #NursesStrikeKe is a fight for the survival of one of the cogs in the wheel of the health system, the care givers. The Clinical officers briefly made a cameo entrance to the thriller with a few hours of industrial action that was immediately hushed by the national and county governments. Maybe it was just short-term expedience to swipe the problem under the carper but sooner or later the clinical officers are bound to come back to the scene with a strike and a hashtag of their own.

The fragmented union activities of the doctors, nurses and clinical officers makes it difficult to have a conclusive and lasting solution to the healthworkers grievances. The different cadres of healthcare have had an ongoing tuff wars that make them not see each other as a team but instead an amalgamation of different and opposing teams. Doctors in general will not have high regard for nurses and nurses seem to be content to harassing new doctors posted at their stations in order to fulfil their dominatrix fantasies. Clinical officers, despite being a fist line care giver in primary healthcare are looked down upon by doctors and this back and forth only yields a messy outcome of scorn, backstabbing and lack of unity.

The current impasse between the nurses and county governments is just a weird sequel of a Quentin Tarantino thriller. Now it’s more than 120 days in and there is no resolution in sight.

A federation of Kenyan health workers unions would be a welcome idea as it would give a forum through which each union would air their grievance towards the other union and ensure a united healthcare workforce representation in all matters related to their interests. All health unions need to realize that the loss of one cadre of health staff is a loss for the whole health system and should ensure their unity of purpose reigns over any other interests so that there is improvement in the health service delivery and terms of their services.

FLAWED JOB EVALUATION

I do know that nurses and other health workers are not demented souls to leave patients dying on the floors of their wards to engage in strikes. There are grievances that led to these acts. Among issues on the table are the recent Salaries and Remuneration Commission(SRC) Job Evaluation that classified  nurses as semi-skilled workers and with starting salaries far below those of other diploma holders in other sectors. The recent SRC job evaluation failed to take into consideration the unique nature of health workers roles and job evaluation resulted in downgrading of cadres of staff. For example a Diploma nurse being equated to a Diploma sales and purchasing graduate on the basis of each being a diploma graduate.

Another flaw in most job evaluations including I presume the SRC one is the classification of staff depending on the number of staff they supervise. These guidelines have not taken into consideration the unique structure of healthcare where a nurse may not necessarily supervise any of her colleagues but the value of her work is measured even in the economic and human development indices of the country based on lives saved, children immunized and mothers attended to in childbirth. Using this simple formula there is no way a nurse or any health worker with Diplomas would be ranked in the same category as clerks in the procurement departments. Furthermore nurses are involved in front line lifesaving tasks fraught with risks including life altering ones such as infection with deadly multidrug resistant diseases and needle pricks that can infect them with HIV in the cause of carrying out their calling.

It’s time the government and the SRC relooked at the health workers classification in the Job Evaluation and include a category of knowledge workers whose contribution to the society is just unquantifiable and very important for human development of the country. Maybe one day we can finally see a nurse or any other health worker not having to do double-shifts just to make ends meet and to have proper family life like the rest of the Kenya workers.

In the meantime all I hope is that that the slogan of solidarity is not mere rhetoric for the other health worker union and that they can bury the hatchet with the nurses union and help them realize their goal of proper job classification and recognition. Dr Oluga, can you hear me?

KENYA, it’s time to ALT+CTRL DEL

Ever the bridesmaid and never the bride, Kenya has always been on the cusp of greatness and successful economic empowerment of her people but derailed at the last minute due to political squabbles and tribal  chauvinism. Our last attempt at unity of purpose and new beginnings was in 2002 when NARC won by a landslide, but what ensued thereafter was a shame of tribal groupings and backstabbing former allies.

In a few days’ time Kenyans shall head to the polls to vote for their leaders of the next five years.7 years since the promulgation of a new constitution and 5 since the first elections under it. I hope that now that we have another chance at glory, we should not let ourselves and our children down by choosing to stay in our tribal cocoons just because we fear giving leadership to the other. All you have to ask yourself before you vote on 8^th August is,

• Are we better off economically now than five years ago?

• Are we secure as a country more now than five years ago?

• Are our social services more enhanced now than five years ago? 
• Are our public hospitals service provision better now than five years ago?
• Is our education system and learning standards better now than five years ago?

Depending on how you answer the above, vote to either continue more of the same into the foreseeable future or choose to change course and embark on a different strategy that can assure a new approach to nation building and economic and social empowerment of all communities in our nation.

Let us remember that despite the machinations of the wheeler-dealers and the power barons, the voice of the people needs to be heard loud and clear next week and the choice of the people respected. We may have diverse political affiliations but we share a common bond of nationhood and so we should strive to ensure justice is done and seen to be done. However we should also ensure respect for the lives and properties of our fellow countrymen and let’s not shed any blood just because of a disagreement over the direction we seek to steer our country.

 
I wish all of you peace and love during elections period and thereafter. Vote wisely and remember your vote will determine the destiny of our nation.

Don't Intimidate,Innovate.....How to Improve Kenyan Health System

Like any developing country, Kenya faces challenges in ensuring the national and county budgets balance and that there is good distribution of resources .It is for this reason that the Ministry of Health including the devolved functions of service delivery in public health facilities would get only 3.7% of the government budget. Health is a driver of GDP growth of a nation and the greater your investment in it the better the returns on GDP. So I just call on the county and national governments and related bodies to evaluate how to implement and continue improving the following to enhance healthcare service delivery and health in Kenya.

Review NHIF and other insurers’ payment methods and reimbursement rates

Recently NHIF introduced greater coverage for contributors both in private facilities seeking surgical interventions. These Increased payouts from NHIF towards surgical cases may seem like a great idea, in fact there have been human interest stories in local press touting how much of a relief it is for the common man.

Read:NHIF Surgical cover eases pain of costly healthcare for Kenyans

However, let’s remember that there is wide variation in the cost of care in different facilities even though the surgical procedure may be the same and the surgeon probably the same.For as long as there is no benchmark rate applicable in all facilities then the cost of care will continue to rise.The government hospitals could do the same surgeries at a fraction of the cost. NHIF does not reimburse at the same rate for the two facilities. For example, a surgery for appendectomy at a government facility is not reimbursed the same rate as private facilities. Am sure if the government facilities were reimbursed the same, the burden on the tax payer for recurrent expenditure in terms of emoluments for doctors would be a thing of the past. The county hospitals would be able to sustain the operations and even subsidize the county governments’ other functions through returns from NHIF. What county governments should fight more should be greater coverage of NHIF in public facilities and improvement of the facilities and terms of service of all health workers in order to even attract private insurance providers to utilize their facilities. Better equipping county hospitals would in the end have greater benefits in terms of increased payouts from NHIF and other insurances.

There is also a need to re-look at our overall provider payment methods.Hospitals would prefer to continue with the status quo of fee for service because they are cushioned against any losses. while insurances might prefer to try a different model.You can read more about this: Read:Taming Runaway Healthcare Costs

 

Invest in preventive healthcare and population health management programs

In as much as treatment of diseases is important, the greatest impact of interventions can be realized through public health programs of better access to water, sanitation and other environmental health determinants. Counties need to invest more in proper utilization of the health data in their areas to improve the environment and healthcare outcomes for the citizens’ .They also need to ensure better water supply, treatment and proper sewage treatment and drainage systems.

Increase tax-funded health coverage in public hospital

If the above and other interventions involving no increase in health budget fail we would have to increase the tax-funding for health. On many occasions I have elaborated that in a society like ours, health-insurance schemes would have challenge of sustainability because of our not so “peculiar” habits. Currently the formal insurance penetration rate in Kenya is still very low despite the availability of the NHIF which has a big potential population. In the recent past there have been attempt to encourage more people to join the NHIF through voluntary contributions. This attempt has increased the risk in NHIF, one called adverse selection. Adverse selection arises when the population covered by an insurance starts to comprise more of the sicker members of the society rather than a blend of young, healthy population and older, sicker patients. The level of adverse selection that the system can take depends on many factors and only hope can save NHIF if it continues to embrace this system. Furthermore, we traditionally have an informal social health insurance in the form of Harambees which have made it difficult for us to adopt the western concept of insurance. This calls for a rethink of the insurance programs to adhere to the needs of the population and develop products that meet these needs rather than chock the populace with a one size fits all system. Alternatively the government just needs to improve the service delivery in public facilities and with a minimal co-pay method to sustain the operations of the hospitals together with the tax-funding.

These are not the only viable options for improving healthcare in Kenya,but just my thoughts and how I think we could proceed,Other alternative ways can be sought also.In the meantime I just sit here hoping against all hope that sanity in healthcare leadership prevails and that the poor of this nation benefit from affordable,quality care.