Why Are Doctors Their Own Second Worst Enemies?

Ever since the start of the #LipaKamaTender doctors strike in Kenya, I have called on the government and all stakeholders to take up negotiations and seek a solution to the industrial action and steps to reform our health system. Doctors have fought a brave battle together with all the Kenyans of goodwill giving the team moral support in pursuit of better healthcare service provision.

Sorry to say this but doctors have been burning bridges instead of building alliances. They have sought an insular cause where they have surrounded themselves with groupthink and see themselves as the only players and only viable option. This “god-complex” among doctors has been characterized by their perception of all other Kenyans commenting on the issue as less intelligent than them. Media reports have shown instances where doctors have failed to give their version of the story because they feel the questioners to be of lesser intellect than themselves. This Icarus effect could cause them to lose moral support due to being seen as aloof and domineering. This lack of social skills is common in knowledge workers whose profession has a meritocracy-based hierarchy with a black and white view of facts with no grey hues. The lack of diplomacy and negotiation skills may partly to blame for the lack of progress in negotiations on implementation of the CBA.

A robust, resilient health system is not anchored on only doctors but all health workers and the community too. As the head of clinical care teams, doctors are entrusted to make the best decisions on behalf of the team but not in isolation. Doctors cannot claim to be the only right solution to the jigsaw. They need to realize that their colleagues in the medical profession, nurses, clinical officers, occupational therapists and allied health professionals too have a voice in the success of the system

In haphazardly arranged protest marches and petition presentations, they risk exposing themselves as just another interested party to healthcare challenges. The petition march scheduled for later this morning from Milimani courts towards a yet unpublicized location does not include other stakeholders and is one of the cases of unilateral moves that risk putting the credibility of the doctors union on the line.

I had noted that the cessation of the strike by the National Union of Nurses (KNUN) was a pivotal point in the doctors’ strike, as it allowed the government a room to maneuver out of the chokehold of a health workers strike. This sigh of relief (albeit temporary) by the government in feeling the wrath of the populace on the #HealthCrisisKE was visible as it gave the establishment leeway to concentrate on politicking and electioneering at the expense of settling the matter of industrial action. But with the possibility of a resumption of the strike by nurses on Tuesday if their promised allowances are not remitted will reinvigorate the #HealthworkersStrike and force the government back to the negotiation table on the back foot and ready to settle the matter.

We can argue that the possible resumption of nurses’ strike justifies the doctors’ lack of trust in the system to meet its end of the bargain and you won’t be faulted in thinking that way. The hypocrisy in the government negotiation team is evident and a radical move by both the executive and council of governors to reconstitute their teams to have better negotiators would help to give fresh impetus to the talks for implementation of the doctors demands and fresh nurses demands.

The doctors however need to realize they have to be accommodative to building a viable coalition of health workers and other stakeholders who can jointly demand for better terms of service and working conditions. They also need to focus on a negotiated mutually agreeable return to work formula that would ensure implementation of the CBA in phases and save Kenya the headache of #HealthCrisisKE. Failure to this will just result in greater suffering to the people of Kenya.

Reasons for Prolonged StandOff in Doctors Strike

Almost two months from the start of the doctors strike, we are yet to find any hope of a break in the impasse and end of the strike. Amidst the pain and suffering of the greater proportion of the Kenyan populace unable to afford private healthcare service delivery the government remains adamant to give an offer worth replying to the doctors. The doctors on the other hand have dug in for the long haul with a resolve not to call off the strike until and unless their demands (justified ) are met. The obstinacy of the two parties make it difficult to reach any agreement. As a concerned citizen my hope would have been a swift resolution of the strike and implementation of the agreements.

There are several major points that will make an amicable solution impossible and the standoff long..

Lack of honest arbitrator

From the onset of the strike, one of the key grievance of the doctors was the lack of trust in government negotiation team and this resulted in involvement of the Ministry of Labour as a convener of negotiations. This too failed after it was evident the Labour ministry’s aim was to kill the resolve of the doctor and to ensure the government won in the industrial action. I previously called on appointment of a honest arbitrator to bring both parties to the table and to instill confidence in the process of calling off the strike and implementing demands of the doctors. With the failure of appointment of an independent arbitrator be prepared for the standoff to continue.

Lack of concern for the people by the government leadership  

If you were a foreigner who just heard about the #HealthcrisisKE you would be shocked with the irony of government busy bodies crisscrossing the country in a voter registration drive yet there has been a deafening silence on the doctors strike.Moreover some of the key people in government  seem to be looking out for vested interests  out to stop implementation of better terms of service for doctors and better healthcare delivery for the common citizen. The roles have surely been reversed with  the doctors speaking for the citizens while government functionaries looking out for their interests.

From the  sound-bytes coming from the government functionaries one reads an insincerity and lack of actions to save the Kenyan poor but instead a concerted effort to entrench a dismantling of the public healthcare system .The Treasury CS in a talk show clip gave an impression that the government was looking at a market-determined privatization of healthcare model like the United States which has been shown to be the worst among developed countries and one which will subject more people to catastrophic medical expenditure and ensure collapse of the public healthcare system. So, a government that looks out at the impact of the strike on the private sector instead of the suffering and interest of the poor majority is surely out of touch with its people. Unless there is a radical rethink of this stance, expect more paid-up infomercials for the privatization of healthcare in Kenya.

Lack of Compromise in negotiations

It is said that you cannot shake hands with a clenched fist, but the memo never went out to the KMPDU leadership it seems. With a lack of trust in the establishment, the union leadership has insisted of nothing short of a full implementation of the 2013 CBA. This stance in my opinion is foolhardy and counterproductive. In any subsequent industrial action, there has to be a room for compromise and phased implementation of demands. Maybe as judge Wasilwa pointed out the union are captives of their members and are unable to make tough decisions to bring an end to the strike .So, unless the union leadership shows some compromise for a phased implementation of the CBA we should brace for a long standoff. The union may however be too cautious due to lack of trust in the government to keep its word due to two previous broken promises. Twice beaten, forever shy.

But in the midst of it all, I ironically hope that the resumption of nurses strike in the coming week will expedite a solution to the industrial action and a path towards reform of our healthcare system.But if that fails I hope you do not get sick unless you have an unlimited medical cover to access care in fully booked private medical facilities.

We Should Stop Killing Our Patients

Sensationalism sells and that's why you were more likely to click the link to check further on the issue raised above.Now that I have got your attention,keep reading to find out.As the talks between the government and doctors on the legality and implementation of the CBA enter its crucial phase, I hope the reduced media propaganda and adversarial stance from both parties will be a sign of progress towards its resolution. Without getting carried away with the valid hoopla and brouhaha I have to admit the resilience shown by the KMPDU leadership and the length to which they have gone to defend their rights as employees is commendable given the intimidation and enticement by the government and peril they put their lives in. The work of ensuring Kenyans get proper healthcare in our public healthcare system starts now. The CBA is not a panacea for all that ails the health system in Kenya nor a solution for some of the challenges faced but a first step in the right direction

One of the components of the CBA implementation involves standardization of disciplinary proceedings against healthcare personnel. I would hope that this clause would include healthcare quality and safety program enhancement and not just subjective disciplinary measures geared towards punishment rather than a remedial and continuous improvement of the system and its components. I would have loved to bore you with how to achieve healthcare quality and safety in resource limited settings, but I will leave that for another day.

In the recent past media reports are rife with cases of perceived unsubstantiated claims of medical negligence that go uninvestigated or incorrectly handled. Hundred other anecdotal cases go unreported and there reduces the confidence of the citizens in their public healthcare facilities. The implementation of the CBA will hopefully put in place better mechanisms to seek redress by the general public from the errors of omission and commission by medical personnel. The current centralized system of medical negligence and complaints handling is sufficient though it needs some review to take into consideration best practices in healthcare safety programs. Furthermore I hope that the enactment of the CBA (If it happens) will give rise to a system of healthcare quality and safety improvement.

Just this evening, one of the media outlets reported of an ongoing court case of a nurse who erroneously gave a wrong diagnosis of HIV to a patient.

There was also a similar case a week or so ago,of a lab technologist accused of the same. Before the Kenyan healthcare system faces a challenge of proliferation of the cottage ambulance chasing lawyers industry we need systematic reforms of our handling of medical errors to avoid cases of misdiagnosis and malpractice to enhance quality assurance of the healthcare service provision. Every facility in the country should have adequate measures such as an active pharmacovigilance and medico-legal reporting and awareness centre and all medical personnel should be cognizant of their duty to offer the best possible care at all times.

The goal of the improvements should be to enhance patient outcomes and increase prompt healthcare service utilization through the confidence in the quality of care in the facilities. It is only though this process of improvement that the populace can understand why they should support calls towards universal healthcare that is tax payer funded and will not result in any catastrophic expenditure or negative health outcomes.

Failure to improve our quality assurance processes in healthcare will result in lower confidence in the facilities and personnel, increased malpractice proceedings against doctors and no achievement of set healthcare outcomes with a greater burden on the health system.

So, it’s time we talked about the quality of care we espouse to give after implementation of the CBA and how it would translate to better health outcomes for this country. If we don’t, then the industrial action would have been a vain pursuit to increase monetary compensation with no complementary increase in quality of care.

Rejoinder to Chatterjee on Hope for Universal Health Coverage in Kenya:

Consider this, a country in the midst of a doctors strike is touted as a trailblazer towards universal healthcare coverage. A country with a region of its nation with the highest maternal mortality rate in the world, and with a non-responsive health administration is viewed as a bastion of good healthcare governance towards universal healthcare. The assertion by the UN regional coordinator Mr Siddharth Chatterjee in an article in HuffPost -Kenya can lead the way to universal health coverage in Africa is preposterous, absurd and myopic at best. I hereby seek to give a rejoinder to the assertions he made.

First of all and on a cynical note, I find the timing of the article to be in bad taste and with a motive that I can’t quite put my finger on. It’s a great coincidence that his article would seek to give a rosy picture while the health system is in shambles, decrepit and on the precipice. With no mention of the current scenario on the ground.

Kenya is a country with millions of individuals unable to access healthcare services due to multiple factors and has not shown any leadership towards reversing the trend. In the post 2015 Sustainable Development Goals (SDGs) era, Good health and well-being is touted as a goal worth aspiring for and Universal health coverage as a path towards it. Not to criticize such a noble goal, I just have to say the goal is broad and does not have enjoiners such as sustainability and responsiveness to the will of the people of each nation. Thus it’s bound to be interpreted differently by different people with varying results.

With a healthcare budget quarter of the Abuja declaration 15% goal, it’s ironic that Kenya can manage to do much with that allocation. In fact if it ever did manage to achieve anything, it would be the new gold standard with which all other health systems should follow. I have on other occasions stated my views on the path towards Universal health coverage and still argue that increase in the government share of Total Healthcare Expenditure is a basic requirement.

Secondly the political will and leadership has been lacking and needs to be made aware of the interrelationship between health and economic development .So, unless the political leadership gives tacit approval to a move to UHC, any efforts would be herculean. I saw hope for greater lobbying for the cause of universal health coverage locally.

Despite devolution of healthcare service delivery, challenges in access of care abound and the current standoff between doctors and the government rolls back any gains attained unless it is addressed with urgency, fairness and finality. The fluidity of human resources for health will further increase through internal and external brain drains of the stand-off and it’s only a matter of time before the health system collapses. So, an international agency like the UN should have been in the forefront to advocate for a rapid and amicable solution.

Financial barriers to access of care has been a key factor in lack of better health indicators. But with the increase in innovative financing schemes aimed at pooling of risk and addressing the community needs have truly helped .The increase in NHIF membership to all sectors of the population is a noble attempt to ensure fewer Kenyans suffer from catastrophic healthcare expenditures through out of pocket payments. Expansion of NHIF coverage without a review of the currently prevalent  provider-determined fee-for-service payment system, the cost of care will increase without a commensurate improvement of outcomes since there is no incentive towards improving quality of care and reducing costs. Moreover, the healthcare financing system needs to be evaluated to determine whether a tax-funded single payer health system or a risk-pooling health insurance exchange akin to the about to be repealed Affordable Care Act in the United States would be beneficial to the people. According to me an open-market health-insurance system is a trap that would not enhance access of care to the people. Various studies have shown the importance of tax-funded health systems and their impact towards increase in health and social development indicators. So, I again call for a more conservative look at health financing to ensure government commitment to the health of the people as enshrined in the constitution before seeking external private equity for investment.

As for the assertion by Chatterjee that maternal mortality rates reduction in 2008-2014 was attributable to government efforts to make primary and maternal services free, it’s debatable. The government free maternity program started in 2013 and most likely the reduction in the maternal mortality rates were due to factors prior to the adoption the government directive. It is even worrying to see the impact of the current industrial action by doctors and the periodic go-slows by all health workers due to hitches in the devolution of healthcare services. As for the Beyond Zero campaign, other than structural measures improvement such as purchase of mobile vans there have not been many studies that have attributed the gains in maternal health in any part of the country to the  initiative. It is still in its infancy and is most likely an intervention that needs to be studied in detail.

Kenya is a hub of technological innovations and its true this can be used to further improve access of care through telemedicine and remote diagnosis and consultations. However any initiative geared towards this is bound to attract vulture capitalists with a desire to benefit from the poor through introduction of closed-system innovations that tie the government and other facilities to their software for a skewed profit sharing. Imagine Uber and Netflix model for healthcare, where a seed company in New York gets to harvest some amount for any procedure reported through the system or consultation through the teleportal. An alternative to this shylock economy is to empower local technology wizards to come up with home-made solutions to the telemedicine dilemma. Currently,the Kenyan healthcare scene has also attracted attention of New York attention, in the hope that health information system for telemedicine falls into their hands. With telemedicine and integrated health information systems, come Health Analytics. A field that has the potential to give solutions to population health through models and predictive algorithms that could shape decision making and further reduction (or increase in care if it falls to the wrong hands.)

Finally if the international organizations are truly looking out for the best for Kenya and Africa, they should stop commodifying healthcare and pushing for private-based investments through the Global Financing Facility and other umbrella ventures. Instead they should work with the governments to come up with solutions that ensure universal health coverage.

Keeping with the spirit of philosophical endings, United Nations has the moral imperative to ensure none of humanity are forced to endure further suffering through still-born initiatives.But if the status quo remains, Kenya CAN NEVER be a beacon to achieving universal health coverage.

Make Universal Healthcare Coverage a campaign issue in Kenya 2017

As we approach #Elections2017 in Kenya many different causes and interests will seek  consideration by the various political parties. My personal inclination could have been to be ambivalent about it all and not bother about the agenda for the elections and its aftermath. But in the midst of the ongoing doctors’ strike and various moves made to entrench privatization of healthcare industry in Kenya I had to get out of my comfort zone and be part of a greater cause. This is a plea and a pitch for consideration of tax-funded single payer universal healthcare coverage or its hybrid as an essential pillar of attainment of the sustainable development goals (SDGs) for health and also the now almost moribund Kenyan Vision 2030.

The goals of universal healthcare coverage as I suggest is to ensure

• All Kenyans have access to basic healthcare services within reach of their homestead
• Improved public healthcare system service delivery through better equipped hospitals and coordination and cascade of care through utilization of quality improvement tools to continuously monitor progress towards attainment of the goals.
• Greater utilization of local healthcare research in guiding policies and government investment in research and training centres in priority areas of healthcare.
• Improve human resources for health ratios and remuneration in line with best international standards
• Increase in government allocation for healthcare to the Abuja declaration goal of 15%.
• Better structures of governance and leadership and enactment of supporting legislations to ensure all tasks related to harmonization of the above tasked are completed.

The above are just a snapshot of top of the mind recall goals and looking closely; you will notice they are the same goals of the #LipaKamaTender doctors strike. However the doctors’ strike did not articulate fully the fact that their goal has been towards universal healthcare coverage.

Attainment of universal healthcare coverage is a human right that must be pursued by all countries of the world. The benefits of UHC funded by state includes a reduced per capital expenditure of health and better health outcomes. Better health translates to economically active population with further gains in production and increase in GDP thus better economic and social development. Academic arguments and writings about the subject are replete with evidence of success of UHC and the basis of actions towards UHC.

The plan of action towards this call to Universal healthcare coverage includes several steps. The first step starts with a petition to the various political parties to state their position on Universal Healthcare Coverage and to consider it as an essential pillar of their party manifesto on the health agenda. The party that shows concern towards the public and accepts to include Universal healthcare coverage has to be tasked to give a pledge that they will implement a series of steps elaborated below on assuming or retaining power. Towards this end, you can sign a petition calling on the major political parties to make UHC a top priority health agenda in their manifesto and for them to pledge to work towards UHC within 1 year of being elected. Of course this is a non-binding petition but it seeks to put pressure on the parties to realize the need for prioritization of UHC in their manifesto. We hope that parties will take up the challenge and follow through on the pledge.

I call on political parties to accept UHC as a priority goal and to follow through with a pledge that would include the following. In the first step, health system researchers and academics to be encouraged to share their works and other relevant studies from elsewhere on workable models for service delivery and healthcare financing. The experts in various aspects of health systems including healthcare financing, human resources for health, commodities management and leadership and governance should be consulted and a consultative forum towards a framework for the model should be held.

The second step will involve public participation to elicit their opinion on the route to use towards UHC. The citizen involvement can include stakeholder forums and surveys on health seeking and perception towards several elements of healthcare including funding, utilization and satisfaction.

Thirdly, a draft UHC policy should be developed and a health system review forum where the policy will be discussed should be convened. With consultation and dialogue it would be possible to come up with a final framework for UHC that can be entrenched in the laws and adopted.

As it is evident, the first step starts with you advocating for UHC through your completion of the petition. I hope that one day we shall look back and realize that change is possible and however difficult a path we shall attain UHC in our lifetime.