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.

The Scramble for Kenya in light of Big Four Agenda

Dear Kenyans,

As the powers that be who dreamt of the lofty Big Four agenda come to terms with the actualization of the agenda,lets remember that a number of players will make a beeline for their El Dorado.Already they are all over the global seeking for a mean to accomplish their dream From New York to Quanzhou they will crisscross to seek deals.In all the sectors involved in Big four expect the following

1.Mergers of local well-connected companies and PE funds and incorporated in tax-havens:

Companies with strong ties to influential businessmen will be heavily bought into by PE funds or other multinationals.This will ensure quasi-local ownership that enables them to term its success as a Kenyan success.All the while the profits generated will be flown out of the country.

A number of the local elites will back different foreign players each running the corridors of power to seek favour to enable them out play their rivals.But all is just a sport for them and they will bot seek to really address the problems of the common citizen but to engradise themselves.

2.Clamour for free land and tax exemptions and concessions:

Since most of the developments in the housing plans and manufacturing require massive capital   investment,the foreign investors involved will request and be granted free land to set up their housing units.Also they will seek for suspension of corporation tax and other tax exemptions and review of regulatory framework to facilitate their works.This is in the guise that they would create a lot of job opportunities for the locals and cheap housing(a fallacy).

Already the CS of Industrialisation has opened the floodgate by reducing the work permit costs for Indian investors in the textile industry.

 Read: Cost of permits for Indian textile expats to go down

All the while the local players will be struggling with high-interest loans and double taxation.

Lets remember this,in low cost housing construction,most of the material come already prefabricated and there wont be added benefit of need for local masons to put up the structures.All that the investors would require are casual labourers easily trained to mount structures.The reduced labour cost will be not passed on to the final buyers of the houses but will just increase the margins for the developers and their 10% kickback bossom buddies.

Is Bill Gates a saint or just another rumbustious Capitalist?

As a follow up to the previous post on my perception of the role IFC in shaping the agenda in  Kenya,I would like to address the role of another puppeteer controlling the agenda setting in Kenya and around the world.

Bill Gates and His Gates foundation:

In as much as Bill Gates improved the condition of millions in tackling the HIV scourge and Stop Malaria initiatives.The organization has in the recent past been involved in moves that either signal intention to benefit from the giving back to society which would be almost like a Dr Evil Character out to benefit from saving humanity or he has just been carried away by his perceived greatness that he has decided he and his team knows the problems of Africans and the world and will go ahead and fix it in his own way.

Healthcare:
The Gates foundation has been involved in partnerships with states to tackle diseases in the past.However in the recent past their partners are an odd outfit of vulture capitalists and for-profit companies such as IFC.Some of the deals the foundation now openly supports is one of privatization of healthcare in Kenya.This move seek to encourage additional private investments to achieve sustainable development goals.

Bill Gates and EU in Shs 13billion private health funding

Moreover the foundation is already in continued funding of the Africa Health Markets for Equity program to the tune of $60million.This initiative is multi fold and involves both increase private healthcare service provision,policy review and financing for expansion through the Medical Credit Fund.It basically is a set-up that creates a parallel health system instead of assisting states in achieving their goals of providing medical care to the citizens.

African Health Markets for Equity program sponsored by Gates foundation and DFID 

The foundation has also invested in collaboration with IFC and private equity funds huge sums of cash to increase health private sector.You just have to wonder at the double life of Bill Gates,a man who would pass off as a saint for the role in control of infectious diseases and his Dr Jekyll capitalist alter ego who invests in ventures that seek to take the little that the poor of Africa have to spare. 

Agriculture:

Bill Gates and his foundation have been in the forefront of forcing the Kenyan government to allow GMO maize to be allowed.Even though the government and the people resisted enough,I think the resolve has been broken and sooner rather than later GMO maize will be accepted and available at a local seed company near you.
  
1.Mosanto and Gates foundation pressure Kenya to lift ban on GMOs 

2.Kenya gives nod to open air trials of GMO maize

Its worth noting Bill Gates holds $23.1 million worth of Monsanto shares.(Not that it counts as much to him). 

Media reports have reported on the progress of the testing and just just as a coincidence this week a feature on KTN had the following on the issue.

To cap it all,at the started of the year Melinda Gates came calling and visited State House Nairobi where she discussed various issues including support for agriculture and healthcare.

3.Melinda Gates visits State House and holds talks with the President 

The irony of all this is that a couple who disposed of their wealth in pursuit of cure and treatment for infectious diseases now find themselves supporting solutions that would not add value to the people but instead rob them of the little they possess.

If ever Bill Gates has a soul,it must be a juke box that only accepts pennies and cents from the poor of Africa to his account.Payback for his help with HIV and Malaria initiatives?

I just hope they seek redemption and stop being on the wrong side of history because you cannot achieve universal health coverage through private health service provision.

Are we pushing IFCs BIG FOUR AGENDA ?

Ever since the announcement of Big 4 for rejuvenation of the economy was announced by the President, I wondered who had the vision to come up  with the four and package them in such a way that it would look like a goal worth pursuing and saving grace for the administration in need of a legacy. Going back to several investment overtures by the above entity, I wonder are we being taken for a ride by a plot hatched to market their investments? Is it a fait accompli or do we have a possible remedy? 

I wonder, does the IFC have such a good a soothsayer who could predict that we would be having a focus on their key areas of investment in 2018? In as much as I have my opinion on the matter of foreign investment in key sectors of the economy, I can’t begrudge anyone in need of investment and finding the perfect opportunity in Kenya. The land of opportunity for some and the land of suffering for others.

At the onset of writing this, I thought IFC is not much involved in Kenya. I guess I was wrong. The IFC has been continuously scaling up its operations in Kenya through equity or debt financing to budding ventures. However its in recent past that the investments seem to have increased to the point I just have to mull it and wonder what it all means.

There are areas of investment that they have decided to focus on that are almost carbon copy of the Big Four plans. Be the judge and tell me if it’s just coincidence or it’s a planned takeover of the Kenyan economy. (In Case the Chinese don’t buy us first).

Manufacturing:

Most of the efforts mentioned in fulfilling the manufacturing agenda of the president’s legacy requires funding for capital investment. The IFC has already imprinted its presence in several local companies. Now for the SMEs and other new entrants there will be a need for loans, which will definitely be offered by those invested areas of which the invested company would benefit most.

IFC now invests in leading Kenyan companies

 

Housing:

IFC had already partnered with a Chinese firm in 2015 to develop 30,000 housing units in Sub Saharan Africa in Kenya, Rwanda and Nigeria initially.

https://www.standardmedia.co.ke/business/article/2000164006/ifc-inks-deal-with-chinese-firm-to-develop-affordable-housing-units

Moreover IFC acquired 5% of Mortgage firm Housing Finance with its acquisition of a stake of Britam. Britam already holds 48.8% of Housing Finance shareholding. The article below also notes other forays by IFC including loans to Equity (to be used to loan to SMEs) and KCB and other investments and credit facilities in the country.

Housing Finance notifies watchdog of IFC 5% acquisition

Also

IFC completes buying 10.3% stake in Britam

IFC has also put LaFarge in the loop to advance loans for "low-cost housing" developers for using Lafarge products for every unit.Quite a noble and altruistic motive I presume? 

Kenyans to benefit from Lafarge low-cost home deals

Healthcare:

I don’t need to point out the various investments in healthcare that IFC has already completed before the call for Universal healthcare. The most recent press reporting on the issue is the article below and other writings including the earlier one I wrote in 2017.

IFC targets Kenya healthcare with Shs 11bn equity fund

If reaping from the middle class was not enough,the IFC also targets what they call impact investing in low-income earners.They have given $4.5million to Medical Credit Fund to scale up SMEa in healthcare targeting poor people.

  
IFC backs Medical Credit Fund with $4.5million

The investments aim at increasing the access to healthcare but seems to be misdirected.Universal health coverage cannot be attained through proliferation of private providers.

 

Food Security and nutrition:

Since the fourth pillar of the plan involves food security and nutrition, trust that there has to be an investment opportunity in starvation. The IFC has scaled up the collection of proceeds from relief operations in conflict and famine ravaged areas  by acquiring a stake in it. It invested in Insta products, a company that provides therapeutic foods for malnutrition in conflict zones. Some of the users of the products are UNICEF and World Food Program.

 IFC invests in Insta Products to fight malnutrition in East Africa

In other food security related coincidence,just as the president is starting the Big four initiative which includes it,open field trials for GMO maize have been completed and you shouldnt be suprised to see them being issued out to farmers by the next planting season.

Kenya gives nod to open air trials of GMO Maize

And just on cue a KTN piece on GMO and its need bearing in mind diminished harvests.

 

Leading GMO advocates in Kenya have been the giant Monsanto and ironically the "philanthropist" Bill Gates foundation.Its worth noting Bill Gates holds $23.1 million worth of Monsanto shares.(Not that it counts as much to him).

Since the greater Rift Valley are all in government this time,there will be no objection to passing of GMO act to allow its availability to a seed depot soon. 

As for fertilizers,IFC has given a loan to Nakuru based plant.

MEA gets Shs 1billion IFC loan for fertilizer plant

Did I mention that the VP of IFC for Middle East and Africa Mr Sergio Pimenta was in the country in January 2018 and met the President at State House.In their meeting some of the ways the private sector could help the government were discussed.

Uhuru meets IFC Chief on support for big four

So, I wonder am I the one missing the point or was IFC on to us and are just getting ready to start scooping all the tenders through their proxy firms which they have invested in ? Only time will tell.


Broadly speaking IFc has its toes in all the waters of the land and not a bird that flies or plane is not touched by its impact.IFC owns 10% of Kenya Airways now.Even Tullow oil has a 5% investment from IFC.

IFC Invests Shs 5 billion in Turkana Oil 

and other investments are with KTDA and other players.


I wish to point out that in all this the modus operandi of IFC is to issue loans and equity to fims and they just seat back and reap the profits while you toil.This is the Shylock syndrome that does not benefit anyone the most except the IFC.

In fact IFC has ensure it has its footprint in most commercial banks such that any loan you might take for a business venture today isnt coming from your bank but IFC.Since in most of the arrangements they are not equity for the bank,it only implies a financing mechanism with their cut assured.

As a conclusion we need to understand that IFC is dipping its toes into every venture that looks in the least bit lucrative and I wonder if they are ones setting the agenda or just that they have good clairvoyance.