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.

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?

Final Nail in the Coffin of Public Healthcare System in Kenya ?

On 7^th March 2017 the President of Kenya, H.E Mr. Uhuru Kenyatta issued an open threat to doctors in the public sectors who were on strike, ”Resume work or get fired”. This act just when some mediation activity was being finalized courtesy the religious leaders signaled a government unwilling to give resolution of the strike a chance. Whatever the legality or genuineness of the strike ,we have to look at this utterance by the President during the Devolution Conference as one that emboldened county governors to take drastic steps to fire doctors and with it reduce the high wage bill they were possibly asking for. What many people don’t understand is that the net impact of such an utterance may have just cost a few thousand patients their lives as the consult of a specialist in a public hospital was a treasured and very rare occurrence that many spend months on the waiting list for a specialist appointment, but It was all lost in one statement.

I hate to say I told you so, but….I told you so. With the imminent sacking of most Kenyan doctors and the promise to the populace that the government will hire foreign doctors to fill the gap left, you have to realize that the second phase towards full privatization of healthcare will be complete soon. Phase three of the privatization involves actively seeking out doctors to join group practices and form consortiums that can provide consultancies to the government hospitals at a fee. This is the way, the breakup of the doctors union will be achieved. Doctors who want in on the action in the consortiums will be asked to renounce their union membership before being allowed to share in the new arrangement of doctors- for-hire. At individual level doctors would have nothing to lose in accepting the new arrangement as they would be assured of better terms of service and better conditions of work. However, Kenya has a deficit of medical doctors and is struggling with a disproportionate illness as compared to the rest of the world. The country is emerging as a major focal point of increased cancer cases in the world. This together with the non-communicable diseases increases call for greater investment in tackling the problem and to safeguard the economic growth of the last decade towards an industrialized nation by 2030.But the moment the government turns back the hand of time and rolls back the gains in health outcomes such as maternal mortality, infant mortality and general health indicators you have to wonder at the sanity of it.

Doctors want improved service provision

Sacking doctors does not in any way help the economic growth of the nation because economic growth is related to level of healthcare improvement in a country. Doctors have all along been advocating for greater government investment in ensuring better healthcare to the bottom of the pyramid Kenyans whose only source of healthcare provision is the local dispensary and district hospital. Proper equipping of the facilities, availability of supplies and sound oversight holds the promise of better health outcomes with minimal per capita cost. However if the intention of anyone is to alienate healthcare from the lives of the poor and to commodify health service provision, many will be left without proper healthcare and facing reduced  greater burden of diseases.

 Creating commercial health workers

Doctors are intelligent knowledge workers who cannot be held captive to any machinations to try and castrate their desire for better terms of service and conditions of work. They will find ways to adapt and already many doctors have started thinking beyond the confines of the borders of the country and we only have to expect a big brain drain soon. Moreover, the nudge they are experiencing will force the few remaining doctors and specialist to move to the private sector and group practices with market-oriented service provision. This will mean fewer doctors and specialist in public hospitals and reduced quality of care and outcomes for the poor unfortunate enough to seek care in government facilities. The private health sector in the country will however will grow in leaps and bounds with market-dynamics forcing focus on lifestyle diseases and aesthetic medicine industry. The specializations involving the diseases of the poor will be neglected and the morbidity and mortality associated with them will be greater.

Public-Private Partnerships

In the spirit of Private-Public-Partnerships (PPPs) most district hospitals will have a private wing dedicated to the provision of better healthcare to those with the financial ability to pay the charges and managed by private firms to ensure “efficiency” instead of strengthening efficiency within the public sector. Later, more government facilities will be urged to give space for PPPs in the false hope that it would ensure provision of quality care at affordable rates. Mercenary doctors will be on hand to treat patients as long as their share is assured. As for the other Kenyans unable to afford the amenity wing, they will not be able to access the same level of care and will just receive palliative care for malignancies, and symptomatic treatment for chronic conditions. The law of demand and supply will obviously make it impossible for the poor to afford specialist care unless they can sacrifice all their little earthly possessions to seek care in the private facilities of the country. So, again I ask, how will the doctors be adversely affected?

Reduced payroll expenses for governments

For the governments both at county and national level however, they only see the reduction in the payroll expense from the offloading of the baggage of doctors’ salaries as a line item in their budgets. This myopic thinking will be the norm and groupthink among governors will ensure uniform implementation of the sack order and replacement of doctors with other cadres of health workers involved in primary care provision. One day in the future, current governors and other government functionaries will regret it because in life you can’t always be on the top of the ladder and one day, they will taste the feeling of not getting a doctor to attend to them when they need it the most.

Private healthcare investment

Another possible enticement for the government is that a market-oriented approach to healthcare will ensure that the populace ceases to look at health service provision as a merit good and instead as a personal good subject to the faulty law of demand and supply. With this thinking the government will be assured of reduced expenditure in the form of payroll expense and increased foreign healthcare investment in line with the recent statement by World Bank President of the availability of $1billion for investment in the next five years. These investments together with others of a similar nature will make doctors lose their sense of social justice and be more inclined to sell their souls to the devil.

So, the choice is clear, reform and improve public healthcare for future generations or break it down for short-term gains of reduced expenditure but with increased fallout. I urge the government planners to think wisely before trapping future generations in an error that could be corrected now.