When survival is the only option

Guest Writer
18 September ,2018

Ed’s note: On the eve of publishing this piece the governor of Nairobi found 12 bodies of infants hidden in boxes in Pumwani hospital. 

Rationally, I think it’s more profitable for this country if I stay breathing. I was – until recently – gainfully employed. A large chunk of that salary went to various government bodies. I file my tax returns on time. I am, by most accounts, good for the economy. If asked on a date and/or job interview, I would say I’m also a good citizen: I read the papers and watch news; I reflect on national politics/gossip, and often argue about it.

And yet, all this considered, I have a sneaking suspicion that Kenya is trying to kill me off.

Certainly, living in Kenya today has its inherent risks: you could die in the hundreds of accidents that happen monthly; your kiosk could be demolished and your entire family uprooted; you could be robbed and killed; you could die in some natural and/or manmade tragedy like your apartment building could collapse with you and your entire family inside, and so on. Let’s think of these as congenital Kenyan problems; if you are born here, perhaps there are some ground assumptions you must* eventually accept.

These congenital dangers are not what I’m talking about right now. I’m talking about what happens when a good samaritan pulls you from the wreckage and rushes you to the nearest hospital. Or when your children are get cholera and you take them to the local clinic. I’m talking about what happens when your wife goes into labour a month before your loan comes through, when your sister has a mental breakdown and must be committed. I’m talking about what happens when you start coughing up blood and need to see a specialist.

Let me explain.

Our national health policy is straightforward: don’t be sick.There is no gesture more characteristic of our medical infrastructure than a silent shrug. Raced over here at 3am with a sick baby but don’t have cash? Shrug. Performed major surgery on the wrong patient, or neglected them? Shrug. Have to travel across the country from your village to access one of the three specialists in Nairobi? Shrug. Raped women who just gave birth in a national medical institution? Shrug. Can’t bury your family until you clear the enormous medical bills? Shrug. Require access to medication or equipment not available in-country? Shrug. Seriously injured in an accident but medical staff on strike? (your guess)

For all the people who have been advocating for better healthcare for decades, this is old news. In fact, it’s in line with what appears to be our broader national ethos: don’t be poor. The difference between our congenital Kenyan problems and the growing urgency of our (lack of) medical infrastructure may not be too large. Both are engineered and sustained for profit. Both are wide-ranging and seemingly intractable. But I do sense a difference, minor perhaps, but enraging. While both problems are stealing Kenyan lives, the health crisis disgusts me primarily because it strikes me as so profoundly preventable as to be malicious. If I survive a car crash only to die in a queue at a referral hospital, hiyo ni uchokozi. If a nurse gives me the wrong name tag and I don’t receive appropriate care, hiyo ni uchokozi. When a pregnant woman dies giving birth in a rural clinic because there was no ultrasound machine, that is preventable.

Here’s what we know: we don’t have even a third of the required number of medical specialists in the country. The current staff are underpaid and overworked. Those in public hospitals, in particular, are decamping at an alarming rate. All the same, the future workforce – medical graduates – are not finding placements. Of those being placed, the distribution across the counties is uneven despite decentralization; over half of medical specialists are in Nairobi alone. Only a quarter of  all Kenyans are covered by health insurance. The National Health Insurance Fund (NHIF) recently downgraded its cover to a maximum of four hospital visits per family for an entire calendar year. In the region, Kenya spends a comparatively small fraction of its GDP (~6%) on healthcare. The entire sector is rapidly becoming privatized, with marked government support for foreign investment. All this is to say: we are nowhere close to achieving universal healthcare. Yes, several other countries are in a similar position. However, given our current resources, and varied happy coincidences of history, our failure is not justified.

But remember, don’t get sick. If you are a patriotic Kenyan, you’ll get malaria, or a bad sore throat. You’ll go to a chemist, pick up coartem or strepsils and be on your way. If you are a rebel, you will break your arm, or contract an STI. You’ll go to a clinic near you, wait, pay, see a GP, get a quick diagnosis, pay again for the medication, and be on your way. If you are at my point or higher then you make it to enemy of the state, and you’ll do something our government seems unwilling to consider but happy to profit from: you will acquire a chronic and/or severe illness.

I used to consider myself lucky. When I first fell ill, I was a consultant and could thankfully afford my own health insurance. In the time I began to worsen, I had shifted to work that provided me with medical cover. Throughout this time, I was still paying monthly for NHIF. Over the past two years, I have been foisted from one doctor to another, crawled from one hospital to another, first trying to get clear diagnoses, and then to find effective treatments, and compassionate care. I’ll spare you the horror of the inbetween. From January to July this year, I accessed over half a million shillings’ worth of healthcare. This does not include the ‘experimental’ or ‘unconventional’ treatments I tried, like additional physiotherapy and testing, that I had to pay for out of pocket.

I have stopped calling myself lucky because I was employed, had insurance, got diagnosed relatively faster than others, received passable care, and responded well to the treatments. Luck should not have to factor here. Let’s go back to the quick maths I started with. Maybe my frame is too narrow. Taxes on my income, and each of my individual purchases may not be enough to earn my keep as a Kenyan citizen. Maybe I’m worth more sick; my being constantly unwell certainly profits a few big clusters: pharmaceutical companies, private hospitals, government official and unofficial coffers. Don’t be sick.

If this country isn’t deliberately trying to kill me, it is, at the very least, not actively trying to keep me alive and healthy. Something has to give. We will continue to be frail humans and if the government insists on not only ignoring but profiting from this fact, then we are playing a fatal game of chicken; whoever blinks first loses. If you don’t get sick, you win. If you don’t get in an accident, you win. If no one in your circle gets ill or injured, you win. Lucky or not, those odds are tough to beat – and no one wins.  I did not.

Alexis Teyie is a writer and editor at Enkare Review

A Health Agenda in Jeopardy

Guest Writer
5 June ,2018

by Dr. Sakulen A. Hargura

Universal health care is a noble idea that is long overdue. For it to bear fruits and build a permanent home in our system, certain fundamental pillars that must be erected. The most important are sound healthcare policies, and adequate expertise to execute the plan contained in those policies.

Kenya has never been short on laws and policies (our constitution attests to our ability to formulate laws and policies). However acceptance, implementation and execution of these laws and policies has always been our weakness. Health is a basic human right. The post independence regime, and subsequent ones as well, laid the foundation for self sufficiency in health. The walk to self sufficiency, however, has been painstakingly slow. So much so that 55 years after independence, we do not have a fully functioning health care system (the kind of which Cuba is renowned for).

Kenya has had shortage of doctors since independence because for a very long time, it relied on only one institution (the University of Nairobi) to train both general physicians and specialists. This hampered the efforts to attain sustainable health care and ensured a constant injection of a low number of doctors into the system, which tried to maintain the distribution of specialists and general medical officers to all corners of the country.

Through remuneration that was commensurate with work environment, for example hardship allowances, and prioritization of doctors in hardship areas for masters study scholarships, the government gave doctors an incentive to move to the far off areas. These scholarships were systematic and deliberate so as to ensure not just constant supply of specialists, but to give the government the leverage to post the new graduate specialists to areas of need as well, be it in the major cities or rural areas. All the original blue print needed was expansion of capacity by giving more universities the resources and mandate to open medical schools in order to expand the inadequate human resource.

The change the Kenya’s public health care system needed to thrive finally arrived at the turn of the millennium with “parallel” degree programs. Medical degrees are long and expensive, and most public universities opened Schools of Medicine to benefit financially. Just as the first batch of these new graduate doctors joined the system, devolution happened. While devolution was meant to attain equity in resource sharing, it was mired by political hogwash that resulted in decisions that were not entirely aligned with the spirit of our constitution. Health was earmarked for devolution, but how to do it without deflation of the existing weak healthcare infrastructure and systems hadn’t been well thought out.

Kenya’s health care was a casualty in the territorial wars pitting Uhuru Kenyatta’s national government against the 47 county governments. To devolve health in its entirety, including human resource, without first holding forums to educate the governors and county health executives on the internal workings of Kenya’s health system was a wrong move. What county government needed was the control and management of the health facilities and infrastructure, as well as the health workers sent to their hospitals by the central government. The core hiring, distribution and training of health workers should, however, have been left at the Ministry of Health until such a time when devolution had been tested and matured.

Right after the hasty devolution of health, many doctors (especially specialists) exited public health care. Many of the counties affected have yet to attract them back despite concerted efforts. The chaos that followed resulted in a disgruntled work force as salaries delayed, the state of health facilities worsened, and the agreements signed with central government prior to devolution were disowned. The county governments not only failed to absorb new graduate doctors churned out by our universities but also refused to release those selected for masters study scholarships. The result was unnecessarily long strikes as central and county governments quarreled over who was responsible

At the moment, we are in a debate about the Cuban doctors joining our healthcare systems. While their credentials and proficiency are not in question, does Kenya need the Cuban doctors or does it need their healthcare system?

Kenya has a shortage of doctors, yet governors have persistently failed to absorb new graduate doctors who have completed their internships leaving them jobless. The same governors have refused to release countless doctors who have been given scholarships to study for their masters to add to the dwindling specialist numbers, with the excuse that they will be absentee employees. This not only denies citizens access to health care, but also derails Kenya’s ability to reach sufficient specialist numbers in the future. The system borne of hurried devolution is gutting Kenya’s public health care.

The Cuban doctors may be appealing, but their presence will not contribute to Kenya’s long term plans of sustainable universal health care. According to the government, they will serve at the grassroots level. This means they will not contribute to systemic education of new specialists in the country, nor will they help drive national policy at the helm. What happens after two years when the Cuban doctors bid us farewell? Do we then have the same program with India?

To bring in Cuban doctors with our existing system, or lack there of, is to transplant a branch of a flourishing tree onto a dry tree. Moreover, to base Kenya’s universal health coverage on a borrowed work force is to throw the seeds of a noble idea on to the rocks.

I believe that Kenya needs to restore the pre-devolution health care system in terms of training and distribution (posting) of doctors so as not to leave the fate of Kenyans in the hands of individual governors. Only then will we see the fruits of the increased numbers of doctors in the country. A body like the Health Service Commission (HSC) could be put in place as a bridge between the county and central governments to enable smooth movement of doctors through the two arms of government for training and posting.

We also need to borrow Cuban health policies, and some of their policy-makers, to duplicate their health care system. If at all their specialists are also brought in, they should be posted to universities and teaching hospitals to help train our doctors, not just to counties where upon the expiry of their tenure they will leave little in terms of long term impact.

Uhuru Kenyatta’s intent and will to implement his big four agenda should be well-informed and concerted. Instead of this public relations exercise, those entrusted with the duty of implementing this agenda should dig deep and consult concerned stakeholders so as to bring holistic and sustainable policies that will see us through another half a century.

Sakulen Hargura is a medical doctor presently pursuing masters in surgery in Turkey. He loves to read, and writes poetry as well as a weekly opinion piece for the Marsabit Times.

What is 1.66 Billion?

Brenda Wambui
1 March ,2016

It has emerged that the amount of money lost in the NYS scandal (according to a report seen by The Nation) could be as much as KES 1.66 billion, up from the previously reported KES 791 million. The extra amount, as much as KES 869,000,000, is thought to have been paid to an additional 15 companies, and is currently under investigation by the Ethics and Anti-Corruption Commission (EACC), though we all know how that will probably go.

According to an affidavit sworn by one of the accused, Ms. Josephine Kabura, the Banking Fraud Investigations Unit (BFIU) of the Directorate of Criminal Investigations (DCI) and the EACC, two of the bodies charged with investigating this theft, took part in committing the crimes and/or covering them up. Kenya Revenue Authority (KRA) has now been drafted into the government created taskforce to investigate the matter (taking over from the DCI and EACC), and claims that the amounts owed by companies mentioned in the NYS theft for income tax and value added tax chargeable on payments are KES 352 million and KES 850.4 million respectively.

It may be hard to visualize what the amounts that are constantly being mentioned in the media as having been stolen from Kenyans by their public officials can do. Perhaps this is why we haven’t seen more sustained public action regarding these thefts: either we are fatigued by the cycle of corruption in Kenya, or do not really understand how much of our livelihood is being taken from us by people we elect, and the people they appoint to serve us. The Office of the Director of Public Prosecutions (DPP) is also currently investigating or prosecuting 88 high profile cases that involve theft of public property in one form or another.

To illustrate the impact of this theft, I will show what KES 1.6 billion (since this is the scandal that will define Uhuru Kenyatta’s first term as president) can do for this country based on a manifesto presented to us by the Jubilee coalition when they went around the country asking for our votes. We will see how many of their flagship projects could have been achieved already with prudent management of our money.

One of the goals the Jubilee coalition had was to resettle the remaining internally displaced persons (IDPs) resulting from post-election violence, the Mau Forest eviction, among other Kenyan tragedies. KES 1 billion was released to go towards resettling the last 5,261 households still in the camps, after which the camps are to be closed. The money stolen from us in the NYS scandal would comfortably have paid for this, and left KES 660 million in spare change.

To improve our security, the Jubilee coalition set as one of its goals the improvement of police pay and conditions of service. This would improve the service they give, and perhaps reduce the brutality occasioned on Kenyans by unhappy/uncaring police officers. According to a new salary structure proposed late last year, a police constable would earn a basic pay of KES 32,880. The 1.66 billion stolen from us would be enough to pay 4,207 police constables for a year. Given that Kenya needs a minimum of 95,000 police officers, up from the current 50,000 (to satisfy the one police for every 450 citizens ratio recommended by the UN), this would reduce our shortage by almost 10% in a year. Their goal in the manifesto is to recruit 15,000 police officers a year, and this would get them 28% closer to that goal. The government also said it intended to spend KES 25 billion improving security. As at July 2015, a quarter (KES 1.6 trillion) of the 2014/15 budget could not be accounted for. KES 25 billion would be 1.56% of this amount. The manifesto put special emphasis on CCTV as a means of improving security. The stolen KES 1.66 billion would be enough to cover 11% of the KES 15 billion tender awarded to Safaricom towards the installation of 1,800 damage proof CCTV cameras, as well as 60 LTE base stations in Nairobi and 20 in Mombasa, connecting 195 police stations in both areas to high speed internet to ease communication.

Health and education are also important pillars of the Jubilee manifesto, with improved pay packages for doctors and other medical practitioners mentioned as one of their goals. Based on a collective bargaining agreement arrived at between the doctors’ union and the government, the lowest paid doctor was supposed to earn KES 180,000 in basic pay per month, up from KES 60,000. KES 1.66 billion would be enough to pay 768 such doctors the pay they deserve for a year.

They also resolved to provide free mosquito nets to all families who need them. Mosquito nets are estimated to cost KES 255 (USD 2.50), last for 3 – 4 years, and protect an average of two people. KES 1.66 billion would be enough to buy over 6.5 million mosquito nets, protecting over 13 million Kenyans from malaria, and saving between 26,000 and 130,000 children’s lives.

The Jubilee coalition set as one of its goals the decrease of the student – teacher ratio to 40:1. Given that we have a shortage of almost 150,000 teachers, and that the Ministry of Education estimates that it would need KES 15.4 billion to recruit 40,000 teachers, KES 1.66 billion would be able to hire 4,311 teachers, leading to a 2.9% reduction. They also set out to provide free milk to every primary school going child, which is estimated to cost up to KES 154 billion per annum for about 12 million children. At an estimated cost of KES 12,833.33 per child per annum, KES 1.66 billion would provide 129,350 primary school children with milk for a year.

To improve social welfare, they set out to provide guaranteed free water supplies to those living in informal settlements pending slum upgrades. As at July 2015, according to UN Habitat, 56% of Kenyans live in slums. Since our population is estimated at 47,217,197 people, this would mean that 26,441,630 people live in slums. The average home uses about 100 litres of water a week. If buying in jerricans, this costs KES 50 per 20 litre jerrican, making it KES 250 a week, and KES 13,000 a year. If buying from a water ATM such as the one in Mathare slums, the cost reduces to KES 2.50 a week, and KES 130 a year. KES 1.66 billion would provide (assuming water ATMs are installed in all informal settlements) 12.77 million households with free, clean water for a year.

These are a few of the ways in which we are robbed by public servants; this is how they steal from us and leave us to die. When will this change? When you and I decide that enough is enough. Until then, the hustle continues.

Architects Of Our Own Despair: Thoughts On Poverty

Brenda Wambui
27 May ,2014

“Once poverty is gone, we’ll need to build museums to display its horrors to future generations. They’ll wonder why poverty continued so long in human society – how a few people could live in luxury while billions dwelt in misery, deprivation and despair.”

Mohammed Yunus

It is easy to think of poverty as a thing that once solved, will lead to unending human prosperity. We just need to find its source and cut it off. Only that poverty has several causes, and once you begin to think about it, it begins to seem like a hydra: when you cut off one head (i.e. when you solve one cause), two more grow in its place. It is exceptionally complicated.

Since money has become the key measure for human well-being, and a human being’s wealth and subsequent value is measured by how much money s/he has, one is considered to be in a state of absolute poverty if s/he lives below $1.25 a day. Absolute poverty is a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information. A person living on this amount of money is unable to access the aforementioned goods and services, and his/her human dignity is undermined.

Poverty is also measured relatively, and this is where studies on income inequality come in. This way of looking at poverty applies social context. The Gini Coefficient measures inequality among values within a frequency distribution, in this case, inequality of income. A Gini coefficient of zero represents income equality, while one of 100% represents a situation where one person has all the income. As at 2005, the World Bank put Kenya’s Gini coefficient before taxes and transfers at 47.7%, while the CIA put it at 42.5% in 2008. For comparison, the global Gini coefficient lies between 61% – 68%. The world’s income Gini coefficient has increased from 43% in 1820 to 68% in 2005. There is no doubt that relative poverty is on the rise. It has been made worse in most countries by both the economic crisis of 2008, and climate change.

There are several theories that attempt to explain poverty. The two major schools of thought are cultural theories and structural theories. Cultural theories blame poverty on the traits of the poor. These theories assert that it is the behavioural patterns and attitudes of the poor which prevent them from being socially mobile. On the other hand, structural theories blame poverty on the conditions in which the poor live: poor education, poor health, poor housing, unemployment, underemployment among others. The distinctive traits of the poor at the heart of cultural theorists’ explanations as to why people are poor are, to structural theorists, reactions or adaptations to the structural conditions the poor live under.

Poverty is more than just an income deficit. Because of this income deficit, poor people are unable to make choices or take advantage of opportunities that would enable them to live long lives with a high standard of living, human dignity and respect from others. Poor people do not live how they do because they want to – it is because of the lack of opportunities to improve their lives. This is why I strongly disagree with cultural theories of poverty, and lean towards structural theories of poverty.

Oscar Lewis, a cultural theorist, coined the term “culture of poverty” in his 1961 book The Children of Sanchez. Lewis based his thesis on his ethnographic studies of small Mexican communities, and his studies uncovered about 50 attributes shared within these communities, for example:

  • A community with little social organization beyond the extended family
  • Mother-centred family organization
  • General feelings of helplessness, fatalism, dependency, and inferiority
  • A strong present-time orientation, including a desire for excitement
  • An early initiation into sex
  • An emphasis on masculinity
  • Frequent violence
  • Middle-class aspirations and values which are not translated into behaviour

Lewis extrapolated his findings and suggested that there was a universal “culture of poverty”. Over 50 years later, many poor communities across the world share these traits. However, to blame their poverty on these traits, as opposed to looking at them as an adaptive technique is fallacious. Certain societal conditions are necessary for the poverty cycle’s continuous perpetration according to Lewis:

  • A profit-based cash economy
  • High under and unemployment for unskilled labour
  • Low wages
  • Little social organization among the poor
  • A bilateral kinship system
  • A value system stressing the individual accumulation of wealth.

This is the portrait of many capitalist societies, and one would even argue that capitalism is the reason why we are poor, but history suggests otherwise. Back when feudalism was the order of the day, the average person was wretchedly poor.

“Capitalism did not create poverty—it inherited it.”

Ayn Rand

So, if capitalism as a system inherited poverty, and we are more prosperous than generations that came before us, what does this mean for us? What can we do on a global scale? Should we wait for things to evolve at their own pace until we have a better system than capitalism, or should we focus on tweaking capitalism until it works?

I believe we should tweak capitalism until it works. Yes, capitalism has brought mankind great prosperity, but its current method of distributing wealth does not work, and this can be seen in the rising Gini coefficient. Our current system allows a small minority to control capital – land, factories, machinery – which are used to produce wealth, encouraging the accumulation of wealth and income by the elite and leaving a relatively small portion of the total of income and wealth to be divided among the rest of the population. With a majority of the people competing over this remainder, it follows that many people are going to be poor. It is inevitable.

In the search for profit, capitalism as it exists now places a high value on competition and efficiency. This motivates companies and their managers to control costs by keeping wages as low as possible (by replacing people with machines or replacing full-time workers with part-time workers). This is rational. It is also rational to shut down entire industries and invest money in other businesses/industries that offer higher rates of return. However, what does this do to society?

It follows, therefore, that we have to do something about the system’s current state, and how it interacts with the people who live under it. To try to change one without changing the other, as has been done by aid programs and governance programs, is futile (their failure rates stand as proof). Wealth tax has been suggested as a means of redistributing income. There would also have to be a few socially geared regulations for companies that prevent them from being able to cause mass unemployment/underemployment because of profits. It may be argued that this goes against the spirit of free markets, but I feel that it would assuage the current situation. For more on inequality, this book by Thomas Piketty makes for excellent reading.

How about solutions that are specific to the Africas? Where can we start the fight against poverty? I believe we should start with food security.

Food insecurity/hunger and poverty in most African countries go hand in hand. Is it possible for all Kenyans to have enough food to eat, despite climate change, growing population and food dependence, inadequate investments in the agricultural sector, food wastage and land misuse? Hunger in many African countries is not because of the absence of food, rather, it is because of lack of income. This is seen in the number of famines we experience. Even worse is the rate of nourishment, or lack thereof. According to the World Bank, as at 2007, 50% of Africans were malnourished and 25% were direly so.

Many of these are urban families, slum dwellers, peasant farmers and casual labourers. Many rural peasant farmers have land, but not large enough or good enough to subsist on without buying from other sources. Climate change has also led to people running short of food during certain seasons, especially the planting season. During these seasons, food reserves are low, while labour requirements are high. As a result, the likelihood of illness increases, partly due to the oncoming rains.

This could be solved by having food reserves and adequate food storage infrastructure. We would need to cut our food loss and wastage. According to the FAO (Food and Agricultural Organization), about 95% of the food loss and waste in the Africas happens during the early stages of food production and supply due to financial, managerial and technical shortcomings in harvesting, storage and cooling techniques in difficult climatic conditions; infrastructure, packaging and marketing systems. Food preservation and processing also needs to become more of a priority. Once we are able to feed our people, we will also be able to ensure they are healthier.

Government failure, which can be argued as the reason why most Sub Saharan African countries have large numbers of poor people, would also need to be solved. People are poor because their governments and capital markets fail them. The youth are unable to get funds to finance their education, the education system is broken in the first place and cannot accommodate enough of them, private healthcare is too expensive and public healthcare does not work, and the poor cannot afford their basic needs because they lack the economies of scale to afford them – as the anecdote goes, being poor is expensive. These things also make it very easy for countries to be in a state of perpetual armed conflict.

One way to overcome government failure is to reach the poor and empower them with information and cause debate, since many of these structural failings that create and perpetuate poverty are in the interests of the rich and (politically) powerful. This is why the West threatening African governments over reform has yet to work. When the poor are aware of the implications of the laws and regulations political leaders make, as well as the importance of voting on principle, perhaps we can begin to see real change. Well informed citizens will also not be easily pulled into armed conflicts, another menace that constantly plagues African countries.

This is not easy, since most poor people work extremely long hours and may have little energy to spare to participate in civic discussions, but it can be done. They also need to be aware of the various ways they can hold public officials accountable, since lack of accountability is one of the biggest enablers of corruption and government failure. Perhaps then, we can begin to see a reduction in mass poverty, and a real increase in the average man’s income and standard of living.