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.