Field Report: Kenya
by Kathryn Paul, MS4, Sarah Leeper, MD, Justin Myers, DO, MPH
From December 2016 to March 2017, more than 5,000 doctors in Kenya’s public sector went on strike in an attempt to improve conditions for doctors and patients. 100 difficult days without public medical services followed. Outside of Kenyatta National Hospital in Nairobi, public hospitals were either closed or staffed only by nurses and clinical officers who have a limited scope of practice. This February, an attending, global health fellow, and fourth year medical student from UNC had planned to travel to Nairobi to complete ongoing research in pediatric emergency care. After years of groundwork, funding, and connections had been made, they decided not to cancel the trip, despite the strike. Rather, they felt it would be an excellent opportunity to continue to further understand and appreciate the complexities of the Kenyan medical system. The following is their report on the situation, examining the factors that led to this impasse and the effect the strike had on patients.
Most Kenyans are highly dependent on public sector health services. In 2013, 58% of all outpatient visits and 56% of all inpatient visits were within the public sector. However, only 6% of the GDP goes to health care expenditures, leaving public sector physicians struggling to provide effective services. Doctors in the public sector used social media to share stories (Figure 1) of working in dangerous conditions with poorly stocked facilities. Dr. Oroko, Chairman of Kenyan Medical Practitioners, Pharmacists, and Dentists Union (KMPDU), said physicians had come to feel that they “needed to go to school to be trained on how to supervise deaths,” due to how ill-equipped some hospitals are.
These conditions, combined with low salaries (the lowest paid received Ksh.35,910 per month - less than $400 USD), have led many physicians to move to the private sector. 74% of Kenyan doctors work in private healthcare facilities, whose fees place them out of reach for the majority of the population. Others leave Kenya; a 2005 study shows a physician emigration rate of 51%.
The physician union points to poorly funded public facilities and low physician salaries as the impetus for the current strike. At issue was a 2013 collective bargaining agreement that was signed by members of KMPDU and the Kenyan government, but never implemented, which included provisions for improvement of the public sector, as well as a salary increase for public sector physicians.
The available literature addressing the effects of physician strikes on indicators of health has not sufficiently addressed developing countries in which most emergency services are withdrawn. However, one prior study in South Africa demonstrated a possible increase in mortality. The strike in Kenya was unique in that Emergency services were nearly completely withdrawn from the public sector. A series of interviews with staff at Kenyatta National Hospital in Nairobi, Kijabe Mission Hospital outside of Nairobi, and Tabitha Medical Clinic in Kibera provided some initial on-the-ground impressions.
Kenyatta National Hospital
Because Kenyatta National Hospital is a national referral center, the Kenyan military employees, non-participants in the strike, were sent to staff the emergency department there. Even with their presence, the impact was severe. The Accident and Emergency (A&E) department went from seeing up to 200 patients per day to around 50 patients per day. Only the most emergent of patients were seen. If admitted, patients could not be guaranteed that physicians would be available to provide inpatient care. One nurse described calling five to ten physicians before someone said they would come. Once they received a commitment, “He would take his time to come or not come at all,” the nurse said.
In the week prior to our interview, KNH had admitted a two-and-a-half month old with gastric outlet obstruction, who came in with abdominal distention from a peripheral hospital. “She was seen, investigations done, ultrasound confirming gastric outlet obstruction. The surgeon…he could not come. They called the next one, he could not come. Until the last one, he said he will come, but he did not come throughout the night, so the child succumbed at 5 a.m. Yeah, it’s very hard.”
Faith-based organizations, which typically charge lower fees than private hospitals but higher fees than public hospitals, were busier than ever attempting to meet the increased demands on their services and had been forced to limit their care to the most emergent patients. Dr. Berg of Kijabe Hospital reported anecdotal evidence that their patients were of a higher acuity than usual, suggesting that they had waited longer to present for care, and mortality rates were higher for the months of the strike than of the months preceding.
Tabitha Medical Clinic
The neighborhood of Kibera in Nairobi, considered the largest shantytown in all of Africa, is home to 250,000 people. A nurse at Tabitha Medical Clinic in this community explained that they had previously relied on referrals to Mbagathi District Hospital when patients required hospital level care. With district hospitals closed during the strike, they referred instead to nearby St. Mary’s, a mission hospital, where patients are often required to make a deposit prior to admission. The lowest paid inhabitants of Kibera live on $2 a day, and many patients struggle or are simply unable to come up with the necessary funds. Patients recently referred (but not guaranteed admission) included a child in sickle cell crisis, an infant in the throes of malaria, and a pregnant woman requiring a caesarian section due to a large fibroid burden.
Now that the strike has ended after a promise from the government to increase salary and to develop a new collective bargaining agreement within 60 days, coordinated research efforts will be vital in an effort to quantify the impact of this conflict. Doctors should continue to deliberate the ethical and societal implications of “industrial action” in our profession. Hopefully, the aftermath of this strike will be a step forward for public healthcare and medical funding in Kenya.