Catastrophe looms as Kenya's health sector suffers crisis after crisis

Kenya is teetering on the brink of a health catastrophe as doctors in public facilities have laid down their tools demanding better working conditions, implementation of the Collective Bargaining Agreement (CBA), posting of medical interns and medical cover.

Patients once assured of care now find themselves in a dehumanising state, left on their own as hospitals and doctors demand cash before treatment.

Across the country, doctors, including those in private hospitals, have given a seven-day ultimatum to the government to suspend the mandatory use of the Electronic Tax Invoice Management System (eTIMS) in the sector or face a nationwide strike.

If this strike happens, it will exacerbate an already dire situation.

Going by the back and forth that has played out over the last seven days between the Kenya Medical Practitioners and Dentists Union (KMPDU) and the government — ministries of Health, Labour and the Salaries and Remuneration Commission (SRC) — it appears patients will suffer a long while.

On Wednesday, the union officials went to public hospitals and drew out doctors who had reported to work.

The doctors are not attending to emergency and critical services in all public hospitals in the country. Major hospitals including Kenyatta National Hospital (KNH), have stopped admitting patients for elective surgeries and even admission in the wards.

Pumwani Maternity Hospital, one of Kenya's leading facilities in maternity admissions, has stopped taking in pregnant women who are now forced to seek services elsewhere.

“There is an influx at KNH of mothers who want to give birth, but there’s no doctor to attend to them. They are taking this lightly and it is going to be a big deal when we start losing patients because of the government’s stubbornness,” said KMPDU Secretary-General Davji Atellah.

He added that they will not be taken back on what they rightfully fought for and the strike would continue until all their demands are met.

“I know it is our patients suffering but we are also suffering. If I cannot even be attended to in any hospital in the country because I cannot afford the services... surely, which government wants to deny its doctors medical insurance?” he asked.

Dr Atellah said reducing the pay for medical interns and healthcare workers is a slap in the face that they will not take lightly.

“We will fight this to the bitter end.”

“As a union, we had intended to strike with minimal human suffering but the government has continued to provoke us, the latest being the circular from SRC purporting to reduce interns’ salaries by 91 per cent. We hope that the government will climb down from the ivory tower and engage with the unions,” KMPDU Deputy Secretary-General Dennis Miskellah said.

Dr Miskellah also disclosed that Public Health Principal Secretary Mary Muthoni went to court on Wednesday morning to “file the purported circular from SRC on interns’ salary to prove that she is now ready to post interns and waiting for SRC to finish the exercise of salary review”.

In an affidavit filed at the Employment and Labour Relations Court, Ms Muthoni says that issues raised by KMPDU, including implementation of the CBA, salary delays, employment of doctors, posting of interns, postgraduate training and promotion of doctors have budgetary implications on the Ministry of Health.

She says that at the time of the signing of the 2017 CBA, the number of interns was low and that the budgetary allocation to the ministry was sufficient to cover their remuneration.

“The Ministry of Health has no control over the number of students being trained within medical training institutions and therefore cannot control the number of interns requiring placement in the health facilities and may not be able to absorb and pay all of them,” Health Principal Secretary Ms Mary Muriuki stated.

She adds that “the remuneration rates of these interns go beyond the salary structure approved by the Public Service Commission” and that it has “greatly impeded the implementation of the CBA”.

Ms Muriuki further indicates that the Health Ministry had sought guidance from the SRC and National Treasury on remuneration rates for medical interns and that the SRC had approved rates that it will use when posting medical interns on April 1.

A circular containing these rates shows that medical interns, who, according to KMPDU, should be earning a net salary of about Ksh150,000 ($1,132) be paid between Ksh35,000 ($264) and Ksh70,000 ($528).

It is the reason doctors fully withdrew from hospitals, halting critical and emergency services including surgeries.

The circular stated that medical officer, pharmacist and dental officer interns would be paid a stipend of between Ksh47,000 and Ksh70,000, while nursing officer interns (degree) and clinical officer interns (degree) would be paid between Ksh35,000 and Ksh50,000 ($377). Clinical officer interns (diploma) would be paid between Ksh27,000 ($203) and Ksh35,000.

Today, doctors, concerned ministries, the Council of Governors (CoG) and SRC, among other parties, are expected to meet to resolve the ongoing strike following summons by Head of Public Service Felix Koskei.

Two days ago a conciliation meeting failed after Labour, Treasury and Health Cabinet secretaries, CoG and the chairpersons the Public Service Commission and SRC failed to show up.

Today’s meeting also follows yesterday’s directive by the Employment and Labour Relations Court that all parties involved in the negotiations physically attend the meeting to consider all the issues raised in the doctors’ strike notice and the perennial grievances in the health sector.

Even as the doctors battle with their employers, some hospitals are turning away patients who rely on the National Health Insurance Fund (NHIF) cards to pay for service.

This troubling trend, is leaving patients stranded at the intersection of illness and financial uncertainty, raising questions about access to essential medical services as envisioned in the constitution.

Even though the government claimed that the one-year transition from NHIF to the Social Health Insurance Fund, which started last year, would be smooth and patients would continue to get services, the reality is that many patients are being forced to forego treatment for lack of cash.

Earlier this month, over 400 rural hospitals announced their withdrawal of service for NHIF covered patients over an outstanding debt of about Ksh1.6 billion ($12 million).

In 2021, doctors told Timothy Mwangi, a Nairobi-based graphic designer, that both his kidneys had failed. As he waits for a transplant, he has since then, without fail, undergone dialysis twice a week.

While choosing a healthcare facility, a key priority was finding one that accepted NHIF card. Everything was going well, until last week.

“We received communication that in the coming weeks, we will have to pay for the dialysis services out of pocket and later claim from NHIF. The management explained to us that they are crippled because of the money owed to them by the parastatal. For the last four months or so, the hospital has been going into its coffers to pay the staff and buy the much-needed equipment,” Mr Mwangi said.

If Mwangi pays in cash, that will be Sh19,000 every week for the sessions and at least Sh2,500 for blood boosters, which were also being covered under NHIF.

“It is depressing. Before this, I was burdened with raising the necessary funds for the transplant, which is about Sh3 million, and transportation to the dialysis centre. But I am now confronted by this. Tell me, how many people can afford to pay Sh19,000 every week?” he asked.

At the start of every year since 2021, Mwangi has been remitting his annual contribution to NHIF of Ksh12,000 ($90) at a go.

“It’s a requirement and with that, I was hoping that I would get treatment without any challenges. So, when I was told to prepare to pay in cash, I kept wondering, where do I get the money? According to my doctor’s directives, I cannot afford to miss a session because that would be detrimental to my health. It feels like somebody is slowly killing us,” he said.

Ms Margret Otieno had to go back with her child home after a hospital in Kisumu refused to attend to them using the NHIF card.

“What scares me is that I struggle a lot to get even the stipulated Ksh500 ($3.77) to remit to NHIF every month, and when I so need the service, I am unable to get it. I have paid till June,” she said.

She chose to buy drugs over the counter for a flu that has persisted for two weeks.

“I only had Ksh500 with me, this would not have been enough for consultation and even the test that I am sure would have been suggested by the doctors. I don’t have the money,” she said.

“We use money to buy reagents and even drugs that we give to patients, and we expect that after we have given the services, we need to be paid by the government what they owe us. What is currently happening is that it takes time for the money to be remitted and at times we are never paid. We are not going to accept the cards until SHIF is rolled out,” said a manager at a private hospital.

Even as the hospitals wait for the rollout of SHIF, registration is yet to begin. As per the gazetted regulations, registration was to begin this month. It is not clear why this has been delayed.

The implementation of the Fund has been marred by confusion, controversy and opposition, with KMPDU complaining that the change will hurt Kenyans who are working in the informal sector, who have no regular income and are required to pay their annual amount upfront or fail to access services.