Tales of neglect, breakdown in Kenya's public hospitals

Monday December 12 2011

By CHRISTINE MUNGAI

Dr Lucy Ngina got into medicine because of a tragic family experience in her teens.  

“I was 17 when my twin brother died of complications from sickle-cell anaemia,” she says.

“My parents are both in the medical field— my mother is a nurse, and my father is a clinical officer. My brother’s illness meant that medical care was an everyday reality at home,” she says. 

Dr Ngina says her brother’s death pushed her to become a doctor. “Losing him was hard... I therefore wanted to save lives, and spare people the pain that I went through.” 

But she was not prepared for what she would find on her first week on the job. “The blood analysis machine broke down on my first week of internship. With no tests possible, I had to either guess what the patient was suffering from, or send them to a private laboratory for analysis.”  

Dr Ngina is now a doctor at a district hospital in southwestern Kenya, but conditions are not any better. Basic provisions like gloves and syringes are constantly out of stock.

“We are always sending patients to buy their own syringes, needles and even bags for intravenous fluid.  

“I use size six gloves, but you can only find size seven-and-a-half gloves if you’re lucky. A month ago, I was performing a Caesarian section on a woman who was HIV-positive. That day, I couldn’t find gloves my size so I was forced to use the bigger size. I ended up pricking myself, and I’ve been on anti-retrovirals ever since.” 

On Monday, she joined thousands of doctors in public hospitals who went on strike demanding 300 per cent pay increase. Should this happen to pass the salary of interns will rise from $337  (Kshs30,000) to  $1,348 (Kshs 120,000), those of medical officers from $674 (Kshs60,000) to $2,696  (Kshs180,000) and the highest paid doctors — medical specialist II — from $1,460 (Kshs130,000) to $5,842 (Kshs 520,000).

Doctors who spoke to The EastAfrican said they did not just go on strike because inflation is hurting them, but also to protest deplorable working conditions and the failure to invest in the public hospital infrastructure.

Though Kenya’s spending on public health has grown in absolute terms to $461 million in 2010 from $133 million ten years ago, the level of investment as a measure of the size of the economy has stagnated at 2 per cent since 2005. This is the second lowest in the EAC, according to data from UNDP. This is also below the 15 per cent recommended by the World Health Organisation. Underinvestment in doctor and nurse training and infrastructure has produced a public health system that is not only bursting at the seams, but dangerous to patients.

The Kenyan health system is one of the most dangerous in the world, producing the worst outcomes as measured by mothers and babies who die during childbirth.

Part of the problem is that the government and major donors like USAid and Bill and Melinda Gates Foundation have focused on the “big” diseases such as HIV/Aids and malaria, which receive a lot of political attention on the global stage. The basic diseases that kill most people are largely neglected, a situation that is aggravated by the deplorable working conditions. Specialist doctors in rural areas are made to do with badly equipped and, in most cases, moribund infrastructure such as operation theatres.

Dr Hannah Kamau works as an intern at a provincial general hospital, where they are the only two interns at the gynaecology/obstetrics department. Normal working hours are from 8 am to 5 pm, but she also does ward rounds and is on call every other night from 5pm to 8 am. “On call means that you work the night shift. If I am on call on Monday night, it means that I have worked from 8 am on Monday to 5 pm on Tuesday.” 

She is also working day and night every other weekend, sometimes performing up to four Caesarian sections (CS) in a night. One CS takes an hour, or sometimes two hours to perform. 

Turns

“We take turns with the weekend off. When I’m on duty, I work from 8 am on Friday to 5 pm on Monday. I mostly sleep in the hospital, and sometimes sneak away to my house for half an hour just to take a shower.”  

With just one more doctor, Dr Kamau would be on call every third night, and perhaps work part of the weekend instead of the solid 72-hour shift that she puts in every other weekend.  

The shortage of doctors is a serious problem, not just in Kenya, but the wider East African region. According to the World Health Organisation, globally, there is an average of 14 physicians per 10,000 of the population, but Africa is served by just two physicians per 10,000.

Even against Africa’s dismal statistics, East Africa still comes up short: There is only one physician per 10,000 of the population in Kenya and Uganda, and less than 0.5 in Tanzania. 

“Brain drain is one of the biggest problems,” says Dr Were Onyino, in charge of media relations at the Kenya Medical Practitioners, Pharmacists and Dentists Union. “We are losing up to 80 per cent of interns to the private sector and other countries.”

The country now graduates over 500 doctors a year, up from just 100 in the 1990s, mainly because of the expansion of the public universities to accommodate privately-sponsored students. About 350 medical graduates now emerge from the parallel degree programme, and only about 150 are government-sponsored.

It takes nearly 12 years and over Kshs3 million to train a specialist doctor in Kenya, five years of medical school, a year of internship in a government hospital, three years of graduate school at Kshs 200,000 each year, and two to three years in which a doctor is bonded to work for the government. Only after all this can a doctor be licensed as a specialist. But even then, one can only hope to make between Kshs 80,000-90,000 a month in a public hospital.

Doctors serving in the public sector have dropped from 3,000 in 1994 to 2,300 today. An increasing population means that the shortages are getting relatively worse. 

The doctors’ number one demand is that the government urgently improves the dismal facilities in public health institutions, which they say have been grossly neglected over the years. 

Dr Kamau says she has had to perform Caesarian Sections by flashlight and candle when electricity at the hospital goes off and there is no fuel for the generator. It is not unusual for her and her colleagues to ask patients to bring their own scalpels for surgical procures and IV fluids.

“The lab is not functioning at the hospital where I work because there are no reagents. That means that I cannot perform the basic tests for diseases like typhoid and malaria, which need blood tests to diagnose,” says Dr Kamau.

“To diagnose pneumonia, I need a chest X-ray done and we can’t do it, so patients have to be sent to a private clinic.”  

If a patient presents with a more complicated illness like renal failure, Dr Kamau is unable even to refer them to Kenyatta National Hospital for dialysis.

Hands tied

“The patient could have all the signs of blood toxicity, and clinically you can tell the kidneys are failing. But Kenyatta cannot admit a patient for dialysis without a urine test that confirms high creatine levels. My hands are completely tied. It’s very frustrating.”  

The harrowing conditions at public hospitals often do not hit home for the middle-class, who have access to private health care. But a doctor at Mater Hospital in Nairobi says that it quickly becomes a reality if one requires a long hospitalisation. 

“Medical insurance often runs out in a matter of weeks,” says the doctor, who wished to remain anonymous. “The only option at that point is Kenyatta, and there, it’s the same miserable conditions for everyone, unless you can afford the private wing.”