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Universal Health Coverage on the backs of overworked doctors

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Universal Health Coverage on the backs of overworked doctors

It’s one of those hot afternoons. The sun bears down mercilessly on our bare heads. The wind blows dust into our eyes. The short walk from the hospital is punishing. My friend, Dr. M., seems edgy. Something is not right—it could be the sun, or the dust, or the workload. I have known him as a cheerful fellow since medical school. This was a visit to that cheerful friend, to see whether the county health system (which I escaped) has done much damage to the resilient one among us.

As we enter his house, I am afraid it has, but I am not sure how severe the damage is.

It’s an eerie environment as we sip cold juice, reminiscing over a past that seems to have handed us over to a present none of us likes.

“It’s too much.” He says suddenly. His head is in his hands, his eyes bloodshot, his countenance too forlorn.

He tells an unbelievable tale of outrageous demands from the hospital administration. As more and more people registered for the UHC, an already busy county referral hospital became overwhelmed with patients. Long queues started forming before dawn and continued into the night. People with all sorts of conditions came in droves. All those who had avoided hospitals because of financial issues came. He describes a chaotic scene with men, women, and children queuing for endless hours. In such a scenario, people get agitated, people complain, people get fed up.

In response, the hospital demanded that doctors work harder. They insisted that doctors must see no less than a hundred patients during their shifts. My friend, who always wanted to do the best for the patients, always fell short of this quota. He had been summoned several times for a dressing down by the management. He was seen as rebellious.

“And there’s no payment. This is madness.” His snarls, hitting everything close to him. The plastic table flies across the room; glasses shatter, the floor is a mess of spilled juice and broken glass.

“They should have employed more doctors to handle the increased workload. I will not kill myself to help others achieve some ill-conceived agenda. The hell with it, am out.”

He throws a few things into a briefcase. We leave hastily, never looking in the direction of the hospital. We drive in silence to Nairobi, where there’s always hope for some locums. There, he’ll find many more like him. Many young doctors who have left the counties after endless frustrations or open hostility by the authorities. Even counties not piloting UHC, the problem of inadequate workforce, more patients, delayed salaries, and threats left doctors with little else but to quit the system. It is not a hard problem for counties, with so many young doctors looking for work. But considered broadly, it casts a dark shadow over the promise of increasing health quality and coverage.

Health workforce Priorities

A strong health workforce is the foundation of a functional healthcare system. The Global Health Workforce Alliance states that “strengthening the health workforce must be made the key priority for countries to be successful in achieving universal health coverage. This strengthening involves everything from improved training of health care professionals, equal distribution of qualified professionals in the different regions, adequate remuneration, and acceptable working conditions. Every nation that has made good its promise of health care reform has had to make serious investments in these stages of health workforce promotion.

The UN general assembly states that “an adequate, skilled, well-trained and motivated workforce” is critical to the achievement of UHC2. Motivation is what my friend (and the entire generation of young doctors) find utterly absent in the public health system. The relationship between Kenya and her healthcare professionals has always been tenuous. The mistreatment of doctors is a historical problem that is primary to all health care issues. Think about the persistent brain drain that is only getting worse. Then there is the dubious reputation of having the most prolonged and costliest doctors’ strikes in the world. These problems have been there for long, yet devolved health care has caused a complete disintegration of health workforce policy to the extent that may bedevil health reforms for decades to come.

Doctors in the devolved era

The only thing worse than lack of doctors is having few, overburdened, doctors carrying the increasing weight of an expanding healthcare system.

For doctors, devolved healthcare has meant pain, agony, and chaos. At any given time, doctors are on strike or go-slow in at least one county. Their grievances include delayed payment of salaries, often for many months, harassment by county officials, and overwork. In nearly all cases, the doctors who dare to complain are dismissed summarily.  

Counties are employing fewer and fewer doctors even as demands on hospitals increase due to a growing population. Since the end of the automatic posting by the Ministry of Health in 2017, county governments have advertised for just a handful of positions for doctors and employed even fewer. Those who are hired soon become overwhelmed by the work. This pressure is especially harder on the younger doctors, many of whom have quit. Even for those dedicated to serving society, work becomes torture beyond a limit of tolerance.

How does this bode for universal health coverage? 

Consider my friend’s case in the preamble. The difference between doctors and all other health professionals is that doctors are the diagnosticians. Diagnosis is a fundamental step in the health care process. You must get the diagnosis right if you are to get the right treatment and save lives. Making a diagnosis requires putting together information on clinical history, examination, laboratory tests, and imaging findings. It is a painstaking process requiring deep concentration and patience. It is not made easier by the fact that many patients are often not forthcoming with their information; blood tests often take longer to process, and at each stage of the diagnostic process, patients have to wait in line.

And there is always the weight of your vows, knowing that if you get the diagnosis wrong, nothing else will matter. The life of a patient, the integrity of a family, and your career rides on each decision you make at diagnosis.

Think about this: you have to listen, conduct a physical examination, order, and review lab tests, order and review diagnostic images, make a correct diagnosis, and prescribe the right treatment. And do this one hundred times in an eight-hour shift!

Mass treatment camps

It is not just impossible, it is a ridiculous expectation. It shows that the rollout of UHC has not been properly thought out. It is one of those projects that started for political expedience with no foresight whatsoever. The idea that such foundational pillars as the health care workforce appear to have been ignored shows that the entire process is doomed from the beginning.

Without the requisite workforce to drive the process forward, hospitals under UHC will only become a worse version of what they already are—mass treatment camps.

Already, patients wait in long queues to get to a doctor. They proceed in long queues to the lab, to the pharmacy, to everything. Those requiring admission share beds in hospital wards.

Think about this for a moment. Consider grown men or women, their bodies ravaged by diseases, sharing a space no wider than three feet. Think about it; one struggles to breathe, coughing violently into the face of another with heart failure who is barely able to turn. They struggle not to fall off, hoping they’ll be the next one the doctor sees next. Waiting, hoping, until, after death takes one of them, there’s a short-lived moment of respite before another patient in worse condition replaces him.

Many wait for months, even years to get to the operating theatre. At the Kenyatta national hospital, where nearly all referrals congregate, the surgical waiting list extends several years into the future. Outpatient specialist clinics have so many patients that many only get to see a specialist once in years. Many die while waiting. With few specialists in county hospitals, all critical cases are referred to KNH. And with the trend of employing fewer and fewer doctors in the counties, this will only get worse.

A crisis of specialists

We would deal with this by encouraging more doctors to return for specialty training. Yet doctors have found it harder and harder to do so because county governments have canceled study leaves. They cannot continue to pay doctors who are not working in their hospitals. It is an understandable argument. But one has to be severely short-sighted to accept this logic. How can we expand our pool of specialists if we will prevent doctors from undertaking specialty training? What happened to the notion of investing in education so that tomorrow is better than today? There is a great deal of shortsightedness in the entire health reform agenda. On the one hand, we import specialists from Cuba, citing the urgent need for specialist care, then turn around and create hurdles for our own doctors to specialize. Do we not need Cuban specialists today because we failed to train our own yesterday? Shall we not still need imported specialists tomorrow if we fail to train ours today?

Health workforce disparity

The issue of advanced training is a critical one for doctors. Many doctors quit their county jobs to enter residency training. It might seem like a good solution—no cost to the counties. But the county governments also lose their negotiation power regarding the even distribution of specialized workforce. No doctor who has financed their years of residency training will think about returning to the peripheries to work there. That means they all enter private practice in Nairobi, where one does not have to worry about delayed salaries or other problems.

This way, urban/rural disparity will persist, and there is no chance of increasing health coverage. In a country where most of the population lives in rural areas, the majority of doctors and nurses remain in the cities and larger urban centers. If expanding coverage is the end goal, the distribution of the health workforce is the means to that end.

Holistic Approach

One, therefore, wonders what the national policy on human resources for health care is. There must be a national strategy. The Ministry of Health is the final, integrative force in health care. If counties are unable to provide a unified strategy for the promotion of the health workforce, it is because only Afya house has a view of the entire system as a single, integrated mechanism. It is from here that a policy for Human Resource for Healthcare must originate to guide the counties. It is especially so when one accepts that the attainment of UHC rides on a properly developed human resource policy that takes care of training, deployment and retention of doctors and other health professionals.

Are there concrete strategies for resolving the health workforce crisis? Is there a recognition of the inter-dependence and the inter-connectedness of the different areas of health workforce development is critical. Stand-alone interventions will not be effective or sustainable. When an investment is made in training new health workers, parallel efforts must be made to ensure that adequate resources, management systems, and incentives are put in place so to ensure that the new graduates can find employment in the health sector. And if everything else were to fail, retaining those already in the system, making them feel respected and valued so that they do not run away, shouldn’t be too much to ask.

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