KMPDU PETITION TO THE MINISTRY OF HEALTH We the Kenyan doctors under The Kenya Medical Practitioners Pharmacists and Dentists Trade Union (KMPDU) are committed to improving healthcare provision in our country Kenya. We however note with concern that there currently exist certain situations that are an impediment to any such commitment: 1. Shortage of appropriate health facilities That anyone should have to travel 400km to a health facility at the level of the two referral hospitals 48 years after independence is, in a self explicable way, unacceptable. Upgrading of peripheral hospitals means more than to change the signboard to read a higher level than it previously did. Existing hospitals must be upgraded in terms of staff, equipment, medication and infrastructure. In addition, at a total cost of approximately 37.6B, just slightly more than the cost of the Thika Super highway, 47 new state of the art hospitals should be built, one in each county, perhaps two in the most expansive counties. We need to emphasize that 90% of Kenya's population cannot afford meaningful private care. It is therefore imperative upon the two ministries of health to ensure that care in public facilities is as good as that which they could expect for their families elsewhere. Given that this is the key responsibility of the two ministries, KMPDU demands that the construction of these facilities be embarked on in the immediate term. 2. Inadequate equipment Equipment for basic yet lifesaving procedures remain absent, inaccessible or run down. For example dialysis machines exist in only four towns and total twenty four in number. Compare this with the more than four thousand kidney failure patients who require dialysis up to three times a week. KNH with its out of date machine remains the only therapeutic radiotherapy centre serving a population of forty million. Functional ICU's are to be found only in the two referral hospitals. Level 5 hospitals still use oxygen cylinders while many district hospitals have none. Whatever class of medical equipment one may think of, there is a gross shortage. KMPDU demands that the ministry lays down a clear plan to address these shortages over a period of 12 months with an immediate upscaling inn certain centres to show seriousness. 3. Poor staffing Our country Kenya faces a shortage of 32,000 doctors as there are approximately 8000 doctors in the country. Of these, only 3000 are in public service! The country similarly faces a shortage approximately 40,000 nurses. There are only approximately 17,000 in public service, and this is while there remain thousands of unemployed nurses in the country! Public institutions are greatly understaffed. There is gross shortage of personnel ranging all the way from specialists to cleaning staff. There is a constant, unchecked exodus of trained personnel from public service resulting from non-progressive and sometimes blind board room policies. The two ministries of health need to get to the ground and see the true needs which they will then have to address in appropriate and lawful ways. KMPDU demands that the ministry immediately employs all the available and qualified medical personnel and sets out a clear plan with a timeline of how the remaining shortages will be addressed. It is noteworthy that the ministry has recently resorted to introduction of slavery edicts to try and forcefully retain staff in public institutions. Meaningful staff retention can only be attained when staff stay willingly because of fair treatment, work conditions, personal development opportunities and fair remuneration. 4. Staff training In healthcare, training of personnel is mandatory. There is no magical way through which specialists and skilled nurses will appear except by training. The shortages in these areas are devastating. Patients suffering operable head injury in road traffic accidents are referred from the City of Kisumu to Nairobi for the surgery because there is nowhere else to find a neurosurgeon. Needless to say, most of these patients have suffered irreversible brain damage including brain death by the time they get to there. The ratio of specialists in public service per population ranges from 1 in 600,000 to 0! in 40,000,000! Some ministry officials have been reported as saying that Kenya does not need specialists. This demonstrates a great degree of either lack of concern or lack of information, or both. Either way, there must be no room for this degree of incompetence in any ministry of health anywhere. For the sake of the Kenyans the ministry purports to serve, the number of specialists to be trained per year should be quadrupled. KMPDU demands that the ministry sets out a clear plan with timelines of how it intends to bridge the shortage of specialists. 5. Enslavement of specialists in training While it should be clear the great need there is to train specialists, while every effort should be made to encourage doctors to go back to school and acquire the necessary skills to bridge the aforementioned gap, the Ministry, in collaboration with individuals and the two referral hospitals, has adopted, propagated and sustained a policy of exploitation and enslavement of specialists in training, coupled to typical slave era like intimidation of those who dare oppose this. Contrast this with Israel which, as part of the agreement to end the recent strike is paying doctors a large financial bonus to undertake specialist training. If that is too far out, contrast that with the Agha Khan University Hospital here in Kenya where their specialists in training not only pay no fees, but also take home nearly twice as much as a government doctor, alone in the periphery. Undoubtedly, industrial and civil action against both the ministry and individuals to the extent of abuse of office – KMPDU intends to pursue individual responsibility wherever possible rather than have the taxpayer meet the cost of individual profligacy – is forthcoming. Having made the request for the last one year to your ministry that this issue needs to be addressed without any response, KMPDU is under no illusion that your ministry cares what we the doctors think. However, be guaranteed that for as long as the free world follows the policy of compensation for work done, KMPDU intends to see the end of this madness – slavery of a country's citizens by its ministry in the 21st century! This is an absolute goal. 6. Intimidation For the last one year, we have urged that the policy of intimidation should end and areas where doctors have been wronged, such as in the wrongful, unprocedural dismissal of Dr. Onyimbo, should be reversed. One area where we must give your ministry marks is consistency. You have consistently ignored our opinion as doctors and carried on with whatever action, programs or policies you wished. That public health provision is inadequate is not a secret – high school students note as much in their debates. Roadside declarations arbitrarily transferring doctors, stopping their salaries or dismissing them altogether with the intention of instilling fear in them has not ended. Why then should a qualified doctor be threatened, interdicted and summarily dismissed for suggesting ways of improving this system? While KMPDU considers the extent of criminal abuse of office Vis a Vis civil litigation against individuals in several of these cases, we demand that the ministry puts a stop to this. 7. Retention of officers who have failed to deliver In a recent newspaper supplement by the ministry of medical services, published on the day of the official opening of the Lucy Kibaki hospital, there is mention of 71% satisfaction by the public with public sector health care delivery. All ministry officials responsible for this attempt at deception should be dismissed. This misinformation is the kind that gets to the principals and other players in other sectors giving the false impression that the health sector is doing well for its citizens while the tragic reverse is the true version. In fairness, let us judge trees by their fruits, individuals by their results. The public health sector is in tragic place. The shortages in staff and infrastructure are catastrophic, maternal mortality has gone up, anyone born in Kenya has an 11.5% chance of dying before the age of 5 years, funding of healthcare as a percentage of the national budget is on the decline, counterfeit drugs fill our shelves, all this contributing to bringing the country to the brink of a doctors strike for the first time in 17 years and potentially on the brink of an unprecedented and catastrophic health sector wide strike. Surely, this points to colossal failures by the so called technocrats who have also been accused severally of being opponents of meaningful change. We propose that it is insane to do the same things, the same way with the same people and not expect the same results. In the health sector, this insanity will result in further needless deaths of ordinary Kenyans and must be stopped. In line with encouraging results and best practice in other sectors such as the judiciary, key management positions in the ministry including the directorate of medical services, must be advertised, competitively applied for and the interviewees publicly interviewed by people with a track record of good performance in the health sector. 8. Management of Public sector health institutions There is a current push to have doctors out of the management of public health institutions the reason given is that they are not trained as managers and therefore make poor managers. We appreciate the fact that someone was looking at ways to come improve the situation and hence the suggestion. However, in medicine given the high stakes involved, trial and error, which is what the current situation in KNH amounts to, is not an option. Decisions must be made not based on ideas, but on research and on facts. We put it that this policy was ill though out and poorly researched for the following reasons: The largest currently available research in the area of hospital management by various professionals Vis a Vis outcomes is the 2008 research by McKinsey and Company and the London school of Economics and Political science which concludes that hospitals ran by managers with a medical background are better run and have better outcomes. Other studies have come to similar conclusions. These studies were either not sought or were ignored. Attributing the major failures of, for example, KNH to its director not only amounts to passing the buck to junior officers (junior to senior ministry officials) but also demonstrates a catastrophic lack of understanding of the problems afflicting the national hospital. We thought the following would be obvious but we will enumerate nonetheless: The most striking and visible problem with KNH is that it is taking care of patients way in excess of its capacity – patients sharing beds, on the floor, waiting more than a year for surgery, terribly long and overwhelming queues and so on. The reason for this is that there simply exist no other facilities capable of handling these cases. To remedy this, should the director turn away patients to nonexistent facilities or should the ministry replace him? None of the above is KMPDU's answer. The solution is to build other institutions capable of handling these cases and take the extra load off. The referral hospitals are underfunded. The total development allocation for the two referral hospitals in the 2010/2011 budget was 100million. Given the innumerable shortfalls in equipment and infrastructure, this amounts to a not so funny joke. There is a shortage of personnel. More than half of the doctors in KNH and upon whom the hospital depends are unpaid slaves. The director does share responsibility for this but only together with your Ministry. The principle on which this policy is based is itself flawed. Private hospitals are businesses and it makes sense to have business managers run these institutions so as to make the maximum profits. However, the primary concern of public health institutions is to provide health services. It is necessary to have health service providers run these institutions as they understand best what health programs will impact the general population's health in what way. This is critical but was overlooked. We cannot commercialize public hospitals nor privatize healthcare. There exist medical professionals who have gone further and done Masters in Business administration. This group of professionals would address both qualification concerns but there seems to be an irrational obsession with removing medical professionals from the running of these institutions, therefore having a medical degree has been made a disadvantage in these applications. The policy is discriminatory against and disparaging of doctors. Nobody is going to argue that because Dr. Willy Mutunga is a lawyer, he is not qualified to run the judicial system, nor will they argue similarly in other professional companies. It is only doctors who are singled out as inept at everything else except treating patients, a clear insult. 9. Working hours Most civil servants work 40hrs a week. Many doctors work in excess p of 70hrs a week. In addition, doctors know nothing like public holidays, weekends, or nights. They work when duty calls, often at great cost to their own health, families, and relationships. KMPDU demands that working hours as stipulated in the labour laws be adhered to when it comes to doctors. Any extra work done as necessitated by the unique nature of the work be calculated and paid for as stipulated in the same laws. 10. Fair remuneration The new constitution entrenches each individual's right to fair remuneration. Looking at the training required to be a doctor let alone a specialist, the value of a doctor's work, the extraneous nature of a doctor's duties, the shortage of doctors meaning that the few available are overworked, the risks to personal and family health involved and in comparison to remuneration in other health systems in other countries, it is clear that the Kenyan doctor is grossly underpaid. KMPDU recommends the following as the gross pay for the various cadres of doctors in Nairobi. Lowest paid doctors (interns) Gross income 214,000 Intermediate level doctors (medical officers) Gross income 285,000 Specialists from day 1 out of school Gross income 428,000 Senior specialists, Lecturers and Professors Gross income 856,000 (All income subject to full taxation as per income tax law) In addition to these gross values, the further from Nairobi one is, the more they should earn. This is to encourage urban to rural posting of medical professionals. There should also be a 6 – 8% automatic annual increment so that the longer serving doctors earn more than the newer doctors. Doctors are not the only poorly paid medical professionals, nor are they the only ones working in the highly biohazardous and hence risky hospital environment. While we don't represent the other cadres of staff, their work and presence are critical to a functioning health system and are key complements to a doctor's work. We recommend that the current gross income for the currently underpaid, overworked, unmotivated and negelected nurses, clinical officers and other paramedics be quadrupled to stem their exit from the public service and thus support doctors better in their work. 11. Comparisons with other civil servants In denying doctors their rightful dues, doctors have often been compared to other civil servants. One such comparison is with others in the same job groups; whether proposed income increases would not be way out of the job group. KMPDU derives from this the logical conclusion that doctors are currently several job groups lower than they should be and this should be addressed. A second comparison is at the entry level where intern doctors are compared with other doctors in other professions. The current PS often gives stories of when she was an intern. KMPDU wishes to point out that the only similarity between an intern doctor and any other intern is in the word "intern."Beyond that, there can be no comparison. For example, how many yet to be born babies, stuck in their mother's wombs threatened with potentially fatal birth complications do other interns deliver alive and healthy, to their grateful mothers? How many baby's at risk of dying by the end of the day from dehydration do other interns save? Perhaps the more important question is how do life-protecting and lifesaving roles compare to other roles? KMPDU demands that these nose-length comparisons aimed at devaluing the work of doctors end. 12. Health service commission This country is witnessing revolutions in the judiciary and education sectors. These changes can be attributed to the meaningful work done by bodies such as the Judicial service commission and the TSC. A similar body, the Health Service Commission, must be created in the health sector. 13. Underfunding of healthcare by treasury. While not absolving individuals who have demonstrated great ineptitude at the two ministries of health, a lot of the shortages in the health sector can be justifiably blamed on underfunding by treasury. The two ministries of health must play their part in pressuring the treasury into meeting basic health funding levels as laid out in the 2001 Abuja declaration and as recommended by WHO. The passive approach hitherto adopted has cost lives and its continuation portends disaster for many families who are stuck with public healthcare. The recommendations made by KMPDU are reasonable in the eyes of any objective observer. Having made similar requests for the last one year to your Ministry without any meaningful response, KMPDU is under no illusion that your Ministry cares what we the doctors think. We do however hope that you will find compulsion from whatever quarters to satisfactorily and in good time address these grave issues. KMPDU on its part will continue to support all initiatives geared towards the attainment of meaningful healthcare Kenya.