One of the most under-recognised causes of morbidity and mortality in healthcare is the illusion that a health service is functioning simply because its doors are open.
A hospital can be open, patients can be admitted, and a maternity unit can appear operational — yet the service may be dangerously understaffed.
In some circumstances, that can be more dangerous than a facility that is closed.
Consider a maternity unit with only one nurse or midwife.
How does one nurse manage a shoulder dystocia, when one of the first actions is to call for help?
How does one nurse simultaneously resuscitate a mother with a massive postpartum haemorrhage (PPH), administer uterotonics, secure IV access, monitor vital signs, arrange blood, document care and escalate to theatre?
How does one nurse manage a cord prolapse, maintain elevation of the presenting part, monitor the fetal heart rate, mobilise the theatre team and prepare the mother for an emergency Caesarean section?
These emergencies do not wait for staffing levels to improve.
A maternity ward is not safe merely because it is open.
THE AVIATION INDUSTRY TEACHES US SOMETHING ABOUT “GOODWILL”
Let me deviate briefly from healthcare.
The aviation industry recently experienced industrial action that disrupted travel and caused enormous losses.
One lesson from aviation is that an organisation can appear adequately staffed because experienced workers routinely compensate for weaknesses in the system.
Experienced aviation personnel know how to make operations flow efficiently. Through judgement, institutional memory and professional goodwill, they solve problems before passengers even realise there was a problem.
The same happens in healthcare.
Experienced nurses routinely stretch themselves beyond what appears on a duty roster.
– They stay beyond their shifts.
– They cover staffing gaps.
– They recognise deteriorating patients early.
– They improvise when commodities are unavailable.
– They call doctors before disaster strikes.
– They mentor younger staff.
– They simultaneously manage several labouring mothers because there is nobody else available.
Eventually, administrators begin to mistake extraordinary professional goodwill for adequate staffing.
It is not.
When workers withdraw that goodwill, the true fragility of the system becomes visible.
DAY 37 OF THE NURSES’ STRIKE
Kenya’s nurses’ strike has now reached Day 37.
Thirty-seven days.
Thirty-seven days in which maternity wards, newborn units, theatres, outpatient departments and emergency services have been operating under extraordinary pressure.
At the centre of this dispute are longstanding labour grievances, including implementation of negotiated agreements, allowances, working conditions and other employment concerns.
Whatever disagreements may exist about the details, one fact should trouble every Kenyan:
A nurses’ strike affecting essential health services should never be allowed to drag on for 37 days.
Resolving it should be a national emergency.
Instead, the country appears to have normalised it.
County governments have attempted to keep facilities operating using locum and other temporary personnel. Their contribution is welcome and important because emergency healthcare — particularly maternity and newborn care — cannot simply stop.
But let us not deceive ourselves.
You cannot adequately replace the numbers, experience, teamwork and institutional knowledge of an established nursing workforce with emergency locum arrangements.
A facility may therefore be technically “open” while operating substantially below the staffing levels required for safe care.
That is the dangerous illusion of functionality.
WE ALREADY KNOW WHAT SUBOPTIMAL CARE DOES TO MOTHERS
I participated in Kenya’s Confidential Enquiry into Maternal Deaths between 2017 and 2022.
One lesson was repeatedly clear:
Suboptimal quality of care contributes significantly to preventable maternal morbidity and mortality.
For years, Kenya has invested in encouraging women to deliver in health facilities under skilled birth attendants.
Now many of those skilled birth attendants are on the streets demanding resolution of their employment grievances.
Meanwhile, women are still becoming pregnant.
– Labour has not gone on strike.
– PPH has not gone on strike.
– Eclampsia has not gone on strike.
– Cord prolapse has not gone on strike.
– Obstructed labour has not gone on strike.
– Ruptured ectopic pregnancies have not gone on strike.
– Premature babies have not gone on strike.
Every hour that the dispute remains unresolved, the healthcare system must somehow manage these emergencies with a depleted workforce.
Speak privately to doctors and other healthcare workers currently holding services together and you will hear disturbing stories of what patients are going through.
THE ECONOMIC CRISIS AND THE HEALTH CRISIS ARE CONNECTED
We must also ask why workers are increasingly angry.
Healthcare workers do not live in an economic vacuum.
They buy food.
They pay school fees.
They service mortgages and loans.
They pay rent.
They buy fuel.
They pay taxes.
They support families.
The Kenya Kwanza administration has imposed an increasingly heavy burden on household incomes through taxation and statutory deductions, including the Avoidable Housing Levy and mandatory health contributions.
At the same time, high borrowing costs and the wider cost of living continue to squeeze households and businesses.
Government cannot continuously take more from workers’ incomes and then appear surprised when those workers insist that negotiated remuneration and allowances must also be honoured.
You cannot increase the cost of being Kenyan while suppressing the price of Kenyan labour.
That contradiction eventually expresses itself through industrial unrest.
And when industrial unrest occurs in healthcare, the price is not merely lost productivity.
The price can be human life.
HEALTH FINANCING IS ADDING ANOTHER LAYER OF DISTRESS
The nursing crisis is occurring within an already strained health-financing environment.
Healthcare providers continue to raise concerns about unpaid legacy NHIF claims, SHA reimbursement delays, rejected claims and administrative difficulties.
When public services are disrupted, patients naturally turn to private facilities.
But when private facilities themselves are struggling with reimbursement and some limit services because of unpaid claims, patients are pushed towards direct out-of-pocket expenditure.
The result can be catastrophic health expenditure for families already squeezed by taxation and the cost of living.
This is how governance failures reinforce each other.
– A labour problem becomes a health-service problem.
– A health-service problem becomes a financing problem.
– A financing problem becomes a household economic crisis.
– And ultimately, some of these failures become preventable illness and death.
EWENE: POLICIES CANNOT SAVE MOTHERS — IMPLEMENTATION DOES
This brings me to EWENE — Ending Preventable Maternal Mortality, Every Newborn Action Plan and Ending Neglected Tropical Diseases, particularly the maternal and newborn commitments around preventing avoidable deaths.
The government has correctly identified maternal and newborn survival as a national priority.
But maternal mortality does not fall because a policy has been launched.
– A policy document cannot manage PPH.
– A presidential launch cannot resuscitate a newborn.
– A slogan cannot manage eclampsia.
– A banner cannot perform an emergency Caesarean section.
People do these things.
– Midwives do them.
– Nurses do them.
– Doctors do them.
– Anaesthetists do them.
– Clinical officers do them.
– Laboratory personnel do them.
– Blood-bank teams do them.
The health workforce converts policy into survival.
Therefore, there is a painful contradiction when government launches ambitious maternal-health initiatives while nurses remain on strike for more than a month.
Parting shot
You cannot claim to prioritise ending preventable maternal deaths while failing to address the Nurses strike noe on day 37!
August 10th 2027 is not far!
Dr Simon Kigondu is an Obstetrician Gynaecologist