PART 1
Licensing doctors
Kenya Medical Practitioners and Dentists Council (KMPDC)
Recently the CEO of KMPDC announced that the KMPDC was in full support of the Health Service Commission as advocated for in the BBI. He raised a storm though by saying that from January 2020 the council would no longer issue licenses for private practice to doctors. While the statement was correct this was misinterpreted to mean that doctors in public service could no longer practice privately, previously licensed as part-time private practice. This interpretation is wrong.
Unification of doctors the doctors’ licence
In the past doctors were issued with two licences, annual retention certificate for the year and either part-time private practice (for a doctor working in the public sector) or private practice licences. A doctor will now get only one licence, a general practice licence or a specialist practice licence. The public and private tag to licensing was removed with the recognition that the medical council is not a HR unit of the ministry of health. Moreover licensure of a doctor is not limited to a single place of work. The nature of the profession is that the services of a doctor are needed by the whole population. Moreover the quality of doctors’ quality of care was not related to employer’s permission to do private practice but to ensure that doctors perform their assigned duties as agreed with in the context of their roles within the contiguous system that is health. The council’s role is to licence, period.
PART 2
WAGE BILL
Wage Bill
The government fixed on the wage bill as the lame excuse of inadequate staff in healthcare. The wage bill is also the basis for the disastrous shift from permanent and pensionable employment to contractual employment in civil service. In the same vein the wage bill narrative has seen the government decline to raise the basic salary of civil servants, partly due to its implications on pension but mainly due to a push by so called ‘development’ partners. Moreover, health workforce wages are classified as ‘recurrent’ expenditure, a rather limited outlook at the outcome of quality healthcare.
Allowances
As a result of this wage bill narrative there is a drive to remove allowances from salaries. Many of these moves by government are targeted at health workers. The background of this is that historically, to circumvent the challenges of raising the basic pay of civil servants, health workers have pushed for several allowances in line with their unique nature of their work. The push towards reducing/ removing allowances is targeted at health workers. It is not the fault of health workers that their professions are unique, and the adequate remuneration is required. It is not unfair to have risk allowance, extraneous allowances for health workers. Health workers are in constant danger of contracting infectious diseases, travelling at dangerous odd hours to work. They should be compensated for that. Further, because the government cannot adequately compensate a doctor for work done in provision of healthcare in the public sector, part-time private practice of doctors should be looked at as Appropriation-in-aide for the government. This is the ‘indirect’ income the government gets, but not as cash. The basis of this is the government may be unwilling or unable to adequately compensate the value of the health worker. It is in the interest of the government thus to promote professional part-time private practice. This practice is threatened by unconstitutional clauses in the proposed EACC conflict of interest bill 2019.
PART 3
EACC CONFLICT OF INTEREST BILL 2019
In relation to this the Ethics and anti-corruption commission launched a draft of the conflict of interest bill 2019. The bill sneaks in a dangerous clause whose import in the field of medicine (and indeed other professionals) is to limit the practice of medicine by a public doctor to the public facility.
The section explicitly states as follows:
(2) Without prejudice to the generality of subsection (1), a public official serving on a full-time basis shall not participate in any other employment that amounts to –
(a) holding another salaried office;
(b) privately practicing the same profession for which the official is engaged
I acting as a paid arbitrator or consultant;
(d) holding on honorary public position; or
I engaging in such employment during official working hours
Dear EACCKenya kindly delete Part II Section 23 (1) to (5) on Gainful employment in Conflict of Interest Bill 2019. It’s unconstitutional & discriminatory to professionals who have no control over the economy & must do public service. It’ll be used to victimize professionals
Impact on the EACC COIB clause 2
These clauses serve several functions and in my view for the medical profession should never be explicitly stated as above. In professional work the clauses are not evidence-based. Whenever the government fails to provide healthcare for the public, they occasionally divert attention from their failures by claiming that the reason healthcare is that doctors are in their clinics instead of in the public hospitals. This innuendo has even been used to propagate the lie that the health service commission was not passed because doctors were in their clinics. This often-repeated lie has been used by government to circumvent their role in providing the necessary conditions for quality public healthcare including a health service commission.
PART 4
WHY DOCTORS’ SHOULD DO BOTH PUBLIC AND PRIVATE MEDICAL PRACTICE
Part-time Private Practice – Backbone of Kenya’s Public Health
The clauses will be used by government to exploit the professionals at the expense of the health of the public. I dare say that the public health sector has over the years been kept afloat by the fact that doctors serving in the public sector are allowed to practice privately as long as they fulfill their mandate to the public institution. The second president of Kenya Daniel Arap Moi understood that part-time private practice for doctors was ‘appropriation-in-aide’ supplementing government revenue and thus allowed part-time private practice, hence the licence. Moreover, the NHS in Britain was birthed partly on the basis of part-time private practice.
Work-life Balance
It must be noted that no doctor loves to moonlight. Doctors would rather be with their babies and travel the world. Work-life balance is thus contextual. For doctors the battle between attention to the patient and family is very real and often takes a toll on the social life of doctors. The sheer need for healthcare and the need to sustain the doctor’s status in society drives the doctor to work hard.
What is wrong with conflict of interest
Conflict of interest is not a bad thing. It is a situation a person or institution finds itself in. UNDECLARED conflict of interest is the issue. Undeclared Conflict of interest is a big problem in Kenya. Politicians do business with government without declaring their conflict of interests. Some have even been charged in our courts of law for the same. Of note is, politicians practice undeclared conflict of interests NOT in their professional fields. Without prejudice I think that professionals cannot have conflict of interest when practicing within their professions. Privately practicing medicine by a doctor who is also in public service is not conflict of interest unless they have deliberately absconded their assigned duties.
The more the doctor works the better
A doctor’s skill, experience and learning improve the more s(h)e works. Kenya has not reached the state where one health system, either public or private exposes a doctor to the full health experience. A major reason for this is that the remuneration in public sector alone is insufficient to allow a doctor to live a life that is expected of the doctor. This does not mean living in opulence. It means supporting the government to support all those who were waiting for the day you become a doctor to sort out all the problems that are as a result of the economy. The expectations to the doctor are so high that being broke and a doctor is thought of as an oxymoron especially in the village. A doctor working in the public sector needs to increase his or her resource base. There is no better way of a professional earning an extra buck in the private sector than by practicing the profession they learnt for so many years. They not only get sustenance but also improve their skill to be better doctors for the public. It is thus foolish to ask a doctor to run a matatu in his idle time instead of practicing medicine.
Public experience
Working in the public health sector exposes a doctor to the widest possible range of medical conditions. Public medical service exposes doctors to the most vulnerable in society and keeps the doctor’s humanity in check. They develop empathy. It encourages a spirit of service. It also serves to train the doctor to see the effects of poverty on access to health, and the doctor thus becomes an advocate for the needy mwananchi. Public medical practice though can also lead to burnout and apathy and a feeling of hopelessness due to factors beyond the doctor’s sphere of influence. Public medical practice can also lead to knowledge and skill decline if not improved intentionally and individually. This intentional improvement can be bridged by private practice.
Private experience
On the other hand, working in private sector exposes doctors to healthcare that is occasionally missing in the public medical sector. It exposes the doctor to additional healthcare services that are desirable for all, but occasionally lacking in the public space. This allows a doctor to improve their skills in medical practice by exposing the doctor to additional equipment and expertise. The private sector also serves to expose the doctor to a category of clients different from those they see in the public sector. Private sector clients may alos have demands and expectations on doctors that help to test and improve a doctor’s patience, knowledge and skills and even grooming. The public health sector client also benefits from the knowledge and skills acquired by the doctors in private institution because this skill acquired in the private setting is also used to treat the patients the doctor serves in the public sector.
A doctor working in both private and public sector is a thus a win-win for the patient.
Supplementation of income
An important aspect of private practice is that private practice also serves as supplementary income to the public doctor. As I jot down my thoughts (Dec 11th 2019) doctors in public sector have not been paid for their November 2019 work. The landlord does not listen to such excuses. The supplementation of income of public doctors by private practice serves two purposes. It retains the doctor in public service and it helps him improve his knowledge and skills for the benefit of the public.
Retention in public service
The first is that it serves to retain the doctor in public service. Public doctors are poorly paid in comparison with doctors elsewhere, in lieu of the work they do. This is in relation to the economic situation they live in, their status in society, the information they carry, the risks they bear and the expectations on them from the village.
What is the value of a doctor’s work?
You can only hold people to account after you have given them all tools of trade and allowed them to work without interference in a conducive environment. A conducive environment includes agreement of what the value of work is. The value of the doctor’s work and the measures of the same are extremely debatable. The biggest mistake has been allowing administrators, whose measure of work is a person sitting behind a desk for eight hours a day, to measure a doctor’s work. Recently even the SRC had difficulty in grasping the complexity and uniqueness of a doctor’s work by even using the Patterson Job Grading System designed specifically with management and thus not suitably applicable to doctors. This is another reason for having a Health Service Commission to avoid managerialism.
The true value of the doctor – The Cuban measure
The government of Kenya recently got it correct when they brought in medical officers from Cuba and remunerated them at more than one million shillings a month. The government may claim that this is propaganda but costing the perks afforded to the Cubans, which is what Kenyan doctors and indeed all other civil servants should be accorded includes their tax-funded housing, protection, travel, benefits of flight tickets and their time-outs. That is indeed the value of the doctor. The government would then have the moral authority to explicitly legislate that doing private practice is conflict of interest for doctors. The government wants to have its cake and eat it. The government is not willing (or able) to pay the doctor their worth and yet in prevailing economic circumstances want to legislate poverty to an already financially- strained doctor.
Trade-off for non-private practice
Previously the trade-off to keep doctors working in a poorly remunerated public health system doctors who did not practice privately worked in a fully functional public hospitals (which were then better than the private facilities). The doctors had access to affordable mortgages to enable house ownership, access to affordable car loans to enable mobility to hospital and were accorded professional autonomy devoid of managerialism. These are the conditions necessary for one to have the possibility on not doing part-time private work. Not practicing privately though should be by choice.
Private medical students learn from public sector too
Private hospitals that are undertaking training of post-graduate students have realized the value of public experience for their students. They send their students to do rotations in public health facilities to gain the valuable public healthcare experience. It is thus ironical that public facilities do not see the value of the opposite. Public doctors should be mandated to experience private healthcare as it serves to improve service provision to the public who have no access to private healthcare.
Alternative supplementation of income
A ban on private practice for medics would increase corruption in the public institutions. This eventually leads to a strain on the little public resources available that are supposed to be directed at service provision. They look at the hospital allocations as a source of supplementary income and may be tempted to direct these resources meant for taxpayer to their pockets. This has in the past been a big problem. A change occurred in the not-so-far past when doctors who do part-time private practice started running public hospitals. Hospital resources were effectively used to run hospitals while the doctors’ supplemented their income via private practice. The alternative was to pocket hospital resources. This led to an efficiency in public hospitals during the Kibaki-era not seen prior to that practice.
Idle doctors
Good practice of medicine is dependent on continuous medical practice. Doctors tend to operate at a high level and need to keep busy. Idle doctors have been known to plunge into drug and alcohol dependence and abuse. Doctors must thus be encouraged to become busy. And one of the ways is to do private practice.
Burnout
Burnout is a phenomenal that is more common with health professionals than with other occupations. Burnout from work combined with poor remuneration is the fastest way of ensuring that no doctor works in the public sector.
Stipulated working hours.
The nature of work for doctors is a mix of duty and call. The nursing cadre work is in shifts. Some doctors work is in shifts such as clinics. The remaining time they are available and on call
Hierarchy
Doctors have a clear hierarchical structure. It depends on several factors including years of service and specialization. As one moves up the hierarchy the nature of work is more of mentorship and skilled service delivery. The measure includes managerial work and intellectual input that can be difficult to measure and difficult for other people to ‘see’ Doctors do a lot of work in terms of inputs to various committees within hospitals. They even carry work home (invisible to administrators) but whose input is vital to the running of the institution.
Research
Research is essential for the development of the profession. This though is underfunded and under measured.
Amenities (private wing) in public hospitals, a panacea
Finally, to address the issues that lead to absenteeism and poor remuneration the amenity system was the panacea for the public health system that addressed poor remuneration of doctors by government, increased presence of the doctors within the premises of the hospitals and increased revenue for the hospitals.
Patient-centred care
Healthcare legislation should take a patient-centred care approach. The patient requires quality healthcare whose features not only include correct diagnosis, correct treatment and healing but also rapport with the health provider that leaves the client feeling happy. For quality healthcare the health provider preferably should be well read, have good experience in the relevant field, have good support including colleagues. In Kenya the doctors experienced in both public and private practice have an edge of networking, exposure to difficult and variety of cases, exposure to technology and even to different clientele characteristics. This exposure is summative and leads to benefit to the patient in both public and private healthcare systems.
Part 5
Way forward in public healthcare
Economic and governance problems should not be addressed by inserting bad clauses into legislation that disenfranchise industrious professionals without taking into account prevailing circumstances. This is letting the governments off the hook too easily and blaming the victims.
- Delete Part II Section 23 (1) to (5) on Gainful Employment from the EACC Conflict of Interest Bill 2019
The suggestion that a doctor in public sector cannot practice his profession outside the public space is thus unconstitutional and an infringement on the rights of the worker to fair remuneration and improvement of his career. It is also not scientific as doctors who work in both public and private sector have been shown to improve the public sector with private experience and vice versa. - Amenity
Examples abound of improving service delivery. The public hospitals that were graded top during the ‘reversing the trend’ years of performance contracting such as Murang’a District Hospital were built on the back of an amenity model. Let us return the amenity model. Doctors who served very well in the hard-to-reach areas did so with difficulty but with integrity and supported by private practice. For instance, doctors posted to Moyale were encouraged to do private practice in Loyangalani. That way they would remain motivated and continue serving the public in the hard-to-reach area. Prior to such arrangements, doctors did not agree to work in such places. The current governor of Kisii has learnt this and at a recent health forum has stated that he is creating a doctors’ plaza in Kisii referral hospital – a brilliant move. KNH should not have the monopoly of doctors’ plaza. - Health Service Commission and Strengthening HR via self-regulation
We need to improve the HR functions in health institutions by understanding that the profession is self-regulatory. Medicine is also hierarchical, and importance is also placed on experience. Only a doctor can measure the quality, quantity of another doctor. They do not need to reinvent the wheel. Let them borrow from what worked. What worked was the supervisory model that the public health sector adopted in 2007 – 2013 where support supervision with an objective assessment tool was used to improve the practice of medicine in public hospitals that in turn generated the revenues that made governors force the TA to unconstitutionally devolve health. A Health Service Commission would also aid in streamlining the deliverables for health workers. - Induction and training on ethics
A training on ethics for all public officers would also boost performance in public institutions - Research
There is need to invest in research. This will go a long way in debunking the myth to the public that the reason public facilities may be substandard is due to public doctors working in private sector. Research on quality of care of patients would prove otherwise and I suspect part-time private practice would be adopted as standard practice for quality care.