Lipakamatender #CBA – How Kenyan Doctors got here –
Public Education
The nationwide doctors’ industrial action to commence at 0000 hrs Monday 5th December is the culmination of politicians playing with the health of Kenyans. As a result doctors are left with no choice but to result in industrial action which seems to be the only thing the government listens to. The hashtag is #Lipakamatender. The contention is failure of implementation of a legally signed CBA between KMPDU and MOH Kenya in 2013.
History of mismanagement of the health docket
Between 2007 and 2013 under the auspices of “reversing the trends” policy the health system underwent significant improvements. This came about because the health system did an introspection of itself, identified the root cause of problems that bedeviled the health system, put them down on paper and chatted a way to reverse the very poor trends in health that had plagued the system since independence. The health performance contracts were used as improvement tools. The DMSOs then were in charge of ensuring that the several hospitals under their supervision made continuous improvements on the line items of the performance contracts. Quarterly meetings presided over by PDMSs led to accountability. Afya house teams also had regular supervisory visits with the PDMSs. Management of health facilities improved dramatically. The health performance contracts are present in the individual hospitals and in the ministry of health.
As a result of this doctor-led improvements hospital managements improved so much that the revenues from FIF (Facility Improvement Fees) in the individual hospitals increased three to four fold in most hospitals. The hospitals were better managed, attracted more clients and revenue continued going up
Parallel constitutional process
At about the same time the constitutional process was ongoing. Guided by the policies that were in place at the time the medics pushed for two items i.e. a Health Service Commission to manage the scarce resource (medical personnel) and patient rights that would have included among other items strengthening further the hospitals with equipment. In the health workers minds health devolution was very clear – Primary health was to be managed by governors (promotion and prevention) while Curative health (medical facilities) were to be managed by central government with all health workers managed by the health service commission. The referral system was working well and would be strengthened. The stage was set and medical workers campaigned for the new constitution knowing that their health service commission was intact.
Political constitutional games played on health
The drama then unfolded.
- The health service commission was sneaked out between Naivasha (Committee of Experts) and parliament. This was very deliberate. A “hidden force” is thought to be behind this. But a 5-year lifeline was put on it. It was stated in the Hansard of parliament that it could be activated by an act of parliament. During the various health problems in the counties members of parliament have tried to form some kind of HSC within the health bill but nothing has come of it so far.
- A new constitution was passed in 2010 with the possibility of a HSC being created by an act of parliament. Luckily for health workers the constitution guaranteed the right to form a union. KMPDU was formed. A few industrial actions down the line only one yielded some fruitful improvements in the welfare of doctors. But to avoid future unnecessary industrial unrests by drs KMPDU and Ministry of Health signed a CBA.
- The first notice in February 2013 that devolved health (notably before president Kibaki left office) was correct. It devolved primary health. Curative health was retained at national level. Afya house in the meantime had developed a fantastic master plan for health. It had 2 components 1. Healthworker management and improvement prior to and hand in hand with 2. Managed Equipment Scheme (MES).. keep this in mind as you read on.
Health workers were to be recruited, trained and deployed all over the country and remunerated well to make use of the medical equipment that was to be bought. This plan was as a result of the Musyimi Task Force report that was done during earlier industrial actions. The basis of this is that health equipment cannot use itself. It needs health workers. - March 2013 the general elections were done and the Jubilee government were charged with midwifing the new government structure. A non-medic is appointed cabinet secretary of health (I think this should never happen again).
- Governors in their hunt for sources of income noted that hospitals were one of the few institutions within counties that had cash income in the form of FIF and the amounts were substantial. They thus wanted in on the gravy train. They directed their guns on the executive and accused them of being anti-devolution. The executive not wanting to look “anti-devolution” asked TA to devolve health illegally. They also did not mind throwing governors under the bus because managing health workers is difficult. What the governors forgot is that the wage bill of health workers does not come from FIF and of course they have continuously fallen short in paying health workers. Governors wanted to have their cake and eat it. The reality was different with the various health worker strikes. Governors though were also short changed by Afya house. Afya house retained the Medical Equipment Scheme portion (a procurement issue). Procurement is usually wrongly looked at as “income” by those handling it. Afya house acquired the medical equipment and pushed down the cost to the governors.
- Transitional Authority unconstitutionally devolved curative health in August 2013 without withdrawing the correct notice of February 2013. This was done with no Health Act in place – total negligence.
- KMPDU went to court in November 2013 and their case was thrown out
- In 2014 health workers joined the case against unconstitutional devolution of health by Okiya Omutatah. Dr Kigondu participated in this case by giving the affidavit of what the spirit of health devolution was. Justice Lenaola declined to defined what national referral hospitals meant but said there was a process ongoing in parliament to streamline the health system. This was taken to mean that health is fully devolved but it did not mean that. If health workers appealed this case they would have won and the mess we are in would not have happened.
- The Health Bill in the meantime was doing its rounds in parliament with multiple mutilations by various interested groups. Everyone is trying to put his hand in the cookie jar. There is no health act as of yet.
- Salaries and Remuneration Commission has been used by the government in an attempt to hoodwink health workers. It does not hold the key to management of doctors. It is the body used to delay all major decisions that have to be made on doctors health. It is the excuse used to avoid having a health service commission. Yet it’s role is on state officers and advisory on all others. The judiciary always twists the law to try to say that SRC proclamations are binding. They are not.
- The counties have continued to mistreat doctors. We have doctors who have been rejected for not being of that tribe. We have doctors who have not been absorbed yet there is need. We have doctors whose statutory deductions have never reached their destinations. Without laid down rules of how to manage doctors in this gubernatorial period without health laws the governors will kill health slowly. To protect the doctors a CBA signed by MOH Kenya must be implemented
In summary doctors are victims of a botched purported devolution of health. Doctors have in the past gone on strike to ask for equipment for hospitals for the benefit of the general public. Doctors have had input into the health bill that keeps being mutilated by too many interested parties not looking at the interest of the profession. Doctors are tired of being manipulated by politicians. Why is it so hard for the government to implement a legally signed document yet it is so easy for them to throw doctors under a governors’ bus unconstitutionally so easily? Why must the welfare of doctors be sacrificed under the alter of political show offs. Doctors are tired. The collective fatigue of a misused profession has come together and this time round the government better listen. Otherwise the government of the people will act.
Ministry of Health of Kenya you will bear the responsibility for not implementing the #CBA. Let all doctors meet on Monday 5th December 2016 at Public Service Club for #Lipakamatender Day 1.
Punda amechoka!