Medicine is difficult
MEDICINE IS DIFFICULT – THERE ARE NO SHORTCUTS was the BMJ2024;387q2163 article by Andrew Elder. The summary of this article was that delivering high quality, patient centred care requires medical training that is long enough, broad enough and deep enough. Nowhere is the interaction of governance & practice of medicine and the delivery of high quality, patient centred care requiring good medical training, clearer than the current plight of medical interns.
Prolonged medical school
The current medical interns have had a prolonged and very checkered medical training that has been interrupted on several occasions by health worker industrial actions and the COVID-19 pandemic. To add insult to injury the Ministry of Health (MOH) reallocated the budget of medical interns to what they considered more politically correct things. MOH went even a step further and had the now fired Cabinet Secretary (CS) of Health propose to trivialize the work of medical interns by proposing to dishonour the court-delivered collective bargaining agreement (CBA) & literally try to get slave labour from the medical interns by altering their terms of service of employment from the entry job group L with benefits unique to doctors as per CBA to free labour. Because of this ludicrous proposal the medical interns suffered yet another delay in deployment to their respective internships. This led to another doctors’ strike earlier on this year that demanded that the CS of Health be relieved of her work for incompetence. Medical interns took to social media with the hashtag #NakuminchiaMustGo. The matter landed in court when a few of the offended interns rightfully sued the government for altering their terms of service.
Court decisions of health workers versus government
The medical interns opted, via a vote, to wait for a court decision on what their pay should be before starting internship. My opinion then was that they should starte medical internship then (March 2024) as they awaited a court decision. The money value of time cannot be understated. From a historical perspective I was apprehensive then about the long time that matters of health that are taken to court, pitting health workers against government take. Moreover, directions that courts tend to take when the government is on their neck tend to maintain a vague status quo. Courts avoid raffling feathers when dealing with government, while attempting to adhere to the law. In the case of the medical interns against MOH the court knew that the court-deposited 2017 CBA was sacrosanct in law, but the court was facing pressure from a belligerent government that uses the financial carrot and stick to threaten allocations to judiciary. And for sure, when the judgement came in June 2024, the court once again pushed the decision to August 2024 to the shock and disappointment of the medical interns. The court was said to be on recess.
This was no surprise to me. In the case that Kenya Medical Association has filed against Kenya Revenue Authority, the courts have not given a judgement. The court knows that the doctors are right, but do not want to raffle the feathers of a belligerent government. I can assure you that this will also play out in the court case dealing with impeachment case of the Vice President of Kenya.
Starting internship on a termless contract
After feeling let-down by the government the medical interns began their internship in July 2024 with what has come to be known as a termless contract. This is a new contracting model that literally meant that the medical interns start work without a pay amount stated on the contract. The stated pay awaits the court to decision.
Support to start medical internship
The professional associations have come in handy with associations and their individual members joining in the efforts to support the medical interns at their stations. KMA SACCO provided intern loans of KES 50,000 to those who applied. This allowed the medical interns to start of at their workstations in the hope that they will pay back, once the government pays them. Many families also continue supporting their children who have now become doctors to start off internship, with the hope that when they do get paid their rightful salaries they would pay back.
Death of a medical intern
Before the dust of the court postponement settled, a medical intern Dr Deseree Moraa, passed on in circumstances that were blamed on exacerbation of mental health issues because of poor working medical internship conditions, partly contributed to by the lack of pay. The medical interns again withdrew their services in solidarity with their fallen colleague. Subsequently the medical fraternity did memorials in various parts of the country, complete with candle lighting, to commemorate their fallen hero and decry the conditions that medical interns were being exposed to. The medical profession also mobilized funds to help with the funeral arrangements and attended her funeral. After many years of medical school this young intern did not even enjoy her first salary.
Back to the collective bargaining table
Come October 2024, the court did not make a firm ruling on the actual amounts the medical interns should be paid. It instead correctly returned the ball to the collective bargaining process. The doctors’ Union and the Ministry of Health (which caused the problem initially), were asked to enter into a bargaining discussion and were given another 90 days to save the medical intern.
Unpaid internship
With all this happening, a concerning trend is emerging. A few families of medical interns who have not yet started internship have been requesting to do internship without pay. The Ministry of Health mismanaged the medical internship situation and caused a backlog of about one year of medical internship postings. This literally means that a medical intern completing medical school today should expect to wait one year before starting internship. It was thus no wonder there were celebrations when the Cabinet Secretary of Health responsible for this mess was fired. Many interns attributed their woes to her decisions.
The argument that those who want to do unpaid internship, even before deployment by the Ministry of Health, is the money value of time. Whereas this makes sense at an individual level, it is a disaster for the practice of medicine. Medicine is difficult. This situation is not unique. Early at the beginning of this century in the last days of the Moi era, Dr James Nyikal, as KMA Chairman then, rejected the proposal to have interns work for free. I am thus here because of that rejection. As President KMA I reject a policy that would make interns work without pay as the previous Cabinet Secretary of Health was purporting to do. The thought of it was evidence enough of a lack of understanding of the medical profession.
7-6-3 to 8-4-4 – The overnight change of an education system
The mess that the Ministry of Health has put the medical interns is similar to the one that the overnight change from 7-6-3 education system to 8-4- 4 made to university entry of the Fom 4s and Form 6s, who all of a sudden, were supposed to be in the same class in first year university, despite spending different times in school and having different qualifications. Some of the form 6s never recovered from that trauma.
Classism
Thr proposal by some yo have some medical interns who can afford do medical internship without pay would set the foundation of classism in medicine. Interns from good support systems would join internship earlier than their classmates and work for free (thus acting as government slaves), effectively allowing government to get away with murder. They would then get market advantage of time over their classmates who would finish a year or two later. This would be a classic example of the rich getting richer and the poor getting poorer that the government is promoting even with the so called new university funding model.
Parallel Program (Self-sponsored) Medical students
In 1997 Medical School of The University of Nairobi UON went on strike to protest the introduction of parallel programs by UON. UON, a public university, had been starved off funds by the governments. Parallel programs were introduced to boost the finances of an institution crippled by The Moi era structural adjustments programs. Privately sponsored students would literally get more attention to complete their courses faster than the regular government-sponsored students. As medical students we rejected this and argued that medicine should not have a parallel doctor and a regular doctor. The campaign did not manage to stop the parallel program in medicine, but it fortunately ensured medical training did not discriminate regular and privately sponsored doctors by mixing them. In medical school it is thus not possible to know who is self-sponsored and who is regular. Moreover, the academic entry requirements for parallel and regular doctors were the same. To this end equity was maintained. The distinction was unfortunately very clear in other programs offered by the University of Nairobi. Paying students did indeed get preferential treatment and that was the rise of an inequity that the society has not recovered from to date.
CUE Act kicks out KMPDC
However, the Commission of University Education (CUE) took advantage of the self-sponsored medical programs’ high fees for medical to sideline the input of Kenya Medical Practitioners and Dentists Council (KMPDC). CUE altered the law to ignore the input of KMPDC on what the ideal number of medical students to ensure that training standard are maintained, and quality of training is safe-guarded, based on infrastructure and staffing available at the medical schools. CUE has thus been over admitting medical students against KMPDC’s recommendations on capacity, watering down the quality of training while increasing the number of medical students needing medical internship. This has also contributed to the increased number of medical interns. As an association we are working to ensure that the CUE Act is altered to make it mandatory to have KMPDC state the number of medical students who can be trained within the capacity of universities.
So, our young medical interns have had their bright future stolen by the Ministry of Health.
What parents of medical interns should do
So, what should those parents who want to subject their young ones to unpaid medical internship do? They should see the big picture. They should learn from history as described above.
- All these parents should form a come together and form a caucus to push for budgeting and posting of their children.
- They should launch a class suit against the Ministry of Health for diverting funds meant for internship training to funds political gain.
- They should advocate for greater funding to the health sector by The National Treasury to reach the 15% Abuja Declaration target
- They shoud push for the CUE Act to be amended and give a mandatory say to KMPDC in the affairs of medical training as it was prior to the Act change.
Double Intake
The immediate solution though will require a situation similar to the form 4 – form 6 debacle when 8-4-4, like SHIF, was dropped like a hot potato on the Kenyan people, – DOUBLE INTAKE at CBA terms. Double intake of medical interns will immediately sort out the medical internship issues that have occurred and will raise the standard of health care for Kenyans in a day. Healthcare in the context of training has been proved over and over again to improve the quality of care.
And as the medical professionals let us always remember, as Myles MUnroe aptly put it, Politicians look at the next election. Leaders look at the next generation. We saw politicians messing up the health policy. We medical leaders, looking at the next generation of medics who are the current interns #SayNoToUnpaidMedicalInternship
Dr Simon Kigondu is an Obstetrician Gynaecologist and the President of Kenya Medical Association.