It’s not too late to redeem health services

By Lukoye Atwoli
Sunday Nation 27 April 2014

The Kenya Medical Association held its 42nd Annual Scientific Conference this past week where it came to light that health services are in dire straits. The Medical Board gave alarming statistics that showed a huge discrepancy between the number of doctors trained in Kenya, and those currently working in the country. Obviously there is an exodus of doctors and other health workers in search of the proverbial “greener pastures”. 

Why is this happening?

Until a few years ago, the terms and conditions of service for doctors were unbelievably pathetic. Following the registration of the doctors’ union and a series of strikes, the government improved the pay packages for health workers and developed a retention policy. For the first time in many years, health workers started seeking change of employer from the private sector to the public sector. Many people in far-flung areas were for the first time in their lives able to see a doctor when unwell.

Then came the new Constitution that devolved a portion of health services to the counties. In a monumental misreading of the Constitution, the national government purported to have devolved the health sector “100 per cent”. As a result, many health workers found themselves in the employ of county governments that had other priorities.

In their first budgets, many county governments did not provide funding for health workers’ pay. As a result, there are still problems with remuneration of health workers. Many health policy decisions are being taken as afterthoughts, without regard to the fact that their impact often means that people could die.

A perception has been created that health workers are against devolution of health to the counties. This is an erroneous assertion aimed at painting health workers as spoilt brats who do not want to be supervised in their work. Many governors are pushing this argument, going as far as to claim that many of those asking for pay are “ghost workers”. Some have embarked on an ethnic audit of their health staff, and others have been encouraging doctors to emigrate to their “home counties”.

Finally, many doctors expect that when employed, their employer would eventually pay for them to undergo further studies in pursuit of specialisation. The national government has, to a large extent, facilitated this through a scholarship programme in the Ministry of Health. Unfortunately, this assurance is lacking in most county governments.

These are some of the issues that are driving doctors and other health workers away from public sector employment to the private sector and, more worryingly, to other countries. Right from the beginning, health workers have proposed solutions to deal with these and other emerging issues. These suggestions have been largely ignored by the powers that be.

Happily, political leaders at the national level are coming to the realisation that unless urgent steps are taken, people will continue to die and suffer from preventable causes. A parliamentary committee has been reported arguing for the formation of a national agency to deal with human resources for health in order to eliminate inequities and address the welfare of health workers and the public.

One hopes that those responsible for the health of Kenyans will take this initiative seriously, unless they are happy with the continued deterioration in the sector. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Be humane in search for illegal aliens

Apologies for delayed posting. But here goes:

Be Humane in search for illegal weapons

By Lukoye Atwoli
Sunday Nation 20 April 2014

There is no doubt at all in my mind that there are terrorists in our midst, hell-bent on causing chaos and inflicting suffering on our fellow citizens. Multiple explosions and shootings bear out this view, and only a person who does not live in Kenya would argue that there is no terror activity going on here.

What is not clear, however, is who the terrorists are. Traditionally, and in other countries, a shadowy terrorist group is always at hand to claim credit for terror attacks. For instance, Al-Qaeda took responsibility for the 1998 US Embassy bombings in Nairobi and Dar-es-Salaam. Similarly, Al-Shabaab claimed responsibility for the attack on the Westgate mall in Nairobi.

In the more recent attacks, it is curious that no group has claimed responsibility, even as we all blame Al-Shabaab. Be that as it may, we cannot take this terrorist activity lightly. Kenyans are paying a cadre of civil servants good money to sniff out the terrorists and ensure that the rest of us get a good night’s sleep without worrying about being attacked.

It is in this light that the government launched an operation to identify and deal with actual and potential terrorists living in our midst. The operation appeared to initially target Somalis in Eastleigh area of Nairobi and some suburbs in Mombasa. The police have since announced that the operation would spread to other regions of the country, and was aimed at catching criminals and foreigners residing in Kenya illegally.


Unfortunately, the perception that Somalis are being unfairly treated persists. At the beginning of the operation, social media was abuzz with activity. Most Somalis pointed out the absurdity of targeting a single community or religious group and meting out dehumanising treatment in the name of searching for terrorists. They gave heart-rending personal accounts of the treatment they or members of their families underwent in the hands of police. 

SMALL SACRIFICE

Many non-Somali Kenyans appeared to fully support the raids, and opined that it was a small sacrifice to pay for enhanced security. That was only until they also bore the full brunt of the operation. Writing from a middle-class neighbourhood in Nairobi, a friend detailed how she woke up in the wee hours of the night to loud noises and bangs at her gate and doors, thinking that the house was being robbed.

In a panic, she called her friends and acquaintances asking them to get help. She later realised that the attackers were not robbers, but policemen conducting an operation to flush out suspected terrorists. Like most of her neighbours, she did not let them into her house. The only neighbour who did had his house ransacked and all rooms turned upside down. By the time the policemen left, most people in this neighbourhood had a very dim view of the police operation.

Is it impossible for our police officers to be more civil in carrying out these operations? Is there no other way of identifying potential terrorists and criminals without causing so much suffering to innocent citizens? Is ethnic profiling the only way of ensuring our national security and enhancing cohesion? How long will these operations last, and how shall we measure their effectiveness?

These are just some of the questions we must deal with, even as we pursue these miscreants. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

‘Healing’ crusade poses serious health risk

By Lukoye Atwoli
Sunday Nation 13 April 2014

Kenyans are a highly religious people. This is borne out not only by their open declarations of religious affiliation, but also by their often overzealous demonstration of religious fervour whenever they are called upon to do so. This, in itself, is not a bad thing. It might even be a good thing, especially in circumstances when this religious zeal is directed at activities aimed at improving the lot of needy individuals or humanity at large.

Unfortunately, due to the nature of religious belief, occasional tragedies occur. There are multiple examples of this, and it is pointless to rehash them here. The reason they occur is that the average religious person takes the message from their holy book or their cleric literally. Many proclaim that their clerics are messengers of their deity, and the holy book is the unquestionable transcription of the deity’s words. Sometimes the outcome of this blind obedience is serious harm and even death, but even these are explained away as the doings of an inscrutable deity.

Over the long Easter weekend, one such cleric will descend upon Eldoret with the professed mission of spreading the message of repentance and holiness. As has been the practice in previous crusades of a similar nature, it is expected that many will ferry their sick relatives from far and wide, and present them to this preacher who is also fabled to be a faith healer. 

ABANDONED MEDICATION

Those of us taking care of thousands of Kenyans with chronic conditions will be waiting for the inevitable outcomes with dread. We know many patients who have already abandoned their medications and clinic follow-ups in anticipation of healing at the crusade, and dozens more who will attend the crusade and abandon their treatment.

We dread the reports we shall get when we follow-up patients with chronic conditions like HIV, cancer, diabetes and mental illnesses to their homes. We fear we will be told some of them died after being convinced they were healed at the crusade thus stopping their life-preserving treatments. We fear we will find them at home, wasting away while believing fully that they have either been healed, or that healing is on the way.

We dread the events we shall continue to encounter in the clinics of the Moi Teaching and Referral Hospital, weeks and months after the four-day crusade. Many patients will show up in deplorable health and, when asked what happened, they will say that they thought they had received healing at the Easter crusade. Many more will suffer irreversible damage due to chronic illness, and will return to the hospital only at the urging of worried family members.

Why do we raise the red flag at this point, before the crusade happens? Because we believe it is still within the powers of the organisers of the crusade to do something about it and ensure that no lives are lost, and no one goes home in worse health.

The organisers and preachers should announce to their faithful that nobody should stop taking their medication or stop attending their regular clinics, in anticipation of healing. That simple message will save dozens of lives, and ensure continuing good health for countless others, which one would expect is a good thing for the organisers of the crusade. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com

Jubilee one year on: Analysis of health pledges in Jubilee Manifesto

Free maternity keeps Uhuru and Ruto health pledge (I didn't do the headline!)
By Lukoye Atwoli
Daily Nation, Wednesday 09 April 2014

Soon after his inauguration, President Kenyatta declared that all maternity care would be offered free of charge in public facilities. Many commentators equated this pronouncement to President Kibaki’s free primary education pledge that was made so early in his term that many thought it would fail. One may suppose that President Kenyatta made his “free maternity care” pledge in this same spirit, and hoped that things would come together somehow and make it work.

To some extent, this has happened in many parts of the country, and the government says that hospital deliveries have registered a significant rise from 40 per cent to 66 per cent. However, there have been hiccups in some parts of the country where, due to limited financing, some counties have decided to start charging for some of the services.

To some extent, the fortunes of the health sector under the Jubilee government may be encapsulated in the success or failure of the free maternity care initiative. In the Jubilee manifesto, party leader Charity Ngilu, now a Cabinet Secretary, indicated that she joined the Jubilee coalition on the basis that it would “ensure that all Kenyans get quality and affordable healthcare.” This then became a key plank in the new government’s agenda, perhaps explaining the President’s haste in providing solutions for the sector.

The coalition identified bureaucracy and corruption as major impediments to improving health services, and further argued that the National Hospital Insurance Fund (NHIF) is “bloated and corrupt”. Brain-drain involving health practitioners, especially doctors, was mentioned as well. The coalition indicated that their first focus would be on preventive health, and universal healthcare was to be rolled out through local primary healthcare centres. Finally, the coalition’s stated intention was to make Kenya an international medical hub with an increase in medical tourism by adopting the “successful Indian model”.

Several specific pledges were made in the manifesto as the method by which the coalition would reach their healthcare goals. The coalition pledged to increase health financing from 6 per cent to 15 per cent of the budgeted expenditure, perhaps to bring the country into compliance with the Abuja Declaration target.

The number of physical facilities were to be increased, bringing a health facility to within five miles of every home, and many previous provincial hospitals were to be upgraded and equipped to the status of referral hospitals. Diagnostic centres for all conceivable illnesses were to be set up, and free mosquito nets would be distributed to all families in need.

Better nutrition was to be encouraged, and medical research, including on indigenous medicine was to be promoted under the Jubilee coalition government. E-health and private sector participation was also to be encouraged and promoted, and pay packages for doctors and other health workers were to be improved.

One year down the line, an evaluation of the Jubilee pledges comes up with perhaps one major success story.

Free maternity care is now government policy, and many facilities across the country are not charging mothers to deliver or get other services related to childbirth. This is a huge plus especially in rural and poor settings where mothers preferred to deliver at home, assisted by local midwives or other women, than go to hospital and have to pay what they considered to be exorbitant rates.

On the whole, however, it is difficult to find much to write home about what this government has done with regards to healthcare. Healthcare financing continues to be meagre, and in the last budget, the national government allocated 2.1 per cent of expenditure to health. It is not known what the counties collectively allocated to health, but the few that were analysed had allocated less than 3 per cent of their budgets to health as well.

The government started out on a bad footing when they appointed both a Cabinet Secretary and a Principal Secretary who were not healthcare professionals, going against the pledge made by Deputy President William Ruto in the Manifesto. This had the effect of delaying any serious initiatives in the sector, given that the two senior officials required a crash course in the sector and how it works.

One of the key handicaps faced by this government is that the manifesto did not take into consideration the changed healthcare environment, with the constitutional shift of primary healthcare and some curative services to the counties. Without a mechanism of ensuring cooperation of the county governments, it is therefore difficult to operationalise many of the pledges concerning healthcare at the county level.

Today, strikes in the sector are an everyday occurrence, and recent reports indicate that many doctors are leaving the civil service to go abroad or into private practice as a result of problems with their terms and conditions of service in the counties. The legislative and policy framework has not done any better. Four years since the coming of a new Constitution, health is the only sector that has not been re-formatted legislatively to conform to the law. The Health Bill has remained in draft form for a long time, and stakeholder involvement in its drafting and progress has been reluctant and limited.

As far as the health sector is concerned, the Jubilee coalition rates a very modest score. 

Dr Atwoli is a senior lecturer, Moi University School of Medicine and national secretary-elect, Kenya Medical Association.

Is it time to regulate religious teachings?

By Lukoye Atwoli
Sunday Nation 06 April 2014

Kenya seems to be in the throes of a major social convulsion and time has come for us to confront certain demons that represent a major threat to our continued survival. Lately, a new monster that had remained largely under the surface has emerged, in the manner of “religious extremism”. This has been blamed for incidents of “radicalisation” of youth, and even some of the terrorist attacks that are becoming common.

However, this term is, in my view, misleading. As part of some research I have done in the past, I have asked dozens of religious practitioners what constitutes an extremist or fundamentalist. Even within the same religion, different responses are given. For instance, some argue that an extremist is one who takes a literal interpretation of their religious book or teachings, and behaves accordingly.

Others contend that extremists “misinterpret” religious teachings and use them to harm others. The problem with this argument is that it assumes that everyone, including non-adherents, understand what teachings are actually being misinterpreted. When pressed, those with this opinion argue that no religion teaches intolerance or hate, and none condones murder of “innocent” people.

Unfortunately, a plain reading of the holy texts of the religions that are dominant in Kenya reveals a different picture. Many passages condone the killing of those that are regarded as non-believers, and condemn to death and eternal suffering those that deny the existence of the deity to whom the book refers. Although there are many other passages describing “upright” behaviour and being available to help other human beings in need, it is difficult for an ordinary adherent to determine what is to be done and what is to be avoided on the authority of the holy book.

From a secular perspective, one is left in the difficult position of determining what conforms to religious teaching and what does not. When someone argues that the holy book teaches one thing or the other, it is difficult to contradict them, even if other sections of the same holy book teach quite the opposite.

What is known is that no religion teaches their adherents to be “lukewarm” or to pick and choose what to believe and what to leave out. Both Christianity and Islam hold their holy books to be comprehensive and infallible. They are considered to be either direct utterances of the deity, or material written under the direct guidance of the deity.

If we are to accept that religious extremists or fundamentalists either misinterpret or distort religious texts, then it follows that one cannot gain complete religious insight from a plain reading of the religious texts. It follows also that for one to fully understand the teachings of a particular religion, there is more learning to be had outside of a plain reading of the religious text. 

NO HINDRANCE

This begs the question why then religious preachers are so poorly regulated. Almost anyone in this country can start a sect and be allowed the freedom to propagate their teachings without let or hindrance. Perhaps religious institutions should be regulated in much the same way the various professions are regulated, in order to ensure that their teachings do not run afoul of the aspirations of our nation as enshrined on the Constitution.

The alternative is to contend with continued religious “radicalisation”. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine. lukoye@gmail.com