By Wambui Mwaura
Doctors in Kenya’s public hospitals have gone on strike, demanding better pay, and for medical interns to be deployed. This strike comes seven years after the longest strike by medical practitioners in Kenya, which lasted 100 days. The 2017 strike also demanded for better wages, and for the government to restore the country’s dilapidated public health facilities. For majority of Kenyans who cannot afford private healthcare, the current strike means longer waits for care, and for some, no access at all.
This shouldn’t be the case, however. Article 43 of the Constitution of Kenya (2010) affirms that every person has the right to the highest attainable standard of health, which includes the right to health care services. Quality universal healthcare, the World Health Organization (WHO) further states, is a fundamental human right and a key indicator of a flourishing nation. Healthcare, therefore, is a public good that aligns with a nation’s interest in maintaining the well-being of its citizens.
The 2010 Constitution devolved the delivery of healthcare services to the counties, leading to a restructuring of the healthcare system and its administration nationwide. Under this arrangement, the national government oversees all Level 6 hospitals, providing specialised care, while county governments are responsible for managing Level 1 to Level 5 health facilities, and these are run by Chief Executive Officers from medical backgrounds.
Rampant inequality
Across the country, there is a shortage of doctors, nurses, and other health practitioners. According to the Kenya National Bureau of Statistics (KNBS) Kenya’s doctor-to-patient ratio is 19 practitioners per 100,000 people, which translates to 1 doctor per 5,263 Kenyans, five times the WHO-recommended ratio of 1 doctor for every 1,000 people. Kenya therefore has an insufficient number of doctors to meet the population’s healthcare needs. An Oxfam report on inequality in Kenya shows that the top 0.1% (8,300 people) are wealthier than the remaining 99.9% (over 50 million people) combined. This wealth gap is expanding, with the country experiencing one of the fastest growth rates of super-rich individuals globally while simultaneously grappling with biting inequality.
The challenges Kenya faces in ensuring equitable access to quality and affordable healthcare are made worse by poverty and a lack of resources, as a 2021 United Nations Development Programme (UNDP) report on Kenya’s Multidimensional Poverty Index (MPI) shows. MPI measures the level of poverty by looking beyond income to consider deprivations in access to health, education, and decent living standards. The UNDP report shows that 37.5% of Kenya’s population of around 55 million is multidimensionally poor, while an additional 35.8% are vulnerable to multidimensional poverty. This high level of poverty and inequality has an impact on access to healthcare, making it a life-and-death struggle for the poor.
The issues are complex
Kenya’s healthcare system is unevenly distributed, with professionals, facilities, and resources more concentrated in urban areas over rural ones. Counties like Mandera and Wajir have notably fewer health professionals per person compared to Nairobi and Kiambu. While nurses are distributed more evenly than doctors, their numbers still fall short of the WHO’s recommended ratio of 25 healthcare professionals per 10,000 people.
Despite these glaring personnel shortages in Kenya, the government of the day has embarked on a plan to export healthcare professionals to Saudi Arabia, Germany and other countries. This plan will very likely undermine the ambitious plans for the health sector that Kenya Kwanza government included in their manifesto, which highlights an inequitable distribution of health professionals, and the fact that many historically marginalised counties do not have a single specialist.
Basic services are lacking
The 2023 Health Facilities Census by the Ministry of Health indicates that 93% of Kenya’s health facilities cannot provide basic outpatient services. The census, which covered over 12,000 health facilities, revealed that a majority lack the necessary equipment for basic services. For maternity services, 84% of around 5,000 facilities lack essential equipment.
The census further reveals that 78% of health facilities are unable to offer critical care, with a mere 2,304 critical functional beds in the Intensive Care Units (ICU) and High Dependency Units (HDU) at public facilities. Moreover, 68% of health facilities do not have access to oxygen delivery equipment, while 69% have no advanced life support ambulances.
In the same report, only 12 counties have satisfied the minimum requirement of the recommended manpower in the provision of health services. Narok County is ranked lowest, with six workers for every 10,000 people, while Wajir and West Pokot counties have 12 workers per 10,000 people. Nairobi County has 37 workers for the same population set, with Vihiga and Laikipia counties posting 31 and 27 workers respectively per 10,000 people.
Indeed, the impact of these challenges is already visible, considering the number of Kenyans losing their lives due to poor healthcare.
Further compounding the problem of access is the fact that there is a shortage of training institutions and graduates. Graduates are poorly paid, and in some instances, they are directed to look for job opportunities abroad after graduation rather than looking for work locally.
Public health facilities in rural areas often lack the necessary funding and resources, making them unattractive for medical practitioners. In response to economic pressures, medical practitioners opt to set up their practices in urban areas, where they are able to command higher salaries and access better facilities, creating a further disadvantage for rural regions.
Maternal mortality is at crisis levels
Despite accounting for the bulk of the country’s population, healthcare services are often inaccessible to rural populations, contributing in part to elevated rates of preventable diseases and a high maternal mortality rate in these areas.
Data from the World Bank found that Kenya’s maternal mortality rate is one of the highest in the world, with 510 women dying for every 100,000 live births. The report also found that rural women are twice as likely to die from childbirth compared to urban women. The fact that cases of maternal mortality are rising is an indication that much hasn’t changed at the county level to ensure that citizens have access to quality healthcare, 11 years after the onset of devolution.
From the graph above, it is notable that Kenya’s maternal mortality rate has remained relatively constant while the regional average is declining.
A report by the Centre for Reproductive Rights, for instance, points to a rise in the number of maternal injuries and deaths due to medical negligence. The 2023 report highlights cases of medical negligence, including the death of Rebecca Wangari at Naivasha Level 4 Hospital due to excessive blood loss during delivery. Medical staff allegedly neglected Wangari for over 24 hours despite her critical condition. Two other cases involved Velma Anita Ochieng, a 19-year-old Kenya Certificate of Secondary Education candidate (KCSE), who died after giving birth at Homa Bay County Teaching and Referral Hospital in November 2022, and Maureen Anyango, a patient at Mama Lucy Hospital, who died in September 2022 shortly after giving birth to twins.
Maternal mortality is compounded by a lack of skilled birth attendants, with several cases of death due to alleged medical negligence in the news.
The Government’s response
The Kenya Kwanza government has taken various steps such as the addition of health facilities and medical personnel in a bid to address gaps in the provision of quality healthcare with the aim of attaining Universal Health Coverage (UHC). Since assuming office, the KK government has instituted significant reforms, such as the approval of crucial bills aimed at advancing healthcare, including the Primary Healthcare Bill, the Digital Health Bill, the Facility Improvement Financing Bill, and the Social Health Insurance Bill of 2023.
As part of its initiatives to address healthcare sector challenges, the Government implemented a pilot programme for UHC, offering medical insurance and substantially improving access to health services. These commendable initiatives generated over 1.6 million additional hospital visits within its inaugural year. Following the pilot, UHC expanded to all 47 counties of Kenya, thereby ensuring that more citizens would benefit from the programme. The pilot programme facilitated the establishment of more than 200 community health units while recruiting 7,700 volunteers and 700 health workers in the process. There was allocation of government funding to cover the health insurance of one million households.
The government has taken steps to tackle the unequal distribution of healthcare resources by introducing programmes to boost the number of healthcare workers in rural areas. However, more needs to be done. These workers need better conditions and remuneration, and more funding needs to go into the construction of additional health facilities in rural areas.
The Health Census Report recommends the scaling up of investments in basic equipment and appropriate infrastructure to support basic services in outpatient, maternity and newborn care. The MoH also underscores the need to prioritise the improvement of pharmaceutical availability, medical personnel, and overall health infrastructure to achieve Universal Health Coverage (UHC).
Adequate resources and better pay are essential
Human resources for health is a critical component in the delivery of basic healthcare, according to Prof. Gilbert Kokwaro, the Director of the Institute of Healthcare Management. “Kenya has got two doctors serving approximately 10,000 Kenyans; this gives you an idea of how critical the shortage is,” he said. Prof. Kokwaro intimates that Kenya cannot afford to train doctors for other countries, as more than half of the doctors trained in Kenya hardly stay in the country beyond five years. “We need a complete change in mindset. We need strategies to not only retain what we have but start increasing the numbers,” he added.
In Prof. Kokwaro’s assessment, adequate resources, better pay and environment for training healthcare workers should have the necessary resources and adequate pay to incentivise them to stay in Kenya. To attain this, he recommends the creation of a central body to look after the welfare of all health workers, which would then be able to negotiate attractive packages for all cadres workers. He also recommends that workers be classified into professional clusters rather than job groups, and to assign specialists equitably based on qualifications and regional needs.
In reality, solving the unequal distribution of healthcare resources in Kenya requires a proactive approach that prioritises rural areas and impoverished counties. There should be investments in training healthcare workers, hospital infrastructure and labour incentives. These measures are some of the ways to make strides toward achieving fair access to healthcare for all Kenyans.
Wambui Mwaura is a freelance multimedia journalist. She is passionate about human interest stories, with a key interest in health matters, governance, social justice, and investigative journalism.
This story was developed as part of the Charter Project Data Storytelling Fellowship.
This is very insightful and highlights the scale of the state of healthcare in Kenya.