By Tebby Otieno
Between 1st October 2020 to 4th January 2021, Kenya experienced its second wave of COVID-19 which saw 104,991 people infected with the SARS-CoV-2 virus, which was 62,429 people more than the 42,499 from the first wave. This meant that the number of people that needed emergency support went up as well. According to the daily media briefing by the Ministry of Health during that period, 6,761 patients were reported to be on supplementary oxygen and ventilator support in Kenya. This number peaked in November with a record of 3,596 patients before going down to 2,529 in December.
Elizabeth Mutunga, one such person, tells us her ventilator story. Elizabeth had just been discharged from the hospital where she had previously been admitted for two days, when she realised she was still unwell. That night while in her home, Elizabeth suggested to her husband that she wanted to take the COVID-19 test.
She says she had palpations and her heart started racing; she thought it was not normal. Elizabeth would call a doctor friend, who passed by her house and advised that her husband take her to the hospital immediately.
“When we reached the hospital my oxygen level was at 45% and immediately I was put on oxygen. They started with a ventilator because I was really struggling to breathe,” she said. Elizabeth was struggling with Hypoxia.
Hypoxia is a condition where the body does not have adequate oxygen, usually because of low oxygen levels in one’s blood. Medically, the normal oxygen level required is between 92%-94 %.. Elizabeth says that a large percentage of her lungs were affected by COVID-19, meaning that she needed to be on oxygen support for the levels in her blood to rise.
“I think if I didn’t go to the hospital when I did, I would have collapsed at night because if my oxygen level had reached 45% that means my oxygen levels were very bad even all this time (sic), but nobody had noticed,” she said.
Elizabeth is a counselling psychologist and founder of the Alzheimer’s and Dementia Organization Kenya (ADOK), a non-governmental organisation that supports caregivers who have loved ones with dementia on how to care for them.
She was admitted a private hospital for over forty days and said that most of those days, she would be on a ventilator which was charged hefty fees of Ksh 700, 000 per use.
“Every time this ventilator would be brought, that is when the money would actually increase my hospital bill. So by the time I was leaving the hospital, my bill was 5 million,” she said.
Their efforts to get room in a government hospital bore no fruit as there were no available ICU beds. Her family registered a pay bill number that they shared with friends, church members, and well-wishers who supported them with donations to offset the Ksh 5 million bill.
“As we speak the bill is about Kshs 300, 000 left. I am still paying the bill, we had an agreement so we had to leave a title deed for the house so that we would be allowed to go home,” she said.
When I met Elizabeth for the interview at a coffee restaurant in Nairobi, she said her health was vastly improved. The first three months after her admission were difficult, but slowly her condition improved.
“That is when I started breathing on my own and then now stabilising, trying physiotherapy because I was not walking for a very long time. I had to be taught to walk again so any time I would take a few steps, I got so breathless my oxygen levels used to go down,” she narrates.
The need to urgently access a ventilator was also experienced by Daniel Otunge’s relative who started having breathing difficulties in his Nairobi house one evening. Having seen his relative show COVID-19 related symptoms, Otunge, the Director of the Africa Science Media Centre, called a doctor friend to attend to his relative at home.
They paid Kshs 5, 000 for the doctor’s fee and initial medication and another Kshs 5, 000 for the ambulance service to the hospital, after the doctor recommended that the patient be admitted. Their first stop was Nairobi Women’s Hospital in Nairobi’s Hurlingham area. Unfortunately, the hospital had no free ICU bed.
“Our next stop was a hospital in Nairobi West. To our surprise they demanded a down payment of a whopping 600,000 Kenya shillings. We could raise only 200,000 shillings immediately since it was late in the night and no banks were open,” Otunge narrated.
Otunge decided to call his doctor friend for help because the situation was getting desperate. The Kenyatta National Hospital’s ICU beds and other COVID-19 beds were full to capacity, so he could not get help from the national referral hospital. Fortunately, Otunge’s doctor friend, based at the Kenyatta Universality Teaching and Referral Hospital managed to secure a bed for patient at Komarock Hospital, a small but well-equipped medical facility in the Utawala area on the east side of Nairobi CIty.
“We rushed the patient there for admission. What shocked us even more was the high cost of ambulance for COVID-19 patients. The cost quadrupled from Kshs 5, 000 to Kshs 20,000. When we asked why the sharp increase, we were told it was because of the need for oxygen and PPEs needed for safety and to deter infection,” Otunge said.
Komarock Hospital agreed to take 200,000 as down payment before admission. They managed to raise the required amount and the patient got admitted and stayed in the hospital for 16 days. The cumulative bill was Kshs 1.2 million. “Fortunately, the patient survived. The bill, though steep, was manageable compared to what other COVID-19 patients paid in the high-end hospitals dead or alive,” Otunge observed.
But even as the families of Elizabeth Mutunga and Daniel Otunge were unable to secure room in any public hospitals in Nairobi, a special audit report on the use of COVID-19 funds shows that some ventilators were in stores either because there were no ICU or because some facilities were not ready for installation during that time.
A case in point is Mama Lucy Kibaki Hospital which, according to the Auditor General’s report received 18 ventilators. An observation by the special audit team which visited the health facility observed that the 18 ventilators were “not in use since there was no Intensive Care Unit (ICU). Items were in store as at the time of the audit.” We reached out to the management of the Mama Lucy Hospital to confirm whether these ventilators are now in use, but had not received a response by the time of this report’s publication.
COVID-19 patients who were admitted to government facilities did not pay hefty bills compared to those who were admitted to private facilities. For example, Zachary Ochieng, a veteran media and communications consultant was admitted at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), based in Kisumu.
“Luckily, I was in a government health institution and the bill was not very high. Part of the bill was waived by the county government of Kisumu, while the National Hospital Insurance Fund (NHIF) paid for the bed,” said Zachary.
A ventilator is like an artificial limb whose purpose is to help with a gaseous exchange.
“A ventilator helps with breathing by taking over and breathing for a human being,” says Dr Jeremy Gitau Njenga, founder, and Chief Executive Officer at Daktari Msafiri.
In an interview at his facility located at Nairobi’s 2nd Parklands Avenue, he said that ventilation is initiated for someone who has gone into respiratory failure.
“If you have any infection that has reduced you to unconsciousness, you are not able to breathe for yourself then we need to take over that breathing, otherwise if we don’t do that, that’s how most people end up dying,” said Dr Njenga.
However, Dr Njenga says that a ventilator itself will not help a patient, the reason being that ICU care is not just the machine. It has to be in a hospital setup with some trained personnel.
“Not everyone can take care of a ventilator, you need ICU-trained nurses and doctors who are the critical care personnel. Like in the laboratory you need to keep checking the blood gas,” he said.
ICU centers operate 24/7 and therefore the issue of having enough trained staff is key.
“You need to have a functioning kidney reader unit because some of these patients who are in the ICU and who are in a ventilator need dialysis,” he said.
The COVID-19 pandemic has increased ICU demand globally. As a result, different governments adjusted by either buying or receiving donations to beef up capacity for COVID-19 response.
For example, Kenyatta University Teaching Referral Hospital, which had 24 ICU beds before COVID-19, received additional 25 ICU beds and 20 HDU beds. This is according to the former chair of the COVID-19 Champions Response Team at the facility in a previous interview. The special audit report also observed that the 15 ventilators which were distributed were received and were in use.
“You can imagine if each bed needs five nurses because the nursing ratio for ICU is 1:1. We talk about five nurses per bed. So one nurse on day shift, one on night shift, one day off, one night off, and one on stand on leave,” said Dr. Njenga.
According to the Kenya Healthcare Federation, in 2020 Nairobi had the highest number of ICU hospital beds at 283 in both public and private health facilities. The same could not be said for West Pokot, Siaya, Kajiado, Baringo, and Lamu counties which were among the 21 counties that had no ICU facilities despite having large populations to serve.
The challenge to get a ventilator by COVID-19 patients was reported even a year later after Kenya reported its first case. In an interview with English News in April 2021, Dr Samuel Njenga, an Infectious Disease Specialist at KNH, explained how difficult it was for COVID-19 patients who required a ventilator or very high levels of oxygen in the country’s referral hospital.
“Sometimes you may only get a bed when you get mortality or a death in the Intensive Care Unit. So basically it is too many infections that may mean too many patients requiring Intensive Care Unit management,” He said.
In 2020, Kenya received funds from the World Bank for recurrent and development purposes in various government facilities. According to data published by the Institute of Economic Affairs, as of July 31, 2020, Kshs 22.4 billion had been directly allocated to the Ministry of Health. Kshs 15.08 billion of the allocation went into recurrent activities and only Kshs 7.35 billion was left for development activities.
Government oversight institutions say there are problems when a government spends more of its borrowed money on recurrent activities instead of developments.
“The reason why public debt should be used on those things that will generate revenues in the future is so that those who come after us can then benefit from the expenditure arising from public debt. Sustainability requires that we fulfil our needs without depleting the shares for future generations,” said CPA Dr Margaret Nyakang’o from the Office of the Controller of Budget.
In an exclusive interview, Dr Nyakang’o also said it was worrying that some new equipment was in storage during a pandemic. She said wrongs must be reported so as to protect the public.
“This information needs to be out there wherever we realise that things are going wrong we need to ensure that everybody is in the know. Some of these things are happening because people feel that no one will know,” she said.
A report looking at opportunity cost analysis on debt financing and provision of healthcare and services launched in December 2021 by the National Taxpayers Association (NTA) showed that recurrent expenditure on healthcare has increased especially after COVID-19. Still though, Kenya’s debt situation puts the country in a precarious place, should there be another national health emergency.
“In terms of opportunity cost, most of the money we receive, the government is forced to first pay its debt, the principal, and the interest before it can focus on taxpayers. Our creditors always take prevalence over and above the taxpayer while the taxpayer is the one funding the system and that is a bit problematic,” said Irene Otieno from NTA.
Kenya recently reversed its mask mandate as COVID-19 infections continue to fall nationwide. There are signs that the country’s healthcare system will emerge from the pandemic stronger, but proper management of Kenya’s resources remains in ICU. Therein lies Kenya’s dilemma for the future.
Tebby Otieno can be reached via firstname.lastname@example.org