Devolving health was the right move but handle medics better

The doctors are on strike again. Various components of medical practitioners from clinical officers and nurses to fully registered doctors have been on strike for the better part of two months.  

Unlike previous occasions, the pain has not been felt at the same level as previous strikes, largely because the devolved nature of the services means there are significant portions of the country where medical practitioners continue to work.

Since there is mobility among the population, patients just cross county borders to seek services where doctors are working.

Not surprisingly, the “patriotic” response by Kenyans who are instinctively centrist is to call for return of health function to the national government. I always find these calls ahistorical and negligently naïve.

They unknowingly feed into a narrative pushed primarily by unions, who were the single largest loser in the devolution of health services as they could no longer use their national pulpit to push the employer on behalf of their members. They now must deal with 47 employers across the country.

Their self-interest push for recentralisation is therefore rational and understandable. For other Kenyans calling for recentralisation, their clamour is ahistorical for several reasons. It assumes that health was better performed in the good old, centralised days. Like the Israelites of old who longed for the garlic and onions of Egypt, they so easily forget the sufferings of the past when troubles come calling.

They have forgotten that after the early 1990s’ application of Structural Adjustment Programmes, health services collapsed across the country. The situation was so bad that at some point in the mid-90s doctors were on strike for about nine months and there was a mass exodus of Kenyan doctors. Countries like Botswana were the recipients of most of these doctors.

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At one time Kenyan doctors were occupying about 60 per cent of the medical workforce of some countries in the south of Africa. The reason Kenyans demanded health be devolved was as a reaction to these collapsed services. I don’t want to be the publicist for the devolved governments, but any objective person will accept that in a significant part of the country, health services have improved since 2013.

That would explain why basic health indicators including maternal and infant mortality, access to health services and disease incidence have improved in most of the country. The details of these improvements are easily accessible in the 2022 Kenya Demographic and Health Survey.

Those who call for recentralisation also fail to see some obvious contradictions in the calls, including the deficient state of services in the referral hospital services that were left with the national government. Kenyatta National Hospital, Moi University Hospital in Eldoret and the Nairobi Spinal Injuries Hospital are providing less than optimal services.

Why would a national government not operating optimally in the areas it has constitutional jurisdiction be allocated more responsibilities? That is not all. Other national level institutions in the medical sector including KEMSA have been quoted routinely for shadowy procurement. That points to a dysfunctional system at the top. Are these the dysfunctions we want to recentralice? That is not to say all is hunky-dory at the counties.

We could do better with the terms of service for doctors and other professionals working in the public sector. County governments need to find a way to improve their conditions of work. Some of this may not be monetary. Could county governments provide better housing and related services to their medical workers through the housing scheme in which they are partnering with the national government?

Could a staff friendly mechanism for inter-governmental transferability be established so that doctors can move between counties without losing privileges? Monetary compensation is unfortunately related to the allocation of revenue to county governments that has been reducing as a proportion of the national budget since devolution.

Consequently, counties do not have the margins to enhance salaries until more money is allocated by Parliament. Bottom line, there are challenges in the health sector that require concerted action. We cannot afford to export our professionals after investing in their training. Our challenges will however not be solved by recentralisation. That ship rightly sailed ages ago.

The writer is an advocate of the High Court of Kenya