Nurses in Kenya need to abandon industrial action for Health Service Commission (HSC) and Universal Health Coverage (UHC). Why – one: because every move from now on by the nurses in Kenya is being watched by all and, two: because HSC and UHC are and need to be our higher aspirations. The nurse is the fulcrum of the moving parts in universal health coverage. Lastly, it seemed something was not quite right with the the strike. It is becoming next to impossible in Kenya to pick your battles.
But let me put this into context. The Kenya National Union Nurses’ (KNUN) issued a strike notice and the strike began February 4th 2019 over failure by the county governments to honour the return to work formula as agreed in November 2017 #PayNursesKe #IMPLEMENTRTWF. Some governors and even the highest office in the land have pre-empted what they should have been saying towards the end of the industrial action.
Nurses demonstrate in a past industrial action [picture courtesy of nationalnurseunited.org]
Health Service Commission
Since we failed to insert the Health Service Commission (HSC) into the constitution in 2010 to deal with human resources for health we have to listen to the governors, some mainly handpicked Public Service Boards and Chief Officers of Health in the counties. This is something that can be rectified in our lifetime if we work together. At least Kenyans by now know that health workers under the county governments does not seem to work or was unlikely to work, though we cannot be too sure about that.
We can lobby to have the HSC item included in the change katiba initiative (change constitution) which is due any time soon. The moment the change katiba vugu vugu started it was the time for on your marks- set Go! Though the change constitution momentum was driven mainly by political considerations of power sharing we need to be careful whether to push for Kenyans’ agenda or our HRH agenda. Even if we don’t get our HSC in the referendum question the katiba change will still happen this year, next year, sometimes, never. Never – is the least likely.
As the political class fight for whether we should have a parliamentary or a presidential system, we need to worry if they can also convince Kenyans (or why would it be so hard to convince the Kenyans) that it was for their own good if Kenya can get a Health Service Commission into the referendum question and subject it to a YES/NO vote. It is a chance we cannot afford to waste.
Kenyans were no longer naïve. It seems a valid observation that Kenyans might wish to eat their cake and have it by leaving ‘their health’ devolved. Whether health remains a devolved function or not need not be the question since it will most likely mix up our issues. There will be those who will want us in the mix, but that is a complicated situation we need to be worried about.
As a HRH we should perhaps not lobby that the health docket goes back to central government (much as we will be watching that space keenly). Let other quarters drive that part of the agenda (but not) on our behalf. Our gem is Health Service Commission. It is our thing and Kenyans would be less reluctant to let us have it. It will be taking nothing away from them; it will be taking away what counties were struggling with. Perhaps governors would find it a relief since HRH has given them enough trouble already; they themselves at different points have admitted that they did not have the capacity to handle HRH. It had earlier been thought that HSC would undermine devolution. That angle is beyond the scope of this article.
But this is how it will look. With all health workers in Health Service Commission (HSC) we will be like ‘seconded to’ or affiliates of the county government by the HSC. A very potent lot. But the county can be left to employ a few of their own in a parallel system. Such a leeway will help counties retain some sense of control which must not be absolute. It’s like the public schools have some teachers employed by schools’ board of governors and the bulk of them by Teachers’ Service Commission (TSC). Without a doubt this balances out workload and boosts performance.
With the national piloting and subsequent rollout of Universal Health Coverage (UHC), it was all systems go. But were the nurses in Kenya … set…and, ready to go? That is a question that nurses will need to answer. What will be their contribution towards UHC? What were the merging nurses’ roles for universal health coverage (UHC)? It was quite presumptuous for nurses to believe that the government and donor partners would play hide and seek with its pet program UHC, all eyes were on Kenya ‘the beacon of hope for Africa’.
The nursing leadership should deliberately rally their followers behind the two agendas – UHC and HSC. Neither was a walk in the darkness nor a walk in the park. HSC was a dream while UHC was like a free kick as we say in football. UHC was a free kick – take the ball and run with it. As for what we can do with it, the opportunities were enormous. There were many goals to score for the nurse. I feel this was going to be reaping time for health workers in this country, but did they see it coming or were they too impatient to wait?
It cannot be about doctors, nurses and clinical officers every time and all the time, there were other health care providers cadres too. We need a strategy that takes care of the HRH, this time leaving no one behind. Just as Universal Health Coverage call was about leaving no Kenyan behind.
Any other approach will yield not just inequity inter, intra-professionally but between individuals who ought to be earning the same amount for equal effort and experience. With a HSC in place when HRH says add – they will, when we say top up – they will want to know if we have any discrepancies they can address.
The main borne of contention in nursing in this country has been first and foremost a poor working environment, a disregard for patient safety due to unsafe nurse to patient ratios. Then we have everything else one could think of including: lack of meritocracy in appointments, discrepancies in pay, re-deployment upon specialization, inaaccessible posting out-of-county, delayed promotions, skewed incremental credits, a fairly inept regulatory body and, poor absorption of degree nurses into public service etc.
Emerging issues include nurse safety and needless to say we now have some fairly careless and negative lot who are practicing nursing in our midst . For all these and more we have fought (sometimes with each other). A strike will never solve a bulk of them, a HSC will. But who would believe me? Nobody wants to wait here in Kenya. The bottom line – a strike at this moment in time was ill-advised.
The effect of this just like previous industrial actions rounded off will be the same = a dissatisfied human resource for health. No amount of allowances will iron out the crux of the matter – that we have a crisis in human resources, and there seems to some people who benefit from the confusion. Those in this radar include those seeking political mileage, some elements in Afya House, some commissions, private hospitals and power brokers etc. The answer for all of them lies in the creation of a health service commission.
I will show you why human resources for health (HRH) need to shed off every hard skin for this one, if not two things -The Health Service Commission and Universal Health Coverage (UHC).
I for one have always felt that the county government have been entering into a discussion which was not theirs in the first place. They seem so eager to be the ones calling the shots in these matters. Health is a viable currency for political negotiation, and that is why we now have Universal Health Coverage coming up. One of the best legacies any government would want to be remembered for is health care. It was unfortunate Kenyans have only come to realize it after so long.
You see the health system is complex and nowhere is it perfect. The closest we have to a near perfect is Australia and Canada. Japan celebrated 50 years of universal health coverage (UHC) in 2011 and South Korea did its 40th anniversary the other day. What can we borrow?
For that reason, we have come to a point as a nursing fraternity in Kenya where we must be ready and willing to critique every move (that we and others make). We must think, plan and act strategically. First stop the infighting and get to work. Never lose focus of the big goals HSC and UHC. In this we should live for, work for, move to any length and breadth and have our being. That is the legacy we can bequeath the next generation. Not every other generation in any country gets a referendum opportunity. I remember when BSNs were routing to be included in the internship kitty, them of those times did not benefit themselves but today BSN interns earn a pretty amount.
Leadership with a conscience
Everything must be done from a strategic point of view. It is a time when our nurse leaders must be willing to be put on the spot, to tell the truth as they know it. Be willing to take up position on the pedestal of truth, to tell the truth, the whole truth and nothing but the truth. No room for presumptions any more.
However for leaders in the system (including the union leaders) telling the truth means they must be good learners and listeners, their opinion should come last. Infact they might just as well not say it, we have heard them long enough. No wonder Kenyans were asking – ‘it’s you again!?’ Every time they see these familiar faces on their screens they have learnt to associate with not very pleasant memories.
We do appreciate that our union leaders have done so much on our behalf. They also know so much from so many but nevertheless in telling the truth need to use some discretion. What can be left out without jeopardizing this understanding? What we call a minimalist approach when dealing with the public (and in some instances their nurse followers).
There is no sense of going into the boardrooms for negotiations then emerge from the front door to diverge everything (to the press and all) dressing it up mostly with our personal vendettas (and hitherto withheld opinions). On the other hand, the other party knows how much was said in there and that the press conference was being treated to some theatricals. The aim of nurse leaders need not be that of whipping the “soft spots”, capable of triggering strong reactions from their constituents as has been the case. They need to be factual and truthful.
HRH has come full circle it’s now a system
The human resources for health (HRH) have come full circle in Kenya, someone even called what was happening in the health sector a movement. We have come so far, it will never be business as usual. So much damage has been caused that will need some healing time. The employers must realize HRH can no longer be actively maintained as the naïve, altruistic cadre of workers. This is not possible anymore; we have long crossed that chasm of decision making.
May be thinking from a systems approach might help (borrowing from the thinking of Hummelbrunner, 2000; 2011). Really can nursing remain stable in a changing operating environment? That should be our prime concern. The health care system has many actors. There are conflicting and often poorly thought out themes and policies. The health care system is perhaps unwilling to yield to its human resources space and the time which are the key resources they could exploit to make it run smoothly. It was unfortunate that the HRH through their union leadership chose to look at the pay aspect almost exclusive of every other.
HRH (including nurses) on the other hand are mainly concerned about the financial aspect (what they earn, ought to be earning, who is earning what and how much more or less and, why and why not?). The-me-too approach driven more by lack of equity (more of why’s – bona huyu, bona wale and kwa nini? ).
However, in this era of austerity measures a few steps into realizing the truth are key. Let’s face it! Honestly. Not many civil servants in Kenya got these quantities and quality of allowances, at least that for sure we know. Those of us in faculty earn much more than the rest of dons because of these allowances. We do not take it for granted that those in the practice suffer more fighting for us. For these we are forever grateful. The university administration has a hard time understanding, yet they are the ones to pay what they themselves were not entitled to nor did many have such prospects.
But then what is the role of nursing faculty? One is to do research around pertinent issues in order to demystify processes. They do commentaries to frame the thinking of the nurses. Some dismiss this as too theoretical, but it is a role few are able to play except for the self-inspired. Basically, a thankless undertaking.
In the words of Florence Nightingale, the founder of modern nursing:
“May we hope that when we are all dead and gone, leaders will arise who have been personally experienced in the hard, practical work, the difficulties and the joys of organizing nursing reforms, and who will lead far beyond anything we have done.”
The media and us
The media is often recognized as the fourth estate (unofficially) of government. We will need to use the media to our advantage not to highlight internal wrangles. The media often find health matters expose quite newsworthy, the perception seems to be that the media’s agenda is to make us “look bad”. Failures in the health care system do unfortunately impact more upon community attitudes towards HRH than all the examples of success.
The last time the media had a field day seeking counter sentiments from each union faction. Different factions fought each other in public and more fiercely on social media platforms. As usual, they disagreed on virtually everything. On 27th July 2017 in a meeting with the Council of Governors (CoG), the factions were requested to leave the venue and agree between themselves first. We can ill afford that now.
Problems and solutions
We will need to define problems from solutions and vice versa (Hummelbrunner, 2011) Systems theory and Systems thinking. Problems are: situations regarded by someone as undesired, which need and can be changed (at least in principle). But we too can construct problems that become the systems’ problems. You can think of a few examples.
What is considered problematic for one actor might be meaningless or even considered a solution by others. Indeed some sections of HRH have reaped massively from divide and rule tactics in equal measures. Prof Atwoli PhD, recently wrote in Nation, on 16th February 2019 that ‘labour relations in health sector were a disaster’.
Therefore we are talking about a problematic situation that has often led to specific patterns where not only systems are creating problems, but problems are also creating systems. For example, we now have a system called HRH crisis in Kenya. It follows a certain predictable pattern.
Unionist will want us to believe these were the stages of a strike, they must be knowing what they were saying. But I learnt too that unionists ought to prepare the striking workers to save what can sustain them for a minimum of 3 months during the strike.
But ask any Kenyan, they will tell you with some degree of certainty what will happen: A lot of bickering culminates into a call into industrial action, and the industrial action takes place, in some areas more intense than others. Leaders get divided. Some court battles become a necessity to keep the tempo, then time drags along and the public loses interest. The strike dissipates, with a sizeable number having resumed duties, finally when it cannot hold; some crafty decision is taken to call it off. Much of the action will be virtual, taking place in the media, social media and commentaries (like this one). The county governments do their jig of beating the drums so loud that the song is not heard. That is assuming the battle is theirs (when it never was in my opinion), it belongs to Health Service Commission (HSC), if we let us work towards making it a reality.
The rummaging effect notwithstanding, the aftermath is felt for a long time. I am avoiding referring to the sick here because that would deviate the debate, but they remain the most important stakeholders whichever way we look at it.
We have come full circle
We have come full circle in the politics of health and politics in health. The problematic system needs to be identified. “Everything changes unless someone/-thing ensures that things remain as they are”. It would be important to learn how problems are maintained, who and what contributes to ‘stabilise’ the situation as it is? Are there actions which take place but should not happen? Are there actions which do not take place but would be needed?
But at this stage, it is also important to analyze the state of affairs we have (here and now, Kenya of February 2019). We will need to make a distinction between problems and difficulties. Difficulties are undesired states, which can either be solved by simple corrective actions or have to be lived with because no solution is known. Let us not be hesitant to think of a lofty dream – What is the good in the bad, what would happen if the problem disappears?
Coming full circle also means we now have some level of maturity compared to 1 or 2 years back, as to whether a strike ought to be the new normal in our profession, we can continue and plan for the next strike during the strike, but how was that going to working so far? We do have a postscript. Especially emanating from the five-month long strike of 2017. So we can afford to analyze previous attempts for solutions:
What should not be tried anymore? Past solutions are often the key to present problems. This is particularly true in cases where false solutions have been applied on difficulties and thus have turned them into real problems. Is the context the same? Even applying proven solutions in a changed context may not be the right thing to do.
We need to identify the crucial factors capable of bringing forth change (leverage effect). What points at future directions? Problem talk creates problems, solution talk creates solutions. Who and what is needed and who and what can be left out?
I will work from the simplistic approach and propose what it might be least costly but most effective. What is the smallest unit needed to bring forth a solution?
Due to the constructed nature associated with HRH’s problems and solutions, the focus must not be placed on the past (that is in trying to answer the question why?), but on the present (what?). What happens now and what can be done about it? This becomes especially important where actors are too entangled in their problems to see a way out or only tend to see the old solutions to new problems. Or were part of the problem themselves.
For that business outlook, we need to SWOT
Even as we seek change, but we need to be made aware what should be maintained. A SWOT analysis might help us to strategize. SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. Balance out nurses’ contradictions and ambivalent tendencies (e.g. good in the bad, bad in the good).
Each of these words can have a small letter that can be matched with another word. For instance Weakness can be matched with opportunity (Wo) and then we see what we can get. Often the lack of unity among nurse leaders matched with opportunity to rally the troops behind a WORTHY cause like HSC (Wo). Our numerical strength (So) matched with a lifetime opportunity for HSC/UHC in this time and season.
What are we bad at doing? What are we good at doing? What do we want to defend against? Certainly the threats and weaknesses (Tw) like lack of unity. What do we want to take advantage of? Opportunity and strength (Ot) our numerical strength and our undisputed trust with patients. What do we want to improve that we have or are not doing right opportunities weaknesses? (Ow) like wanting to do things like doctors, teachers and, soldiers yet we are not, if anything can be better!
Developing a factual base for our opinions ensures an informed dialogue with others, supports our views with hard data or factual evidence to increase our credibility. The nurses’ knowledge about patients, ability to translate patient care systems into financial language, and ability to focus on how to design future patient-centred systems of care is a significant contribution that no successful health system can afford to ignore.
“Nursing is a business and it is in the profession’s best interest to craft our arguments in a business-like manner” (John Welton Ph.D., RN) as he proposed on Paying for Nursing Care in Hospitals. He has done a lot of work nursing care costs, nursing billing, and reimbursement. In his argument, prospective payment system must more accurately represent nursing care. One way was by utilizing nursing intensity billing (Welton, 2006).
Balancing the act by use of external interveners
What if we kept our interventions balanced by exposing to external views in a moderate way, without confronting openly? Due to the selective processes of self-referenced unionists, each only sees specific parts and is not aware of the blind spots, since ‘we don´t see that we don´t see’. This can only be achieved by increasing the reflective capacity, and for this external assistance can be of great help.
Every system, in the end, does what it does best according to its logic but what of trying to utilize mediation, interveners? We have not tried this and failed if we gave it a fair chance. Let’s give it the power and resources. Regard interventions as a cyclic process. There will always be another day to try what we feel must be implemented now-now! But just a minute – What if we tried something else? Who knows, maybe the Third World War (WWIII) has been thwarted this long because of this last minute; what if, just a minute approach quite often the suggestion came from the least of those involved.
External observers are much sought after; they will provide that additional perspective and help us overcome internal blockages. Above everything else we need to spell out their terms of reference, narrow them to specifics.
We cannot anymore operate in silos. The silos of – ‘those, them and we’ nurses. We can work collaboratively with Kenya Medical, Pharmacists & Dentists’ Union (KMPDU), and Kenya Union of Clinical Officers (KUCO) etc. The way into the future is skills-mix, task-shifting, task-sharing inter-disciplinary, inter-sectoral and we cannot possibly avoid it on our path to UHC as a low and middle-income country (LMIC). If that is the way we will work why not start from a welfare point of view?
We can do some circular dialogues with the help of external facilitators. After all, what has working each on their own achieved anyway? Mixing efforts might yield divergent results sometimes but it is never too late to work together if we can reduce our suspicions of each other’s intentions. Lastly and, this is the crux of the matter – Will rallying everybody back to the streets be the best option? Nothing could be worse than leading a scared lot on the streets of Kenya today, especially after waning public sympathy for the cause of the industrial action.
Whatever statements were being issued from the highest office in the land to the governors tell a different note -Times have changed. Even the KNUN top organ was now saying it was the branches that called the strike and not the national organ and that it would recognize the RTWF with counties, in effect making the national RTWF of 27th November, 2017 a lame duck.
Perhaps look at the fruits hanging up there, not just the low hanging ones. The fruit up there is hidden in Health Service Commission and Universal Health Coverage. Now is the time, Nursing Now! If anyone followed my posts since 2017, never ever did I say that nurses should not be paid what is due to them since I am one of them. I am only trying to frame the debate for our weighing and consideration.