A critical analysis of the nursing situation in Kenya in the advent of policy change demands

1.0 Introduction

This is a critical analysis of the nursing situation in Kenya as it focuses on highlighting day-to-day conundrums that we all face as nurses in the advent of policy change demands.  It is a trail of social media postings by various individuals on the subject over time.  A realistic approach to policy analysis using SWOT is included.  It employs back links to related materials as well as a bibliography at the end.

An advocacy approach is utilized to sensitize fellow nurses to get past the riddle of getting a Health Service Commission (HSC) and also to embrace Universal Health Coverage (UHC) even as we look into alternative ways of dispute resolution.  The proposal to have a health service commission for Kenya will need a constitutional referendum, a tall order by any standard.  Kenya is in a constitutional making moment right now (though driven more by political interests), a chance nurses cannot afford to waste.

Nurses in Kenya have been faced with a need to rise to demands of frequent policy changes in the last couple of years. But generally the human resources for health in Kenya has undergone a difficult period ranging from industrial action to frequent policy changes. But the most critical so far has been the devolution of health services from the national government to county governments.  The government nevertheless has seen to it that with the rolling out of universal health coverage (UHC) Kenyans will be able to access affordable care. However, this raises significant challenges in terms of assuring quality health services.  Staff need a voice that advocates for their needs.

Nurses just like other health care providers might be better off in a Health Service Commission (HSC) which will take care of their welfare and iron out most pending issues.  This article attempts to look into the intrigues of HSC and UHC and why it might be in their best interests to pursue these noble agendas.

1.1 Why bother?

Nurses in Kenya need to abandon everything else for Health Service Commission (HSC) and Universal Health Coverage (UHC).   Why – one: because every move by the nurses in Kenya was being watched by all and, two: because HSC and UHC are and need to be our higher aspirations.

Let me put this into context: The nurse is the fulcrum of the moving parts in universal health coverage and the system realizes that.  Every other cadre in the health system expects the hunter (in this case nurses) to wrestle the prey, but it is becoming next to impossible in Kenya to pick your battles.  It seemed something was not quite right with strikes affecting human resources for health presently.

Previously around February 2019 the Kenya National Union Nurses’ (KNUN) had some counties on strike  over failure by the county governments to honour the return to work formula (RTWF) as agreed in November 2017 #PayNursesKe #IMPLEMENTRTWF.

Different counties were either on go-slow or on strike literally over delayed July/August/September/October 2019 salaries occasioned by the impasse over the revenue allocation bill.  The Senate, parliament, governors and even the highest office in the land have pre-empted and pronounced themselves on the matter.

Nurses demonstrate in a past industrial action [picture courtesy of nationalnurseunited.org]

1.2 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 County 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 must lobby to have the HSC item included in the change katiba initiative (whether it will be Building Bridges Initiative (BBI), Punguza Mzigo(PMI) or any other change constitution caucus) which is due any time soon.  The moment the change katiba vugu ‘change constitution initiative’ started was the time for on our marks- set Go! Not every other generation in any country gets a referendum opportunity.

In view of the BBI and PMI both are done with collecting views, need we wait for our messiah still?  BBI will be released any time now, while PMI seems to have been prematurely hatched. Ugatuzi (devolution) initiative is taking its sweet time reading the times and fate of others before it.

Even though the change constitution momentum was seemingly being driven 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 are 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 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; instead it will be taking away what counties were struggling with – HRH.  Perhaps governors will 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 the formation of HSC would undermine devolution. That angle is beyond the scope of this article.

But this is how it will look, in my view.  With all health workers in the Health Service Commission (HSC) we will be like ‘seconded to’ or affiliates to 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, though they already messed it up by grossly underpaying their contractual HRH in the current setup. The pay gap between the contracts and the permanent & pensionable is exponentially wide.

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 emerging nurses’ roles in universal health coverage (UHC)?  These are all fertile research questions. This author was working around what were the medical education implications of the nurses’ role in the advent of UHC?

The nursing leadership should deliberately rally their followers behind the two issues – UHC and HSC.  Neither HSC nor UHC was a walk in the darkness or 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. 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 government knows for a fact there is no UHC without HRH and quality care was at the centre of this (Wangia, 2019).  There were many goals to score for the Kenyan 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?

1.3 Universal Health Coverage and the nurse

UHC emphasizes that people must have reasonably equal access to covered health services, without becoming poorer as a result.  Key to the success in providing effective coverage to the population was the readiness of the health service sector (Lu & Chiang, 2018).  The study referred to Taiwan’s experience towards UHC which it achieved in 1995.  Achieving UHC involves distributing resources, especially human resources for health (HRH), to match population needs.  Countries aspiring for this must show financial commitments on HRH in support of UHC.  It calls for evidence to inform practice and transform various health policies (Campbell et al., 2013).

However, it seemed that the Jubilee government of Kenya decrees assumed an existing knowledge and readiness of systems when it pronounced itself on certain on UHC in August 2017.  Evidence shows that many nurses just like other health care workers might have a challenge understanding the complexities of health care systems as a starting point (Porter-O’Grady, 2015).  This deficiency was also highlighted in the Institute of Medicine of the US (IOM, 2001) in their distinguished blueprint The Future of Nursing and supported by Kurth et al., (2016) ‘Investing in Nurses is a Prerequisite for Ensuring Universal Health Coverage’.

There were often conflicting requirements of donors and governments weighing on the implementers in some cases. These could lead to transformation fatigue especially when health care providers as often happens when they were faced with a battery of frequent, often contradicting policy initiatives. This was a key observation by Armstrong & Rispel (2015) in a South African study on nurses and social accountability.

UHC was still fairly new in Kenya, just past the piloting phase. UHC episodes were more likely to be reported in the media than in academic publications (Russo et al., 2019).  From Kisumu County the media reported during a nurses’ industrial action by that ‘…gross understaffing has ballooned the crisis even further, and the universal health coverage program, only adding insult to injury, raising the number of patients they serve per month to about 2000 concerning a level 2 facility’ (Otieno, February 7th, 2019).

Further, this author observed that a good number of people both in policy making and training believed that if a nurse did all they had been trained they will be able to assure Kenyans of universal health coverage.  It will be by fair chance that they could be able to meet many of the UHC requirements if they did that.  Far from that, nurses will likely be concerned about their enhanced and new roles in UHC since they tend to spend more time with patients than other clinicians (Schveitzer et al., 2016) and (Koon et al., 2017). The later studied ‘nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector’.

What is it we can do about the new horizon that UHC is?  We can come up with a white paper on care delivery models to improve outcomes for poorly serviced populations, including the aged, people with multiple, chronic diseases and those who are marginalised and disadvantaged by geography, culture or poverty. We can demand that the government recognize the full scope of skills, services and support the nursing profession can provide in these aspects but utilizing multidisciplinary patient-centred health care models.

2.0 What exactly ails the HRH in Kenya?

In this author’s view whenever there was a dissenting voice on HRH and health system it was from certain quarters, while a majority of HRH were passive, docile or perhaps mute.  But HRH cannot be about doctors, nurses and clinical officers every time and all the time, there were other health care cadres too.  We need a strategy that takes care of the HRH, this time leaving no one behind.  Just as Universal Health Coverage clarion 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, inaccessible 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 nurses’ 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 many strikes going forward just like the more recent ones rounded off will be the same = a dissatisfied human resource for health, with barely nothing to show for the strike.  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.

It was unfortunate that the union leadership chose to look at the pay aspect almost exclusive of every other aspect. HRH (including nurses) were 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?) Swahili for why this one and not the other was getting so much. A strike will never solve that even into the infinite future!

Let’s face it honestly. In this era of austerity measures a few steps into realizing the truth were key.  Not many civil servants in Kenya got these quantities and quality of allowances. At least that for sure we know.

2.1 Can we get anywhere near perfect health system?

I will show you why human resources for health (HRH) need to shed off every hard skin for this one HSC, if not two things -The Health Service Commission and Universal Health Coverage (UHC). The Ministry of Health used to run the whole system almost exclusively so we know what it is capable of doing. Infact it will be a shocker for it to lose its staff to HSC.  We are also not blind to see what has been happening with Teachers Service Commission. So HSC will not get us anywhere near perfect health system, but it is a step in the right direction.

I for one have always felt that the county governments 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.  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?

2.1.1 Uganda has a Health Service Commission

Just next door Uganda has a health service commission. This is not a by the way. Even though UG is not the best prototype but truth be said, they are ahead of us in this matter. From the website the vision of UHSC (HSC Act, 2001) ‘….fully resourced health workforce that is responsive, efficient and effective in Uganda socio-economic transformation process’. Mission ‘to build a fundamentally strong and completent human resource base for efficient and effective health service delivery.’ Just take a second look at the mission statement. I was especially attracted to the phrase complement human resource base. I was almost tempted to think the most appropriate word could have been competent, but how wrong I was. Oh how real the phrase was, indeed every cadre is incomplete in itself but HRH complement each other for efficient and effective health service delivery.  I also found out that individuals post their resume and keep updating it via the self-service health workers’ portal, while job recruitment was done online.

2.2 Too much mistrust

Contrary to our Ugandan counterparts, the Kenyan health care providers are very sceptical about formation and effectiveness of HSC, maybe because of the previous working relationship especially between doctors’ and other health professions. There has been suspicion that there may not be equity in terms of representation in the Health Service Commission to be. Anyhow these challenges can be discussed and resolved now that we have the new Health Laws (Amendment) Act 2019.  We need a well-resourced and all inclusive HSC which would help resolve many of the long-standing health related issues.

For that reason, we have come to a point as a nursing fraternity in Kenya 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. 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.

2.3 HRH has come full circle it’s now a system

May be thinking from a systems approach might help (borrowing from the thinking of Hummelbrunner (2000; 2011). 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.

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.

2.4 Role of nursing faculty

What is the role of nursing faculty in nursing politics or the politics of the health system?  One is to do research around pertinent issues in order to demystify processes.  We fight alongside those in clinical practice, albeit not always from the visible front. 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. But then we realize that we need to give back to the profession; we owe so much to it.

Those of us in health sciences faculty earn much more than the rest of dons because of extra allowances (clinical, extraneous, uniform etc.) by virtual of being nurses, clinical officers, doctors etc.  The university administration usually has a hard time understanding this. For instance why a nursing don the level of an assistant lecturer/tutorial fellow earn much more than a full lecturer in non-health programs who were not entitled to such allowances nor did many have any such prospects. We do not take it for granted that those in the practice suffer more fighting for the allowances than we do, for these we are forever grateful.

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.”

2.5 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 performance than all the examples of success.

The last time the media had a field day seeking counter sentiments from each nurses’ 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 nurses’ union factions were requested to leave the venue and agree between themselves first. We can ill afford that now.

2.6 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 TV 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 revolving doors 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.

3.0 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, 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.

Compleat Nurse* 2017

The cog wheels of health system

3.1 We have come full circle

The cogwheels of the health system have come full circle in the politics of health and politics in health. The later was hardly their concern for a long time as evidenced by the circumstances in the run-up to the constitution 2010.

But the problematic system needs to be identified. “Everything changes unless someone/-thing ensures that things remain as they are”, Hummelbrunner (2011).  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, the Kenya 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 has that worked so far?  We do have a postscript.  Especially what emanated from the five-month long strike of 2017.

The fact remains more than ever before WE NEED REFORMS NOW. The beauty of it is that the occasion has been presented to us.

mural courtesy of colorED

 

3.2 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.

3.3 For that business outlook, we need to do a SWOT analysis

Even as we seek change, 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.  Strengths and weaknesses are usually regarded as internal while opportunities and threats as external but this may not always be the case.

SWOT analysis in our strategic planning should help us to balance out nurses’ contradictions and ambivalent tendencies (e.g. good in the bad, bad in the good, the good with the not so good) cross tabulate the matrix on and on as follows:

Table: A SWOT/Swot analysis matrix

Attributes

S W O T

s

Ss Ws Os Ts

w

Sw Ww Ow Tw

o

So Wo Oo To

t

St Wt Ot Tt

Each of the attributes can have a small letter that can be matched with it or any other attribute.  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).  Nurses’ numerical strength (So) matched with a lifetime opportunity for HSC/UHC in this time and season (e.g. HSC and UHC).

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) includes lack of unity. Why do we need to have five nurses’ associations or do I say unions? These can all be easily collapsed into one.

What do we want to take advantage of? Opportunity and strength (Ot) our numerical strength and our undisputed trust with patients.  We can successively argue that point with evidence, backed by years of surveys worldwide. For the US according to Gallup (2018), for the last 16 years, Americans’ ratings of the honesty and ethical standards of 22 occupations found nurses at the top of the list.

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).

3.4 Balancing the act by use of external interveners

What if we kept our interventions balanced by exposing to external views in a moderate way, negotiating 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 some of 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.  I believe some of us have used SBAR; Situation, Background, Assessment, Recommendation.  SBAR is a framework for communication between members of the health care team, a concrete mechanism useful for framing any conversation, especially critical ones, requiring the other party’s immediate attention and action.

External observers are much sought after nowadays in the corporate world; 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.

3.5 Working Collaboratively

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) (Rubinstein et al., 2018).  If that is the way we will work why not start from the welfare point of view?

A recent anonymous post to a social media wall read ‘…I long for a time when KNUN and KMPDU can merge and push pertinent issues affecting us in a more powerful manner’ [End of quote]. After all, what has working each on their own achieved anyway?

We can do some circular dialogues with the help of external facilitators.  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 all too frequent rallying nurses 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 apparent waning of public sympathy for the cause of the industrial action in the health sector. But ask many a Kenyan, they will tell you with some degree of certainty what will happen. 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 beforehand what can sustain them for a minimum of 3 months during the strike.

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 of the industrial action 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.  The patient ends up as pawns in the fight, some getting crushed or falling through the cracks.

Whatever statements were being issued from the highest office in the land to the county governors tell a different note –Times have changed.   Even the KNUN top organ was now saying it was the branches that called the strikes and not the national organ.  KNUN said that it would recognize the RTWF with counties, in effect making the national RTWF of 27th November, 2017 a lame duck.

Perhaps we need to 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!  Health Service Commission Now!

We must desist from roasting colleagues who dare challenge the decisions made by our leaders in HRH. 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. It is my humble submission then that nurses in Kenya should abandon everything else and work towards ensuring the formation of a Health Service Commission (HSC) and the realization of Universal Health Coverage (UHC).

[The author Simon Kamau worked as a critical care nurse both at the bedside and as nurse manager of critical care division at Moi Teaching & Referral Hospital, the second largest hospital in Kenya. Thereafter he transitioned to academia.  He has a Masters in Nursing Leadership & Health System Administration from University of Colorado, Denver.  He is a doctoral candidate.

He sometimes comments and posts using pseudonym compleat nurse.]

Bibliography

Armstrong , S. Rispel, L. (2015). Social accountability and nursing education in South Africa. Global Health Action, 8:1, 27879, DOI: 10.3402/gha.v8.2787

Atwoli, L. (16th February 2019).‘Labour relations in health sector were a disaster’. Daily Nation, NMG, Nairobi

Campbell, J., Buchan, J., Commetto, G. et al., (2013). Human resources for health and universal health coverage: fostering equity and effective coverage. Bulletin World Health Organization. 91(11):853-63. doi: 10.2471/BLT.13.118729.

Hummelbrunner, R. (2000). A Practitioner Handbook on Evaluation. Edward Elgar Publishing.

Hummelbrunner, R. (2011). Systems thinking and evaluation. Evaluation. 17(4): 395-403

https://doi.org/10.1177%2F1356389011421935

Koon, A., Smith, L., Ndetei, D., Mutiso, V., Mendenhall, E. (2017). Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector. Critical Public Health, 27(1), 28–38. https://doi.org/10.1080/09581596.2016.1208362

Kurth, A. , Jacob, S., Squires, A., Sliney, A., Davis, S., Stalls, S., & Portillo, C. (2016). Investing in Nurses is a Prerequisite for Ensuring Universal Health Coverage. Journal of the Association of Nurses in AIDS Care, 27(3), 344–354. https://doi.org/10.1016/j.jana.2016.02.016.

Lu, R, Chiang, T. (2018). Developing an adequate supply of health services: Taiwan’s path to Universal Health Coverage. Social Science Medicine. 198:7-13.

DOI:10.1016/j.socscimed.2017.12.017

Megan, B. (Dec. 26, 2017). ‘Nurses Keep Healthy Lead as Most Honest, Ethical Profession’. Gallup.

Otieno, L. (February 7, 2019). ‘Inside the life of a nurse: Why are they on strike?’ Citizen Digital. https://citizentv.co.ke/news/inside-the-life-of-a-nurse-why-are-they-on-strike-

Rubinstein, R., Barani, M., Lopez, A (2018). Quality first for effective universal health coverage in low-income and middle-income countries. Lancet. 6(11) Pe1142-e1143

Schveitzer, M., Zoboli, E., & Vieira, M.(2016). Nursing challenges for universal health coverage: a systematic review. Revista Latino-Americana de Enfermagem, 24(0). https://doi.org/10.1590/1518-8345.0933.2676

Wangia, E., Kandie, C.  (2019). UHC policy Brief:  Refocusing on quality of care and increasing demand for services; Essential elements in attaining universal health coverage in Kenya. MoH, Monitoring & Evaluation Unit

Welton, J., Zone-Smith, L., Fischer, M. (2006). Adjustment of inpatient care reimbursement for nursing intensity. Policy, Politics, & Nursing Practice. 7(4): 270-280. DOI: 10.1177/1527154406297510

 

12 Comments

Please leave a reply