A reflective analysis of the nursing situation in Kenya: Framing the debate ‘2020, the year of the Nurse’

This is a reflective analysis of the nursing situation in Kenya: Framing the debate ‘2020, the year of the nurse’

Abstract: WHO has declared 2020 the Year of the Nurse & Midwife. Nurses in Kenya have been faced with a need to rise to demands of frequent policy changes in the last couple of years. The most critical change so far has been the devolution of health services from the national to the county government and the rolling out of universal health coverage (UHC). Initiatives like the Building Bridges Initiatives (BBI) may spell some hope for health workers to finally get a Health Service Commission (HSC).  An advocacy approach is utilized to sensitize fellow nurses to embrace universal health coverage even as we look into alternative ways of dispute resolution including a Health Service Commission (HSC).   Method: This is a reflective analysis of the nursing situation in Kenya amidst frequent policy changes. The author has been studying happenings with interest. The emergent design started as a trail on media postings including blogs by various actors.  A realistic approach utilising: SWOT analysis, Maslow’s Motivation Theory, Hummelbrunner’s Systems Theory and, Nightingale’s ideals at the end.  Rigor: To control for reflexivity the author is first a trainer in nursing leadership and health system administration; then as a doctoral candidate, thesis touching on the nurses’ role in the advent of Universal Health Coverage in Kenya. The writer maintains an active voice based on a dated follow-on reflective journal juxtaposing UHC and HSC in an effort to bracket two seemingly dissimilar notions.  It also employs backlinks to related materials. Conclusion and recommendation:  While universal health coverage (UHC) will mean that Kenyans will be able to access affordable care, it appears like there was some disharmony between supporting structures for UHC or more likely the system UHC has to support. This raises significant challenges in terms of assuring quality health services. Staffs need a voice that advocates for their needs. Nurses just like other human resources for health (HRH) might be better off in a Health Service Commission (HSC) which will take care of their welfare and iron out most pending issues. However, the proposal to have a HSC 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.

Key words: Kenyan nurses; human resources for health; Kenyan constitution; BBI, universal health coverage; county government; health service commission; devolution of health services.

1.0 Introduction

This is a reflective analysis of the nursing situation in Kenya. It explores the possibilities for framing the debate for a Health service Commission and making a case for Universal Health Coverage.

It highlights the day-to-day conundrums that nurses in Kenya faced in the advent of policy change demands in the recent past.  It follows a trail of media postings by various individuals grossing on the subject over time, employing backlinks to related materials.

Nurses in Kenya have been faced with a need to rise to demands of frequent policy changes in the last couple of years, though generally, the human resources for health in Kenya has undergone a difficult period ranging from industrial unrest 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.

Staffs 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?

This writer submits that 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’s put this into context: The nurse is the fulcrum of the moving parts in universal health coverage and the system realizes that (see Figure 3 below).  Every other cadre in the health system expects the hunter (in this case nurses) to wrestle the prey (a less than perfect health sector), but it was becoming next to impossible in Kenya to pick your battles.  It seemed something was not quite right with strikes affecting human resources for health.

Previously around February 2019 the Kenya National Union Nurses’ (KNUN) had nurses in 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 salaries in one or the other month(s) occasioned by an impasse´ over the revenue allocation bill.  The Senate, parliament, governors and even the highest office in the land have variously pre-empted and pronounced themselves on these matters.  The matter was complicated by the National Treasury’s decision to withhold funds for counties which had pending bills owed to suppliers.


Figure 1: A section of nurses in Kenya stage a sit-in outside the Ministry of Health headquarters in a past industrial action [Picture courtesy of nationalnurseunited.org]

1.2 Health Service Commission

Since we failed in 2010 to insert the Health Service Commission (HSC) into the constitution to deal with human resources for health we have to listen to the governors, some mainly handpicked County Public Service Boards and County Executive Members (CEM) of Health in some counties.  This is something that can be rectified in our lifetime if we work together.

Allow us to make a fair guess here; that at least Kenyans by now know that health workers under the county governments does not seem to work or were unlikely to work properly, though we cannot be too certain about that.

At least we now managed to lobby to have a HSC item included in the Building Bridges Initiative (BBI) change katiba initiative even though we did not get it into Punguza Mzigo (PMI). The moment the ‘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 initiatives this far: PMI was done with collecting views before they could slot us in.  PMI seemed to have been prematurely hatched after getting only 2 out of the 47 counties giving it a nod, but it was all but dead. Its drafters have since revised it and it is just about to get a new facelift.  I am not certain if it has now proposed a HSC. The Ugatuzi (devolution) initiative is taking its sweet time reading the times and fate of others before it…

BBI report released recently had the Health Service Commission (HSC) in clause 163 section: A and B. The dye is cast for health workers and personal convictions aside most will be tempted to support it.  Whether there is anything else that will be good to write home about as far as the BBI is concerned is another matter altogether.

The BBI team has since been granted a goodwill extension to fine-tune the recommendations. In this validation phase the real work begins which will include the national debate.  This is where we all need to come in before the 30th of June deadline.

Lawyers are fond of saying the law or the constitution is very clear. This writer is no authority in matters law but sees that the bearing for clarity concerning the HSC ‘burden of proof’ will have to be borne by the HRH themselves and hope that Kenyans will be willing to listen and buy it.

It will not be that easy to withdraw a function of the county government by the stroke of a pen. With the rolling out of universal health coverage (UHC), there will be some contradiction in saying – devolve all pillars of health care and leave the HRH central or else with a HSC.  With counties going to be getting 50% of previous years’ audited GDP (as proposed by BBI), there will be a push-pull situation since HSC will take back some of that funding, or will mean counties get less of that.

Even though the change constitution momentum was seemingly being driven by political considerations of power-sharing we the HRH need to be careful whether to push for Kenyans’ agenda or our HRH agenda.

As the political class fight for whether we should have a parliamentary or a presidential system, we need to worry if they too can 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.

We can start by convincing the electorate that HSC has been a long time coming; that it was not a new idea.  Moreover, it is well articulated in the Vision 2030.

Previous attempts at HSC: It was in both the Bomas Draft and the Waki Draft.  Now that they had HSC, but what happened?  The HSC got buried somewhere in between and finally the Naivasha Draft which omitted HSC.  Why was it dropped?  What were the real concerns? Were there any minutes to that effect?  Concerning its mandates, structures, composition, and possibilities what can we adapt? Can we convince Kenyans?

In the pre-2010 constitution-making period, there were those who wanted HRH in the mix and, that is still a complicated situation we need to be worried about if Kenya gets into another constitutional review proper.  Many are those who would us like to enter into ‘non-issues’ like ‘when does life begin? ‘Abortion is illegal, except…’ like it happened last time at Bomas.  However, we have to say any of this with a lot of caution.

Kenyans are no longer naïve.  It seems a valid observation (and BBI seems to be saying so in clause 163b) 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 health care workers we should perhaps not lobby that the health docket goes back to the national 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 the Health Service Commission.  It is our thing and let’s pray that Kenyans would be less reluctant to let us have it.  At least it will be taking nothing away from them; instead, it will be taking away what counties were struggling with – the HRH.  Perhaps county 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 is a battle we must be ready to fight going forward to convince everybody otherwise. That is even though there will be numerous occasions that we the HRH will need to shed off every hard skin for this one thing – HSC.

But this is how it will look, in this writer’s 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 some of their own in a parallel system, even 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 the schools’ board of governors but the bulk of them by Teachers’ Service Commission (TSC).  Without a doubt this would balance out workload and boosts performance.

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.  The 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 UHC in August 2017.

However, 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).  It was also supported by Kurth et al., (2016) ‘Investing in Nurses is a Prerequisite for Ensuring Universal Health Coverage’. This deficiency was also highlighted in the Institute of Medicine of the US (IOM, 2001) in their distinguished blueprint The Future of Nursing.

There were often conflicting requirements of donors and governments weighing on the implementers in some cases. These could lead to transformation fatigue especially on 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).

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?

Further, this author had 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’.

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?

According to Crisp, Brownie & Refsum (2018) nurses were well-positioned to provide simultaneous health-promotion and disease-prevention activities and take on roles in coordinating and supporting teams in Universal Health Coverage. Notably, Prof. Sharon Brownie is the Dean School of Nursing, Agha Khan University Kenya.

1.3.1 UHC: a higher aspiration

This writer is working from the assumption that nurses will have the interest of UHC at heart and that universal health coverage was an ultimate aspiration for the patients as well as for HRH themselves. WHO’s Director-General was candid about it when he wrote, ‘we have a moral duty to look after the people who look after us when we are at our most vulnerable…it is a reasonable social contract’ (Ghebreyesus, 12th Dec. 2019).

Oh, how true this could be; excerpts from media reports from Kisumu County during one of the several of nurses’ industrial action cited, ‘the ultimate aspiration ought to be universal health care for the all patients (as well as for care providers themselves) and not just universal health cover’ (Otieno, 7th February 2019).

‘Some nurses cannot access the same services they provide when they need them’, snapped Alfred Obuya, the Chair National Nurses Association of Kenya (NNAK) during a recent conference (Wamochie, 17th Oct.  2017).

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 they 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’.

2.0 What exactly ails the HRH in Kenya?

In this author’s observation, whenever there was a dissenting voice on HRH and health system it was from certain quarters, while a majority of HRH was passive, docile or perhaps mute.  But it cannot be about doctors, nurses and clinical officers every time and all the time, there were other health care cadres too.  The health care system has many actors.  We need a strategy that takes care of all 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, poor absorption of degree nurses into public service and, what many felt was a fairly inept regulatory body 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.  Miscellaneous issues include perennial cadre rivalry issues and, the sometimes overlooked cross-generational issues, etc.

For all these and more we have fought (sometimes with each other).  A strike will never solve a bulk of them, an 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 apparently in this radar include: some of the union leaders seeking political mileage, its being said 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!

Looking at Maslow’s Theory of Motivation (1946) salary is not even in the 1st hierarchy, it’s in the second hierarchy, and there were 3 levels above it like: Social needs – being part of a team, healthy work relations, feeling wanted; esteem needs– achievement and status, responsibility, reputation; Self-actualization – job fulfillment, value addition and higher purpose.  The reader is encouraged to critique the two lower rank of the pyramid (see Figure 2 below).

Figure 2: An ideal Health Service Commission will take a holistic, human and personal approach health worker’s needs (derived from Maslow’s Theory of Motivation. Framework courtesy of Vipin Ramdas (2016)

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, and the Salaries and Remuneration Commission (SRC) has noted that and they were not amused at all.

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, if not two things -The Health Service Commission and Universal Health Coverage. 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 (TSC).

No less than the Cabinet Secretary for Education, one Prof George Magoha questioned the rationale of working with teachers managed by an independent body ‘TSC’. He said this was very frustrating.  He was speaking to the Parliamentary Select Committee on Education on 19th Feb. 2020. 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.  It’s been said that 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.

This writer was especially attracted to the phrase complement human resource base. He was almost tempted to think the most appropriate word could have been competent, but how wrong he was. Oh how real the phrase was, indeed every cadre is incomplete in itself but HRH complements each other for efficient and effective health service delivery.  He 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 skeptical about the 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, all inclusive forward looking HSC which would help resolve many of the long-standing health-related issues (see Figure 2 above).

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 losing 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, they 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 postulates 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 the chasm of decision making.

Really can nursing remain stable in a changing operating environment? That should be our prime concern.  There are conflicting and often poorly thought out themes and policies.  The health care system is perhaps unwilling to yield to its nurses 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.  They fight alongside those in clinical practice, albeit not always from the visible front. They do commentaries to frame the thinking of the nurses.

Though some may dismiss them as too theoretical, it is a role few are able to play except for the self-inspired.  Basically, a thankless undertaking.  But then we realize that by virtual of being nurses ourselves, apart from moulding the future workforce we need to give back to the profession; we owe so much to it.

Faculty cannot take it for granted that nurses in clinical practice sacrifice more fighting for allowances that others end up enjoying. For these, we are forever grateful.  For instance, those of us in health sciences faculty earn much more than the rest of the dons because of extra allowances (clinical, extraneous, uniform, etc.).

The university administration has a hard time understanding for instance why a nursing don the level of an Assistant Lecturer/Tutorial Fellow could earn much more than a Lecturer in non-health programs. These others were not entitled to such allowances nor did many have such prospects whatsoever.

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 but 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.  At some point 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 will need to 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.  Their words can never be regarded as innocent.  They have led to intense suffering to the public. No wonder Kenyans were asking – ‘it’s you again!?’  Every time they saw these familiar faces on their TV screens they had learned 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 necessarily be that of whipping the “soft spots”, capable of triggering strong reactions from their constituents as has been the case. They just 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 Ph.D., a professor of medicine wrote in 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

Figure 3: The cog wheels of health system  (Courtesy of Compleat Nurse 2019©)

[The author’s impression of the nurse as the fulcrum in the moving cog wheels of health care system. Why? This was because caring was at the centre of nursing and quality people-centered services for UHC.  In any case if the moving parts conspire against the fulcrum the integrity of the system can no longer hold, the patient might ‘get crushed’ or ‘fall through the cracks’.]

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 (see Figure 3 above). These were hardly their concern for a long time as evidenced by the fairly ‘indifferent’ attitude 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 that take place but should not happen?  Are there actions that 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 2019/20).  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? (See Figure 2 above).

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.  Whether we can continue being accused of planning for the next strike during the strike, but how has that worked so far?  We do have a postscript.  Especially what emanated from the dreary 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.  We fought hard to be at the table and, we do not think we are the menu, but can we read the menu? (See Figure 4 below).


  Figure 4: Why we need reform now [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 Hummelbrunner (2011).

We need to identify the crucial factors capable of bringing forth change, what is referred to as the leveraging effect.  Who and what is needed and who and what can be left out?  What points at future directions?  ‘Problem talk often creates problems, solution talk creates solutions,’ Dr. K.N. Jacob one of the mentors I follow is fond of saying.

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.

There are numerous pillars in the health system and HRH is just one of them, so HSC would be the least likely panacea for all of them.  Then there are the constitutional functions of Salaries Remuneration Commission (SRC), Public Service Commission, Ministry of Labour, Ministry of Health etc.

Technicalities like -what will be the structure of HSC, whys and why not? Or maybe just anchor HSC through an act of parliament to start with. Why did we not consider this option? ‘We didn’t need #BBI to see, acknowledge the need for an HSC…’ cited a posting from social media.

Some quarters mainly from people at KMPDU even suggest it is very much possible. It’s possible they might be having something worked out, hopefully with everyone’s interest at heart. There is no problem with each cadre coming up with a draft then comparing notes.

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 (see Table 1 below).

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:

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).

Table 1: 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

[Courtesy of Compleat Nurse 2019©]

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) include 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.  Nurses’ knowledge about patients, the ability to translate patient care systems into financial language, and the 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 might 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! (Hummelbrunner, 2011).

But just a minute – What if we tried something else?  The 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) among others.

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? (See Figure 5 below).

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.

Figure 5: If all the HRH unite nobody falls [Courtesy of the clip developer]

Lastly and, this is the crux of the matter – will the 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 the apparent waning of public sympathy for the cause of the industrial action in the health sector. Ask many a Kenyan, they will tell you with some degree of certainty what will happen. It follows a certain predictable pattern:

Unionists will want us to believe these were the stages of a strike, they must be knowing what they were saying.  But I learned 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).  Meanwhile, the county governments’ bigwigs 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 this writer’s 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.  This author was 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 (see Figure 3 above).

Whatever statements were being issued from the highest office in the land, to the county governors tell a different note – i.e. 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 this writer’s posts, never ever did he insinuate that nurses should not be paid what is due to them since he was one of them.  All he was trying to do was to frame the debate for our weighing and consideration.

It is his 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).

4.0 Conclusion and way forward

While universal health coverage (UHC) will mean that Kenyans will be able to access affordable care, it appears there was some disharmony between supporting structures for UHC or more likely the system supporting UHC.  From now on all effort should be about how get nurses to support UHC and also how to get past the riddle of getting a Health Service Commission (HSC) for health care providers.

HSC and Universal health coverage (UHC) need to be our higher aspirations.  Hopefully stakeholders too will be looking at these as alternative ways of dispute resolution to the troubled health sector.  Need we wait for our messiah still? Yes and No.

We ought to get it into any other change constitution caucus which may come up anytime and every time (just in case the BBI flops).  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.  In the meantime nurses in Kenya need to somehow rise to demands of frequent policy changes with ease.  The reader can get more about this author’s thoughts on the BBI here and, here.

There are good times ahead e.g. This year 2020 is the WHO’s Year of the Nurse in commemoration with the bicentenary (200th) birthday of Florence Nightingale, the founder of modern nursing.  This year meant something to the good lady as envisioned in the following words:

     “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.”

Have we lived up to the dream?


[The author Simon M. Kamau RN worked as a critical care nurse at the bedside and as the Nurse Manager of Critical Care Division of 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 The University of Colorado, Denver (US).  Currently a doctoral candidate – Moi University, Kenya.  He is widely published and has served in editorial boards of a number of local and international journals. He sometimes writes using pseudonym Compleat Nurse. More of his writings can be found on his blog: www.compleathealthsystems.com]



[1] Armstrong , S. Rispel, L. (2015). Social accountability and nursing education in South

Africa. Global Health Action, 8:1, 27879. Available: https://DOI:10.3402/gha.v8.2787.

[2] Atwoli, L. (16th February 2019).‘Labour relations in health sector were a disaster’. Daily

Nation, NMG, Nairobi

[3] BBI (October 2019). Report by the presidential taskforce on Building Bridges to Unity advisory

Building Bridges Initiative (BBI)

[4] 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. Available: https://doi:10.2471/BLT.13.118729.

[5] Crisp, N., Brownie, S., Refsum, C. (2018).Nursing and Midwifery: The key to the rapid

and cost-effective expansion of high-quality universal health coverage. Doha, Qatar: World Innovation Summit for Health – 2018.

[6] Ghebreyesus, T. (Dec. 12, 2019).  Keeping the promise to the women who will deliver

uhc. WHO Newsletter. Available: https://www.who.int/news-room/commentaries/detail/uhc-day-2019-keeping-the-promise-to-the-women-who-will-deliver-uhc

[7] Hummelbrunner, R. (2000). A Practitioner Handbook on Evaluation. Edward Elgar


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

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

[9] 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. Available: https://doi.org/10.1080/09581596.2016.1208362

[10] 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. Available: https://doi.org/10.1016/j.jana.2016.02.016

[11] 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. Available: DOI:10.1016/j.socscimed.2017.12.017

[12] Megan, B. (Dec. 26, 2017). ‘Nurses Keep Healthy Lead as Most Honest, Ethical

Profession’. Gallup.

[13] Punguza Mzigo (PMI). The Punguza Mizigo (Constitution of Kenya Amendment) Bill,

  1. The Thirdway Alliance.

[14] Otieno, L. (February 7, 2019). ‘Inside the life of a nurse: Why are they on strike?’

Citizen Digital. Available: https://citizentv.co.ke/news/inside-the-life-of-a-nurse-why-are-they-on-strike-

[15] 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

[16] Schveitzer, M., Zoboli, E., & Vieira, M.(2016). Nursing challenges for universal health

coverage: a systematic review. Revista Latino-Americana de Enfermagem, 24(0). Available: https://doi.org/10.1590/1518-8345.0933.2676

[17] Vipin, Ramdas (2016) Revisiting Maslows Hierarchy Available:


[18] Wamochie, R. (The Star, 17th October, 2017).’ Improve nurses’ welfare for UHC success

– specialist’. National Nurses Association of Kenya (NNAK) Annual Scientific Conference held in Murang’a on 14-16th October, 2019.

[19] 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

[20] Welton, J., Zone-Smith, L., Fischer, M. (2006). Adjustment of inpatient care

reimbursement for nursing intensity. Policy, Politics, & Nursing Practice. 7(4): 270-280. Available: DOI: 10.1177/1527154406297510

[21] ‘How to go on strike’. wikiHow. Available: https://www.google.com/url?q=https%3A%2F%2Fwww.wikihow.com%2FGo-on-Strike&sa=D&sntz=1&usg=AFQjCNHa_owTqKmoWvQLibINNuWcD6HUSQ


Please leave a reply