Nursing is the fulcrum to the moving parts in universal health coverage. It is true that every moving part in the primary health care as well a health system in general was important. This is important since there are lots of moving parts and pieces that actually go into patient care need a coordinator. But by default others recognize that nursing is more than a cog in the wheel in the system; in that that nurses can provide that vital fulcrum/convener for the moving parts. A nurse is more why, when, how, where and much more.
It was of great concern that Health Act 2017 was drafted in such a manner that it curtails the leadership potential for nurses in the health system in Kenya. Recent appointments by the CS Health show that positions of leadership in the MOH dockets is the preserve of some cadres. No one wants to break the tradition, the prescribed beaten path that has failed the health system in the past.
Empowering nurses to reach their full potential in service delivery and practice would have been the right thing to do if the act was in cognizant with the additional demands of UHC on the nurse. Much as the drafters terms of reference was to align the act with the constitution, it fell short of the nurses’ expectations.
I shared a poem in one of my posts ‘A Nurse is more’ [adapted from a poem written by Richard G. Shuster].
It is not anything nurses had chosen to be, it is by design that caring is the heart of health system and so is nursing. It has a very important effect in elevating the quality health care.
Going back to the concept of moving parts, many of these are outside the nurse’s control. Some decisions by other moving parts or the management may not appear to have the interests of the patients at heart, so the nurse tries to advocate for the patient. It was unfortunate that in some resource-constrained settings the moving parts often times appeared to have one common agenda: – to crush the fulcrum. Everyone then pulls in a different direction, and the patient might fall through the cracks.
May be for once lets look at how the nurse’s role as a fulcrum has been in the last 3 years. We will even start from an angle not so pleasant though: the industrial actions. This is an illustration on the fulcrum role of the nurse that many can easily relate to.
Let us consider the following sentiments however skewed [on 7th August 2017, a subscriber A.M. posted on Facebook wall Enlightening Nurses. This was the national nurses’ strike in Kenya entered the 65th day. Mimi nashangaa maana only nurses among the 20 cadres are on strike…ati wanfunga hos… where the others? Imagine 1/20 stronger than 19/20… Paraphrased from Swahili-English ‘Sheng’. Imagine only nurses out of the 20 or so cadres of medical staff were on strike, yet some hospitals were but closed. Where were the others? Do we then take it that 1/20 (nurses) was stronger than 19/20 (the rest)?
The following schema tries to dissect the concept of the cog wheels in health systems:
Fig: The moving parts & cracks of the health system
Above: Caring is more than a cog wheel – it is a vital fulcrum. Sometimes the carer might be crushed leading to pulling in different directions; the patient might fall through the cracks. Caption developed by Compleat Nurse* 2018©. Below is a picture of a nurse working in a congested ward [Picture courtesy of WHO ]
Someone observed that a good number of the other cadres ‘smartly’ liked to ride on the others’ industrial action with they themselves threatening to strike, but ever postponing it, feigning some united front with the cadre on strike. Or joining in too late in the day ‘to show some solidarity’ leaving the back door open but looking up to the nurse who has taken to the unbeaten path. All the time being ready to make a hasty retreat if need be.
I do not necessarily mean a particular RTWF but, there were allegations that some cadres were getting their RTWF or even CBA’s signed without ever needing to go on strike or else signed within 20 days of the strike. All this, while nurses were still on strike for 5 months in 2017. RTWF was enameled with such nice captions such as as ‘… call off the strike after signing deal with govt; officers to resume work from tomorrow, latest to report on Monday’. It was notable that this was an almost 5 days grace period. The word ‘Must’ was deliberately missing. All this while nurses were being referred to deal with their individual counties, some other cadres were having theirs signed from a central level MoH, CoG etc.
The employers used such docile groups as a bait or use them to prove a point. All the while each one of these docile groups prayed, preyed or scavenged on what the hunter got.
But now is time to abandon industrial action for more noble causes: Health Service Commission and Universal Health Coverage (UHC). May be we will get it right this time. The one sure way that UHC will see the light of day as not just a Jubilee legacy but something that makes one proud to be a Kenyan is if we allow the fulcrum to take it on. Take the nurses (practicing and faculty) to Cuba and Thailand for further training if need be. Nurses are more resilient as most other care providers will testify.
Give more opportunity for nurses to practice primary care indipendently and as agencies. It is at this juncture that we need to ask whether Kenya needs advanced nurse practioners. Recognize nurses for who they are and, for what they can deliver. Read my article on why nurses need to consider their stand on UHC and HSC aand if indeed Kenya owes her nurses a job even as they consider reducing the training period for health professionals.