The epidemic of health workers’ strikes that has gripped Kenya in the last few years raises questions as to the government’s commitment to ensure the fulfilment of ‘Right to Health’, as constitutionally guaranteed. At the same time, Kenya’s health care professionals cannot extricate themselves from their ethical obligation, from the solemn oath they took at graduation, which requires that the patient’s interest always comes first. Neither nor can they disengage from the unwritten contract that is established every time a doctor accepts to take care of a patient.
The Constitution of Kenya (2010) in Article 41(2) states: “Every worker has the right (a) to fair remuneration; (b) to reasonable working conditions; (c) to form, join or participate in the activities and programmes of a trade union; and (d) to go on strike”. Thus, the Bill of Rights guarantees the Kenyan worker the right to go on strike. However, whenever it has involved health care providers, a strike action has elicited both ardent support and fervent opposition, this depending on whose opinion is sought. On their part, health care professionals find themselves confronted by a complex ethical dilemma- including the interpretation of the universal principle that “the patient’s interest always comes first” and the unwritten contract that is established every time a doctor undertakes to take care of a patient.
From the medical ethics perspective, it can be argued that doctors on strike still remain ethically bound to attend to emergency services in order to ensure no one dies or suffers permanent damage as a result of their withdrawal of services. They can stop attending to new non-emergency cases, but must continue the care of in-patients, discharging them only when they are better. The ethics of medical practice forbid doctors from abandoning patients in the middle of their treatment; the onus is placed on the doctor to arrange proper referral of the patient to another doctor of equal or greater skill than her/himself. Ideally, doctors who abandon their patients because of a strike action risk sanctions by professional regulatory bodies, e.g. the Medical Practitioners’ and Dentists’ Board.
Just as employees in any other industry, health care providers—including doctors, clinical officers, nurses, midwives, and others—are indisputably entitled to a voice in the terms of their employment. However, they are also providers of an essential public service, much like fire-fighters and police officers. Frequently, availability of their services becomes a matter of life and death, for many. Why, then, have doctors’ and other unionized health care workers’ strikes become so commonplace in recent years?
Strikes by health professionals remained unknown in Kenya until the 1970s, but even then these tended to be isolated and short-lived. My generation of doctors had proceeded through training that overly stressed the vocational nature of our profession, to the extent that we had come to believe nothing should ever detract us from our healing mission. Not even the many hours we were made to work, or the meagre wages we endured!
But it would be utter dishonesty on my part not to admit that living conditions have changed a lot since then. The cost of living was then much lower; the shilling’s purchasing power was at its all-time best since Independence. Doctors were respected, felt appreciated and were able to mingle with former college mates in clubs and other social gatherings without any sense of pecuniary embarrassment. Doctors and nurses were housed decently, and comfortably, close to their place of work. Also, unlike the situation today, cars were within easy reach of junior doctors. Within the hospital, systems worked more efficiently. Cancelling of an operation theatre list because of lack of this or that was then something unheard of. The Pharmacy dispensed almost all the drugs we prescribed and could quickly source any that were not in stock at that moment.
In the ongoing dispute, health workers have complained of delayed promotions, low salaries, and delayed salaries. According to the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPPDU) more than 2,000 doctors have resigned, most of them because of delayed promotions. To what extent these complaints reflect inefficiency in the performance of the devolved system of government remains to be established. What is clear however, is that in the affected counties, services in most hospitals have been seriously disrupted leaving many sick persons including mothers and children, with no choice but to go home, or for those with means, to seek care in private hospitals.
Generally, medicine in public service is practiced through a kind of triumvirate system which involves governments, health institutions and health care providers; just how smoothly the three entities work together determines how successful they are in meeting their moral obligations to the sick. Strike action normally arises from failures on all three sides: failure on the part of the government (employer) to act in accordance with its stated policy recognising the importance of health care (=prioritisation), failure on the part of health institutions to provide suitable work environment for optimal provision of health services, and failure on the part of health care providers to consider seriously their duties and obligations to patients and the profession. Kenyan health workers have often expressed discontent with the health care system and management. Doctors and nurses have often complained of shortages of staff, equipment, drugs and supplies in health facilities. This is a common cause of job dissatisfaction among them.
Doctors like everybody else want a decent life for themselves and their families; they want to educate their children and save for a comfortable retirement. They want recognition and good working conditions and an environment that is conducive to self improvement. They want to be appreciated, especially the nature of their work, which is often fraught with many health risks to themselves and their families- think of the many contagious diseases they have to handle; think of the deadly Ebola.
When can a strike action by health professionals be deemed ethical? Considered from a utilitarian perspective, a strike action may be justifiable if there is evidence of greater long-term benefit to health workers’ welfare, improved health care delivery system, and most of all, an enhanced quality of health care for the public. In fact this has been the justification advanced for many of the strikes by health workers, not just in Kenya. To many well-meaning people a strike action that is focused on improving the quality of health care- improved infrastructure, better staffing, drugs and supplies, etc., and especially if it is likely to stem the steady outflow of qualified health professionals from the public service (and the country as a whole), is justifiable and worth support. They’ll see such an action as bringing common good for the majority of the people.