Category Archives: health systems

When can a strike action by health professionals be deemed ethical? Japheth Mati

Kenyan Nurses on Strike

Kenya National Union of Nurses calls off Monday strike

http://www.nation.co.ke/news/Kenya…of…/-/index.html

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.

 

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What prospects for complementary use of African and western systems of medicine?

Human societies have, from time immemorial, independently evolved and sustained systems of healing; Africans were not an exception. Despite efforts to suppress indigenous African medicine during and even after the colonial era the practice still thrives throughout the continent. The big question is whether there are prospects for complementary use of western and African medicine?

The World Health Organisation (WHO) defines traditional medicine as the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses. Traditional African medicine and African religion are intricately intertwined; it is through African theology that illness, disease and misfortunes are understood.

Traditional African Medicine is a holistic discipline that embraces the use of herbs, African spirituality (diviner-healers), and traditional midwifery. African spirituality is centred on a belief in a supreme deity above a host of lesser semi-divine figures, including the power and intercession of ancestral spirits.

Normally, every rural African community will have a traditional healer, to whom they go for advice on a variety of issues, including health problems. The traditional healer would be knowledgeable about plant species that have medicinal value, including their ecology and conservation.  

The philosophy underpinning traditional African Medicine differs significantly from that of western medicine. Whilst the latter is based on a system that focuses on identification of a specific disease-causing agent (germ theory), African medicine takes a holistic view. Good health, disease, success or misfortune, are seen as interrelated circumstances, which do not happen by chance but arise from the actions of living individuals or spirits of ancestors. Thus, the practice of traditional African medicine embraces the two mutually reinforcing elements of African spirituality (divination) and the use of herbs (herbal medicine).

Unlike in western medicine where the Hippocratic Oath obliges practitioners to be open with their modalities of treatment, absolute secrecy is what has sustained and protected the knowledge and mystery of traditional African medicine, through the ages. The gathering of medicinal plants is customarily restricted to the healers and their novices only, who normally will not divulge the nature of the plant, its environs and the details of its prescription to clients.

Christian missionaries were the indisputable ushers of western medicine in Africa. European and American missionaries pioneered ‘modern’ medicine in Africa, establishing health facilities deep into the interior way in advance of the colonial medical services.

Dr David Livingstone, the Scottish doctor and traveller, is recognized as the main source of inspiration for the involvement of Christian missions in medical work. His writings between 1851 and 1873 played a significant role in the recognition of medical care as an integral part of missionary activity. As a result, starting in the second half of the nineteenth and during the early twentieth century, mission hospitals, dispensaries and other medical facilities were established in West, East and Southern Africa[1].

Generally, Christianity was initially introduced at the Coast, before the missionaries penetrated the interior. By 1878, the White Sisters (Catholic Missionaries of Africa) had initiated health activities in the regions of the great lakes in East Africa. Among the earliest health facilities in East Africa were the Church Missionary Society (CMS) Hospital at Mengo, Uganda, established by Dr Albert Cook (1870-1951) in 1897, the Church of Scotland Mission (CSM) Hospital at Kikuyu, Kenya, in 1907, and the Africa Inland Mission (AIM) Hospital at Kijabe, Kenya, in 1915.

Mengo Hospital 1897 download

IMAGE: Mengo Hospital 1897

The arrival of the Christian missionaries provoked a cultural confrontation, especially when they completely ignored the existence of African spirituality. Influenced by their strong belief in the superiority of European culture, early missionaries viewed their primary mission to be that of exposing Africans to Western standards and practices, in other words, to ‘civilise the native’. In the mistaken belief that a spiritual vacuum existed in the lives of Africans, ready to be occupied by Western religion, they assumed that whatever forms of religion Africans subscribed to, could easily be supplanted by a superior religion, Christianity. They failed to distinguish between the roles, in the lives of Africans, of traditional culture and practices on the one hand, and of Christianity, on the other.

Professor John S. Mbiti, the pre-eminent African theologian and philosopher, has since exhorted that Christianity cannot afford to neglect, despise or even condemn outright, African traditional religions. Nor should the connection between African traditional practices and Christianity be seen as an “uncomfortable form of compromise”. He observes that in traditional African societies, religion and culture were completely integrated into one holistic way of life so that there was no distinction between what was sacred and what was secular. He advocates that Christianity ought to be viewed as the “fulfilment of that, after which African religiosity, in all its richness, has groped”[2].

Establishment of colonial medical services in East Africa was largely driven by the needs of colonial service officials and the white settlers. This was particularly the case in Kenya where there were numerous, and increasing numbers of Europeans in the so-called ‘white highlands’. Second to be considered were Indian, on whom the colonials looked upon to cater for their needs. Lastly, the meagre services extended to Africans, generally targeted the employees in the colonial administration and labour in white settler farms. As though to absolve themselves of the guilt of not providing for the health needs of African communities, the colonials have been quoted as blaming the preoccupation of the natives with witchcraft: ‘It was almost impossible to administer to a people so thoroughly riddled with witchcraft that no one could do anything with them because they refused to tell anything’!

The earliest government hospital to be established in Kenya (in 1901) was the Native Civil Hospital (NCH), Nairobi. This 40 bed facility provided in-patient services for Africans, while outpatient services were availed at the Government Dispensary which was located along Government Road (now Moi Avenue), close to Kingsway Police Station (today’s Central Police Station). The NCH was the precursor to the King George VI (1952), later renamed, in 1964, the Kenyatta National Hospital.

For the large population of Africans, especially those who lived far from the urban centres where colonial medical health facilities never existed, it mostly fell on missionaries (and/or traditional healers) to provide the much needed health services. Even today church-based hospitals and health care programmes continue to account for 25 percent to 50 percent of available services in most African countries, including Kenya.

Enjoy the best of both worlds? Practitioners of western medicine have over the years, eschewed traditional African medicine dismissing its methods as primitive, superstitious and pagan. Besides herbs, some healers may involve in their treatments, charms, incantations, and the casting of spells (demons); others may employ music and dance as in the case of the Akamba kilumi.

Under colonial rule, traditional diviner-healers were outlawed being considered to be practitioners of witchcraft. Similarly, African religious practices and medicine were labeled sinful by white Christian missionaries, and as such use of traditional medicine was forbidden for followers. However, in more recent years, traditional medicine has become more accommodated, and practitioners of “modern” medicine have increasingly acknowledged that there is much to learn from certain aspects of traditional medical practices. Indeed even the World Health Organization (WHO) has a department that promotes traditional medicine.

In any case, this was bound to happen since in most African countries, the penetration of ‘modern’ medicine remains such that large populations lack access to it, due to its relatively high cost and the concentration of health facilities in urban centres. According to the WHO, in some African countries, as much as 80% of the population may depend on traditional medicine for primary health care. This, among other reasons, legitimizes the call for enhanced research into the various practices employed in African traditional medicine. Africa is endowed with many plants that can be used for medicinal purposes. In fact, out of the approximated 6400 plant species used for various applications in tropical Africa, more than 4000 are used as medicinal plants, used in the treatments of many varied diseases and illnesses[3].

220px-Inyanga_preparing_drying_out_fresh_muti

Image Traditional healer

 

Faced with the mammoth challenge of making ‘modern’ health care services accessible to all, African governments have increasingly adopted policies in favour of integration of traditional African medicine into national health care systems. For example, in 2001, the African Union (AU) Summit of Heads of State and Government declared the period 2001–2010 as the Decade of African Traditional Medicine, and in 2003 adopted a plan of action for its implementation. In 2008, the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa reiterated the Alma Ata Declaration by calling on countries “to set up sustainable mechanisms for increasing the availability, affordability and accessibility of essential medicines and the use of community-directed approaches and African traditional medicines”, among others.

In countries, such as Kenya, governments have a constitutional obligation to facilitate the right of the citizen “to the highest attainable standard of health, which includes the right to health care services, including reproductive health care[4].

However, it would be unfortunate (perhaps naïve?) to simply define healthcare in the context of ‘western’ medicine only. In fact, while still pursuing the ultimate goal of making healthcare available, accessible, affordable, and of good quality for all citizens, governments should be prudent enough to take the bold step (hard choice) of accepting the reality that a large segment of the population is already relying on traditional medicine.

There is evidence to show that traditional medicine and modern (western) medicine are quite frequently used complementarily, with traditional therapies serving as a first-line treatment before modern drugs are sought. For example, within certain communities in Kenya, majority of pregnant women will have consulted a mganga (traditional healer) who administered to them herbal preparations and potions to ward off evil spirits, before making their first antenatal clinic visit[5]. These women perceive antenatal care services obtained at health facilities, and those provided by TBAs and herbalists, to be complementary, and generally, they seek both types of care interchangeably.

The above is a strong reason why governments ought to establish appropriate regulatory mechanisms for accommodation of traditional medicine within the national health care system. Such a measure can go a long way towards assuring safety and effectiveness of the practice. A lesson may be learnt from the way traditional systems of medicine have been facilitated to grow in India and China, to the extent that today, leading institutions in the West are teaching and licensing practitioners of Ayurvedic medicine and Traditional Chinese Medicine.

However, a critical challenge for integration is sustaining the holistic concept of traditional African medicine, which traditionally embraced herbal medicine, divination and spiritual healing as mutually reinforcing systems, capable of dealing with physical, emotional and spiritual indispositions.

Whereas a considerable body of knowledge exists on herbal medicine, there is a dearth of scientific data on the other modalities of traditional medical therapy. This ought to be a challenge to African scientists, to engage with traditional medical practitioners, in the hope of establishing what is, and what is not practicable to integrate.

[1] H. J. O’D. Burke-Gaffney The History of Medicine in the African Countries http://www.ncbi.nlm.nih.gov/pmc/articles/…/pdf/medhist00144-0036.pdf‎

[2] Extract from a lecture given to the Christian Churches’ Educational Association of Kenya, 19 September 1969; see also J S Mbiti African Religions and Philosophy (London: Heinemann, 1969)

[3] Network on Medicinal Plants and Traditional Medicine (Eastern Africa). http://www.idrc.ca/EN/Resources/Publications/Pages/ArticleDetails.aspx?PublicationID=713

[4]The Constitution of Kenya, 2010 Article 43. (1)(a)

[5]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

What will define Kenya’s Health Care System in Devolved County Governments?

 

 

President Kibaki in a past event. He presided over the handing of ambulances to District Hospitals

With the impending devolution of healthcare management functions to the counties anxiety looms over the levels of preparedness for such an undertaking in all the counties. In an earlier post a number of challenges were identified, including uneven inter-county levels of development- unequal distribution of resources for health especially the distribution of health facilities, human resources, and poorly developed communication infrastructure. Also unevenly distributed across the country are poverty levels, the effect of which is to make health services largely inaccessible to a large chunk of the population that cannot afford the high out-of-pocket expenditures, which prevail in Kenya. This post reviews the extent to which the decentralisation policy of the Ministry of Health (MOH) has been implemented and how this may impact on assumption of fully devolved management of health services by county governments.

The term “decentralisation” has been used to signify a variety of reforms characterized by the transfer of fiscal, administrative, and/or political authority for planning, management, or service delivery from the central MOH to alternate institutions. “Devolution” is a category of decentralisation; it implies the ceding of sectoral functions and resources to autonomous local governments, which in some measure take responsibility for service delivery, administration, and finance.

Despite decades of intention to decentralise, Kenya’s health care system has remained largely centralised with decisions taken at MOH headquarters from where they are conveyed top-down through the provincial medical officers to the district level. Centralised functions at the headquarters include policy formulation, coordinating activities of all health players (government and non-governmental organizations), initiating and managing implementation of policy changes on various issues including charging of user fees, and undertaking monitoring and evaluation of impact of policy changes at the district level.

Centralised decision making may have contributed to, among others, regional disparities in the distribution of health services, inequities in resource allocations, and unequal access to quality health services, resulting in the wide regional differentials in health indicators which successive demographic and health surveys (KDHS) have highlighted[i].

On paper, the MOH through the various health sector strategic plans has expressed commitment to decentralisation intended to provide increased authority for decision making, resource allocation, and management of health care to the district and facility levels. For example, in 1992 the MOH established the District Health Management Teams (DHMTs) and the District Health Management Boards (DHMBs), which were charged with managing public health services at the district level. Together, the DHMT and DHMB are supposed to provide management and supervisory support to lower level health facilities (sub-district hospitals, health centres, and dispensaries).However, despite the fact that these bodies coordinate health activities in the district and may develop plans for spending cost sharing funds, the final decisions on budgets and resource allocation is retained at the central level. Lack of funds and transport are the most commonly cited reasons for failure by DHMTs to meet their supervision targets despite the near universal existence of documented supervision plans[ii]. Budgetary remittances to the districts have neither been regular nor timely.

Health care under devolved system of governance:

The Constitution of Kenya (2010) has assigned the larger portion of delivery of health services to Counties, the exception being the National Referral Services. This implies that Counties should bear overall responsibilities for planning, financing, coordinating delivery and monitoring of health services toward the fulfilment of right to ‘the highest attainable standard of health’.

For many Kenyans, devolution is looked upon as the answer to the persistent regional disparities in the distribution of health services and inequities in resource allocations. However, much as that is an ideal goal; its realisation may not be immediate, especially because of the current varied levels of preparedness within the counties. Some counties starting at a relative disadvantage will take time to build up their capacity and ability to use devolved resources well, which may lead to even wider disparities. Such counties will require particular assistance to catch-up. In the long run, success of devolution will depend on availability of resources (both financial and human) for counties to carry out their assigned functions, and their empowerment to use resources effectively.

The draft Kenya Health Sector Strategic & Investment Plan[iii](KHSSP)July 2012 – June 2018 proposes a three-pronged framework for overall health sector leadership, i.e: Partnership, Governance and Stewardship– which taken together should address the health agenda towards the fulfillment of the right to health.

The strategic plan proposes that within the counties, the stewardship responsibilities for health services will be exercised at three levels: the National Directorates for Health, the County health management teams, and County Health facility management teams. However, scrutiny of the prescribed responsibilities, functions and roles[iv] of these bodies portrays a continuation of dominance by MOH headquarters in matters to do with policy formulation, planning and priority setting, which leaves the county management teams to be purely concerned with programme implementation (under close supervision from above). This is unfortunate since it perpetuates central planning which has not always taken into consideration the peculiarities of our country’s diversity, with consequent wide disparities in health status.

Planning at the county level should enable better definition of local priorities and design of innovative models of service delivery that adapt to local conditions, e.g. serving pastoralist communities in arid and semi-arid areas. It also can improve quality and legitimacy owing to user participation in decision making; and greater equity through distribution of resources toward traditionally marginal regions and groups. Local hiring of service providers can improve staffing levels and appropriate deployment, especially in rural health facilities.

One major challenge facing proposed county health services is the serious shortage of resources, human and material, especially due to financial limitations. Currently the public health sector is seriously under-funded and is generally operating on shoe-string budgets, inadequate infrastructure and lack of essential supplies. Although better distribution and deployment of health personnel may somewhat alleviate current acute shortages in some counties, still more will be needed. Many counties will especially require strengthening in health planning and monitoring.

[i] Ministry of Health (MOH) 2006 Reversing the trends, The Second National Health Sector Strategic Plan of Kenya: Annual Operational Plan 2 2006/07. Nairobi, Kenya.

[ii] Ndavi, P.M., S. Ogola, P.M. Kizito, and K. Johnson. 2009. Decentralizing Kenya’s Health Management System: An Evaluation. Kenya Working Papers No. 1. Calverton, Maryland, USA: Macro International Inc.

[iii] Ministry of Medical Services and Ministry of Public Health & Sanitation KENYA HEALTH SECTOR STRATEGIC & INVESTMENT PLAN (KHSSP) July 2012 – June 2018: Transforming Health: Accelerating attainment of Health Goals

[iv] National Directorates for Health: provide overall direction- policy formulation, national strategic planning, priority setting, budgeting and resource mobilization, regulating, setting standards, formulating guidelines, monitoring and evaluation, and provision of technical backup to the county level. County Health Management Teams: Provide Strategic and operational leadership and stewardship for overall health management in the County, including resource mobilization, creation of linkages with national level referral health services, monitoring and evaluation, coordination and collaboration with State and Non state Stakeholders at the County level health services. County Health Facility Management Teams: Develop and implement facility health plans for levels 1–3 health care services; coordinate and collaborate with stakeholders through County Health Stakeholder Forums; undertake in-service training and capacity building; and supervision, monitoring and evaluation.

 

Thirty first of every August is ‘African Traditional Medicine Day’ but how many know about it?

Over a span of about 150 years three members of my family have practiced medicine. My grandfather, my brother and I have all at one time or another provided medical care to the needy, all of us receiving acknowledgements from our patients and society. However, that is about where the similarities cease, for with the coming of the colonial power to our lands my grandfather’s practice became severely restricted and despised. Generally, he practiced in secrecy from then on. On the other hand, in the case of my brother and I who were trained in ‘scientific medicine’ by the colonials, our practices were legitimised by stints in the ‘motherland’ as well as being registered by professional regulatory authorities.

 African traditional medicine

In all countries of the world there exists traditional knowledge related to the health of humans and animals. The World Health Organization (WHO) defines traditional medicine as “the sum total of all the knowledge, skills and practice, based on the theories, beliefs, and experiences indigenous to different cultures,whether explicable or not, used in the maintenance of health as well as in the diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing”[i].

This definition applies to all traditional systems of medicine whether in Europe, India, China or Africa. Yet whereas European missionaries and colonial administrators left alone, sometimes even encouraged, traditional medicine in India and China, they almost violently discouraged African traditional medicine. In particular, the intricate relationship between African medicine and African religion[ii] made traditional medical practices key targets of attack by early European Christian missionaries, who considered many African traditional religious rites and rituals to be against Christian teachings and morals. Traditional healers were regarded as heathens because of their participation in African Traditional Religion.

The medicine my brother and I practice derives from the germ theory of disease (see below) while my grandfather’s traditional African medicine is based on concepts that are much broader and holistic. In traditional African societies it is believed that good health, disease, success or misfortune are not chance occurrences but arise from the actions of individuals and ancestral spirits according to the balance or imbalance between the individual and the social environment. African traditional understanding was that sickness was a kind of punishment by the spirits of the ancestors to those who do not observe the rules of good social behaviour, from whom the ancestors withdraw their protection leaving them exposed to the whims of evil spirits who cause physical and mental dysfunctions. Traditional healers use plants in a variety of ways, depending on the illness to be cured. Parts of plants can be applied directly to wounds and cuts or, if necessary, prepared as powders, infusions, or even used in the form of smoke or fumes. African herbal medicine is often associated with magic[iii], for example the prescription of amulets and charms as prevention or treatment of diseases.

Today, many Africans including some self proclaimed Christians, and especially politicians, consult a traditional healers for advice on various issues, including health-problems. The African traditional ‘doctors’ have skills in both herbal remedies as well as in spiritual healing, the latter involving various traditional religious rites and rituals. In this regard, African medical practice is holistic- it takes into account all of patient’s physical, mental, and social conditions in the treatment of illness.

The Germ Theory of disease

The Germ Theory of disease is the foundation of modern (western) medicine and was an important basis for innovations such as antibiotics and hygienic practices. Germ theory was validated in the late 19th century, thanks to the works of Louis Pasteur (1822-1895) and Robert Koch (1843-1910). It proposes that microorganisms are the cause of many diseases. Hence management of the disease is focused on establishing which microorganisms are responsible and applying specific drugs (antibiotic) for their elimination. Modern medicine is also referred to as Allopathy, which is defined as the treatment of a disease by using remedies whose effects differ from those produced by that disease. This is the principle of mainstream medical practice, as opposed to that of homeopathy– a complementary disease-treatment system in which a patient is given minute doses of natural substances that in larger doses would produce symptoms of the disease itself.

There is no doubt that introduction of antibiotics (e.g. Penicillin), revolutionised medicine and remains one of the most important milestones in the history of medicine. However, as observed by some critics, the concentration in modern medicine on fighting germs using antibiotics has tended to ignore the “soil upon which the bacteria flourish[iv]” In other words modern medicine tends to focus on the disease not the whole person, as is the case in traditional systems of medicine. “Modern medicine seems too grounded in the study of disease [pathology] and in its eradication and not enough in studying health and how to create and sustain it”. This in fact, is where the great divide exists between modern medicine and African traditional medicine.

 

Preparing and drying out freshly picked mutis

Bridging the divide- Integration of traditional medicine in national health systems

The World Health Organization estimates that 80% of the populations of Asia, Africa and Latin America use traditional medicine to meet their primary health care needs. For many people in these countries, particularly those living in rural areas, this is the only available, accessible and affordable source of health care. In scenarios such as these African governments should have no option but to ensure there is collaboration between conventional and traditional health practitioners. To this end, Ministries of Health need to set up mechanisms for the regulation and integration of traditional medical practice in national health systems.

The 50th Session of the WHO Regional Committee for Africa which took place in Ouagadougou, Burkina Faso, 28 August to 2 September 2000 recognized the importance and potential of traditional medicine for the achievement of health for all, and set 31st August of every year as African Traditional Medicine Day[i], [ii]. The Regional Committee adopted a regional strategy for the promotion of the role of Traditional Medicine in national health systems, including establishing structures, programmes and offices in Ministries of Health to institutionalize traditional medicine. Currently 39 countries (including Kenya) have set up such offices, and a few training institutions have established departments of Herbal Medicine[iii]. Other examples of collaboration between traditional medical practitioners and modern medical practitioners are to be found in Uganda and South Africa. In Uganda the Traditional and Modern Health Practitioners against HIV /AIDS (THETA[iv] ) have demonstrated the positive impact traditional medical practitioners can make on health care delivery. In South Africa research conducted by AMREF shows that traditional practitioners can play important roles in integrated HIV/AIDS/STI/tuberculosis programs[v].

Conclusion:

As we look forward to this year’s African Traditional Medicine Day it cannot be lost on us that the ongoing WHO-led collaboration appears to focus solely on herbal medicine, yet traditional African medicine is a broader concept than that, incorporating (beside use of herbs) divination and healing of physical, emotional and spiritual illnesses. In any case, a large proportion of herbalists also engage in divining causes of illness and providing various solutions to spiritually or socially-centered complaints, in addition to use of plant and animal products. To this extent herbal medicine and spiritual healing act as mutually reinforcing systems of African traditional medicine. Accommodating the holistic approach in the proposed integrated health systems remains a critical challenge for all involved including WHO.

[i] http://www.afro.who.int/en/fiftieth-session.html

[ii] African Traditional Medicine Day, 31 August, Special issue, African Health Monitor, World Health Organization Regional Office for Africa).2010

[iii] The Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, established a Bachelor of Science Degree in Herbal Medicine in 2001 to train Medical Herbalists.

[iv] Initiated in 1992 through a partnership between The AID S Support

Organization (TA SO) Uganda Ltd and Medicines Sans Frontières (Doctors without Borders), an international humanitarian organization.

[v] Melusi Ndhlalambi:Strengthening the Capacity of Traditional Health Practitioners to Respond to HIV/AIDS and TB in Kwa Zulu Natal, South Africa AMREF Case Studies 2009.

 

Medical negligence and malpractice is rife in Kenya’s health facilities, a Public Inquiry reports

The recently launched report[i] of a public inquiry into violations of sexual and reproductive health rights in Kenya has highlighted the existence of widespread medical negligence and malpractice in health institutions. Indeed many of the complaints of mistreatment in health facilities, especially those raised by former obstetric patients, frequently bordered on medical negligence and malpractice. Medical negligence and malpractice interfere with the quality of care received by patients, and deny them enjoyment of the right to the highest standard of health care which is their constitutional right.

(Women are being counselled at a RH clinic. Picture source: J Mati)

Medical negligence can be defined as the commission of an act that a prudent person would not have done or the omission of a duty that a prudent person would have fulfilled, resulting in injury or harm to another person (patient)[ii]. Medical malpractice means bad, wrong, or injudicious treatment of a patient professionally, which results in injury, unnecessary suffering, or death. Malpractice and negligence may occur through omission of a necessary act as well as commission of an unwise or negligent act[iii]. This may be in the form of misdiagnosis, wrong decisions and treatment, prescription errors, and medical or surgical complications, all of which may result in suffering, permanent injury or death.

In Kenya, medical, nursing and midwifery practices are regulated by statutory authorities, including the Medical Practitioners and Dentists Board[iv] (established under Cap 253 Laws of Kenya), the Nursing Council of Kenya[v] (established under the Nurses Act Cap 257 Laws of Kenya) and the Clinical Officers Council (established under the Clinical Officers [Training, Registration and Licensing] Act Cap 260 Laws of Kenya)[vi]. These bodies are obliged to protect members of the public by ensuring that the medical practitioners (including dentists), nurses and midwives, and clinical officers are properly qualified, that they perform their services to patients with skill and diligence, and that they observe at all times high moral and ethical standards

Evidence regarding alleged mistreatment in health institutions was received at all sittings of the Inquiry, and among the witnesses raising complaints of medical negligence and malpractice the majority were obstetric cases that suffered various types of injury and suffering to themselves and their babies. Complaints of long waiting periods and delays in getting attended to in health facilities were common. Sometimes this was occasioned by doctors or midwives on call refusing to come when summoned, or due to shortage of staff. Associated with the above were complaints of negligent management of labour resulting in stillbirth, mentally handicapped child and maternal death. There were other complaints of persons who had been subjected to various surgical procedures such hysterectomy without their consent (See below). In spite of this, hardly any of the complaints had been reported to the regulatory authorities.

Selected examples of specific complaints of medical negligence and malpractice:

· Denial of information- failure to explain the nature of illness or injury and the modality of treatment and its consequences. In particular, there was inadequate information given to the patients before and after surgery.

 Sterilisation without consent:

A mother of three was admitted with abruptio placenta at a Mission Hospital, where she was later taken to theatre for C Section and, unknown to her, bilateral tubal ligation was carried out. She was not informed of the latter and since she did not wish to conceive shortly after the operation she commenced on a family planning method. She had taken two doses of Depo Provera when a doctor (elsewhere) happened to read her discharge card which showed she had actually been sterilised!

· Case of malpractice-  Doctor who was drunk;

A case of ruptured uterus and fetal death:

A woman was admitted at a public District Hospital in early labour. She had previously delivered by C Section and so was asked to sign consent for repeat CS which she did. However, a doctor who was drunk saw her in the Labour Ward and asked her to begin pushing the baby, without any success. He then tried unsuccessfully to apply forceps. By the time she eventually was taken to the operating theatre her uterus had already ruptured, the baby had died, and she subsequently developed difficulty in controlling urine (?Vesico Vaginal Fistula). She has not conceived since then and she could as well have had a hysterectomy done.

· Case of medical negligence- denial of services

Forgotten foreign bodies after surgery:

A relative told of the case of a woman who had a C section performed by a doctor during which an abdominal pack was (accidentally) forgotten in the abdomen. When she returned 2 weeks later complaining of abdominal pain and swelling she was told she needed another operation to remove a foreign body which required further payment. This could not be done because she did not have any more money. The patient died of complications most probably associated with the foreign body.

 Another case was that of a single mother of two who delivered normally at a Health Centre (Level 3). An episiotomy had been performed and a swab left in the vagina which should have been removed after a few hours. However, the patient was not informed about it, and the swab was left in for 2 weeks. By that time infection had set in and she had also developed faecal incontinence (?RVF). She is now ashamed of her condition and has not mentioned it to anyone except her mother. [It is a possibility that she suffered rectal injury when the episiotomy incision was made].

 · Negligent management- failure to apply standard procedures:

Management of labour in a HIV+ woman did not conform to guidelines for prevention of mother to child transmission of HIV infection: An HIV+ woman was admitted at a public District Hospital with ruptured membranes. Her husband, also HIV positive, told the staff that they had been advised by another doctor that the delivery should be by CS, but this was declined, besides, she was not given ARV therapy as instructed in the PMTCT guidelines. Instead, she was allowed to have a prolonged labour, delivering a fresh stillborn child.

Failure to give an essential prophylaxis:

A primigravida at term was admitted in a private hospital where she had made several antenatal visits. Her labour was uneventful, delivering a healthy male child. However, although she had been informed at the same hospital that she was Rhesus Negative she was not offered a standard vaccine, anti-D gamma globulin to protect against Rhesus iso-immunisation. In addition, she was not advised what to do in case of a subsequent pregnancy.

· Negligent management of labour, doctor refused to come to the hospital when summoned:

A mother of three was admitted to a public District Hospital in labour where she remained for 48 hours without delivery mainly because the only doctor who could do a C Section refused to come. When eventually the doctor came she was taken to theatre, delivered of a very depressed child who breathed after prolonged resuscitation, but the mother died on the table. The child is now intellectually handicapped.

· Negligent management- Hysterectomy performed without consent

Hysterectomy performed without consent on a disabled person:

A woman with dwarfism (possibly achondroplasia) was diagnosed with uterine fibroids at a provincial Hospital and advised she needed an operation to remove the fibroids. She was taken to theatre but afterwards was not explained what had been done. When three weeks later she realised that a hysterectomy had been performed she sought explanation from the doctor. She was taken aback when the doctor wondered aloud if in her condition she really expected to get a baby!

Hysterectomy performed in a woman diagnosed with an ovarian cyst:

A married woman, a mother of four girls had hope that a boy would come someday. She was seen at a Provincial Hospital complaining of abdominal pain, where an ovarian cyst was diagnosed and confirmed by an ultrasound scan. She was advised to undergo an operation in order to remove the cyst; at no time was possibility of a hysterectomy mentioned. “Later when I read the discharge summary it stated that the uterus had a fibroid and a hysterectomy was performed. That shattered our hope for another child, perhaps a son”. She has contemplated suing the doctor but does not have the resources to do so.

Hysterectomy performed possibly because of intractable post-partum haemorrhage:

A woman in her first pregnancy was under care of a private obstetrician who saw her several times during pregnancy. When she went two weeks past the due date he admitted her at a private hospital for induction of labour, but for three days labour did not set in. However, when labour started on the fourth day her doctor was nowhere to be found; it was not until the next day that he appeared in the middle of the night and attempted to deliver her by vacuum extraction, but this was abandoned because there was a lot of bleeding. She was then taken to theatre and a CS was performed- a baby boy weighing 4kg. When she was returned to the ward the bleeding continued and had to be returned to theatre again, but was not told what was done there. “What annoyed me the most was that the details of my operations were only made known to my husband when he went to clear the bills, and then it was not until three months later that my husband actually informed me of the loss of my uterus. After some years, my husband left me for another woman and to have more children. I contemplated suing the obstetrician, but another doctor dissuaded me saying whatever was done was to save my life”.

Conclusions

The Public Inquiry report makes specific recommendations addressing the various aspects of maltreatment, medical negligence and malpractice in health institutions. It specifically calls on the Government to implement the provisions of Article 43 (1a) in the Constitution of Kenya (2010) and to ensure that health facilities at all levels are adequately staffed and equipped to provide quality health services.

The Ministry of Health and health professional regulatory bodies should ensure adherence to internationally accepted ethical standards and guidelines that govern medical practice with a view to eliminating the rampant cases of mistreatment, medical negligence and malpractice, in health facilities. The codes of practice must incorporate the obligations of health care providers to their patients, and should outline the rights of the patient with clear penalties spelt out in cases where the provisions are not adhered to. The government must make it mandatory that all health facilities establish complaint mechanisms aimed to enable clients forward their complaints to the relevant authorities for action in cases where they feel violated.

Finally, there is urgent need to increase the number of health care providers, across the country. Health training institutions have a duty to inculcate among their trainees high moral standards and respect for patients’ rights, including the right to information and informed consent. The government should recruit, train, employ and deploy more health personnel, and strengthen supervision, with a view to address the current shortage that is being experienced throughout the country.


[i]Kenya National Commission on Human Rights: A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya, April 2012.

[ii]Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier.

 [iii] Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 Saunders, an imprint of Elsevier.

 

Selected case studies of women who were denied enjoyment of ‘right to health’ in Kenya

 

A review of ‘Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?’ and ‘Barriers to enjoyment of health as a human right in Africa’ provides a useful background to the case studies.

The recently launched report by the Kenya National Commission on Human Rights[i] highlights several incidents and situations where women were denied their right to health care services both because of non-availability of resources and non-affordability of services, as well as misdeeds on the part of health care providers. People living with disabilities (PWDs), in particular, complained of mistreatment, especially delays in getting attended to in health facilities. Most health institutions were not disabled-friendly in terms of infrastructure and means of communication, for example, facilities for sign language or Braille.

A Level 2 Health Facility at Mtwapa, Mombasa County (Picture: J Mati)

Witnesses raised several complaints related to the inefficient referral systems in several health facilities that caused considerable delays in obtaining higher level care, not infrequently resulting in fatal consequences for the women and their babies. This was particularly a serious problem when it came to referral of patients from levels 1 and 2 to appropriate higher level facilities.

In some cases, women in rural areas had to be transported on wheel barrows by family members or on donkey carts. Where hospitals had ambulances, the patients or the relatives were required to pay amounts ranging from KSHs. 500 to KSHs. 3,000 supposedly to fuel the vehicles. In situations where people were unable to pay, patients were denied treatment. In other instances, blood was not readily available in hospital blood banks, or the facilities lacked adequate infrastructure to obtain blood for emergency transfusions.

In Tana River, for example, a woman who developed complications after delivering at a dispensary (level 2) died while waiting to raise funds, through harambee, to fuel a government ambulance to take her to Hola District Hospital. A similar report is given in connection with a maternal death due to lack of transport between Magarini Dispensary and Malindi District Hospital, both in Kilifi County.

In Lamu County, patients who needed to be referred to Coast Provincial Hospital in Mombasa were reportedly required to pay between KSHs. 8,000 and KSHs. 10,000 to fuel the hospital’s ambulance. Where there are no ambulances, as in Wajir and Marsabit District Hospitals families had either to hire expensive taxis or resort to donkeys and camels to transport their sick members.

Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled attendance at delivery. A witness during the inquiry stated thus: ‘Many women deliver at home because they do not have enough money to go to the hospital’.

 Corruption, especially among hospital management staff, was also cited as a barrier to accessing maternal health services. According to witness accounts from Kitale, corruption in health facilities meant that patients ended up paying for drugs and other items that ought to be provided for free. Similarly, bribes were solicited to facilitate earlier scheduling of surgical treatment, as stated by a witness at the Coast: “For one to get an operation done quickly at Coast General Hospital one has to pay bribes or know someone because there are long queues, so I left”.

Mistreatment in health facilities by unkind, cruel, sometimes inebriated hospital staff, who scolded, abused and even beat patients also features prominently in the report. So are delays in getting attended to in health institutions, particularly in the labour ward, where witnesses complained of being neglected during labour, in some cases ending in delivering unattended within the hospital. An example is the case of a woman who waited at the out-patients from 5am to 4pm before being admitted to the labour ward, ending up with a stillborn child. Women complained of being admitted in overcrowded wards and sharing of beds; up to three women with their babies sharing one bed, even when some of them were still bleeding, which exposed them to potential risk of infection, including HIV and Hepatitis B. Detaining of women for non-payment of hospital charges obviously contributes to congestion in hospital wards.

There were complaints of frequent lack of essential medicines, equipment, commodities and supplies in public health facilities resulting in denial of services to the needy. It was common in most public facilities for patients to be asked to purchase medicines, gloves and dressings, besides being referred to private institutions for specialised radiological and ultrasound diagnostic examinations. Essential resources for effective provision of sexual and reproductive health services were lacking in many health facilities. For example, many lacked the drugs needed for post-exposure prophylaxis (PEP) following sexual abuse including rape. The Inquiry established that non-availability of family planning commodities was a fundamental barrier to accessing comprehensive family planning in Kenya, this being illustrated by the frequent stock outs of commodities. There were complaints of frequent shortages of various contraceptives which denied clients a wide choice of family planning methods.

Several witnesses complained of negligent actions by doctors and midwives, for example, forgetting items such as surgical instruments or swabs in a patient’s abdomen; performing procedures such as hysterectomy without prior informed consent; poorly managed labour leading to ruptured uterus, maternal morbidities such as VVF and RVF, intra-uterine foetal death or a mentally handicapped child,. Other examples of negligent actions or omissions were performing episiotomy and failing to repair it, and failure to recognise accidental injury during surgery and failing to repair it immediately. There were women who complained that not enough information was given to them about the various diagnostic and treatment modalities they had been subjected to by health providers. In particular, there was inadequate information given to the patients before and after surgical procedures.

 The Report cites an article published in The Daily Nation Newspaper of 18th January 2011 on a case of maternal death associated with abortion:

“A woman aged 40 years who was held at Murang’a police station for allegedly procuring an abortion died after she developed complications while in the police cells. The Police said the woman was reported to have terminated the pregnancy by swallowing some chemical, and locked her up in a cell at the police station. They said she later developed complications and was being rushed to hospital when she died en route.”

 It can be argued that had the police taken the woman to a health care professional, instead of holding her in remand at the police station, she most likely would have survived. In other words this was a case of preventable death associated with denial of enjoyment of right to health. Yet this was after the promulgation of the Constitution of Kenya 2010 which has relaxed the rigidity on termination of pregnancy that existed previously. Article 26 (4) permits safe abortion if in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law.

What can be learned from the above case studies?

Clearly, they demonstrate that Kenya has yet to address the well known factors and barriers that have over the years sustained the prevailing high rates of maternal and newborn mortality and morbidity. Maternal health services that are inaccessible, non-affordable and of poor quality, have been perpetuated by several serious weaknesses in the health systems- inadequate capacity in terms of human resources and health infrastructure, negligence and malpractices especially among over-worked de-motivated health service providers, and various socio-cultural barriers, among others. Addressing these barriers is a prerequisite to meeting local and international goals and targets including the Vision 2030 and Millennium Development Goals.


[i] A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya

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