For some two to three weeks in late February/early March, news of the KNH botched operation moved at a dizzying and harrowing speed. And thanks to concerted efforts by both the Mainstream and Social Media, the central facts of the case were always at hand to fuel our rapidly growing outrage. Since I don’t wish to belabour mechanics of the case or rehash the sequence of events that followed, I will restrict my take to the coverage itself.
The tone with which the media covers stories generally dictates the tone of public discourse on the subject; which elements of a story are important? what feelings should they evoke? Who should be the target of said feelings? In so far as the coverage of this story, a few things were done right i) The media took the operation seriously enough to elicit the necessary public anger and demand for accountability and ii) Some of the media took some effort to put the story in the wider context of a failing/failed healthcare system eg this piece by KTN News. I say “some media” and “some effort” because in popular news outlets the story was largely postured as a “freak” accident that was horrifying only because it was unpredictable and unexpected of the “largest referral system in East Africa”. The economic and political context in which KNH and this operation exist was not only ignored, it felt deliberately obscured. Allow me to use this comically distasteful article by the Daily Nation to illustrate the point. The objective of the article, it seems to me, was to aggrandize the difficulties of the CEO job at KNH, but attribute the entirety of said difficulties to the individual CEOs unfitness for the job. Even the title of the article implies that to be a CEO at KNH requires exceptionalism that is not necessarily true of other institutions. The article then goes on to list all the individuals that have run the institution since antiquity, but does not concern itself with the political interference, inadequate funding, and other problems in the health sector that have made being a CEO at KNH so difficult in the first place. The writer’s only motive through and through appears to be to make a somewhat comedic entreprise of the high position turnover and leave it at that.
Now that I have highlighted what was right and wrong with the coverage, what was un/under highlighted?
- KNH is underfunded
I don’t imagine it is news to most people that KNH is grossly underfunded, but it is surprising that most analysis on what ails KNH makes no mention of it, especially given that it is arguably the biggest contributor to the poor state of affairs at the hospital. So surprising in fact that there seems no explanation for it other than the general avoidance of Mainstream Media to antagonise the Jubilee government; do not poop where you dish and all that. I will illustrate the magnitude of this point using some numbers. From KNH’s and Auditor General’s archives, I was able to access audited financial statements for the hospital for the years ending June 2014, 2015 and 2016. This is not enough to demonstrate a patterned underfunding over the history of the hospital, but it’s sufficient in putting recent events in their malnourished context. For the year ending June 2016, KNH received KES 6.67B from the national government, KES 150M from donor funded projects and KES 3M from public contributions and donations. Including the KES 4.6B collected from rendering of services (revenue collected from patients) the total annual revenue was KES 11.7B. Of this, employee costs took up KES 7.7B, which is 66% of total revenue and 115% of the grants from Treasury. The rest was mainly spent on clinical costs (pharmaceutical supplies, surgical consumables, lab chemicals, patient food etc) and General Admin expenses (Utility bills, legal fees, security, cleaning etc). In short, the funds received from Treasury is not enough to cover employee costs, much less the clinical costs and administrative expenses to run the hospital. The implication is simply that patients have to dig into their pockets for the operational running of the hospital, many of who are not able to pay at all or in time. The hospital therefore often runs on steam.
There are a few reasons this underfunding bears emphasis. i) Universal Health is one of the Big 4 Agenda items that the Jubilee government has committed to delivering in its second term and ii) The underfunding is not for lack of funds, but done so that more money is available for the blatant and persisting plundering of the state’s resources by the powers that be. The three years I looked at (2014, 2015, 2016) tell a similar story, with overall National Treasury grants amounting to KES 20.8B against a combined employee cost of KES 22.7B (circa 108%).
Based on the direness that these numbers portend, it should not be surprising that KNH is grossly understaffed and only employs about 450 doctors, that it heavily relies on postgrads from the University of Nairobi for the bulk of clinical work (KNH has least 700 registrars), that patients often share beds or even that doctors do not have the time and capacity to give each patient the due care mandated by the profession.
2. The referral system does not work
In January 2016, the then Health CS Cleopa Mailu announced that in two years KNH would stop offering outpatient services in a bid to decongest the hospital and enable it to focus on inpatient care. More than two years later, KNH is still not a full referral hospital, and is still taking walk ins . Worse still, there has not been a statement from the Ministry of Health either from Mailu or from the current CS Sicily Kariuki on why this was not achieved, or what the adjusted timelines are.
From an observer, there have been a number of contributors to the non-achievement of this goal including unequipped, inefficient and unsympathetic County Level 4&5 hospitals (I once tweeted at length about the maltreatment of a loved one at Thika Level 5 Kiambu County hospital, but that’s a story for another day), the poor coordination between County hospitals and KNH and as always a lack of goodwill from both the County and National governments in ironing out the system. Failure of the referral system has been known as one of the main reasons for the congestion of KNH and the underfunding discussed in preceding paragraphs only serves to exacerbate it.
3. The health sector’s general attitude to medical errors.
It would take me another thousand words to talk about the God complex in the medical field that make misdiagnosis particularly prevalent and painful for many patients. For a field that was manufacturing measly grams of insulin out of vast amounts of liquefied cow and pig pancreases less than a 100 years ago, the demonisation and instinct to bury/ not to acknowledge medical errors is befuddling. On the KNH front, it was disappointing that at least initially, suspending and vilifying the staff involved was sold to us as important and sufficient, feeding into the trope that errors in medicine only result from malice. It was a prime opportunity for the media to lead a discussion on how the gaps in medicine’s feedback loop can be closed and how one unfortunate error can be studied to make structural adjustment to processes such as patient labelling and filing of records. This opportunity was missed.
That being said, the level of public participation especially on Social Media went a long way in making up for shortcomings on Mainstream Media and it’s my hope that we will continue to engage with each other on this issue, but more importantly, that relevant stakeholders are paying attention.