FINANCIAL INEQUALITIES AND FRUSTRATIONS IN KENYA HEALTH SECTOR

 FINANCIAL INEQUALITIES AND FRUSTRATIONS IN KENYA HEALTH SECTOR 

I have worked mostly in the public health systems and financial woes amongst clients are real. A little bit of exposure in the private has magnified this gap for me and breaks my heart a lot . When I was an intern , one of my seniors warned me that I risked bankruptcy if I continued paying for things for clients out of mercy. I would always mobilize colleagues to contribute and buy clients drugs and emergency essential equipment such as chest tubes. I gave up with time and accepted things as they were. 

When I started working , I.C.Us were only a luxury of the two main national referral hospitals in the country and a few private facilities in Nairobi; things have changed for the better with devolution . It wasn’t uncommon to baby-sit impending deaths because relatives couldn’t afford the 10s of thousands for public ambulance transfers to Nairobi . It was what it was!! I would always peep in to see if client was still a live or if the bed had a new occupant. Most of the times we would try all manner of manouvers documented and undocumented to atleast keep the clients alive but mostly it didn’t work especially if ICU care was the only modality of care to support breathing. 

In 2013, when I was doing my long weekend call on a public holiday , the then regime announced full free maternity services for all. This eased many burdens , admission files were dumped at the tables and we could admit freely without demanding for a receipt , surgeries could be done freely , ultrasounds were for all , we no longer held clients long after their Caesarean Sections due to lack of pay , neonatal unit drugs equipment and drugs became free . I was demanded to go empty the wards and discharge all who had been held for non-payment. It was a joy . This joy extended when I joined postgraduate training and things like I.C.U and dialysis were fully covered for any pregnancy related issues whether procured from high end private facilities or in the public hospitals. I loved being a Kenyan . I remember one time organizing a brain surgery for a client who had just given birth and this was done freely with confirmed free I.C.U after surgery . This is what I had come home to Kenya to practise ; optimal care for all without a worry about costs and family social status. Many of my colleagues undertook research topics that involved pregnancy because they knew any tests they ordered especially after 28 weeks of pregnancy would be covered , D.V.T in pregnancy stopped being a dilemma ; you would get admitted , get your KSh.30,000 stock of monthly blood thinners  and go home without paying a dime , family planning immediately post delivery was covered . 

Somewhere in between, Free-Maternity changed to a fancy word ‘LINDA-MAMA.’ This came with tons of limitations. Whereas we were used to free services , many things changed. It mostly covered chiefly the costs of maternity and delivery . Most of the other things had to be paid for by the clients from the pocket depending on the level of facility. Ideally Linda Mama scope only includes 4 free antenatal visits, 4 free postnatal visits , normal and Caesarean deliveries . However these are the usual nurse-run M.C.H clinics so any mother requiring high-risk clinics run by Obstetrician-Gyanecologists has to pay for consultation from their pockets even in public facilities . Ultrasounds (not even one) are not covered and any other care such as dialysis/ICU/ambulance transfer has to be borne from the pockets. Essential drugs in pregnancy for some select mothers such as the anti-D injections for clients with Rhesus negative blood groups are not covered and lab works including antenatal tests  have to be paid from the pocket . I have seen mothers go on their knees and beg me to see them for free in the weekly GOPC/HIGH RISK ANC CLINIC for lack of the 300 shillings consultation fee ; which I always do without blinking but they don’t get the luxury of having files opened. Despite the above challenges, I still advise all my clients even those in private to be registered to LINDA-MAMA irregardless of their rich insurance covers ; it could favor a free high-end public service waiver if the worst got to the worst (e.g ICU or dialysis) or at least fully cover delivery of one’s insurance small-print goes against them. 

Financially speaking , it’s very frustrating for me as an obstetrician practising in public . The cheapest ultrasound in public facilities costs 1,200  and clients must pay for it . Drugs are bought out of pocket and surgery needed in between pregnancy such as the Mc-Donald stitch (to prevent 2nd trimester losses in clients with short or incompetent cervix) are paid from the pocket. Of course there is some added relief for NHIF card holders depending on the type of NHIF (with the national cover KShs.500/month scheme users mostly getting a raw deal in outpatient services especially in private facilities). 

I have had crazy experiences . Like a client requiring a Mc-Donald stitch deciding to carry on with the pregnancy without it because of tight finances . The other alternative would be daily vaginal progesterone insert which cost upward of 100-200 shillings per tablet ; a husband once told me that their rent was 2500 per month and they were in arrears so 150 shillings tablet per day would drain them and so they were ready to lose the pregnancy if it came to that . 

I once advised a client that the Shs.5000 Anti-D injection was mandatory for her and she just laughed and brushed it off ; where would she get such an amount if she had to trek to avoid paying the 50 shillings motorcycle transport fee . The effects of lacking the injection can be catastrophic and could lead to an irreversible life long pregnancy losses . 

I still wonder why the government insists on Hepatitis B screening for all pregnant mothers yet the follow-up tests and drugs for those who turn positive are just out of this world to the common citizen in terms of costs yet not available in public facilities . 

I have had to come to terms with a lot in practice and not just to pregnancy related matters . If you suffer from  infertility and you are poor , you are likely doomed if you have an irreversible condition . The tests themselves are exorbitant and procedures such as InVitroFertilization are too expensive unless well covered with a rich insurance cover . 

One night, my covering-nurse on duty called to inform me that the referral facility had rejected a client we had referred because they had no I.C.U space . She was to look for deposit money running into hundreds of thousands and get a slot in one or the neighboring private ICUs. This client  had been brought by good samaritans drunk like a kite from a cheap drinking den ; how on earth was she to afford Kshs. 300,000? We called her relatives and they told us that they didn’t want to be involved because that amount was a dream to them and could be called to collect the body in case she succumbed . In my naivety, I called a senior to try and negotiate for ICU space in private then the government hospital could pay up with Linda Mama ; he duly educated me on the limitations of this scheme and how impossible it was but promised to give my client priority if an ICU bed became available. I remember crying on my drive home and feeling extremely sorry for the client; the Government had failed her , her poverty had failed her. 

On the contrary to above misery , I have seen the wonders of insurance and NHIF-civil-servant-scheme  in offering outpatient facilities in the private sector . Clients freely get seen by specialists and get high end services without paying anything . The same applies to inpatient surgical services all insurance holders including NHIF-national scheme. 

I was a campaigner for NHIF a few years ago and made videos on the same . I reminded my fans to stop limiting themselves to the outpatient challenges but to look at the big picture in case emergency surgeries are needed , in the event of required dialysis or in the unfortunate diagnosis of cancer . I remember commenting how NHIF was only 20 shillings per day if one was to save up for the monthly fees. A few listened and I pray that they keep up at it despite the outpatient frustrations. 

I hear that there are new NHIF terms ; I’m yet to dig in - but I pray that it doesn’t complicate things further for the needy Kenyan Hustler .

HealthCare is costly and I pray that the government gets to widen NHIF scope for national scheme and improves on services available in the public facilities - the usual unavailability falls squarely on the citizenry who are forced to pay cash in private. 

I also hope that we can one day go back to the free-maternity services which had  a wider coverage and benefit to pregnant mothers and under-5-year-old children. 

The government should also consider providing what has been traditionally viewed as rich-private-facility services . For example , our main national and county referral facilities should offer subsidized fertility services such as I.V.F and minimal access surgeries to all; it shouldn’t be limited to the rich only. 

So there goes my frustrations and takes !! 

P.S : Today is Mother’s Day 2023 , I hope our government enhances the free maternity coverage as a gift to motherhood ; women leaders are you listening?

Update in 2025 - I have since changed employment to a government department with a very organized health department  , NHIF has since changed to SHA, the dollar rates changed and some prices quoted above have since almost doubled , Linda Mama no longer exists; my thoughts on the public health sector still apply.