In some ways Gundua Health Centre can be compared to a regular Swedish medical care office. There is a reception to register and bill the patients, there are talented nurses treating our patients, a qualified laboratory where tests are conducted, a decently well-sorted pharmacy, there are dentists on the premise and for certain difficult cases, there is also a doctor working half time. In addition we provide information and educational services, offer special care for mothers and children and a delivery room. Like a regular Swedish medical care unit, but with some differences.
I have been reading Maciej Zaremba’s articles about Swedish care in the Stockholm daily newspaper Dagens Nyheter. Well-written and interesting – and somewhat alarming. As responsible for Gundua´s health care unit here in Kenya, you get another perspective on things like care quality and productivity.
Here are some unsorted thoughts and reflections on the Kenyan care situation and how to run a health care unit in the Kenyan countryside.
One of the first things that happened when I started was that all employees wanted a 200% salary increase. I thought it was at spelling error, they must mean 20%. But, no. Here in Kenya it’s quite allright to ask for as much as 200 %. Everybody does it, for instance, the doctors demanded and got a 300 % raise the other year. This drives inflation, needless to say. The logic is: everybody knows that the country’s highest officials and institutions not only have much higher wages than ordinary employees, they also try to benefit from tax incomes and other things – “and if they can,we can…”. People also know that agreed increases are not always carried through and that the monthly pay sometimes doesn’t come at all. So you go on strike and demand high increases. After a lot of discussions with the Gundua employees we finally landed on a more relevant level of between 15-25 %.
There is thus often strikes, especially among the state employed nurses with the consequence that the state owned hospitals run into great problems since it’s the nurses who do the lion part of the work. This became very evident a recent night. We had a patient who had been severely beaten in the head with a panga, a type of machete. As she had no money she wanted to be sent to the state owned hospital in the town of Meru, 40 km away. As we went, she became steadily worse. When we arrived the hospital was closed. This was the only state owned hospital within 100 km, and it was shut down because of striking nurses. We were forced to turn around and ended up in a private missionary hospital with our very ill patient. They took care of her immediately. A so called Clinical Officer, the level under a regular doctor, shaved our patient’s head, confirmed that there were three deep stabs, one of which had crashed her skull, cleaned the wounds and sew it all together. No questions asked. “Should we X-ray”, I asked discretely. “No, the machine only works on weekdays, she will have to wait to tomorrow”. And the next day, after x-ray, she was released.
In Kenya, it’s a big difference between care and care. My own personal opinion is that Swedish emergency care is very good, probably world-class. It may happen in Kenya also, but never where I have been involved. Our talented nurses at Gundua can handle a lot, both emergency and less acute cases. But certain things they can’t do. Delivery complications, bad poisoning cases, cuts and really ill patients we are forced to transport to the neighbouring hospitals with more resources than we have. And in some cases this feels like we are leaving them to an even worse fate. It works slowly, a sense of urgency is often lacking, lots of bureaucracy, poor equipment, low hygiene, missing competence. A woman is moaning with half her arm almost torn a part, but nobody seems to notice, in the state hospital. A baby dies a day after we left her for more qualified care. After-care is often about releasing patients as fast as possible, which seems to be the same as in Sweden. Beds are missing and the patients can’t pay for the expenses, so away with them quickly…
Health care is not for free in Kenya and therefore highly segregated. In Nairobi there are large, modern university hospitals for the privileged. At the local state hospitals, care and medicine are subsidized but still not for free. Oftentimes these hospitals are running low on medicine-stock and the medical resources vary from hospital to hospital.
The patients from our area are very poor. They complain that a medical exam at Gundua costs 50 Ksh (3.50 SEK) and that the medicine (that we sell practically at cost) is too expensive. They often choose, instead, to visit the local state health clinic where the cost is 30 Ksh, and where they always hand out medicine for free, often malaria-medicine, despite the fact that malaria is not prevalent in this area. This is a dilemma. We want to help as many as possible to better health and a decent life. But care has a cost, even here. Often we subsidize patients who are lacking all means, sometimes we have helped pay patients’ medical bills to get them out of the hospital to which we transported them in emergency situations. One solution is NHIF, National Hospital Insurance Fond, an insurance that covers the most basic care. But the locals don’t understand the logic of paying in advance for something that might happen, and even if they do understand, they can seldom afford to pay.
Over all the lack of knowledge and insight in health-related matters is worrying. The importance of eating right, washing and keeping clean, handling food correctly, clean teeth and basic hygiene, etc. are not well known. We conduct different information and coaching activities within different areas, such as personal care and hygiene, nutrition, family planning, mother and child care, HIV, emergency care etc. to get the individual to take more of a personal responsibility for their own and their family’s good health.
There is also a risk for waste and there is a bit of cheating. This happens everywhere of course, even in Sweden. When I started to analyse the accounts at the Clinic, they didn’t add up. We bought medicine for quite a lot of money, and we dispensed a lot as well, but our income was very moderate. Something was wrong. After some meetings and more analysis it was clear that the revenues did not match the deliveries. Friends, mothers, siblings and others are probably included in the group who had been given medicine for free. We have managed to change this however. We now have a more thorough control and follow-up of medicine, revenues, lab-tests, inventory, etc., and this has had a positive effect. Our revenues are up 50 %.
Prescription of medicine and especially antibiotics is a challenge. In the western world there is a lot of discussion about resistance to antibiotics, probably even here in Kenya at government level, but not so much locally. There are several reasons why it’s more common to prescribe antibiotics here. The nurses are taught to think “better safe than sorry”. They often use mass-prescriptions; everything at the same time, since you never know if the patient will return. There is a cost for the trip as well as for the medical appointment. The environment is a real breeding ground for infections. Often dirty, hot and humid or cold and humid, a lack of clean water and small possibilities for cleaning wounds as well as general knowledge of how to treat a wound. So antibiotics get to be the general cure. There is also an anticipation that medicine is necessary to get well. Like malaria pills that are prescribed all the time for different illnesses putting pressure on the nurses to prescribe medicine that might not be needed at all.
At Gundua we are striving to use lab-tests to support the diagnosis and the recommended treatments. We have tougher requirements than other clinics to prescribe certain medicine. It’s not always appreciated by the locals, but it as a given for us.
To run a health clinic in Kenya comes with a certain setup of challenges. What is possible and natural in Sweden is not always possible here. We need to combine flexibility with structure and control. However, it’s fantastic to realize how much can be achieved with relative moderate means and practical efforts. This last year we have seen over 6000 patients, delivered almost 40 children, conducted a series of information/educational meetings and have contributed to better health conditions for the people in Ex-Lewa. This is something to be really proud about.