UNIVERSAL HEALTH CARE: THE ELEPHANT IN THE ROOM

Eleven years ago, as a young intern doctor at our national referral hospital, I was quite impressed to receive a patient who had been air-lifted from the northern frontier for much needed highly specialized care. She had developed severe high blood pressure in pregnancy, leading to multiple organ damage. She needed critical care and renal dialysis to save her life. I was young, naïve and excited that the hospital helipad was actually not just decorative!

I thought this medical evacuation was standard care available to all patients in our hard to reach low density population areas in Kenya. Two months later, while in the medical rotation, we received a young seventeen year old female patient from Moyale. She was of Ethiopian origin and had crossed the border as a refugee. She fell ill and could not access even basic laboratory tests to diagnose her condition. She was referred to us, arriving after thirteen hours on the road, hanging onto life by a thread. Angry at what she had endured to have a shot at survival, I could not understand how such a sick patient could be subjected to road transport yet she clearly needed air evacuation. She stayed with us for five weeks while all manner of tests were conducted on her. She died without a diagnosis.

These incidences came to mind when I heard of the mother in Homa Bay County who had quintuplets and lost them all due to inadequate ante-natal and neonatal care. While in the developed world, survival of quintuplets is almost being taken for granted since the first surviving set in 1972, in Kenya it is still a miracle when quadruplets survive.

A colleague once narrated to me how he sat twiddling his toes in the same county just four years ago as a mother lost her baby because they were stranded on an island on Lake Victoria, unable to safely transfer the mother to the mainland for surgery. Why did this happen? Despite the county investing in ambulance boats, the might was besieged with a nasty storm that made it dangerous for the boat to make it across the angry waters. By the time the waters were navigable, death had robbed the mother of her baby and the still calm of the lake brought pain instead of relief.

As we continue to tout universal health coverage in Kenya, I keep wondering whether we have the full comprehension of what it means. Today even if all Kenyans had a medical insurance cover, would that translate to universal health coverage? Therein lies the fallacy. Our system is not yet structured to provide this.

Let us look at our private subspecialty hospitals for instance. The sub-specialty status is only fulfilled in the main hospital that is based in the capital city of Nairobi. All other branches will be far below par in terms of staff complement, infrastructure and even just the aesthetic beauty of the facility. Indirectly, the population targeted for care is indirectly discriminated upon, and where an upgrade is needed, they are referred to the capital.

This has been the trend even in public hospitals, where there has been unequal investment in the health sector since independence. Health resource availability is literally based on the size of the city within which a hospital is domiciled. A patient requiring specialized care is referred to Nairobi or Mombasa or Eldoret, irrespective of whether they are seeking care in a public or private hospital. This is so instinctive that we do not even think about it. Yet it is a clear demonstration of our neglect of a large segment of the society that is regarded as not sufficiently empowered economically, to pay for the services.

How then, pray tell, shall universal health coverage be achieved if we cannot bring these specialized services to our most disadvantaged? Take for instance the noble Linda Mama programme. The care provided to a mother seeking services at the national referral hospital in Eldoret will be miles above that provided to the mother in a health centre in Wesu despite both mothers being entitled to the same privileges under the National Hospital Insurance Fund.

For this reason, we shall see mothers migrating to urban centres to deliver their babies in well-equipped faith-based and public hospitals while we continue to have bad outcomes in the rural and marginalized areas. Empowering an individual mother with a national hospital insurance fund card means nothing to her when she starts to bleed profusely after delivery and the nearest facility with capacity to provide a much needed blood transfusion is 270km away of a road fit for camel caravans only.

We must appreciate the totality of universal health coverage. It must be solidly built on equitable access to health, built on the pillars of adequate financing, human resources for health, technology, adequate medical supplies, research and health systems management. That it spans beyond just the immediate health sector to involve country infrastructural development to enable physical access to care; education to increase empowerment and create demand for advanced service delivery in every corner of this country; and good governance to root out the cancer of corruption that shall be the death of the country if we can’t stop it from bleeding our systems dry.

The concept of devolution of health was intended to be the beginning of addressing universal health coverage by having key decision makers on the ground having a realistic view of what the local needs are. It must be strengthened to achieve this without fear or favour. Mediocre politicizing of this key function is too costly for us to ignore.

Counties that have been marginalized for decades must be supported to improve access to care, through strengthening and implementation of policies, adequate financing, supportive supervision and proper collection of data and its use in decision-making. Mission hospitals such as Kijabe have demonstrated that one can be based in the rural areas and still provide sub-specialty care. I live to see the day patients will travel to Makindu for specialized orthopaedic care!