Toying with thoughts of employing foreign health professionals to replace striking Kenyan doctors is akin to planning to take a walk in a professional minefield. Following the doctors’ rejection of the government’s 40 per cent pay increment proposal, Health Cabinet Secretary Cleopa Mailu has hinted that the government could look offshore for alternatives.
Three weeks ago the 47 county governments also published notices inviting interested and qualified professionals to apply for employment as doctors. The exercise, if it takes off, is set to be fraught with a wide range of intractable challenges. Replacing the striking medics is certainly easier said than done.
For a start, doctors in the public sector serve at two main levels whose entry requirements and procedures will have to be considered, if not observed. The entry point is that of the Medical Officer (MO) who is a General Practitioner (GP). This will usually be a fresh graduate, holding the geminate degrees of Bachelor of Medicine and Bachelor of Surgery. Then there is the Consultant. He or she will have taken a Master’s of Medicine degree in a specialised field.
Now Medicine is one area where mistakes cannot be tolerated, for they could be life threatening, or even life limiting. On this account, a very rigid and rigorous process is followed when employing a doctor in Kenya. This will be the first impossible hurdle for the government to cross, in any effort to recruit about 4,500 doctors.
Long and complex process
Employment of an MO from another country requires that the person should first be licensed by the Kenya Medical Practitioners and Dentists Board (KMPDB). But even for a Kenyan trained outside the Republic to be licensed the process is still long and complex. The professional must first work under very close supervision by a senior doctor – usually a Consultant – for between four and six months. During this period, s/he will do rounds in the hospital, covering four major professional areas.
These include Obstetrics and Gynecology, Surgery, Pediatrics and Medicine. Within each of these areas is an array of sub areas, numbering upwards of thirty. When the rounds are satisfactorily done, the candidate will take a Board examination – both written and clinical – which s/he must pass. It is only now that s/he can be registered as a doctor and licensed to practice anywhere in Kenya. The practicing license is of course renewed every year, as a mechanism of minimising malpractice.
Foreign doctors who wish to practice in Kenya are required to obtain a temporary license from the KMPDB. The license is valid for a maximum of 12 months and is subject to renewal. The doctor must provide evidence of being licensed in the country of origin. S/he must also give proof of proficiency in English. The temporary license restricts the foreign doctor to working in a specific hospital in the country. Its renewal is not automatic. Both the doctor and the institution must justify any request for renewal. These requirements may have to be relaxed if the government is to bring in foreign medics.
There are about 4,500 doctors in public hospitals in Kenya, a majority of whom are GPs. Replacing them means taking the same number of foreign trained applicants through the procedure we have just described. The first challenge is where are you going to get such a number of medics ready to come to Kenya. The terms would have to be exceptionally attractive, which takes us back to the present problem.
Second, the foreign medics will need a functional hospital environment for their six months of supervision. That environment is not there at present. The would be supervisors are on strike. Beyond this, the newly registered foreign doctor in Kenya will have to undergo a 52-week internship programme before being allowed to practice. The present environment is not supportive of this arrangement, particularly taking into account that the focus is not on one, but on almost 4,500 doctors. It is a veritable nightmare.
Professional peer reviews
Meanwhile, engaging a foreign trained Kenyan Consultant requires that the candidate will be interviewed by a panel of at least three professionals in the field of specialisation. The professional at this level will possibly have published some original work in medical journals, or in other respected places. S/he will be expected to speak to these publications and to emerging issues in that field. If the peer reviewers are satisfied with the interviewee, they will recommend him or her for registration to practice in the country. Moreover, the Consultant will require the same kind of equipment and ancillary working conditions as Kenyan doctors have been asking for.
A third option for both the National and County Governments is to get into a government-to-government arrangement with foreign governments to bring in doctors from their countries. KMPDB will still be expected to vet such doctors. The government, depending on its negotiations with a foreign government, may have to pay a regular agreed amount to the foreign government, over and above paying the doctors. A related consideration is that consultants work in specialised areas of healthcare. Consultants are unlikely to want to do the work of a GP. They would also be possibly asking for a handsome pay package.
Spread of diseases
In healthcare, there is what is known as epidemiology. This is the branch of medicine that deals with the incidence and geographical occurrence and spread of diseases and their symptoms. If a doctor encounters an anemic patient in Turkana, for example, the causes could be quite different from a patient with similar symptoms in Machakos, Kisumu or Wajir. That is why locally trained doctors always have an advantage over foreigners.
There is little doubt that the Kenya government is cast squarely between a rock and a hard place in the ongoing strike. Part of the challenge is that the medics are proving that they can sustain the strike. Part of the challenge for the government here is that the striking doctors are able to do locums in private hospitals and clinics and therefore fend off immediate adversity.
A further factor that is helping to sustain the strike is the family background vis-à-vis the training of doctors in Kenya. Over the past two decades, training in medicine has become the preserve of youth from well-to-do families. A majority of students at the medical school are funded by their families. Universities have cashed in on this, making it very difficult for youth from poor backgrounds to study medicine. The implications of this for the strike is that a critical mass of these people are able to find safety nets on the domestic front. If the government expects attrition to force them back to work this may not quite work.
Additionally, their privileged background will have exposed them to high standards right from kindergarten, through high school all the way to the university. The first time they come face to face with poor standards is when they go out for internship in poor public hospitals. They are now demanding high standards at work. In all, the government is in a difficult place. It will need negotiators and not tough talkers.