The politics of Kenya's health sector over the last 20 years

Health CS Susan Nakhumicha. Left, a doctor picketing along the streets of Nairobi on April 16, 2024. [File, Standard] The return to work formula that was to be signed today, had the government had its way, could have become a rare solution in a sector riddled with strikes in the last two decades. Interviews and conversations that The Standard has had with stakeholders in the health sector, including a former minister of health, reveal that the sector has been unsettled since the Kanu era and that medics have continued to raise demands, which authorities have failed to meet, since 2004. President Mwai Kibaki's administration, which was voted in with excitement and high expectations, was greeted with health workers' wrath three years into office. In 2005, 2300 medics went on strike demanding a 600 per cent pay increase. Then Health Minister Charity Ngilu issued the medics with sacking threats even as she described the situation at the hospitals as a medical catastrophe before deploying nurses from the military, volunteers and cooks to fill in for striking health workers. In all the protests called by the medics and nurses, the issues have remained the same: delay in posting and general mismanagement of the medical internship programme, immediate payment of basic salary arrears for doctors as per Collective Bargaining Agreement (CBA), a plan for employment of doctors and post-graduate training, lack of comprehensive medical cover for union members, poor contracts and exploitation of doctors and inadequate funding of the health sector. The CBA that the health workers keep referring to in their current push was a product of the longest health workers' strike in Kenya's history. The 2017 strike lasted for 100 days for doctors and 150 days for nurses. The health workers downed tools after the government declined to sign another CBA that had been agreed upon between the Kenya National Union of Nurses (KNUN) and the national and county governments in December 2016 following a two-week nurses' strike. The CBA contained the same grievances that the medics are demanding in the current strike. Health workers have been energised by the 2010 Constitution which, in Article 41, gives them and other workers, except disciplined armed forces, the right to demand fair remuneration, reasonable working conditions, form, join or participate in the activities and programmes of a trade union. The article gives every trade union the right to engage in a collective bargaining agreement and with legal backing, Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) was registered on August 30, 2011, giving rise to over ten nationwide strikes and countless regional strikes between 2010 to this year. Immediately after their union was registered, health workers demanded, among other things, a salary increase and a transformation of the "ailing" health sector. However, then Minister for Medical Services Anyang Nyong'o equated the striking doctors to spoilt children demanding peremende (sweets). The remarks fanned the strike getting the name peremende movement. In what looks like a precedent to his successors, Nyong'o threatened to sack the doctors and advertise jobs for the 2,000 striking health workers. The Ministry of Medical Services, on September 4, 2012, suspended government-sponsored registrars, interns and self-sponsored registrars who participated in the strike on account of an unauthorised absence and subsequently, Kenyatta National Hospital management withdrew their admission rights and gave those who resided at the hospital notices to vacate. Although the strike lasted for three weeks, it left Prof Nyong'o with an egg on the face with KMPDU saying it was the incidents that created a formidable base of their protests and later led to a successful strike in 2017. Current KMPDU Deputy Secretary General Dennis Miskellah says the only gain they got after the 2013 strike was a salary increment from Sh38,000 to Sh100,000. That was after successful mediation by former President Uhuru Kenyatta who was then Minister for Finance and Deputy Prime Minister, working with then-Minister for Public Service Dalmas Otieno. The CBA was signed in the last days of the Mwai Kibaki administration. But after the formation of the new administration in 2013, Miskellah says, the medics embarked on yet another strike to agitate against delayed implementation of a devolved health sector, until the government put in place structures that would sustain the sector, among other agreements that had been entered by the CBA. "This was prompted by the general mismanagement by the governors who did not have a clue of running the health sector, delayed salaries, lack of remittance of statutory deductions, provision of adequate protective gears, failure for the post-graduate training, posting of interns. Inter-county transfer among other issues became the order of the day," Miskella told The Standard. Healthcare workers downed tools demanding the establishment of structures at the county level but they did not receive backing from healthcare stakeholders and were seen to be fighting devolution. Governors came together exerting pressure on then-President Uhuru Kenyatta to downplay the medics' concerns. The health workers could later organise another strike in 2014 agitating for new medical equipment after the older ones broke down while at the same time demanding health centres with medicines, issues that largely affected patients but failure by patients to support the doctors led to calling off their strike and going back to work. They would later renew their push for implementation of the 2013 agreement in 2016 but their pleas fell on deaf ears as the Uhuru administration disowned the document saying it did not recognise it since it was signed by the former administration. "We tried to inform them that the government exists in perpetuity but they maintained that they could not recognise the CBA agreement of 2012. This is what led to the longest strike ever in the country. But it came with sacrifices as some of our officials were found guilty of contempt of court and were jailed," said the KMPDU official. The seven KMPDU officials were jailed for one month by Labour and Employment court judge Hellen Wasilwa who ruled that the doctors did not demonstrate to court any new and compelling issue or pointed out any mistake or error apparent on the record or any sufficient cause that would warrant a review of the court's order, after they sought review of their jail term. "There is no sufficient reason why the court should review its order. The orders of this court will now crystallise and you can now start serving your sentences, "Judge Wasilwa ruled. After paralysing the health sector for close to four months, the Uhuru administration made an offer to negotiate a new CBA and which led to the signing of the new CBA on March 14, 2017, calling off the strike. However, in 2019, the government went against its own document and stopped the automatic absorption of interns as agreed in the CBA and the medics started complaining, threatening a new strike. This led to regional strikes in counties and saw Kirinyaga governor Ann Waiguru fire 457 workers, former Murang'a governor Mwangi Iria fired 427 nurses for absconding duty, while then Laikipia governor Nderitu Mureithi fired 61 medical doctors over claims of participating in an illegal strike. That opened litigation between medics and the county governments. KMPDU joined their members for a strike in 2020 following the Covid-19 pandemic that led to the death of one Stephen Mughuso who was a doctor at Machakos Level Five Hospital. The KMPDU noted that despite the threat to life the disease bears, the government had not issued personal protective gear to the health workers while the doctor's statutory deductions had not been remitted which meant that he had no medical cover. While declaring the strike, then KMPDU Secretary General Chibanzi Mwachonda, said the deceased was the 13th union member to die of Covid 19 and that they could not attend to patients without assurance of their treatment, compensation to the young families and comprehensive medical cover. In July 2020, Dr Mwachonda, in conjunction with 12 doctors at the Kenyatta University Teaching and Referral Hospital, sued the government for non-implementation of the 2017 CBA. Before hearing and determining the case, he lost his post to Dr Davji Atella who now occupies KMPDU's seat of power. In the CBA agreement, doctors in Job Group M, N and P were entitled to Sh72,000 in emergency call allowances and Sh80,000 while they were to be paid an extraneous allowance of Sh30,000 and Sh20,000 risk allowance. The judge directed the government to implement the CBA and to return to court within 60 days. This never happened and it prompted push and pull between the government and the medical workers. When the Kenya Kwanza administration came into power, KMPDU started pushing for the implementation of the 2017 CBA and this saw Cabinet Secretary for Health Susan Nakhumicha, on January 6, 2023 together with Nairobi governor Johnson Sakaja sign a plan of implementation of the CBA. Sakaja signed the document in his capacity as the Labour chairperson at the Council of Governors. It was after claims that the government had started implementing the agreement that KMPDU embarked on verification of the same and after asking the CoG to provide them with proof, they found out that their data had some of their members' names, including Attela's, missing. "We turned to Integrated Payroll and Personnel Database (IPPD) where we analysed the data for the better part of the year and we finished in October which indicated that government owes us Sh3.5 billion in arrears of salaries between 2017 to date and which we maintain must be remitted to us before resuming work," said Miskella. The behind-the-curtains negotiations kicked off and on October 16, last year the KMPDU met the Kenya Health Human Resource Advisory Council (KHHRAC) that had been inaugurated in June with the mandate of tackling pressing challenges faced by the healthcare workforce through its strategic focus areas, including postgraduate training for medical professionals, facilitating transfers, creating a framework for internships and subsequent employment, prioritising staff welfare, and promoting the sharing of specialised expertise. The meeting, held at Safari Park, was a precursor to another one held in Kericho on October 19 bringing together top government officials, christened Kericho declaration, which saw government and health workers unions ink a deal that would end the perennial strikes by the health workers. The deal was unveiled by Head of Public Service Felix Koskei and signed by government officials led by Nakhumicha, Public Service CS Moses Kuria, CEO of the Council of Governors, and Veronica Nduva, PS in the State Department for Performance and Delivery Management. The pact carried 17 agreements, including establishment of intern county transfers, and said that within nine months government would have facilitated implementation of pending promotions and re-designations for healthcare workers who meet necessary requirements. Failure by the CS to keep her word on posting interns in February this year and the Salaries and Remuneration Commission (SRC) recommendations of lowering the medical intern's salaries from Sh206,000 to Sh70,000 a reduction of 91 per cent was the deal breaker and the trigger of the 2024 strike. The CS would later argue that the intern doctors needed not to be paid as they were students. The medics say Nakhumicha's flip-flopping and her careless utterances, have aggravated the situation.

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