It's time to determine best approach to manage medics and avert strikes

KMPDU Secretary General Davji Bhimji (second right)  addresses a press conference to demand the employment of doctors, at Ufungamano House, Nairobi. [ Jenipher Wachie, Standard]

Recurrent strikes among healthcare workers in Kenya have become unavoidable.

This industrial action, which is both regrettable and unfortunate, forces us to consider whether the strike was truly inevitable. Health workers are trained to save lives, protect, and promote the well-being of their patients, and as Mr Wachira, Chair of the Clinical Officers Union, states, a strike should only be the "action of last resort" when all other options have been exhausted.

In recent years, the government has set targets for universal health care, aiming to fulfill the Constitution's mandate for citizens to have the highest attainable standard of health care. This can only be achieved with an adequate, well-distributed, motivated, and available healthcare workforce. Any strike undermines investments in other pillars of an effective health system.

In 2017, the healthcare sector experienced several strikes: Doctors for 100 days, nurses for a record 150 days, and clinical officers for 20 days. The issues at the time were unfulfilled collective bargaining agreements and disputed payment of allowances. Since then, additional labour disputes have arisen, such as the lack of protective equipment during the Covid-19 outbreak and the current salary delays.

The Kenya Medical Practitioners, Pharmacists and Dentists Union, Kenya National Union of Nurses, Kenya Union of Clinical Officers, Kenya National Union of Pharmaceutical Technologists, Kenya Health Professional Society, and Kenya Union of Nutritionists and Dieticians downed tools on April 19, to protest delayed salaries and other withheld statutory deductions. These unions asserted that their members are unable to fulfil their financial obligations and meet their needs, which prevents them from going to work.

The affected health workers were from Kisumu, Mombasa, Nyamira, Kisii, Murang'a, Nyeri, Laikipia, Bomet, Embu, Vihiga, and Taita Taveta counties. Ten days after the strike began, three out of the 12 affected counties—Bomet, Nyamira, and Kisumu—still had workers withholding labour. Health services resumed in Vihiga and other counties that had paid their health workers. Interestingly, Kisumu reportedly obtained a court order to prevent industrial action until the salary delay issue was resolved.

As we compare this situation to the 2017 health workers' strikes, we must ask ourselves tough questions. Was this strike inevitable, or could it have been prevented through better leadership, management and governance of healthcare workers? More importantly, what measures can be taken to avert such situations in the future?

For patients a health workers' strike is a period of pain, anguish, and loss. Delays in receiving care can lead to poor health outcomes, particularly in emergency units, maternity and child health units, and communicable and non-communicable disease clinics. Time is of the essence in healthcare settings, as diseases worsen, complications arise, and suffering increases and death can occur with every passing minute.

Missed opportunities for immunization, skilled delivery by healthcare workers, family planning, and screening for nutritional deficiencies may have dire and long-term consequences on the health of the population. About 98 per cent of citizens, particularly middle and low-income earners, do not have private insurance and are thus limited in their options for seeking care.

In 2017, the doctors' 100-day strike revolved around the collective bargaining agreement, while the nurses' record 151-day strike focused on the payment of allowances. The clinical officers' 20-day strike centred on both issues. This time around, healthcare workers in some counties downed their tools to protest delays in salary payments and remittance of statutory deductions. Health workers and their union leaders have consistently maintained that it is not their wish to abandon their patients since they are trained to save lives. These workers, often referred to as "madakatari," hold a special place in their communities as they epitomize wellness, which encompasses physical, social, economic, and emotional well-being. Delays in salary payments can profoundly impact all these aspects.

The unions have proposed returning health workforce management to the national government. Similar to teacher management by the Teachers Service Commission and police management by the Police Service Commission, they propose the creation of a Health Service Commission to manage the health workforce.

However, this proposal is not universally accepted, as some argue that health is already a devolved function, and the Health Service Commission was not included in the constitution-making discussions before 2010. The governors, on the other hand, are content to manage this devolved function, as they maintain control over workers in remote counties such as Samburu, Turkana, Marsabit, and Kajiado, among others. The counties contend that if the national government timely remitted funds, they could pay all employees on time.

Alternative solutions have been proposed. The Kenya Health Laws of 2017 introduce several bodies and forums designed to enhance the governance of human resources for health. These include the Kenya Health Human Resource Advisory Council (KHHRAC), the Kenya Health Professions Oversight Authority, and the Kenya Health Sector Inter-Governmental Consultative Forum. While the secretariats of these bodies may have been commissioned, the establishment of their governance structures and financing for their operations has not been implemented. The President recently alluded to intentions of making the KHHRAC fully operational. These bodies could provide solutions to proper management and governance of human resources for health.

In the meantime, roundtable dialogue forums should continue between health workers unions, county health departments, and county public service boards. The Chief Officers of Health Forum at the Council of Governors (CoG) and the Regional Human Resources for Health Consultative and Sharing Forums, which were previously facilitated through a USAID-funded National Human Resources for Health Mechanism, need to be reinvigorated. These forums provided a platform for dialogue, best practice sharing, and learning on governance and management of the health workforce.

As health workforce stakeholders, we must discuss and determine the best approach to managing health workers—either centrally or in devolved units. A meeting of unions and other stakeholders in the health sector has proposed the creation of a task force constituted by the government and unions, CoG, civil societies, and private sector players in health. In the counties where health workers' strikes are still ongoing, we hope that all outstanding issues will be addressed expeditiously to alleviate the pain and suffering of patients.

- Wangalwa is the Deputy County Director, Amref Health Africa in Kenya, while Maingi is human resources for health specialist with USAID Imarisha Jamii Programme in Turkana county