Devolution on trial: Leadership failure pushes Kenya’s health system to the brink

Public health in Kenya is under serious strain as county-level hospitals face recurrent strikes by medics.

The labour actions have been attributed to weak leadership, mismanagement of human resources and a mounting financing gap.

KMPDU deputy secretary general Dr Dennis Miskellah told the Star the core problems lie not in infrastructure, which has improved, but in funding, leadership and governance at county level, coupled with poor human resource management.

“We currently have a financing gap of Sh50 billion in the health sector. There is also a severe shortfall in the human resource as the counties are not employing and promoting medics as required,” he said.

“The morale is also very low as medics are going for months without pay, no promotion and failure to do inter-county transfer,” Dr Miskellah of Kenya Medical Practitioners, Pharmacists and Dentists Union said.

He regretted that county governments are frustrating doctors from further training and capacity building.

And when it happens, doctors are not promoted, he said.

Health is a devolved function other than for the referral facilities.

Over the past year, a number of counties have seen healthcare workers, ranging from doctors, interns, clinical officers to nurses, go on strike or threaten to.

Clinical officers in Marsabit are currently on strike for a month now, demanding the implementation of a return-to-work agreement, comprehensive medical cover and promotions.

In Kiambu, a doctors’ strike lasted 151 days until late last month, crippling maternity and emergency services. The strike also strained surrounding health facilities, particularly the Kenyatta National Hospital and Murang'a Level 5 Hospital.

In Nairobi, more than 140 facilities were paralysed from February 27 over salary arrears and unpaid deductions.

In May, the KMPDU threatened to go on strike in Nakuru, Kajiado and Laikipia counties over promotions, wages and insurance issues.

In September, medics in Lamu also went on strike over salaries, promotions and employment terms.

Kakamega medics ended their strike in late May after reaching a return-to-work agreement with the county government.

Elsewhere, healthcare workers in Meru, Nyamira and Taita Taveta were on strike in September last year over medical insurance coverage and delayed pay.

Dr Miskellah said the failure by county governments to remit statutory deductions has become a perennial problem, resulting in a lack of access to treatment and blacklisting by the Kenya Revenue Authority.

This is among the grievances that medics in Marsabit and on strike about: failure to remit deductions dating “several years back”.

They are also aggrieved by the lack of a comprehensive medical cover, promotions and redesignations.

Another gripe is the failure by counties to absorb or pay some health workers who had been contracted by the Global Fund15 years ago to help manage the TB-HIV scourge in public hospitals.

Kenya Union of Clinical Officers national chairman Peterson Wachira has particularly taken issue with this.

“These workers have gone for 14 months without pay though they continue to offer services in their various facilities,” he says.

The challenges started after the Global Fund wound up its operations, with an agreement that the 91 medics would be absorbed by the Ministry of Health and counties for continuity of the services.

“The Public Service Commission released a circular directing the Health ministry and the Council of Governors to absorb those working under them into their permanent and pensionable establishment,” Wachira said.

“The ministry absorbed theirs but the CoG declined, citing lack of funds, yet they continue employing other health workers.”

Dr Miskellah said most of the challenges doctors face in the counties are not in the national referral hospitals under the national government.

The Public Service Commission provides comprehensive human resource guidelines for doctors, covering areas like recruitment, discipline, training and performance management.

However, some counties are unwilling to implement the PSC guideline, citing autonomy.

The CoG has acknowledged underfunding of devolved health services, citing delayed Exchequer releases.

The financial squeeze exacerbates unpaid salaries, poor hospital equipment and workforce frustrations.

The Kiambu strike dragged on for months due to a failure to honour collective agreements, forcing the CoG to mediate.

A Senate Health Committee oversight mission in May laid bare a litany of failures in Mandera, Wajir and Marsabit counties, exposing deep-rooted challenges in the healthcare system in the region.

The inquiry, led by Uasin Gishu Senator Jackson Mandago, found a crisis spanning drug shortages, outdated equipment, understaffing, neglected infrastructure and questionable financial accountability.

Key health workers were absent, infrastructure was in decay, drugs unavailable and disposal practices were dangerously inadequate, the committee said.