Time to take action on the shrinking nursing workforce

I have spent the past week touring various public county referral hospitals across the South Rift region and the findings on the ground have been amazing. Devolution on the ground is what you choose to make of it. Nothing reinforces this statement more than the state of the public health facilities.

Two weeks back, a colleague working for a county referral facility elsewhere took to social media to express his utmost frustration at the state of the facility. He was disappointed by the attitude and lack of support from the county government in ensuring the facility delivers on its mandate to Wanjiku when it comes to health service provision.

The picture painted was unacceptable. The stockouts of drugs and other non-pharmaceutical supplies, the non-functioning equipment, the demoralised and overstretched health workers, you name it!

What was even more disappointing was that in the recent past, this has been a model hospital to be emulated. The downward spiral is astounding yet those concerned with reversing the catastrophic trend do not appear to be bothered.

It was therefore quite refreshing to see facilities that had little to show 10 years ago boasting such amazing services! Rift Valley Provincial Hospital, Nakuru; as it remains named on the record, is by all means a level six  facility right now.

The facility boasts a myriad of high-level services, with advanced investigative and curative technology, a wide array of sub-specialists and specialists and a huge turnover of patients seeking services on a daily basis. The hospital caters to a regional population and remains a referral centre for many neighbouring counties.

Further, it hosts a variety of institutions, training a wide array of healthcare cadres, from nurses, clinical officers, general doctors and even specialist doctors. By all means, the facility checks all the boxes and deserves an upgrade to parastatal status.

Kericho County Referral Hospital is the cleanest public hospital I have seen in a decade! The congestion that is typical of public health facilities still plagues the hospital considering it is the sole referral facility in the county. However, it hasn’t compromised its state of cleanliness and sanitation. It boasts a state-of-the-art laboratory, a busy renal unit and an ICU run by a highly motivated duo of Cuban critical care specialists led by a very committed but soft-spoken anaesthesiologist.

Longisa County Referral Hospital has probably experienced the most dramatic growth in the past decade, from a glorified health centre to a facility boasting a regional eye (ophthalmology) unit and a busy renal dialysis unit. The upcoming mother and child centre will definitely be a game changer! Narok County Referral Hospital may have grown a little slower, but the existing modern intensive care unit and renal unit already point to what to expect once the newly constructed hospital unit is commissioned for use!

With the huge steps made forward in putting up structures and equipment, it is important to take note of the challenge that is quietly creeping up on us. None of these fancy units can function without a skilled health workforce!

I must commend the county leadership in all these counties for investing in training health workers to run these precious amenities. Highly specialised doctors, nurses, clinicians, lab technologists, pharmacists and other cadres of staff are no longer the exception but rather the norm. These people are keeping these highly specialised units smoothly running.

However, this has created a new dilemma. As many of these staff transition upwards to provide more specialised care, the generalists that bridge the gap between entry into the health system and transition into the specialised care units are rapidly shrinking and remain unreplaced. The worst hit cadre of staff are the nurses yet they are the basic building block of any health system, spanning the preventive and promotive aspect all the way to the curative end.

Nurses are the primary contact with patients. Their scope of work does not leave room for compromise. A unit without adequate nurses spells doom for the patients. It is heartbreaking to walk into a ward and see a nurse single-handedly attend to 60 patients in an eight-hour shift.

What is plaguing our system? Is it that counties are refusing to hire healthcare workers? This is the short narrative that we are used to hearing. What is the unaddressed issue? It all starts with how our budget has been legislated. The law is clear with regard to how much money counties are allocated as a total share of the national budget under Chapter 12 – the Public Finance Act.

Further, counties must abide by the Fiscal Responsibility Principles that expressly forbid a county from spending beyond 35 per cent of its budget on the wage bill of its public officers. It then means that even though we expect counties to widen the range of health services it provides to their people, we will be forced to limit just how much they can spend on ensuring we have adequate numbers of the requisite cadres of staff to safely execute this mandate. Constitutionally, every person is entitled to the highest attainable standard of healthcare. It means that we will not stop training our health workers to provide the highly specialised services that Wanjiku requires. As the population expands, so will facilities. But we need to appreciate that facility expansion means that we will be forced to hire more health workers!

How do we go around this specific Fiscal Responsibility Principle? Health is a basic human right, one that unfortunately cannot be compromised. Failure to provide quality healthcare is tantamount to sentencing Wanjiku to death. It borders on genocide.

It means that we must either consider an increase in county budgetary allocation from the consolidated fund; a review of the 35 per cent cap; or the national government taking over the wage bill of county health workers under a health service commission. Which way Kenya?

Dr Bosire is an obstetrician/gynaecologist