On any day of the week, public hospitals across the country are buzzing with activity and long queues of patients waiting to be attended to.
The hard benches placed along cold, often worn-out corridors, are fully occupied by the crack of dawn.
For poor patients who cannot afford services in private hospitals, it’s a race to be first in the queue.
They wait in line until very late but mostly go home disappointed, turning to painkillers after failing to see the doctor.
The doctors, who are on government payroll but also run private clinics on the side, either simply fail to show up on their clinic days, or turn up late and attend only to a few random patients.
A month-long investigation by the Nation team revealed widespread neglect of duty by specialist doctors across the country, leaving poor patients to die of largely treatable illnesses.
The Nation investigative team followed close to 15 specialist doctors attached to various public health facilities and spoke to hospital administrators, county bosses, medical interns, subordinate staff in hospitals and the union.
We mapped the clinic days of specialists attached to public referral hospitals and arrived at their clinics early, waited until the doctors clocked in – for those who showed up and stayed on until they clocked out.
On most occasions, most of them did not come to the clinic and those who came arrived late, with some as late as 3 pm when the majority of patients had left.
As per the 2017 Salaries and Remuneration Commission recommendation, specialist doctors earn between Sh250,000 and Sh700,000 per month, including allowances, depending on their level of experience.
The doctors then complement this income with earnings from their private practices, which could add up to several million shillings per month.
At their private clinics, the doctors charge between Sh1,500 to Sh10,000 consultation fee per patient, typically attending to tens of clients per day.
A doctor attending to 20 patients per day, charging consultation fees of Sh2,000 for 25 days a month makes Sh1 million, excluding surgeries and other medical examination fees such as laboratory, radiology and X-ray services.
With health being a devolved function as per the constitution, hospital administrators and governors have in the past attempted to confront this malaise with little success.
In most public hospitals, medical interns with little experience do ward rounds and even conduct clinics without the supervision of specialists, putting patients’ health in grave danger.
At the Coast General Teaching and Referral Hospital, the largest hospital in the region serving Kwale, Kilifi, Taita Taveta, Tana River, Lamu and Mombasa counties, specialists are busy traversing between the three main private hospitals in the city.
Instead of treating their patients at CGTRH, they would rather go offer their crucial services at private facilities, where they make good money.
A doctor attending to 20 patients per day, charging consultation fees of Sh2,000 for 25 days a month makes Sh1 million, excluding surgeries and other medical examination fees such as laboratory, radiology and X-ray services.
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The three private hospitals are frequented by wealthy Coast residents, politicians and businessmen who pay to see the doctors.
On Tuesday, September 13, some patients who were waiting for the sole cardiac and thoracic surgeon who heads the heart clinic at CGTRH (name withheld for legal reasons), went home dejected after the secretary told them the doctor was away.
However, the specialist was at a private hospital offering his crucial services for financial gain.
The doctor is among the most sought-after specialist in the entire region, which has a high incidence of heart ailments due to the residents’ lifestyles.
When the Nation visited his private clinic, they found him attending to patients.
“If I have to wait for four months to get my salary at a county referral hospital, how will I survive? I have children to feed, rent to pay and school fees. Doctors are also human beings, furthermore, the engagement we have with our employer is that we are free to offer our services in other hospitals,” said a consultant who sought anonymity.
During the frequent medical workers’ strikes in former Governor Hassan Joho’s 10-year reign, the county boss called out the doctors for absconding duty while concentrating on their private practice.
The Joho administration openly accused the specialists of neglecting patients in public facilities and instead going to their private hospitals to offer their services.
However, the then Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) Coast branch secretary-general, Abidan Mwachi, rebutted the accusation. Dr Mwachi, who is the current KMPDU chairman, also runs a private clinic.
Even as doctors abscond duty and pocket taxpayers’ money every month, the legal line between dual public and private practice remains blurred.
The Kenya Medical Practitioners and Dentists Council (KMDPC), which is the regulator, stopped issuing licences to doctors for dual practice in 2019 when the sector proved difficult to regulate.
Kenyan doctors are currently licensed to practice either as general practitioners (GP) or a specialist.
“No doctor has two licences. It is either you are licensed as a GP or a specialist. We fought so many wars while we were trying to regulate the sector. Doctors were not adhering to the code of practice, you could find that as early as 9 am a specialist is busy in his clinic yet there is a long line of waiting patients at the public hospital clinic,” said Mr Daniel Yumbya, Council chief executive officer.
He told the Nation investigative team that it is now upon the employer of the doctors, and county governments, to crack the whip.
Just like specialised doctors in other countries including South Africa, Egypt, Indonesia and Mexico, about 80 per cent of specialised doctors have private practices on the side.
In the United Kingdom, over 60 per cent of public hospital doctors conduct private practice alongside their public service.
In Bangladesh, most doctors, particularly specialists, earn more than half of their income in private practice.
The KMDPC before 2019 licensed doctors to work part-time in specific public hospitals, but this is no longer the case.
Nearly all specialist doctors and GPs employed by counties now have their clinics running on the side.
Guidelines issued by the counties and hospital administrators show that some have two to three-day work weeks depending on the public hospital deployed.
Whenever county governors sack health workers for absenteeism, their unions rush to court and obtain court orders reinstating them.
An intern at the Jaramogi Teaching and Referral Hospital in Kisumu confided in the Nation that when they do ward rounds in the absence of their supervisors, they often make mistakes that cannot be rectified.
He mentioned that he could not report the doctors because even their bosses run their private clinics.
“If you are going to report, you must be careful not to fall into a trap because even the people who are on top of the ladder have their side clinics,” said the intern.
Kenya's health workers are heavily burdened, with one doctor for every 10,000 people.
According to data from the medical council, the country has 9,096 doctors licensed to care for 47.5 million Kenyans.
Out of these, 3,160 are registered specialists. Of the licensed specialists, gynaecologists are 429, internal medicine and paediatric and child health specialists are 366 each, general surgeons (353), anaesthetists (166), radiologists (146), orthopaedic surgeons (125) and 110 ophthalmologists.
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The entire country has only one clinical pathologist, one diabetologist, two emergency medicine doctors, one neurologist, one immunologist and one palliative medicine specialist.
There are two urologists and four oncologists against the new annual cancer incidences of 28,000.
One reason why the dual practice was encouraged before, according to Dr Yumbya, was to allow the movement of specialists from one county to another to address the problem of shortage of medics.
Getting sick for the majority of poor Kenyans is often the beginning of multiple trips to hospitals as patients seek diagnostic scans and blood work from different health experts and health facilities that are either privately owned or church-based.
In Central Kenya, for instance, patients interviewed by the Nation said that it was easier to see the specialists in their private clinics than in public hospitals, adding that they receive better care and attention from them compared to when they visit them at public facilities.
“In the private clinic, the doctor spends more time with the patient because they are motivated by the money they get,” said Ms Anne Gachanja.
Despite the Nyeri referral hospital having pathologists, patients are sent out and asked to come back on specific clinic days, usually every Thursday of the week, when the oncologist sees patients.
Though the clinics run every day, patients are attended to by oncologist nurses and a clinician who does the bulk of the work. Private health facilities are mushrooming in the county.
A number of people who spoke to the Nation investigative team said at one time or another, they have been referred to private clinics owned by doctors or their associates.
“It is a chain that involves specialists… and almost all of them have set up their private clinics across the town such that in a way you will end up in those clinics while seeking medical services in the county hospital,” said Mr John Mwangi, a Nyeri resident.
The law is not clear on how much time or hours doctors employed by public hospitals should spend at their private clinics.
Nyeri county health chief officer, Adan Ibrahim, said they were concerned by the increasing absenteeism of specialists at the referral facility.
Their scheme of service, backed by the Collective Bargaining Agreement (CBA) they signed, however, allows them to practice in private entities.
The long queues of patients seeking treatment at the Nyeri referral hospital are drawn from across the region – Laikipia, Murang’a, Nyandarua, Embu and Kirinyaga. It takes hours before patients can be attended to.
“I am in so much pain; this is my second day waiting in the queue. I want to go home because I do not think I will see a doctor soon,” said a patient who had travelled from Nyandarua county seeking further diagnosis after doctors detected a tumour in her body.
By the time of the interview, she was triaged number 231 at 10 am. By 2 pm, the clinic had been shut. Many patients had not been attended to. They were asked to return the following week on clinic day.
Relatives of patients admitted to ward six of the referral hospital said they are rarely seen by a doctor, as the nurses and clinicians are left to handle most of the work.
“We are frustrated but there is nothing we can do,” said one of the nurses allotted duties at the said ward. She declined to be named for fear of victimisation.
According to Mr Adan, there are no specific timelines that a consultant should work at a public facility, however, they have a duty roster and are appraised and overseen by a supervisor.
The Nyeri referral hospital has about 51 specialists employed by the county. Due to space limitations at the hospital, the chief officer said they were planning to create more amenities at the Mt Kenya Hospital – a subsidiary of the referral hospital to ensure more consultation time and reduced bookings.
“We have formed a committee to work that out and conduct some assessment on how we are going to have more room for consultations so that we can also avert increased hospital time outside,” he said.
On September 12, at the Embu Level Five Hospital, a Nation reporter posed as a patient seeking gynaecology services for abdominal aches related to a Urinary Tract Infection (UTI).
Though the clinics run every day, patients are attended to by oncologist nurses and a clinician who does the bulk of the work.
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After review, a medical officer recommended a raft of medical tests that were not available on that day due to a lack of an operator and equipment to run the tests.
They later prescribed some drugs and the reporter was booked to see the specialist on October 6 – almost three weeks after the visit to the facility.
The gynaecologist at the hospital only sees patients every Thursday. A patient is more likely to see the same doctor in a private hospital than in a public hospital.
A doctor who did not want to be named said they prefer working in private clinics because there is better facilitation and pay.
Furthermore, the doctors, especially surgeons, say they have only one theatre list week and a clinic day per week, meaning they have enough time to offer their services in private clinics.
“Most patients actually ask to be seen in private clinics because they do not have to spend long hours in queues waiting and the care is personalised,” said the specialist.
The Nation established that a doctor who works in the gynaecology department and another in the ear, nose, and throat (ENT) department at the Moi County Referral Hospital is engaged in private practice at the expense of patients at the public facility.
Due to financial challenges, the county department of health opts to retain the specialist despite complaints from patients.
Patients interviewed said they are forced to queue for long hours before being attended to at the ENT and gynaecology clinics.
"When you are finally seen, the doctor does not have quality time with you as is the case in his or her private clinic. Sometimes, I prefer seeing him privately because I will get better services," said Ms Purity Syombua, who recently visited the ENT clinic at Moi hospital.
Patients have also reported having been given the wrong medical diagnosis and prescription, thereby risking their health conditions.
"The doctor at the ENT clinic sometimes fails to come, comes late or shows up drunk. This is very risky to patients," said another patient. Due to the shortage of doctors in the county, private facilities in the county engage the medics to work on a part-time basis at their clinics
A patient pays up to Sh2,000 to see a gynaecologist or an ENT specialist at a private clinic in Voi. County chief officer for health services Philomena Kirote said it was difficult to tame medical workers.
"As the administration, our work is to ensure that we strive to strengthen the quality of services by putting in checks and balances to ensure facilities have what it takes to meet the needs of our clients," she said.
By doing so, she said, patients will have no reasons to be redirected to private facilities for treatment.
At the Kakamega hospital in Western Kenya, Health Executive, Dr Collins Matemba, said the health workers working at the level five facility are required to record their checking-in time and when they leave, to curb absenteeism.
With this, the facility always has a record of the number of hours each medical officer has worked and immediate disciplinary action is taken against those who work for lesser hours.
“The former governor would also make impromptu visits at the facility without the knowledge of the experts just to ensure they were not missing," he said.
In Busia, the former governor had fired two doctors for absconding duty yet the situation is no different. Eastern region patients have nothing to smile about as well.
At Machakos hospital, which was chosen as one of the piloting counties on universal health coverage, many accident patients do not see a specialist.
The orthopaedic surgeon goes to the hospital late and at times does not show up altogether. In the surgical ward, some patients with accident fractures have not been seen by the doctor.
On Friday, when the Nation team visited the hospital, the doctor was in.
In Makueni, one of the health administrators in the county runs a six-storey nursing home in Wote town, while still in public service.
Another medic who heads the gynaecology department at the county hospital also owns and runs a hospital in Wote. They are in their private practice most of the time.
In Kitui, a team of 19 medical doctors who were among health workers employed by the county government in 2017, had their monthly salaries terminated after they went for further studies, prompting a court battle.
Through their union, the doctors moved to the Employment and Labour Relations Court challenging a decision by former Kitui Governor Charity Ngilu to withhold their salaries for allegedly absconding duty.
The doctors had applied for study leave and were admitted to various universities both local and foreign when Governor Ngilu questioned the procedure in which they were released from the county employment.
Inter-governmental participation
According to suit papers seen by the Nation , the bone of contention was a decision to continue paying the doctor's monthly salaries while still away from work.
KMPDU secretary-general Dr Davji Atella took the dispute of withheld salaries to the Labour Court and even threatened to call a national doctors' strike protesting Kitui County’s decision.
After months of hearing the case, Justice Monica Mbaru of the Employment and Labour Court ordered the county government to reinstate the doctors on the county payroll, and the matter was finally settled.
“We never refused to pay the doctors. Simply, we couldn't afford to retain them on our payroll while the health services we recruited them to offer were not being rendered when patients are dying at the hospitals’’ said Kioko Kiilu, the county chief officer for health.
Dr Andrew Mulwa, the Director of Medical Services, says a policy is being formulated by the Ministry of Health in consultations with all stakeholders to guide the inter-governmental participation in the training of doctors.
Dr Mulwa, a former county minister for Health in Makueni, explained that the ideal situation is for counties to release health workers for further training in fields with identified manpower gaps.
“Counties should first agree with the doctors before releasing them for specialised training to only specific areas where they will improve their expertise and capacity’’ said Dr Mulwa.
Last week, Makueni Governor Mutula Kilonzo Jnr ordered all 58 specialist doctors and medics to leave their offices in the county headquarters and attend to patients in the sub-county hospitals and clinics.
The medical officers are required to routinely go to health facilities in the county to offer specialised healthcare services and limit unnecessary referrals.
Dr Atella said hospitals with a higher number of consultants including Kenyatta National Hospital and Moi Teaching and Referral Hospital have better records of attending to patients because they have facilities to execute their work.
“Counties have known that they are the problem and they should not complain that they cannot manage the specialists. Why is it that it is only hospitals managed by the counties that specialists are absconding duties why not major referrals being managed by the national government?” Dr Atella asked.
