Striking for Doctor's Rights in Kenya with Nicholas Okumu

Guest: Dr. Nicholas Okumu, Orthopedic Oncology Specialist and CEO of Stratos Medical

Key Points:

1. Kenya faces a shortage of healthcare workers, with around 4,000 trained physicians, dentists, and pharmacists currently unemployed.
2. Recurring strikes by healthcare workers are common, often related to compensation disputes and lack of implementation of collective bargaining agreements.
3. Poor remuneration and lack of opportunities have led to brain drain, with many Kenyan healthcare workers seeking employment abroad.
4. Public perception often lacks empathy for healthcare workers' demands, viewing them as privileged individuals.
5. Potential solutions discussed include pay-for-performance models, public-private partnerships, and incorporating entrepreneurship and management training into medical education.
6. Dr. Okumu's venture, Stratos Medical, focuses on medical imaging, teleradiology, and developing a platform for accessing electronic health records.
7. The ongoing strike has limited healthcare services to emergency care, causing disruptions and delays in crucial treatments.
8. Dr. Okumu emphasizes the importance of advocacy, collaboration across disciplines, and interdisciplinary approaches to address systemic issues in healthcare.

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Transcript

0:07

Hello friends and welcome to season three, episode six of the global health unfiltered podcast. I am your host, Ulrich Sidney Kanmounye. Today, we focus on Kenya where the Kenya medical practitioners and dentists union has reported a whopping 4, 000 trained physicians, dentists, and pharmacists are unemployed. Unfortunately, this number is going to keep increasing because Kenya is training approximately a thousand of those graduates each year, and there are other challenges that the health care professionals in Kenya are facing. as well as remuneration challenges and workplace issues. And so to discuss this, we invited a strong advocate for healthcare worker rights. Dr. Nicholas Okumu, was heading the orthopedic oncology unit at Kenyatta National Hospital, and he is the CEO of Stratos Medical. He holds a master's degree in orthopedic surgery and an MBA. He's equally a graduate of Harvard Medical School's Surgical Leadership Program, and he is a Global Surgery Advocacy Fellow. He is dedicated to improving orthopedic care and health care accessibility in Kenya and mentoring future leaders. So welcome, Nicholas, and thanks for joining us. So we'll start with the recent events. 100 striking doctors were laid off by the Kenyatta University Referral Hospital. This comes after 2023 strikes were settled with a collective bargaining agreement. And that was between the Ministry of Health and representatives of practitioners, pharmacists and dentists. So this events tell us a consistent story that strikes are not uncommon in Kenya. So Nicholas, can you tell us why that is the case and how did we get here? Okay. Thank you, first of all, Ulrich, for inviting me and allowing me to share a few of my opinions, I would say, about the current situation with the healthcare workforce in Kenya. And strikes, as you say, they're not too uncommon in Kenya. They have, they have been recurring probably in around a seven year cycle. So in the last 21 years, we've had roughly three major strikes. around doctors compensation. And the first strike was during a time when there was, the political space was not so open. So that one was crushed fairly rapidly by the government of the time. During the last major strike, we managed to get some concessions from the government in, in the form of a document, which we call a collective bargaining agreement. And this CBA actually laid out what doctors at different levels would earn right from internship all the way to when you're a consultant specializing in a certain area. And so this current strike actually focuses on three major issues. Which is number one, the medical interns, which for which the government is now saying they cannot pay the salaries they had agreed to pay in the collective bargain and agreement which was signed in 2017. The other aspect is about training of, of, of specialists. We would like the government to honor its commitment to pay the fees for residents in training because these are the, we, our country also has a dire need for, for specialists. And the last part of the issues we are raising is that just that the, the collective bargaining agreement has not been implemented in full since it was signed in 2017. It's now reaching a point where we are supposed to actually renegotiate a new collective bargaining agreement. And if the government has not implemented the CBA that it signed in 2017, how are we supposed to then expect them to honor a new agreement? And those are basically the crux of the issues that that we're, we're talking about. If I was to give you numbers, you've already mentioned a few. There's a total of 1, 300 interns that have not been posted. And in Kenya, you cannot get a practicing license and be able to, you know, practice independently as a doctor if you don't go through the internship process. So these doctors are literally in limbo. They're just hanging out, waiting for the posting and that posting has to be associated with a budgetary allocation, which is what the government failed to do. You have mentioned there are a total of 4, 000 doctors in Kenya today who are unemployed, which is a strange thing because actually our doctor to patient ratio is about one to 6, 500. Which is way off the WHO standard, which is 1 to 1000. And again, if you were to look at the distribution of these doctors, majority of them are in urban areas. So there is still also maybe a discrepancy in, in, in coverage of areas which are more rural in our country. So I think basically that summarizes the issues we're, we're discussing around this strike. So you mentioned that there's been strikes at intervals of seven years and that there was already an agreement back in 2017, which was not completely implemented by the government. And there is a new one coming out. And so it's, some may argue that healthcare workers maybe should not strike given the potential for lost lives and increased morbidity. Notably, this was the case in the last strike, the 2017 100 day strike. So, such situations definitely put healthcare workers in a difficult position because if you have, you make priority for your patients that have emergency conditions so that they get the necessary care, then the government, the private employers may not feel compelled to provide that care. Come to the negotiation table and come to an agreement because they know these things are covered. So long as the emergency is covered, it may be reluctant. But on the other side, as the healthcare workers go out there and they say, okay, let's try and maybe force the government's hands or the private employer's hands by making them see our value. then the patients will suffer. So in this kind of context, I wonder if with what has happened, especially with the 2017 one day strike and in the recent strike, what have been the public sentiment in Kenya? Regarding healthcare workers, I think if I was to talk about public sentiment vis a vis healthcare workers in general, my, my, my, my description of Kenya would be more of apathy. The general public seemed to view, especially doctors, as maybe I would say some rich individuals who are just complaining for nothing, whereas from our point of view, when we are coming to this discussion, we are not just talking about pay for doctors. We are also talking about our working environment facilitation of our services. For example, I'm a surgeon. If if, even if I was available in a hospital and there are no facilities to be able to fix for example, a fracture, maybe I don't have the operating table. I don't have imaging, I don't have the surgical implants that I require, then there's no purpose of my being there. I may as well not be there. So we have consistently said that when we are canvassing and fighting for doctor's rights, these are also patient rights. You, you our constitution says that Kenyans have the right to the highest attainable standard of health. Does, just doesn't mean that a doctor is there. It also means that you have a doctor who is enabled to provide the quality of service that you deserve. And Kenya, in Kenya these days, the big buzzword is universal healthcare, UHC. We are talking about being able to provide every Kenyan with a level of care. We're saying a minimum standard of, of, of healthcare that will, will adequately serve their needs. And we cannot ignore the human resource. The human resource is what will make all these things work. If, if, if the government built a hundred hospitals, and it didn't have doctors, nurses, you know physiotherapists, and all these other people, there would just be buildings. So human resource cannot be ignored. But maybe from my point of view, sometimes my opinion is that the general public are just not interested in what we are saying. I think that that aligns with some of what has been discussed recently where there's increased interest in what some experts will call the hero tax. They, they would define that as some of those professions that are, because they are serviced by nature, they're considered sort of hero professions, whether it's in healthcare, teaching, armed forces and essential services like fire department, the police and all that. And so there, there, there's this description that because we expect those in those professions to be servicing, we don't really make sure that they have what they need to do their job properly because at the end of the day we can give them a few claps and we can encourage them or we can write articles about them. And this was best probably seen during the COVID 19 pandemic. We had all these beautiful videos of people just clapping for healthcare workers around and saying, Hey, you guys are doing a great job and whatnot. And then the healthcare workers came out and said, Hey we need, you know, we need equipment, we need support. We need all these different things. And it doesn't feel like you're helping us or you're listening to us. Right. And so when that kind of a situation happens. It puts again professionals in this space, in that situation where you're mentioning where I'm sure the average Kenyan probably recognizes how much healthcare workers bring to the table. But they're not necessarily ready to support them when they go out there and say, Hey, this is about your health care. We want to make sure that, like you said, not only we are in the best conditions that you get the best care because this is your right. It's part of the Constitution, right? So with this, we want the what does that means for a health care worker, for example? To seek greener pastures because that's the opposite side, right? That you're seen as a hero and whatnot. And then if you're not supported, you're thinking maybe I should be looking for other opportunities and greener pastures means mean people just saying, let's go all to Nairobi and let leave the rural areas. Or maybe let's leave the public sector and go to the private sector. And in the last, the last case, it could be, let's leave Kenya altogether, right? So there is that controversial thing where it's like, Oh, you guys are heroes. We're not going to give you what you need, but if you try to find a solution for yourself and go somewhere else, we wouldn't look on you, upon you kindly. And we saw the Kenyan government reacts quite sternly to this, right? By, by, by, by putting together some rules to prevent people from emigrating. So what has been the what has been the conversation from the Kenyan government about, for example, emigration by health care workers and how has that impacted some of your conversations? Okay I think what you're talking about is a hero profession. In Kenya, you would hear people say that medicine is a calling. You are basically thought of as someone who is supposed to serve sacrificially. to give without expecting much back. But we are still human beings and we have needs. We have families. We need to educate our Children. We have to pay for rent. The calling will not pay those things. So I think you're very correct sometimes that there's some perception of some professions as It's maybe sacrificial that we're supposed to give without considering our, our needs. And that, and that's true of the Kenyan medical profession. So it makes, it makes it really challenging to say that you're just going to work and give without expecting something in return. In addition you are right when you talk about the effects of this poor remuneration. on on, on the Kenyan Health Workforce. If I start with the first strike 21 years ago, you will notice that there are a lot of prominent Kenyan healthcare professionals all around the world, in the USA, in South Africa, in Australia. And this group of people actually left during the first strike. When they realized that their country did not value them, they actually left and have been contributors to, to other parts of the world. In terms of advancing science and, and, and healthcare. In, in the recent past, what we've been noticing is a lot of healthcare workers, especially nursing professionals, are leaving our country because they can see that there are better opportunities out there, especially in countries like the United Kingdom, the United States, and Australia as well. And so that effect is that we are losing a big chunk of our professionals to other countries because we are not able to compensate them adequately. So we might be viewed as people who are in a profession that's a calling, but I think at the end of the day money still matters because We, we still live in the real world and we have you know, we have a needs that we need to meet for ourselves and our families as well. What you've described sounds like a day And, and some might even think that it's unsolvable. And, and you write, in your recent op ed, Healing the System, Unlocking Fair Wages and Quality Care in Public Health, you suggested some solutions to solve this problem. Can you please shed some more light on it so that those who haven't read it and are listening would be able to understand how you hope to solve this problem? Thank you. In that article, I was actually talking about the power that the government holds over certain sectors where they are the main employer. And that is defined in a word that's not so commonly heard, which is called monopsony. It means that in that certain specific market for example, the healthcare market, the government has a lot of influence on the wages that will be paid because they are the main employer. But this is not a situation that we, we will always find sustainable and we need to find creative ways to, to, to, you know, overcome this barrier of government control of wages. Because in most occasions, what that would mean is that the worker is undercompensated. And we talked about solutions such as unfortunately the, the ability of the workers to form unions, which would then collectively fight for their rights. And that's something that is enshrined in the Kenyan constitution and it's a right that we have actually had to go to court to allow to be allowed to form a union and also to be then be able to negotiate collectively with the government. The other things are solutions that are created. For example something that is already implemented in other countries in Africa, which is pay for performance. So you could pay health care workers better, but in return demand a quality of care that is better. Countries like Rwanda have implemented this, and their health care workforces are better off for it. They do receive better pay, but in addition the level of quality of health care has improved significantly. Especially when you look at areas such as maternal and child health. Where over a space of four years, Rwanda was able to reduce the metrics by levels up to 35%, which is incredible. And then we talk about private public partnerships, which can create you know, more creative ways of, of dealing with challenges in the healthcare sector. For example, the use of technology. Techniques that improve efficiency. And this would then allow more resources to be channeled to the healthcare worker in terms of compensation because you're saving money in other places. And I think those are some of the things we discuss in the article to, to suggest that, you know, the government doesn't always need to have all the power and it has to facilitate a discussion where, you know, healthcare workers or people in other industries. can negotiate for fair compensation. Now how have all these problems that are ongoing now, this situation impacted your care for, for your patients?. So currently as a strike is going on, the only type of care we can provide is emergency medical services. Okay. So for example what I would normally be doing like my clinics, the ward rounds, my elective surgeries, those are currently on hold. And it means that especially for me because I deal with Orthopedic oncology, which, which, and we're dealing with cancer patients. It means that a lot of patients are actually missing out on critical care. And when it comes to cancer, time is life. And so that's, that's, that's an issue that really is affecting us. And so I would say, although we are able to provide emergency services the majority of our patients are now suffering because they are not able to access. the normal care that we would give if if we were available without a strike. And so I think it's, it's, it's important to realize that. Something that Ulrich had said is that maybe the government might think because we're still providing some services the problem is not so bad, but it's actually still creating a significant challenge in the, in the healthcare system and in the lives of the patients who would normally be serving. I fully understand how, with oncology, time is, is everything. The time it takes for the patient to get to the hospital the time it takes for them, like, just within the hospital system to get the kind of treatment they need. It's very important and time is, is really everything. And with everything you've spoken about and everything you're saying and all I'm hearing is you advocating for your patients. Like, right now, Your worry is not the fact that the government wants to sack doctors, but you're advocating because sacking those doctors would mean that the patients I hear you advocating for your patients, I hear you advocating for patients, right? I wonder how you combine the two, like as an advocate, how did you find as an orthopedic surgeon how did you find your space, yourself in this space of advocacy? Okay. This year I'm actually participating in what is called the Global Surgery Advocacy Fellowship. And this is a program facilitated by Operation Smile the University of Global Health Equity and then Care for Policy Institute. And it's actually something that has opened my eyes to an extent because you realize that when you're seated in the hospital facing, you know, that patient that you're dealing with, you are not able to impact a larger aspect of the, of the, of the health system you're, you're actually participating in. And to be honest, as you can see, even with a strike, if we are not dealing with every aspect of the society, including our leadership, and the general public, then something eventually will break in the system. So I, I, I think I've realized this year that advocacy is a part of what a doctor should do. We need to be able to engage with policy makers. We need to engage with the general public. We need to engage with our patients. We need to engage with, with the media. To kind of highlight and bring to the forefront the important issues that need to be addressed to make our healthcare systems stronger and to make them work better for the people they are intended to serve. So that's basically where I would say we, I'm, I'm working to improve my, my, that aspect of my work, which is advocacy. But I, I, I started engaging with issues around systems when I, I actually became the head of department of orthopedics at my hospital, which is one of the biggest, largest referral and teaching hospitals in, in, in the region. And that takes you literally from the operating room to the office. You start dealing with things like budgets, you start dealing with things like procurement, you start dealing with with staffing and you realize that wow if, if, if these, all these things are important, they need to be dealt with. And the only way you can actually make these things work is if you're fully engaged. I'm glad that through my work, we've been able to make some changes in, in the system where I work in, for example, our orthopedic department, became a subspecialty based department and that's really helped to actually allow patients to receive a higher standard of care, but it also surprisingly improved our surgical output by 25%. We went from doing around 2, 600 surgeries to close to 3, 000 and in the space of one year and, and that's It's something that actually shows that if you're advocating for the right policies, the right changes, you can actually make a difference on a bigger scale. Wow. Those are some very impressive results. I mean your, your track pathway really emphasizes that need to, to be a bit more around that beyond. Knowing the right indication, being able to perform the right intervention and getting the right surgical outcomes because again, it goes back to the health system and everything that's around that. One of the things I wonder though is when you, because you've had to almost learn this as you go. So it is. Have you thought about ways maybe to get your residents involved your junior colleagues so that they too do not have to wait to be consultants to, to, to get some of this experience? Because I mean, it really feels like being thrown in, in the, the, the hot waters immediately started to think about staffing and, and all that, because I'm not sure, at least For, for, for Cameroon, for example, again, I'm not sure those kinds of courses are in the residency training programs about thinking about budgeting and whatnot, right? I think you, I think to, to what you said is very true that our typical medical school programs do not teach this kind of issues at all. And maybe even the, something I would stress even more in the situation we're facing right now where 4, 000 doctors are unemployed is the issue of entrepreneurship. I, I happen to, to also be involved in the private sector with an organization called Stratus Medical and entrepreneurship is really, really important. It's, it's, it's the way forward for finding solutions that probably will not be found in the private sector, in the public sector, sorry. And so we need to maybe incorporate these things in our curriculars right from our undergraduate degrees. So that our graduates are coming out with an idea that, oh, I don't need necessarily to be employed by the government. There are solutions that we can find together. Another thing that maybe learning a little bit about this management issues will teach us is that we are stronger when we are together. medical people are typically selfish. We, we we, we want to achieve things on our own. I don't know if that is true for you guys as well. And it's the culture that we have been brought up in. You have to publish, you have to do research, you have to you know, get all these titles. And so I, I think those are all issues that we need to try and address. So that our health care workers are more rounded as they come out of medical schools. And I think what entrepreneurship and learning about management and all these other things brings to, to us would be to teach us that we are stronger when we're together and that we need to collaborate to actually achieve greater things. So that's basically what I was saying. And I think entrepreneurship management need to be incorporated in, in the training of healthcare professionals, I think, right from undergraduate levels. Because the future is more in finding solutions outside of the traditional public sector jobs and, and things like that. So on the theme of entrepreneurship and your personal experience, what, what has Stratus Medical offered as a solution? So if you can take us through maybe which, which problem you identified and the solution, maybe some of the challenges you face and how you've adapted to that, to, to, to today, because I would think that if You know, one of the not just Kenyan, but African health care workers is listening to you and they want to dip their feet into entrepreneurship that it's very different how we have, how we do entrepreneurship in, in, in Africa compared to how we do entrepreneurship in other countries, right? Because I can, I can see so many, so many things we have to take into consideration when we're talking about just doing that. And then there's also the aspect of healthcare. So please share your experience with Stratus Medical with us. So typically with entrepreneurship, I think the pathway is to first identify a need, something that you can, you can change in the world. And then Think around solutions that can serve to provide answers for this need. And lastly, then maybe not alone, but collectively with partners, with people who share your vision, try and provide the answer to, to that problem in, and, and typically, ideally you want at the end of the day to, to generate some income, make a profit. I think the basic part is starting with a genuine need that you can provide a solution for. So Stratus Medical started first of all primarily in medical imaging. So that's what we saw as our area of need. And we started as an outpatient medical imaging center. So we, we now have all the imaging modalities, including MRI, CT scans, ultrasound x ray. But along the way, we also added aspects such as teleradiology. So we now do reporting for other healthcare institutions. And currently we serve 14 other institutions within Kenya. We are also looking at the problem that we have, which is access to health records which is a, a big challenge across Africa. And right now we are working on developing a platform that will allow our patients and patients in general to be able to move around with their health records. Thanks. And this should actually be able to democratize healthcare remove the silos that many health facilities are creating by simply just holding on to your information, which if you were to look at, again, our constitution, it says that health records are actually that belong to the patient. So why is it that health facilities then want to create systems? That lock those health records within the facility and means that the patient has difficulty when he moves from one facility to the other or one provider to the other. So that's a solution we're looking at solving and we are actually in an advanced stage of developing a product that will allow, allow that to happen. So we are looking at different things around medical imaging, healthcare technology. and trying to find solutions to meet the needs of the Kenyan population. Hopefully one day we'll be able to do that for Africa as well. Oh, we hope so. We definitely hope so because every one of the problems you're sharing is things that I think every healthcare practitioner in Africa has gone through. And then I know just having a patient go from one facility to another is something else you it's you have to start from zero and this is a patient usually that is already behind schedule, right? There are delays in them seeking care, delays in them reaching care, and then it adds to delay in receiving care. It's so frustrating, especially when you speak to a patient that wasn't necessarily. informed about what happened in the past. I mean, especially when you're as an intern, that's when you learn these things about just trying to find out what chronic conditions the patient may have or what drugs they were on. And you have to go through this almost Puzzle riddle like conversation of what was the color of the medication? How often were you taking it? And then you're trying to guess, right? Because yes, you don't have access to that. So yeah, it's definitely a pinpoint and a solution to that will be very well, welcome digging this fact to thinking about this, what you just said. And then what you said earlier about just, Some of those things that are non traditional medically, but are very important for us to find solutions in that context, because the kinds of problems we're facing require local solutions and people like ourselves to find those solutions. I really struggle and wonder why we haven't had more Integration between a medical schools and other faculties. A lot of universities have all these big schools or faculties, whether it's engineering or business and whatnot. But funny enough, I don't know of many cross cutting training programs of maybe having even dual degrees or saying, okay let's train doctors. They can be MBBS or MBBCH. And let's have them maybe have an additional year where they are learning something in business or they're learning something in engineering. And I feel like that would probably help us solve a lot of problems. Because then you get people having the actual experience speaking with engineers or speaking with people from the business side. I know of the program, I think from the University of Global Health Equity, where they have the students automatically doing the Masters of Global Health delivery. But it feels like that could definitely be one of those options, one of those opportunities and, it. It's nice to see that you've definitely pursued some of those, whether it's with the Surgical Leadership Program or the Global Surgery Advocacy Fellowship. So it's very, and it's very exciting to just to see that even not you've done that, but you've also implemented, implemented some of those. So, I mean, what do you think? What do you think? Do you think that we should focus, still focus on maybe completing that program and seeing where people want to go? Or should we also be thinking about integrating some of those? Cross cutting training programs. Actually, I, I strongly believe what you're saying is correct in terms of integration. One of the projects I'm involved in is with an organization called Afrotech. Afrotech is a brainchild of the Carnegie Mellon University, and it's financed by the MasterCard Foundation. And what they have done is to try and create a multi center research project. That cut across different areas. So, in our project currently, we are actually dealing with prosthetics. And it's a collaboration between the University of Nairobi the University of Rwanda, Carnegie Mellon, University of Africa. And another university in Kenya called Dedan Kiyomadi University of Technology. We are actually looking at kind of improving the process of producing prosthetics for our patients through the use of technology such as 3D printing. And something in AI called machine learning. And you can see the collaboration needs IT specialists. It needs engineers. It needs doctors. And that's the beauty of the project we are doing that at the end of the day these different disciplines are talking together to find a solution for a problem that exists. We have been able by and large to produce low cost prosthetics, but the problem with the process is the speed. And with the 3D printing, you can actually take a process that takes roughly three weeks and do it in a day just by developing technology to scan the limb. And we're using something as simple as a mobile phone, which is amazing. Putting together the the computer. I'm actually not a computer guy, so I'll tell you computer stuff, which which my colleagues in the project understand better and being able to use a I and machine learning and 3D printing to actually then be able to produce this prosthetics. So I think more and more. We need to look at solutions like that that bring different disciplines together. Because I think like I've said before, collaboration is the future of finding solutions. We can't exist in isolation. and expect to find or change the world. You have to talk to other people so that you're getting ideas from across the board. It's really exciting to hear that you're doing all of this. And there's hope that you can extend a hand to the rest of the continent as well. Yeah. I want to thank you very much for joining us today. Thank you for your time. Thank you for your insights. Also, we want to thank our listeners. We want to hear from you. Reach out to us on social media or email us at editor at globalhealthunfiltered. com. 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