Many questions lingered in my mind about root causes of healthcare problems in Kenya and immediately I shifted to Nursing school. Last week as I read about a case of a nursing officer at KTRH, I was taken back to 2015. This is a year I was involved in tragic road accident and had near-to death experience. Despite having done internship in KTRH back in 2012/3, I never got services there and I had to outsource services of personal doctor in a private facility. Many questions lingered in my mind about root causes of healthcare problems in Kenya and immediately I shifted to Nursing school. Not withstanding any level of training, you must have begun your nursing training as history of nursing either as block 1 or fundamentals of nursing or something close to that. Unfortunately, emphasis was on Florence Nightingale, Dorothea Orem, Roper-Logan-Tierney and other nursing theories. Then came King George VI Hospital now KNH followed by nursing schools and NCK as regulatory body. As I recalled, nothing touched on history of healthcare in Kenya. Suddenly, I remembered the graduations I have undergone where I was given powers to read and do what appertained the degrees I have accumulated. The maji maji rebellion and other history that makes no sense to me to date quickly crossed my mind which sparked this article. Here I share the history of healthcare, this is not something to tickle your ears but to help you understand the problems we undergo as healthcare professionals.
Let us begin in precolonial period. During this era, African communities sought services of traditional healers and mostly used herbal medicines to cure various diseases. And it seems we are gradually going back there. This was followed by colonial period where colonialists and missionaries had many reasons for establishing medical and health programs.
Medicine was a colonization tool whereby British made Africans to believe they were unhygienic and had primitive practices hence acted as vectors and reservoirs of diseases which called for treatment. This intervention created a safe environment for trade that benefit imperialists. During this time, missionaries who were majorly Catholics and Protestants, used medicine to revitalize bodies& souls and alleviated suffering during “hospitalization” conducted in church as they influenced local people to abandon Indigenous religion. Equally, the climate and environment threatened imperial expansion as diseases such as malaria killed colonizers; a disease that Africans resisted. This called for medical attention that saw the use of quinine from cinchona tree to treat European military. The colonialists needed a healthy workforce for increased productivity in their farms during agrarian revolution in the process of colonization and extract African resources optimally, they had to be healthy, a role colonial medicine had to play. For a country like Kenya, white settlers concentrated on farming of tea, coffee etc which are currently termed export goods and colonial masters still determine prices of these commodities to date. This affects our nutritional state as a country. At the same time colonialists took away minerals and labour in form of slaves worth billion dollars from Africa to build European and American economies, shaping today’s wealth distribution. Essentially African countries are wealthy but ironically topping in disease burden and unable to manage the diseases due to impoverishment due to draining of resources. As if that was not enough, the colonialist impoverishment nightmare continues to haunt Africa healthcare to date. The poor wealthy African nations including Kenya are investing little in health (5.9% of GDP) resulting in weak health systems. For survival, governments employ few personnel who are poorly paid, work in dilapidated conditions, and rarely advance their careers. Left with few alternatives, health personnel get pushed to migrate for greener pastures in developed nations crippling the already weak health systems where they offer health services to developed countries. Alternatively, the health personnel resort to donor-funded projects which are well paying further weakening public health systems. Therefore, one might be right to think that the extraction of resources is here to stay.
Still in the colonial era, medical and public health programs provided differed across populations. Colonial medicine initially served the military and troops who were guarding the colonies and later extended to European administrators & civilians in ports and urban areas. They did so by putting the health system in places they occupied that was managed by administrators which are currently big urban centres. They offered curative care, conducted massive campaigns, and collected epidemiological. These programs aimed at preventing diseases rather than strengthening health systems. The focus was on general population, “the collective others” which later advanced to be tropical medicine. Missionary medicine on the other hand was more individualized with emphasis on individual disease, hygiene, and sins as a way of spreading Christianity. Their engagements were direct with local population in rural areas. The medical missionaries later aided “civilization” through their constant communication with colonial masters whereby they updated them with information about the colony. They were used to penetrate and pacify to interior parts of colonies. The missionary work was only possible through facilitation from home churches that catered for beds and clinics. They described Africans as primitive and viewed them as backward, immoral and primitive making the colonized feel inferior which was best illustrated in Pearson soap advertisement. This still stood out on health programs designed for general population. Since the colonized were rendered poor, socialization for scarcity approach was used in delivering cost-effective preventive interventions where minimum resources are used to reach most population without considering the impact. This also played out in 2001 when the head of USAID claimed that Antiretroviral therapy would fail in Africa citing inability of Africans to understand time for taking drugs.
The traveling among colonialist introduced new diseases like smallpox to the indigenous population, facilitated transmission and spread of diseases which increased disease burden. However, this is rarely highlighted. The west only show one side of the coin and it is up to us to find out the flipside.
After most African states had gained independence, their economy was in a sorry state due to previous economic exploitation. In 1978 , Primary Health Care (PHC) the UHC version of that time , also a health equity model focusing on social determinants of health, resource distribution, development of health systems and put emphasis on basic health services with aiming of reaching all people with health services was proposed following Alma Ata declaration. PHC was considered Inclusive as it gave people the opportunity to participate in the planning and implementation of health. Since PHC targeted health for all, it demanded international financing thereby placing fulfilment of health right to the international community on top of holding government accountable. The health budget per person on annual basis stood at $5 for developing countries. This was supposed to be funded by all countries, but the rich nations pulled out as it was not serving their interests as they termed it ambitious and unrealistic agenda. Instead, they introduced selective primary health care (SPHC) that focused on specific diseases and specific population mainly women and children with the goal of improving statistics nor include people in designing and implementation of interventions. The interventions included Growth and monitoring, ORS, Breastfeeding, and immunization popularly known as GOBI. Again, SPHC based their interventions on the availability of resources guided by prevalence, morbidity and feasibility hence vertical programs fitted the bill. This did not develop health systems, unlike PHC, SPHC targeted impoverished countries with the highest disease burden, donors applied socialization of scarcity with countries using little resources to finance the selected interventions. SPHC, therefore, was narrow in scope and the budget per person annually was close to $0.25.
Still in 1970s-1980s, structural adjustments (SAPs) were introduced in African nations as part of neoliberal policy. This is where user fee was introduced in attempt to raise funds to finance health sector. This further dilapidated sector after IMF and world bank restricted funding in sectors including health, education, agriculture etc. Subsequent years have been health have been faced with conditional funding such as USAID that restricts its utilization whereas World bank financed projects are loans we are or shall service with interests. While Global fund for HIV/AIDs, TB and malaria formed under Koffi Annan provided perfect opportunity to strengthen our health system, little can be shown of it apart from numbers reached.
Current Kenyan healthcare system is a replica of colonial and missionary medicine. But as my mentor puts it, colonial state was unconcerned with indigenous populations but was majorly to protect colonist against local diseases just as health is a tool for political elite to woe voters including health professionals and bridge to richness for tenderpreneurs. Dr Lancott describes the situation as follows,” The medical mafia in different levels is made up of the pharmaceutical industry, the political authorities, the great labs, the hospitals, the insurance companies, the medication agencies, the board of medicines, physicians, WHO, MOH, the world governments under the shadow of money.” It is a system with vested interests. This begs the question, is health act of morality or humanity? As this self-centeredness persists today as demonstrated by purchase of 100,000 body bags and land for cemetery, the right to health is undermined by fear of contagion in biosecurity case by “others” that was witnessed by KTRH nurse and people suffering from Covid 19. Now you know. Have a great week ahead.