Positioning Surgery at the Core of the Universal Health Coverage (UHC): My Conversation with Senior Surgeons-Dr. Aruyaru Mwenda

In 1978, over 3000 world health experts converged in present day Kazakhstan  to chart the way forward in mattes public health. Some of you may remember that the Kenyan team was led by Prof Miriam Were. At the conclusion, the delegates who adopt 10 resolutions that became immortalised as the Alma-Ata Declaration.

The Alma-Ata Declaration was a giant leap for public health. But it was never to be even a small step for surgery. And so for years to follow, surgery would remain consigned to the periphery of the global public health agenda. Even when statistics showed that trauma ( a small portion of surgery) was causing more deaths than Tuberculosis, malaria and HIV/AIDS combined.

Paul Farmer and Jim Kim would later so aptly describe surgery as the ‘neglected stepchild of global health.’

But in 2015, during the 68th WHA , surgery was adopted as a key primary health care component of the UHC. 

You and I know that UHC is among the top four agenda of the current Kenyan government.

Are there challenges that we still face in ensuring surgery is squarely represented in the UHC agenda? How do we mitigate such challenges? How do we fund surgery? What about training?

On the 4th of July, 2019, I had the privilege of moderating a panel discussion as part of the Continuing Professional Development (CPD) activity of the Central Division of the Surgical Society of Kenya (SSK).
The panel consisted of senior surgeons from Mt Kenya region and the audience was made up of all cadre of doctors, both specialists and generalists.

I posed the following questions to the panelists during the one hour session. Some questions were answered by a single panelist while others were answered by each panelist in turn. We also had a couple of questions from the audience.

Question. What challenges do we face in bargaining for surgery as an important component in the UHC agenda?

Answer:

  1. Surgeons are so busy operating and thus are not available to attend lobbying meetings and policy conferences.
  2. The cost of providing quality surgery remains a big hinderance. The people do not get the best surgical service on account t of cost. Even the ones under national hospital insurance coverage will not get the best unless the insurer is able to cater for everything.
  3. Most surgical diseases are not communicable and as such not emotional. It might be easier to plead with donors and political leaders when handling more emotional communicable diseases like Sexually transmitted Diseases, malaria , etc.

Q. Kenya has 2.35 surgeons per 100,000 population against the lancet commission target of 20. A capacity study (MOH) among 254 level 4 hospitals across the country shows there are only 88 surgeons, 62 gynaecologists and 48 anaesthesiologists. What are your views on how we can fast track training to bridge the gap?

These figures are discouraging. The other discouraging thing is that whereas in the past there was a guarantee of post graduate training sponsorship by the government, the same is not the case with the devolved units. There were times when there was a lot of training for surgeons until at some point, people began being discouraged from training in surgery and encouraged to pick other specialties. We need top re-emphasize the need for training of more surgeons.

Q. Does the National Hospital Insurance Fund (NHIF) as currently working represent a good financier of surgical care? Are there areas that need improving? 

The NHIF is trying. The challenge is in the methodology used to allocate the funds towards surgery. The categories (minor, major and specialised) need to be revised. The quality control in the fund my benefit from consultant surgeons input so that the monies allocated are commensurate with the complexity level and extent of consumables utilised.

Q. There have been cry after cry from surgeons towards private health insurance agencies about delayed remittance of fees for services. What is your experience and what suggestions can you offer to streamline this? 

The best financing model that will help meet the population’s surgical services needs is a publicly supported one. The private insurance should exist to bridge the gap and mostly for patients in the private facilities. The emphasis should be on strengthening the NHIF to ensure that it caters for quality surgery for all.

Q. The Abuja declaration called for 15% budgetary allocation to health. The World Health Report 2010 suggests that countries aiming for UHC should spend 5-6% of their GDP on health. Kenya allocated only 2.5% her GDP to health in the 2015/16 financial year.  How do we get more funding into surgery with this trend?

The funding for health per see has been a challenge. Political commitments have rarely been followed through with actions. We have the huge responsibility of lobbying so that we diversify on the sources of funding for surgery.  Depending on the treasury alone might not me enough.

Q. ‘Doctors have not done enough to persuade the politicians to buy into our course’. Any tips on how to engage the political leadership? 

Every opportunity is a golden one, let us take it up and speak fro surgery. When opportunities to take up political leadership arise, let us seize them. As long as we are consistently speaking in the same voice across the different strata of political and policy leadership, we are likely to score advocacy goals for surgery.

Q. The mystery of the missing surgeon: Sometimes we blame the government for lack of resources, poor staffing ratios , etc. But as surgical healthcare providers, are we doing our best in terms of availability and commitment?  What are your comments

The commitment in the private sector may not be in question. The challenge is in some cases in the public sector. As surgeons, it is imperative that we are at the frontline in offering the best care for the patients who may neither have the voices to challenge us, nor the resources to seek a second opinion in a private setting. This is a huge moral obligation that we bear, being the heads of our teams in our respective clinical settings.

Q. As we speak, there are two counties (Laikipia and Kirinyaga) where the doctors are on trike. What can we do as an association (SSK) or as individuals to avert frequent industrial unrests in the health sector?

The spike of labour unrest in the health sector has been witnessed after devolution. We all agree that the devolution of the human resources for health did not help the employer-employee relations pertaining to human resources for health. It is important that we revert the Management of the Human Resources for Health to the National government and form a Health Service Commission (HSC) to ensure the surgical workforce for the entire country is managed by a central body.

Q. We are in the era of the 4th industrial revolution. How can we leverage on technology to achieve more, quicker?

With priority we can leverage on technology to advance access to surgery. The county referral hospitals could, for example, establish themselves as centres of excellence where all specialists are pooled in. Imaging and diagnostics can be improved through tele radiology for reporting of images if there are no radiologists on site. But even before we get there, we could make use of the manufacturing industry (1st industrial revolution) by for example leveraging on the plenty of clean water from Mt Kenya and setting up a large scale intravenous fluid production plant. This way we become self sufficient in intravenous fluid manufacturing.

Q. What cultures (from a patient point of view) have you encountered that you think will impede effective delivery of surgical care?

  1. Most cultures are fluid and dynamic. Each case is particular to the patient, not even their age or community. Majority of these isolated cases usually involve a patient who will not accept the surgeon’s advise about the best option of surgery because they cannot deal with the stigma of a life changing surgery (like living with a permanent colostomy).
  2. In matters UHC, there is a prevailing culture that Health is free! As a result, even people who have the financial ability are shying away from contributing for they NHIF because UHC should be free. In addition, people do not value free things. Unless there is a way for Kenyans to contribute towards UHC, they will not value it and thus it may not be sustainable.

Q. The Ministry of Health Statistics show that of all the facilities in the Country, only 48% are public. The others are either private or faith based. In terms of delivery of Surgical Care, have we got it right in terms of Private-Public Partnership?

Private-Public Partnerships are paramount if we have to summon all our resources in the fight against disease. What needs to be done is to extend the partnerships to involve human resources as well as procurement and supplies units. The statistics from the UHC pilot counties indicate that the available resources in the public sector are not enough to cater for the surge in the number of patients. The private sector will be vital to plug the deficits from the public sector.

About the Author:Consolata Hospital Mathari

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