Areas of ReportingThe Health System

Poor Referral System Chokes Kenyan Hospitals

Kenya’s health sector has been dogged with numerous challenges, key among them being the poor referral system. The referral system in the country is a major national problem that needs to be addressed urgently. The Kenya health sector referral strategy 2014 -2030 identifies various health system requirements for a well-functioning system.  For a successful referral, the strategy notes that there must be geographical access to referral care facilities.

At the beginning of his second term of administration in 2017, Kenya’s President Uhuru Kenyatta identified health as one of the four pillars of his plan for socio-economic growth, alongside food security, affordable housing and manufacturing.

Through the universal health coverage (UHC) policy agenda  of ensuring everyone, everywhere, has access to quality health services without financial hardship, the President pledged to make quality health care services available to all households within four years. This is an ambitious target in a country where 80 percent of the population does not have any kind of health insurance.

In Kenya, citizens seeking medical care often bypass primary care facilities and seek care directly at referral care hospitals for illnesses that could easily be treated at the primary care facility.  This often overburdens the referral facilities and is often costlier for the caretaker and the health care system.

Further, most patients being taken care of at Kenya’s leading referral hospitals such as the Kenyatta National Hospital (KNH), Moi Teaching and Referral Hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) etc, are suffering from minor ailments that could be handled at level one health facilities.

What should be done to strengthen Kenya’s referral systems?

An article published by the Daily nation on 6th February 2018 titled “Overwhelmed: How Kenya’s overzealous patient referral system is clogging the pipe” revealed that referral hospitals in Kenya are perennially congested, at KNH, patients share beds, while at JOOTRH in Kisumu, ‘the floor sometimes is the only available space for in-patients.’  The article noted that this sorry state of affairs is replicated in all the major referral hospitals in the country.

A parliamentary Health committee report that was tabled in parliament in May 2019 revealed that the congestion at Kenyatta National hospital suffers from congestion. The maternity ward for example is designed to accommodate 50 mothers yet it accommodates more than 100 at any given time. The report further revealed that the overcrowding has led to overworking the health care providers, specifically nurses who are forced to attend to at least 50 patients each.

To address this challenge, there is need to fully implement the referral guidelines, but this has become an uphill task.  According to health experts, hospitals and doctors are bound by the law to take care of the sick since Article 43 criminalizes the denial of healthcare to Kenyans who visit health facilities — these hospitals end up admitting and taking care of patients they ordinarily should not.

Hospitals at lower levels should act as a filter, but, they don’t, so patients end up being treated at high referral hospitals who do not meet the referral criteria and who should otherwise have been treated at the lower levels.  This means that sub-county hospitals need to create awareness of the services they offer which should be known to all Kenyans.

The 2013 – 2017 sector plan for health by the Ministry of Health admits that strengthening the referral system is critical in ensuring holistic delivery of services, the sector plan noted that this has not been appropriately coordinated or targeted hence the referral mechanism between communities and facilities is still very weak.

What the public should know about Kenya’s health systems

As the writer prepared to put together this article, he randomly inquired from different people whether they knew the existing public health facilities in Nairobi.  Interestingly, the only public health facilities that cropped up were KNH, Mama Lucy Hospital, Mbagathi District Hospital and Pumwani Hospital.  These are all high-level referral level facilities which patients should only visit when referred from lower level facilities.  When the writer checked the statistics on available public health facilities, he discovered that Nairobi has a total of 80 public health facilities, all offering free medical services.

The county list of health facilities document has clearly laid down all available facilities, in each sub-county. Each sub-county has an average of nine health facilities.  This means that each resident has adequate physical access to health and related services and financial barriers should not, in any way hinder access to healthcare services.

Kenya’s healthcare system can be divided into three sub-systems.  The public sector, commercial private sector, and non-commercial private sector.   The public sector dominates Kenya’s healthcare sector.  According to Kenya HRH strategy 2014 – 2018, the public sector leads with ownership of health facilities with a total of 3,956.  The facilities include all government-run health facilities (hospitals, clinics, and dispensaries), medical schools and the public pharmaceutical supply chain.

The commercial private sector has a total of 2,652 facilities.  These include healthcare facilities, medical distributors, pharmaceutical manufacturers, health insurance, health management advisory and training institutions.  The non-commercial private sector is divided into faith-based facilities (FBO) and non-governmental (NGO) healthcare facilities.  Faith-based are run by religious institutions and the total is 881 while the NGO facilities total 306.  They include mission health facilities (hospitals, clinics, and dispensaries), medical schools and faith-based pharmaceutical supply agency.

The public health sector is funded by the national treasury to address the population’s demand for and access to relevant health services. For the past five years, the government has actively restructured and expanded the National Hospital Insurance Fund (NHIF).

What journalists should do

  1. Find out why citizens seeking medical care often bypass primary care facilities and seek care directly at referral care hospitals
  2. Find out whether the Kenya Health Sector Referral Strategy 2014 -2030 is being fully implemented and/or challenges being faced to implement it
  3. Find out the barriers that hinder effective referral systems in Kenya
  4. Find out whether sub-county hospitals do create awareness of the services they offer which should be known to all Kenyans.
  5. Read more about the different health strategies by the Ministry of Health meant to strengthen healthcare including referral systems in the country.

By George Achia



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