How strikes, staffing threaten Universal Health Coverage push

Health care workers on strike [Fiele-Standard]

Protus Wafula Nyongesa lost his wife, 36-year-old Beatrice Nyongesa, in August during a prolonged nurses’ strike.

Beatrice was taken to a traditional birth attendant in Endebess, where she delivered safely. But after returning home, she developed severe bleeding and died.

“I took my wife to a traditional birth attendant because nurses were on strike. Hospitals were not operating. Sadly, she died. I wish she got professional delivery,” says Wafula.

His experience highlights the potentially devastating consequences of disruptions in the health workforce, particularly for pregnant women who require timely access to skilled care.

The case comes as the Kenya Kwanza administration pursues Universal Health Coverage  (UHC), an agenda health professionals say cannot be achieved without a stable, adequately staffed and properly remunerated workforce.

“They're talking about Every Woman, Every Newborn Everywhere (EWENE), going to UNGA, talking big about maternal health, yet maternal deaths are taking place in this country, and nobody will take responsibility for that,” says Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) Deputy Secretary General Dr Dennis Miskellah.

“Nowadays, when you hear vuvuzelas, you know it's healthcare workers striking,” he adds.

The disputes are far from over, with doctors threatening industrial action over salary arrears and implementation of collective bargaining agreements (CBAs).

KMPDU says at least 20 counties have yet to fully implement basic salaries provided for under the 2017 CBA, while doctors are also pushing for the signing of their 2026–2029 agreement.

“We have had 150 strikes since devolution. It is mad. This does not seem to bother anyone,” says Miskellah.

He argues that the Government cannot achieve UHC by concentrating on financing and equipment while failing to resolve the workforce crisis.

“Healthcare workers cannot talk about SHA and equipment when the current problem is the human resource problem. You can have SHA and all that you want, but this SHA does not treat health workers who are on strike. If so, then you're not helping?” he asks.

Kenya Union of Clinical Officers (KUCO) Secretary General George Gibore says health workers are central to the delivery of UHC, which he defines around access, affordability and quality of care.

“You cannot talk about UHC without addressing the issue of healthcare workers who guarantee services,” says Gibore.

He says shortages have left hospitals congested, with patients sometimes waiting for prolonged periods before receiving care.

The Government, he argues, has not employed enough health workers to meet demand.

During the 2022 election campaigns, President William Ruto, then Deputy President, pledged to employ at least 20,000 additional healthcare workers.

Gibore says the commitment has been complicated by devolution, with counties retaining responsibility for much of the health workforce.

“All is status quo, because we have not added any. We are now priding in UHC with those who were employed by the time when he was the Deputy President,” says Gibore.

“Governors allege it is tantamount to interfering with the powers of counties. This made it hard for him to achieve this aspect,” he adds.

The management of human resources for health remains complicated by the division of responsibilities between the national and county governments.

While some counties have made progress, others continue to experience staffing disputes. Clinical officers in Nairobi, for example, have been involved in industrial action.

Gibore says healthcare workers also feel undervalued because of delays in promotions, career progression, medical cover and implementation of CBAs.

“It beats logic to have back-to-back strikes pushing for common things like promotions, career progression, medical cover should be done without much push,” he says.

The prolonged negotiations and delayed implementation of CBAs have also fuelled discontent among health workers.

“It beats logic that you negotiate for a CBA for eight years, yet a CBA cycle is just four years,” says Gibore.

He says doctors currently have a running CBA, while agreements for nurses and clinical officers have stalled.

Some counties, including Wajir, have yet to sign the clinical officers’ CBA, according to Gibore. He says efforts to secure implementation have also resulted in confrontations in counties including Marsabit, Kakamega and Makueni.

In Marsabit, he claims, elders have visited the homes of clinical officers and warned them against participating in protests.

“Health workers are treated like prisoners because if you raise any concerns, you are intimidated, given show-cause letters,” says Gibore.

During the August strike involving nurses, clinical officers, laboratory workers and public health workers, Council of Governors chairman Ahmed Abdullahi directed counties to take action against striking employees.

Abdullahi described the nurses’ strike as being in contempt of court and said the Sh5.9 billion CBA had been signed under duress, remarks that angered the nurses.

Gibore says some county health workers have served in the same positions for more than 15 years without promotion.

“If a person who guarantees your safety is not safe, as a patient, you are not safe. Today, a health worker serves over 70 patients a single day. What do you expect of such an individual? That person is already tired,” he says.

Although health is a devolved function, KMPDU says county governments have not done enough to resolve persistent workforce challenges.

Miskellah accuses governors of failing to adequately address the crisis and says the national government has also been reluctant to confront counties over failures in healthcare management.

“The government of William Ruto has not been courageous enough to face the counties and direct them to style up,” says Miskellah.

He argues that political considerations may be influencing the national government's approach to county governments.

“President Ruto has fears county governments and governors might impact on his re-election. He cannot just come out, stop them from nonsense, tell them we cannot just have strikes going on,” he says.

One of the outstanding disputes involves health workers recruited under the UHC programme during the Covid-19 pandemic.

Ruto has promised to resolve their employment status by having the national government place them on permanent and pensionable terms. Miskellah says the process remains unresolved amid disagreements with governors over the proposed arrangement.

He also accuses some county governments of failing to remit SHA contributions for their employees on time despite receiving funds from the National Treasury.

“Ruto is not brave enough to call counties for UHC issues. You cannot be given money for SHA. The President should bravely face governors for smooth healthcare in counties,” says Miskellah.

He says the President has also not held sufficient consultations with the Council of Governors and health unions to resolve the disputes.

According to Miskellah, commitments made during the Health Summit and through the Intergovernmental Budget and Economic Council have not adequately addressed the concerns raised by health workers.

He says the administration has instead placed emphasis on upgrading Level Five hospitals to Level Six, while deeper workforce problems remain unresolved.

Some health professionals have consequently renewed calls for greater national government involvement in the management of the health sector.

Miskellah says unions will continue using industrial action to press their demands.

KMPDU has also raised specific complaints against counties. The union alleges that Siaya has delayed doctors’ salaries for three months, while Bomet has failed to provide some doctors with promotions, medical cover and study leave.

Miskellah says the health system also requires multiple cadres working together, rather than relying on a single category of health professionals.

For Prof Peter Anyang’ Nyong’o, a former Minister for Health Services and current Kisumu Governor, the workforce crisis cannot be reduced to the number of health workers taking industrial action.

He identifies human resources, particularly remuneration, as one of the most persistent challenges facing the health sector.

“I think the problem has always been in human resources, the remuneration of health workers, because health workers are very important in our lives,” says Nyong’o.

In an interview with The Standard, Nyong’o calls for closer cooperation between the national and county governments, arguing that inadequate resources have contributed to persistent problems, including strikes, delayed payments and shortages of medicines and medical supplies.

The two levels of government, he says, should agree on the actual cost of delivering  healthcare and ensure adequate funding for doctors, nurses and other health workers.

“When somebody goes to a health centre or a county hospital and does not find medicine, it is devastating,” says Nyong’o.

As the country moves towards the 2027 General Election, health workers' strikes, staffing shortages, delayed CBAs and disputes between the two levels of government are likely to remain a critical test of whether the Government's UHC reforms can move from policy commitments to reliable services for patients.