Addressing false Either/Or choices in global health.

Universal Health Coverage is the idea that every human being on the planet can and should have access to healthcare.  It is feasible in most parts of the world including Kenya, and the U.N. is lobbying for countries to achieve this goal by 2030. 

The attitude toward UHC that is playing out in Kenya is that only a certain level/amount of healthcare is fundable, so the government should pick and choose from a best-buys list.  

Utilitarian logic – do the most good for the most people for the least cost – might suggest primary care treatment: vaccines, mosquito nets, WASH and maternal-child health programs are cheaper and touch more people than surgery or other forms of specialized care so they should have priority in a health system. 

But if we zoom out and look at the big picture, we realize that a healthy health system provides effective care at all levels, not solely the top or the bottom.  There is no either/or choice between primary health and specialized care.

In this article I address 6 ideas:

1. A zero-sum assumption is false.

2. Money tells a story about what we value.

3. A health system based on primary care cannot be realized without support from a network of hospitals.

4. Teaching and referral hospitals cannot adequately serve populations without excellent primary care and community health programs.

5. Don’t cut off the head to save the body!

6. The head cannot neglect the body.

1. A zero-sum assumption is false.

A zero-sum assumption, or a fixed-pie mentality, holds that the amount of money in a system is fixed, allocated, and when it is used up it is gone.  So for a country with a GDP of $10,  think $9 for general country expenses minus $1 healthcare expenses = $0.  

But the fixed-pie does not exist.  In a snapshot of time, say a budget for an individual year, a zero-sum happens, but in the long-term, it is not true at all.  

The amount of global wealth has roughly doubled each decade since World War II.  Barring temporary calamity in a specific system, tomorrow will have more resource potential than today.  

If anything, rather than being a fixed size, the pie of global wealth seems to be exploding.

The actual resource-limiting factor in healthcare is not the size of the pie, it is the size of the vision: willingness to dream, creativity in engaging potential funders/partners, ability to tell compelling stories, viewing healthcare through the lens of equity and possibility rather than the scarcity.

2. Money is a Story 

“Money is a story.” – Seth Godin.

Every single person in a healthcare system tells herself a story. These stories determine how affordable and accessible healthcare is for all.

Do I consider healthcare a personal responsibility, a community responsibility, national issue, a shared global challenge or some combination of these?

Do I generally feel powerless to make change, or do I feel can I influence the world around me?

Am I optimistic or worried about the future? Do I think my life will be better tomorrow, relationally and financially, than it is today? Do I think my country or region will be better off tomorrow than today?

Do generally I trust the promises of my local and national government?

Do I trust my insurance will pay if I suffer an injury?

Do I consider antenatal care visit worth the travel and time and expense? Can I balance this with cost of food, schooling and shelter for my other children?

What do I tell myself if I fund chemotherapy for a child, build a surgery suite or put a nursing student through school? Do I feel I am a generous person? Am I making an impact on the world? Am I modeling morality to my children? Am I living out my faith? Am I being a good steward of God’s gifts?

The stories we tell, both as individuals and as a society, determine how we use money in healthcare at the micro and macro levels.

With Friends of Kijabe, the story is shamelessly optimistic.

We believe together we can make a significant difference in healthcare access and quality.

We believe in possibility, not scarcity.

We believe East African voices are beautiful, strong and powerful – we listen to them and share them.

We believe provision of compassionate healthcare is a God-given calling.

We have a responsibility to steward God’s resources wisely and ethically.

We believe all doctors and nurses in the Kijabe team are missionaries, that training and discipling will have significant impact in Kijabe Hospital and across Kenya for the physical and spiritual health of those we serve.

3. A health system based on primary care cannot be realized without support from a network of hospitals. 

Consider this purpose statement from the Kijabe Community Health Volunteer program, a training program used in partnership with government primary care programs around Kenya:  

“To improve health promotion and disease prevention with a focus on Maternal and Newborn health module using a government certified curriculum which includes; importance of ANC (antenatal care), developing an individual birth plan, danger signs in pregnancy, how to care for newborns, danger signs in newborns, importance of exclusive breast feeding, expanded program on immunizations, danger signs in a postnatal mother and the role of men in improving maternal and child health.”

A community health volunteer (CHV) equipped to speak with mothers in her community about birth matters is a tremendously effective resource, perhaps the best bargain in global health.   

But if the CHV sees danger signs before and during pregnancy, she must be able to refer the mother or infant to a local primary health facility qualified to treat the problem.  If a clinical officer at this  facility sees further warning signs, she must be able to further refer the mother to a facility able to handle the issue.  

Good as the CHV program is, it can only be as effective as the referral network it is connected to.

4. Teaching and referral hospitals cannot adequately serve populations without excellent primary care and community health programs.  

A talented West-African surgeon recently told me he performs 4-10 typhoid bowel perforation surgeries daily, the result of untreated exposure to water-borne illness.  

If the root cause is lack of clean water, the first-line solution is wells and filtration systems, not surgery.  He cannot operate his way out of the problem.  

In Kijabe action of the pediatric neurosurgery department in the early part of this decade was an example of the proper relationship between specialized and primary care.  

Hydrocephalus and neural tube defects occur naturally, but are much more frequent due to failings in antenatal (folic acid supplements) and postnatal care (testing for menengitis in febrile neonates).  

Action at the national level with Iron and Folic Acid supplementation based on Kijabe research was a critical step forward. Additionally the Bethany Kids team worked on partnering with the Association for the Physically Disabled of Kenya (APDK) to create awareness on the availability of treatment for patients with neural tube defects.

A healthy health system delivers patient centered-care, providing the right treatment at the right time.  

Primary and specialized care must go hand in hand. 

5. Don’t cut off the head to save the body!

You know the old story of a chicken running with it’s head cut off.   The same is true of a health system.  If the head is cut off, the system might function for a time, but eventually it will die.  

Consider the structure of healthcare in facilities in Kenya: 

Level 1 – Community Health

Level 2 – Dispensaries (Primary Care)

Level 3 – Health centers (Secondary)

Level 4 – District referral hospitals (Secondary)

Level 5 – Provincial referral hospitals (Tertiary)

Level 6 – National referral hospitals (Tertiary)

Where does medical education occur in Kenya?  

At medical schools connected to level 5 and 6 facilities, like Kijabe Hospital, Kenyatta National Hospital, Moi Teaching and Referral Hospital, Tenewek Hospital and the Aga Khan hospital.

These facilities are the head because this is where the knowledge transfer happens that keeps the entire body healthy.   

Book learning is one matter.  Real experience + knowledge + compassion + vision for what is possible – these attributes are what make a health care provider great, no matter the level on which she serves. 

Consider the Kijabe intern graduate sent to a rural facility.  She watches the maternity team deliver a flat baby, wrap it in a cloth and place it on the counter, assuming it will not survive.  Shocked, she picks up the baby, stimulates it. The maternity team is equally shocked to see the baby crying, turning from grey to pink.  

Quality training is quite literally life-and-death.   

In a well-functioning system, the first-level and mid-level providers must be able to recognize conditions and treat appropriately; diagnose, stabilize and refer up the chain when necessary for surgical conditions, high risk pregnancies, or other complex conditions.  They must ensure antibiotics prescribed appropriately, perform ante and postnatal follow-ups at the appropriate time, give vaccinations, provide health education and counseling.  

If the level 5 & 6 facilities fail, so do the schools connected to them, competent medical providers are not produced, and the entire system will suffer.     

6. The head cannot neglect the body.  

The vision of Kijabe Hospital is to be a leader in healthcare provision in East Africa.  

Kijabe Hospital has consistency pushed the edge what is possible in Kenyan healthcare, whether an NICU mortality rate consistently under 5%,  piloting antimicrobial stewardship, introducing new surgical techniques to Kenya (free-flaps, mastectomy, bone transport, etc.), creating training programs like Pediatric Surgery, ECCCO, PECCCO, KRNA, FPECC.*  

While Kijabe has been instrumental in creating graduate and post-graduate level training programs through Kijabe College of Health Sciences and the Graduate Medical Education division, it has barely scratched the surface of possible partnerships, continuing education programs and short courses.  

In short, vast knowledge remains in the head and does not flow to the body.  

What would it look like to partner with government facilities on comprehensive health initiatives (as is currently being discussed with a hospital in Northeastern Kenya)?  

How can information that saves lives and influences practice best be distributed? 

Can we form a Kijabe University to offer education in comprehensive health-related fields? 

Can we view all Kijabe Hospital alumni as missionaries and equip/support them in whichever health systems they serve?

A partner recently commented, “Kijabe is a sleeping giant.”  

Building on Kijabe’s unique strengths while dissolving the walls that separate it from the rest of the Kenyan system and the people it exists to serve – this is what it would mean for the giant to awaken.

Written by David Shirk with advice from Dr. Mary Adam and Dr. Evelyn Mbugua. View do not necessarily reflect those of AIC Kijabe Hospital.

*ECCCO – Emergency and Critical Care Clinical Officer,

PECCCO – Pediatric Emergency and Critical Care Clinical Officer,

KRNA – Kenya Registered Nurse Anesthesia,

FPECC – Fellowship in Pediatric Emergency and Critical Care

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