A poster series about UHC recently came across my What’s App feed that betrays a flaw common in thinking about health care in “developing world” countries like Kenya. I have a hunch this mindset is connected to the current NHIF restructuring in Kenya.  Simply put, the flaw is thinking about specifics rather than the big picture of the overall health system. 

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, however, 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.  

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, also known as a fixed-pie, 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 and ask, creativity in engaging potential funders/partners, ability to tell compelling stories, ability to demonstrate change and measurable outcomes. 

2. Money is a Story 

“As we ceased to trade, we moved all of our transactions to the abstract world of money. And the thing about an abstract trade is that it happens over time, not all at once. So I trade you this tuition money today in exchange for degree in four years which might get me a better job in nine years. Not only is there risk involved, but who knows what the value of anything nine years from now is? Because of the abstraction and time shift, we’re constantly re-evaluating what money is worth.

Pricing based on cost, then, makes no sense whatsoever. Cost isn’t abstract, but value is.” – Seth Godin 

Apply this thinking to healthcare and we see the challenge of access and affordability in healthcare is not actual cost, but perceived value.    

For a Kenyan, is the value of purchasing National Health Insurance Fund coverage worth the cost?   

Is an antenatal care visit worth the travel and time and expense?

What about vaccinations or regular cancer screenings?

An international donor might ask the following questions (among others):

– What is it worth for me to provide a mother safe delivery or surgery for a child born with spina bifida or anorectal malformation?  

– What is the value to me to ensure that talented surgeon is able to practice to the best of his ability in his home country rather than emigrate to the West? 

– What is it worth for a nurse to receive scholarship aid so he can complete school, serve in the health system, and pay for his younger siblings to receive education?

Answers to these questions can be overwhelmingly positive in a context like Kijabe, as the impact versus cost of healthcare provision is minuscule compare to what it would be in America, Europe or Australia.

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, and 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, not surgery.  He can’t operate his way out of the problem.  

Far better would be a community health network focused on prevention, a primary care network to treat contracted illness and the surgeon working in the operating theatre for procedures only he is qualified to do.  

In Kijabe pediatric neurosurgery is an example of the proper relationship.  

Hydrocephalus and neural tube defects can occur naturally, but are much more frequent due to failings in proper antenatal (folic acid supplements) and postnatal care (test 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 proper functioning system delivers patient centered-care, providing the right treatment at the right level at the right time up and down the system.  

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.  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, ante and postnatal follow-ups are done 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 facilities at every level 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? 

As one 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 system and the people it exists to serve – this is what it would mean for the giant to awaken.

Written by David Shirk with help from Dr. Mary Adam and Dr. Evelyn Mbugua

*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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