Are we the world?
March 7, 2006 -- Recent articles have painted a grim picture of how nursing is valued in Kenya--and elsewhere. Today the Standard (Nairobi) ran a short piece by Elizabeth Mwai reporting that Kenyan assistant health minister Enock Kibunguchy has called for his government to ignore a hiring freeze imposed by the World Bank and IMF, so it can hire more nurses and others to address urgent health needs. On March 3, Reuters issued a long article by Katie Nguyen that described the state of Kenyan nursing in detail. Nguyen's generally good piece reports that "underpaid" and "undervalued" Kenyan nurses have continued to flee the nation for better opportunities in developed nations, which are eager to get them. In those nations, not coincidentally, working conditions have also driven away many local nurses with other options.
The Standard piece, "Ignore the World Bank on health, says minister," appears to be based entirely on comments by Kibunguchy at an AIDS workshop in Nairobi. The assistant health minister reportedly noted that over 1,000 nurses leave Kenya each year, and that it urgently needs 7,000 nurses, 600 physicians, and 2,000 "clinicians and laboratory experts." He noted that 130,000 infants born each year to HIV-positive mothers were not getting adequate care, stressing that preventing mother-child transmission required more staff and better infrastructure. Therefore, he argued, the government should start hiring, and "tell the International Monetary Fund and the World Bank to go to hell." The piece does not discuss any fallout from Kibunguchy's comments, whether the Kenyan government has the funds needed for the new positions, or why the international institutions would apply such fiscal constraints to the most basic needs of the health sector.
The Reuters article is headlined: "Underpaid and undervalued: Kenyan nurses lured away." It has a lot of the standard information about the dimensions of the African health staffing crisis. The World Health Organization estimates that up to 20,000 highly qualified nurses and physicians leave Africa every year for nations like the U.S. and the U.K. This "brain drain" deals a double blow because local governments have paid to train the workers--effectively subsidizing wealthier nations' health systems, as a recent U.N. Population Fund report noted. Kenya has reportedly lost about 3,400 of its "brightest" nurses to "rich nations" in the last five years, "frustrating the fight against HIV/AIDS, malaria and tuberculosis--Africa's biggest killers."
The piece focuses on Nairobi's 1,800-bed Kenyatta Hospital and one of its nurses, "Florence," who did not give her real name because she feared that her job was at risk (!). The piece says that Florence, a 20-year veteran, has "lost heart in what was once a revered profession" because of poor pay and short-staffing: "Now, I always tell my daughters nursing is not the best." The resulting "hand-to-mouth" existence drives many overseas for jobs in developed nation hospitals and nursing homes that can pay 10 times more, despite the difficulties involved in such a drastic move, and the fact that some recruiting agencies ask them to pay "extortionate recruitment fees" from their wages. Florence says she wants to stay in Kenya but "would go to the U.K. tomorrow. There are quite a number of nurses who are really dying to go there."
To illustrate what happens when they do, the piece tells the story of Nancy Itotia, who now works in a nursing home in central England, "saving to open a clinic for mothers and children in rural Kenya." This goal does raise at least a potential silver lining the piece does not explore, namely the possibility that some of the nurses will return with more financial and professional resources to aid Kenya. (The piece also does not discuss remittances the overseas nurses may be sending back, which is a factor in nations like the Philippines, though it's not clear if that could compensate for the training resources lost, to say nothing of the staggering cost of widespread ill health.) The piece explains that Itotia had a "rough start" in the U.K., fighting homesickness and "demeaning" attitudes, and having to pay the equivalent of her first 10 months wages to the agency that brought her and registered her for "the necessary courses." She says there is "no rest" in the U.K., and that things are expensive, but she has "no regrets" because the money offers her the chance of opening the clinic.
Back at Kenyatta Hospital, the piece reports, an average of three nurses care for 80 or more patients in "shabby" wards with "out-of-date equipment." In May, the nurses went on strike because of poor pay. The piece says that during the strike, "patients delivered babies, corpses lay forgotten among the living and children with cancer screamed in pain, needing their drugs." The nurses returned after two days because they were "threatened with being fired." It's not clear if they got any more money. The piece notes that unions blame mismanagement for the lack of resources. The health ministry "declined to comment on the state of health care" (despite assistant health minister Kibunguchy's obvious willingness to speak several days later). The piece also says that the health department's proposed 2006-2007 budget amounts to $15 per person.
At the end, the piece suggests that Kenya is actually "not short of nurses," quoting the National Nurses Association's Fredrick Omiah as saying that 7,000 Kenyan nurses are jobless. Omiah notes that this is the same number of nurses who are urgently needed--and it is indeed the same number Kibunguchy cites. This suggests that, beyond an apparent lack of funds to pay nurses, the nation may lack nurses willing to endure the poor conditions of employment that prevail, especially since many have other options. Of course, a shortage of willing nurses is a critical problem in the same developed nations to which the Kenyan nurses are going. It's hard to miss the similarity between what's happening in nursing, on the one hand, and what's happening in other fields in the developed world in which workers are increasingly drawn from overseas migration--an issue that has fueled intense debate in the U.S. and Europe.
The piece closes with Omiah's concern that a new health crisis such as an outbreak of deadly bird flu (the virus was recently detected in nearby Nigeria) could make the Kenyan nurse staffing situation even worse. This suggests the key role of nurses in responding to such an outbreak, something that seems to have eluded those responsible for recent pieces from elite press entities like NPR and the New York Times, which have suggested that the big problem is a shortage of ventilators.
We commend the Standard and Reuters for keeping the focus on the international nursing crisis, which raises questions about how both rich and poor nations value nursing and health care generally.
See the March 3, 2006 Reuters article "Underpaid and undervalued: Kenyan nurses lured away" by Katie Ngyuen.
See the March 7, 2006 article "Ignore the World Bank on health, says minister" in the Standard by Elizabeth Mwai.