Context: Kijabe hospital and the strike

AIC-Kijabe Hospital9 has been serving the poor and vulnerable in the Rift Valley of Kenya for more than 100 years. It is a 363-bed facility that performs between 9000 and 10 000 surgical procedures annually and sees over 180 000 outpatients per year. The institution has grown from a small mission outpost into a major tertiary care referral hospital and training centre. Half of the staff physicians are Kenyan and half are expatriate volunteers. Paediatric surgical care and training at AICKH occurs in partnership with BethanyKids, a non-profit faith-based organisation focused on children with surgical problems. The newborn nursery at AICKH only admits sick infants under 1 month of age.

Clinical demand and hospital response during the strike

Throughout the duration of the strike, the clinical demand of patients presenting to AICKH, exceeded the hospital’s capacity to respond and options to transfer or refer patients were rare to none. As such, AICKH systematically refused referral admissions from outside institutions. We do not have data on the number of patients turned away. In order to expand capacity, an administrative decision was made to open and staff an additional room for sick inborn newborns, as this was the area of greatest need. There was neither room nor staff to open additional paediatric beds. A de facto system of mass casualty style triage was effected to establish highest priority admissions and automatic referrals of presenting patients based on bed availability in all departments each day. Overload and inability to care for more sick newborns, limited our ability to respond to the demand of women in premature labour or with high-risk pregnancies, even though the hospital added beds for sick newborns. Obstetric admissions were also intermittently closed during the strike due to inability to care for any additional obstetric patients.

The physician staffing, including specialty trainees, at AICKH remained stable throughout the duration of the strike with the exception of the loss of government-sponsored medical officer interns (n=10). Clinical officers (CO), functioning as midlevel physician extenders, also continued alongside the physicians, nurses and ancillary staff at AICKH to provide care to as many sick children and pregnant women as feasible while taxing the already limited resources of the hospital infrastructure.

The provision of services remained intact, being limited only by bed space across all acuity levels of care. With only five ventilated beds for the entire hospital and an additional six monitored ‘high dependency unit’ (HDU) paediatric beds, there was not enough capacity to provide the ideally desired acuity of care for all paediatric patients. The de facto system of mass casualty style triage included decisions made not to escalate care for those children whose prognosis was most grim in an attempt to offer the extremely limited high acuity care to others with improved prognoses.

Kijabe experience before, during and after the strike

One-way analysis of variance (ANOVA) with post hoc Tukey honest significant difference (HSD) tests, ORs with 95% CIs and effect sizes were used to compare prestrike, strike and poststrike data within clinical service units.10 11

The volume of patients during the strike increased and patient demand exceeded the ability to admit patients. The average number of admissions in the sick newborn nursery service increased during the strike and decreased after the strike (figure 1). A difference in the average monthly number of deaths was seen in all units across the prestrike, strike and poststrike time periods. The monthly rate of deaths also increased on the sick newborn nursery service, the paediatric medical service and paediatric surgical service during the strike (figure 2). In the sick newborn and paediatric medical services, there was an approximate fourfold increase in deaths during the strike and a nearly eightfold increase in the paediatric surgical service. In obstetrics, there was approximately a threefold increase in monthly maternal deaths but this was not statistically significant (table 1). Effect size was moderate in the sick newborn nursery, paediatric ward and paediatric surgery service at 2.7, 3.3 and 5.1, respectively (table 2). ANOVA of each service demonstrated meaningful change in each time period for all services except obstetrics (table 2). The numbers in obstetrics were not large enough to be statistically significant, but the trend was in the same direction.

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Figure 1

Average monthly admissions by unit before, during and after the strike.

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Figure 2

Monthly death rate by unit before, during and after strike.

The impact of the strike at Kijabe hospital

The experience of the sick newborn, paediatric medical, paediatric surgical and obstetric services at AIC-Kijabe Hospital during the national physicians’ strike in Kenya during the months of December 2016–March 2017 demonstrates a significant negative impact on patient survival. This is in contrast to the stable or reduced mortality rates reported by Cunningham et al in which they reviewed doctor strikes over a 40-year period along with the coinciding mortality figures. They concluded that physician strikes are associated with a reduced mortality rate.12 In all the cases reviewed, the strike modality implemented reduced care but continued to offer emergency and life-saving care.12 In the Los Angeles, California, USA, strike experience, surveys of the population indicated people either had access to their usual care sources or access to open emergency rooms.13 In the Israeli experience, striking doctors staffed emergency rooms as on holidays and weekends and in major population centres impromptu aid stations were staffed by physicians.14–16 Bhuiyan and Muchowski reported a decrease in mortality and admissions during a 20-day physician strike in a single province in the Republic of South Africa at the lone functioning referral centre.17 In this South African experience, emergency services at the government referral hospital were functioning.

The strike in Kenya differed from the strikes reported by Cunningham and others in that the public sector was crippled in its ability to offer emergency and life-saving care, even though some management level physicians in the government stepped in to do clinical care. Indeed, the Secretary General of the Kenya Medical Practitioners Pharmacists and Dental Union publically stated, ‘Kenyans should not expect any emergency services in hospitals, including Kenyatta National Hospital’ (KNH- Kenya’s premier public referral and teaching centre).18 On the fifth day of the strike, 290 specialist physicians at Kenyatta National Hospital joined the strike. As an emergency measure, a few physicians from the Kenya military were deployed to KNH.19 Children presenting to AICKH with medical or surgical problems during the strike were 4–8 times more likely to die than those who presented in the 12 months prior to the strike.

While our single-hospital experience may not be generalisable across all non-governmental healthcare facilities in Kenya, published reports and personal communication from other faith based (Gainey M. Personal comunication, 2017) and private sector hospitals indicate our strike experience is not unique.20 21 The Kenya public sector hospitals were non-functional. The Kenya clinical information network (CIN) was established in 2013 to collect data from public hospitals.22 Two thousand four hundred children were admitted to the 14 CIN government hospitals every month between January and November 2016. Yet, admissions dropped to less than 1% of previous levels at the 14 hospitals during the physicians’ strike (Ayieko P. Personal communication, 2017) . A significant percentage of Kenya’s population who were affected by the strike likely suffered and died as a result of no access to care. Patients who were either economically unable to afford the modest fees at faith-based institutions or who were limited by geography and were unable to travel to where other care was located had no options.

The question of whether, and under what circumstances, healthcare workers should take collective/industrial action has been the subject of extensive ethical reflection.23–36 The WHO Director General, Tedros Ghebreyesus, considers universal health coverage an ethical mandate.37 Achieving universal healthcare coverage by 2030 is one of the sustainable development goals.38 Strikes by healthcare personnel certainly disrupt service delivery. Where essential life-saving services like caesarean section, care for sick newborns and emergency surgery are unavailable for whatever reason, there is a substantial impact on universal coverage.

This report has several limitations. It is from a single centre. As such, we do not have regional or county-level data for reported mortalities across the three strike-related time periods. Given the fact that all government hospitals were crippled by the lack of physicians, patients who otherwise would have presented, and potentially died, at a government hospital now had no choice but to present to a non-government hospital. Therefore, our strike-related increase in mortality may be reflective of a de facto referral bias. There were no records of the number of patients turned away. The overwhelming number of patients and the inability to manage them required a mass casualty style triage system, but no scoring system for acuity of patients was in routine use. A mechanism to track the number of patients for whom we were unable to care and attempted to refer would have further substantiated the tremendous load carried by those physicians and staff who remained on duty during the days when the government system was crippled. AIC Kijabe Hospital’s own nursing staff went on strike for 1 week in February and that disruption likely resulted in reduced ability to care for patients and may have contributed to negative outcomes that month. It also likely accounted for the overall reduced numbers of admissions across services since in February as the physician leadership implemented measures to prevent new admissions and to discharge all but the sickest of patients in the few days leading up to the local nursing strike. Fatigue due to overtime and overwork under stressful conditions may also have contributed.