Kenya faces a growing non-communicable disease burden (NCDs), with 51% of adults affected in 2023 rising to 61.7% within one year, and projected to nearly double by 2035; this burden is compounded by inadequate healthcare financing, with only 2.44% insurance penetration and less than 1% of the national budget allocated to mental health (WHO recommends 5%), creating significant barriers to early diagnosis and preventive care while the healthcare system struggles with reactive rather than proactive health-seeking behavior and insufficient human resources, particularly in mental health where one psychiatrist must serve approximately 380,000 patients.
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Kenya's Healthcare Finance & Disease Burden |Added:
We'll get into our conversation for the hour now. As Floris mentioned, we are at the Nation Health Summit live from the KICC and this hour and the next one are about financing our health care and the burden or the cost that comes along with it. Why do we think of it as a burden?
Are we missing something and how do we make sure that all Kenyans have access to quality affordable health care as is guaranteed for them in the constitution?
We're joined by several guests beginning with from my left, we have Albert Ogedi who is the chief executive officer at Luton Hospital. We also have Dr. Bundi Ogallo.
She's a consultant psychiatrist at Mathari National Teaching and Referral Hospital. We also have with us Dr. Crystal Voulavou who is the head of corporate wellness at Minet Kenya. So, let's talk health care financing and the disease burden. Good morning doctorates and CEOs.
Big shots, it's good to have you.
I'll begin just by get doing a deep dive into the conversation and health care financing is something that all of us talk about. It comes in so many different ways, but as either people who work in health people work in health care either as doctorates or as executives and managers, what is the one thing that is incredibly expensive about health care that most people don't realize? That one cost that people don't realize is incredibly expensive. Let me start with Albert.
>> Uh thank you very much. I don't think there's one cost. Health care generally is very expensive. If we look at it in Africa and develop worlds, health care generally is very expensive because you have to do so many things and you have to do it. Unlike other things that things that you have choices of doing, but when it comes to health care, you have to do it cuz you're sick or you want to find out if you're sick or something. So, health care is generally expensive, but you have to prepare for it. That is what it is. So, you cannot say that there's one particular thing that's expensive. Generally from your out patient to your surgicals, everything is expensive in health.
>> Everything is okay. I was hoping to hear, "Oh, you know, it's the stitching. It's the the the He said, "No, it's everything." Dr. Bundi, when your case uh what is that Yeah, if if you can, but if not, if everything's expensive, say my tooth PA everything is expensive.
>> For me, I look at health in two ways.
So, preventive or promotive or curative.
So, I'm answering it from that perspective. And I believe that curative is always more expensive than promotive.
So, what we're doing here, having a conversation, somebody's watching, maybe will pick up a thing or two and say make a decision that will be cheaper than them coming 3 months later with something that needs a lot of medication.
>> That I think that's a great way to look at it. Cheaper to prevent than to cure.
Yeah, but then it's it's hard to convince people because, you know, uh if the prevention is not um has no direct side effects like right now, you know, it's like, "Oh, okay.
Uh go to the gym. Eat healthy. The the the the the That sounds expensive, but there's my body there's nothing wrong right now."
You know, it's like, "Okay, the the knees are doing what they're meant to do." So, I that we'll talk about that as well. How to change that mind frame around preventive health care. Dr. Crystal, for you, does that hold or you have a different view on expensive health care?
>> Um so, I do agree with the two panelists.
Um preventive health care is definitely Yes, it's costly, but it's less costly than uh curative care. And as our CEO has told us, you know, everything is expensive. And if you So, if you look at it from maybe the payer side, the insurance side, then I'd say what we seeing, for example, when he mentioned outpatient, then when it's an outpatient visit, you'd find that what is most costly is maybe the medication that's being prescribed. Or sometimes the extent of lab investigations that need to be done. And then, of course, that is expensive because if it's drugs they're being imported, all that.
Yeah. And then, if it's lab test, you know, there's reagents, there's people who are behind it, who are doing all that. Uh there's the equipment, which is insanely expensive that you need to be maintaining. If you come to inpatient care in theater, for example, the gases that are being used for anesthesia, insanely expensive. The human cost into it, if it's joint like everything really that goes into treating a person is insanely expensive.
We cannot escape that fact that healthcare is expensive and, you know, somebody has to pay for it. So, at what point are you paying and um to what extent? I think that's the question.
>> At what point are you paying and to what extent? Now, we'll we'll bring in the share aspect because majority of Kenyans fall under that health scheme and whether or not it's structured properly to address the disease burden that we're looking at. But, I want us to start from the point of disease burden and what the numbers are looking like. So, as of 2023, the percentage of non-communicable diseases, and here you're looking at hypertension, diabetes, and the likes, the numbers stood at um around 51%.
Then, that shot up to get this 61.7% in just 1 year.
So, you're having the disease burden going up and whether or not we have one the the the funding to manage that is what we're here to answer. And also, the why, because is it that Kenyans are getting more sick? Is it that, you know, there's something that is broken somewhere and again, we have the experts on this panel that will help us understand that.
Again, 51% is the estimated number of Kenyan adults who are living with at least one non-communicable disease.
Hypertension, diabetes, depression, and I'm happy that we have Dr. Bundi on the panel. We can be able to speak about mental health and the funding that is going towards mental health. We had cardiovascular diseases, cancer, or chronic kidney disease. Now, projected number of Kenyans needing non non-communicable disease services by 2035 will nearly double the current 15.4 million.
So, this is us future-proofing as well.
So, maybe starting again from uh Daktari from Luton Hospital, is [snorts] why we're seeing this sudden spike in NCDs, and do we even have the supporting structures to be able to manage these numbers?
>> I think we do. I think the reason why you could say the numbers are high is because of diagnostics. We have uh better machines now. People are more aware. Kenyans are relatively more educated. So, guys go to hospital earlier when they feel something. And then we have the technology right now to be able to diagnose early. In the previous In the past, it was not easy to diagnose because they didn't have the equipments, the technology, the people to be able to diagnose. So, I think the numbers are high because we are able to diagnose early. People are investing, hospitals are investing in better machine, better equipments to be able to find out what exactly is going on with with you. So, I think that's the reason why the numbers are high, which is a good thing because the earlier you diagnose, the better treatment you get.
So, when we have those numbers should not be a worry. For us should be a reason for us to invest more and to be able to take care of these diseases before they get worse.
>> Before they get worse. I like that.
So, I like it, but I'm wondering if two things can be true at the same time. Is it um that yes, we are diagnosing more, we do have more information, we're going to the hospital more, yes?
Is it that we're also suffering from these diseases more, like just in general? I don't know.
>> [laughter] >> That's all. I'm trying to think about um I don't know, growing up, hypertension, diabetes, like a lot of these non-communicable diseases were Yeah, it was uh TB and a tiba.
>> Yeah.
>> Uh campaigns against HIV, You know, that was it it was communicable diseases. So, I'm wondering if the shift is large is only on on on our uh diagnostics and us being a bit more health conscious or if indeed they are more prevalent. I don't know. Maybe Albert or or Dr. Crystal, Dr. Wundi can let me know.
>> I can I can speak on mental the mental aspect of it. The numbers are the the the data is indisputable. One in four Kenyans suffer from a mental illness and it it's not that there's been a spike.
Again, we are more vocal about putting terms out there, helping people to understand where they can uh seek help from. I believe growing up not a lot of us even had the language to say I'm depressed or I'm anxious.
And Mathare was seen as this asylum where the extreme go. So, we've changed the narrative a lot through advocacy.
But on your uh question about SHA and okay, I'm not a representative of the ministry, so I'll just have to speak as a health care provider within a public hospital. So, SHA is is working on the inpatient level. So, when you come and you're admitted with depression, postpartum depression and you're admitted, you're taken up in the hospital, they cover.
And the unfortunately, the issue is we are uh they don't cover for outpatient.
I mean, SHA doesn't cover for outpatient. So, what we are seeing is a patient comes in, admitted and then upon discharge, they do very well, but 3 months later they come back because they went home and are not able to get their medication. So, if we could find a better framework for SHA to also be able to cover for the outpatient, that would be growth. Again, with mental health again, um 4 million out of the 18 million people who are registered for SHA, only 4 million are actively contributing.
So, that might also contribute to the gaps that SHA can be able to to to to go all the way.
>> Yeah.
>> And I I believe that if these gaps were closed, because the framework is there, but it's the implementation that we start questioning, um, can it is it working optimally?
>> Mhm.
>> Very true. I like that you've mentioned, um, the funding gap, and it's very true.
Every time we talk about SHA, the numbers are always very nice as far as how many people are enrolled in SHA, but then how many are contributing? That's where the rubber meets the road, like you've said. But just to hold on to this mental health, um, system, healthcare system, and the healthcare system as a whole, we understand how the referral system works when it comes to primary healthcare.
Sometimes we tend to separate it from mental health. Tell us about if like the referral system works the same way, because I think Kenyans are beginning to get an understanding of if I have a homa, I don't go to Kenyatta National Hospital. I start from maybe CHP, dispensary, and so on and so forth.
Does it work the same way for mental health, and are Kenyans aware?
>> It should. So, I'll take you back to the Mental Health Action Plan 2021 to 2025, the Mental Health Task Force. So, it was this big, um, stakeholder task force that was set up, led by Dr. Njenga, went round the whole country looking at the status of mental health in the country, and they came up with recommendations. One of them was to incorporate mental health services at the primary level.
Let me give you an example of maternal mental health, which is very dear to me.
I believe that if we were to incorporate mental health services at the MCH level, the maternal child health level, we would catch these ladies who are getting depression during and just after they give birth. Because what happens is they come to Mathare having been referred months later when they are so severe.
So, one of the recommendations of the task force was to incorporate that. Has it been done? No. Back to my point of we have such good uh frameworks and strategies.
Implementation and follow-up is where we lack.
>> For that particular one on um the mental health assessment that was done across the country, where does that report sit?
At the Ministry of Health?
>> Uh yes, it sits at the Ministry of Health, but you can download it. And the the thing is it actually ran So, it lapsed in 2025.
Ideally, what happens after something like that is we're supposed to have a review.
>> Okay.
>> Review of the plan. We say, "This is what we said we would do." Um what happens next? So, we're supposed to then come up with 2026 to 2030.
The task force recommended for a mental health commission to be set up so that when power changes, regimes change, we don't see things stalling. So, the commission continues. So, has that commission been set up? No. So, I think one thing that I would really advocate for where I'm sitting and I mean, anyone in any big office, let's advocate for that review to be done and the commission to be set up.
>> The people that are supposed to do this is again the Ministry of Health or what body is supposed to see one the implementation of that report and the setting up of the commission. I just want to draw them out.
>> Um it's where the next step because we had um an an advisor that was appointed by the former president. We don't have one now.
So, that's ideally the person who should have >> Uh-huh.
>> So, basically what we're saying is we need political goodwill.
>> Uh-huh.
>> Beyond the ministry.
>> Beyond the ministry. Yes, I like that.
Mhm.
>> Yeah. When it comes to what you said about goodwill, that's we'll do that as a whole half hour, I don't know, full hour conversation. But, um I like that all of you have spoken to where we are as far as our diagnostics are concerned and how essentially our health care system should be working.
Let me ask now as we move towards a disease burden that is highly non-communicable, then like we said, prevention becomes half the game. Early detection becomes half the game. When you look at Kenyans culture, our our health care culture, what are the green flags, red flags that you notice in Kenyan in Kenya's health care culture? Are we proactive? Are we becoming more proactive? Are we more like, "You know what?
How do we deal with that? Dr. Crystal, I see you >> [laughter] >> I I feel like this is something that is probably is you something that you see on a daily basis and you can speak to it very well.
>> Um so, as a population generally, I'd say we have a very interesting health-seeking behavior.
>> Mhm.
>> So, uh you mentioned proactive versus reactive and I was tickled because um we are mostly reactive. So, we mostly only go to hospitals or even sitting on the provider side, we mostly see patients when you know, you're feeling sick or your child is feeling sick. Um and when we do attempt to be proactive, um I mean, there's the cohort that's doing, you know, doing well, taking care of their physical health, doing their annual checks, etc. There's that level of proactivity, but there's that proactivity that comes out very interestingly that I've seen with Kenyans where you you know, you tell the doctor, "Okay, so we've treated this child. Give me another cough syrup in case the other one gets sick."
You know, or okay, thank you for giving me amoxicillin amoxicillin now. Please give me a like double the dose so that next time when I'm sick, I don't There's that interesting but so it's not really proactive but >> [laughter] [laughter] >> very problematic. Always two but yes, yes, yeah. So I'd say that's the that's the interesting observation that I've made when it comes to our health-seeking behavior.
>> Aha. That one about yeah, wanting double the dose or yeah, because I can see that you might test Dr. Bundi akuna bacterial infection. Now the other one has a cough. See, you take two. Everyone takes amoxicillin. I see the problem though. Albert, is that true for you as well?
>> I think also one thing that we have to look at Dr. is also the issue of cost.
People really uh get treated depending on the cost.
Someone looks at their insurance and they say, "How much do I have in outpatient?" Before I go to hospital, how much does my family have? If you're a family person, maybe you are you have an insurance but it's only 100,000 for the entire family. So you're sick but you're like, "I cannot go because my son or my daughter will get sick and maybe I'm an adult so let me stay at home. Let me take my own." So there's that issue of cost and also the cost goes to the hospital like from the hospital perspective. We also look at patient's types of cost. How much is the insurance going to pay me? How much is Shah going to pay me for this particular patient?
So I'm treating you but at the back I'm also looking at the cost of it. So am I giving you a better health care? It's debatable. The cost is also a very important thing that we have to look at as a society. Are we giving our our patients the right medication? Are we treating them properly or are we just looking at the cost?
>> You're the CEO of a private health care institution. You're the best place to answer where exactly the line between the level of care and commercial interests, where those lines either blurry or they intersect or they're crossed.
>> I think the line is very very very defined.
The idea is that you cannot go into health care business if you do not care about the patients. So, you have to put the care first. But, also you have to look at survival. I think the biggest thing that we have as a society or in a health care sector is the fact that we have the doctors. Kenya is one of the countries that we can boast about, a third world country with properly educated. We have doctors, we have nurses. We have also educated population who know they're sick and they're not sick. The issue is that can the hospitals afford to treat you?
We are not sure if they can because they're not getting payments on time from the insurance, they're getting payment on time from SHA. There's also how much you can be able to to pay. The insurance are asking you, "Please don't go beyond 10,000 per patient. Don't go beyond 4,000 per patient." SHA is giving you limitations on how much you can go.
Normal delivery, don't go beyond 10,000.
So, you're always looking at the cost because if you go beyond, you're not in business as a private institution. But, I think that we have the goodwill in terms of we want to take care of the patients. That's a fundamental thing that is there in health care. That's what we want to do. But, also we have to do it at a survival rate. Otherwise, you're not going to be there anymore.
>> Right.
Sorry, this is so naive of me. I did not know that insurers and SHA give these kinds of caps and we'll hold that thought like just right there and come back because me I saw for the first time like I know it sounds crazy. You guys are health care professionals, you deal with this every day. Let's take a really short break. Hashtag is Fixing the Nation NTV. Ask your questions around health care financing and the disease burden in Kenya to the doctors and executives of various hospitals that are seated here [music] and we'll be more than happy to answer them in the next hour.
>> What's up? What's up, nation? My name is George Mokio from Mombasa.
A climate and environment champion.
I'm so concerned about the 15 billion trees.
>> [music] >> Mhm. Always lovely to see and hear from Fixers. We are live at the KICC for the Nation Health Summit and we're having a conversation around financing our healthcare system and the disease burden. We are joined of course on set by Albert Ogedi. He is the CEO of Luton Hospital. We also have Dr. Wanjiru Ogalo. She is a consultant psychiatrist at Mathari National Teaching and Referral Hospital. We also have Dr. Crystal Vlavu who is the head of corporate wellness at Minet Kenya. And now joined by Dr. Reuben Okoth, who is the acting director of medical services and research at Nairobi Hospital. Karibu sana, Dr. Reuben. Good to have you. Just before we went on break, we were discussing um the balance or the line for between profitability and care in in in private facilities. And I just learned from Albert that I didn't know insurance have like their own internal caps for like whether it's procedures or or specific treatments. So, in my head, the cap that insurance has is what I have as as a client or, you know, insurance taker. In that, if my limit is 500,000, 1 million, 2 million, 10 million, as long as I have not reached said cap, I can receive whatever treatment. Is that not always the case?
>> Um that's not the case. The case is that you have procedures and procedures have cost. So, you have how much you're going to pay for a CS. For example, a CS, depending on the insurance, maybe the insurance is 120, maybe it's 150,000.
So, as a facility, we cannot go beyond the 120 or the 150,000 that insurance has given us as a cost. Maybe outpatient is 3,000 for consultation. We can't go beyond that. So, there's always a very difficult I mean, battle between cost and providing a service because you always have to stay within the cost as a hospital. I have to make sure that when you come, I'm able to get it at give you our patient services for 3,000 shillings. So, there's always that part of it that you have to deal with.
>> So, if I require two back-to-back consultations, now we're over the 3,000 limit. What next?
>> [laughter] >> Um so, I'd say for a situation like that for example, of course there are there are defined pathways. So, for example, it could be that you saw a general practitioner and then you're referred or you need to see an orthopedic consultant for example. You'd still be, you know, it would still be paid for because it's part of that referral pathway. So, it's not, you know, like unnecessary treatment because again, what um like from the industry side, again uh the biggest thing is trying to manage cost. And it's a delicate balance because um if, you know, if if it's let to be uh free for, I'm not, you know, I'm not saying Albert, but people would, you know, if I build you 15,000 for consultation for example because you have insurance, um then it doesn't make sense. So, what most insurance companies do is that you take an average like industry average. So, on average, how much does it how much is it to see a specialist? Then it's usually at that average cost. How much is on average for lab tests for example or something like that. Then the averages are what informs most of the policies. Of course, if there's a need for it, um then usually you're able to push back.
Um and most people don't know this again because I think majority of people you don't have the knowledge. It's sort of um if you're not exposed to it, you would not know. But for example, what we do as um as an intermediary within Minet, then we are able to push back to the insurer and say, "No, no, no, but for this case they actually need this.
So, let them proceed. Let it proceed."
So, if you didn't have somebody to tell you that or somebody to do that for you, then you might get the short end of the stick.
>> Yeah. And a bit later, I will talk about medical advocacy and the importance of just having whether it's your insurer, whether it's a friend, a parent, a partner, some your doctor, someone go with you through the medical journey of whatever it is. But, Dr. Reuben, just to welcome you with a question on the gap that exists for medical research in in Kenya. Um and Africa as a whole. We've talked about it before. We had uh someone from the Africa Population um and Research Center and the numbers were were very shocking as far as how much research comes from the continent. Um when it comes to medical research, I don't know how big the gap is and how much more we could be doing. But, I know there's people doing amazing work.
KEMRI, um even KEFRI, but in the medical world specifically, how big is the gap for research?
>> Uh thank you and good morning. Um the gap is so huge um that is compared to a sea or an ocean for that matter. And um there's uh a frequent um reference to the privileged north vis-à-vis the underprivileged south.
And this is in relation to research specifically.
We have so much data. We have so much um information that is untapped um in the global south.
And it is because of underfunding.
So, we tend to rely quite often on funding from the more privileged north.
Unfortunately, um there is a perception which may be true that the privileged north does take advantage of the underprivileged south when it comes to data.
And um we we we we are seeing uh deliberate efforts now to try and change that.
And I do know even within our own country that we have um research funds and um if you look at, for example, NACOSTI which is uh mandated to really promote uh research in Kenya, they are advocating a lot for home-grown research and linking researchers with uh funding. And some of these funding is actually uh internal from uh within the country.
But what is more important when we talk about research and the the gaps is how informed are our clinical interventions if we rely on research from other continents. And we have seen significant differences in how our population responds to treatments, which means we need to do our own research.
Um to mention um a few other positive moves is when you talk of quality and the standards within medical institutions, then we are looking at um global standards such as ISO, such as JCI.
They demand literally that you must have an element of research as a medical institution and even uh at times dictate what percentage of your turnover should be dedicated to research.
And uh not to belabor the point, there are many other aspects that come with research, R&D, for example. How uh and copyrights. Who owns the copyrights when I am uh an employee of a particular institution and I come up with a uh life-changing intervention. So, we don't have uh laws, rules that um protect researchers as much as we have in the global north.
So, other than funding, there are other small issues that we still have to put our say in order.
>> Mhm. It's interesting that we land on research and I'll look at what was most recent in the news and it's still making headlines cuz we did see the PS of Health respond to it yesterday, which is the establishment of a quarantine facility here, of course, by the Americans. And the reason behind that was two things. One, you actually are better informed and well researched to handle this. And second is the aid aspect of it.
Is that if you allow for this quarantine facility to be set up, then you will be able to get access to funding, which was withdrawn from the United States upon that administration's takeover. So, there is clearly negotiation that is happening with a continent on matters health, but are we adequately prepared to present our needs and those of our people fairly in a way that protects our people when we are negotiating for these things, because collaboration is a very big thing and I'm happy that you did point to the copyrights. Who gets the ownership of that? Is it the person who's funding it, publishing it, or you, the person who's behind the research?
That's a much bigger conversation. So, do we have enough as the health care system and stakeholders to be able to present ourselves at the table as equals because we actually do have something to offer.
Dr. Reuben, I'll start with you.
>> Uh thank you. That's it's not an easy question. However, I must say that when we talk about research and um what goes into research, it's not just, you know, what the institutions, the governments do.
Um I think what is most fundamental is protection of the research subjects. And um that should be core to any collaboration, should be core to any discussion, whether it's between government, whether it's between institutions because at times we do have research that is, you know, between teaching institutions or private um institutions.
Um in Kenya, we probably have better laws that protect research subjects.
Not as good probably in some of the East African and, you know, sub-Saharan African um countries.
Um but there is a deliberate effort within the region, um even within the East African Community, to build up research blocks such that we generate research internally, which is targeted to benefit the population within the the East African country.
Um I did allude to the aspect of funding that tends to flow from north to, you know, to the south. And at times the conditions that come with it might not be very palatable.
But it's upon uh we as the guardians of our patients, the research subjects, to make sure that any collaboration that we engage in first prioritizes the interest of the population and the research subjects.
>> Absolutely. And on matters data, because research is backed by data for you to get financing. So, it's a cycle by itself, yeah? I want to throw this to Dr. Vundia as far as mental health data is concerned. Now, you work in an institution that has been there since time. So, there's a lot of data that is domiciled within that institution. Are we using that data properly to one inform whatever preventative measures or even putting in say mechanisms just across the country in terms of the mental health conversation because it's almost as if we are denying the problem exists.
Um but for us to acknowledge is the numbers have to speak to it. So, what data is coming from the Mathari Teaching and Referral Hospital and are we actually putting it to use?
>> Yeah, so I am when it comes to the data that has been there since the establishment of Mathari, there is a lot of data.
But only recently, I believe it was just until last year did we establish the School of Research in Mathari Hospital.
Uh yes, we are a teaching and referral hospital, meaning we train residents.
So, anybody wanting to do a master's and a specialty in psychiatry passes through Mathari. They do a thesis, they do a dissertation. So, we have so much uh data, so much research, but the problem is a lack of confidence as well from us. So, we don't publish.
I didn't publish my thesis and it's a wonderful um study. And many of us, we just want to pass and go and do the next thing. So, the beauty of >> So, why didn't you?
>> Uh confidence.
Confidence. I just felt like these journals, maybe let me explain publications are at at the global arena.
And sometimes when you submit your study to um a journal I'm like I'm trying not to be but sometimes go right ahead. I know somebody who submitted their study for a journal and and they were told that their English is not up to par. You know, it's it's sounds a bit of a race issue, but now I don't know if that's something that we have told ourselves there is fear, there's confidence, but Madurai has taken it upon itself to set up the school of research and this year they sponsored a bunch of us. I believe about 15 to do a course in grant writing.
Because in grant writing at Aga Khan.
Because they want us they are pushing us like publish. So I hope I will at the end of this not only publish, but seek for a grant. So we've got a lot of good things coming up in Madurai. It's just I'm happy about the current leadership.
They've they've seen that you guys you can't keep doing this academic sort of research and keeping it in the library.
Let's do more.
>> Cuz it doesn't help anyone because what I'm seeing is in talking about mental health, the the biggest pushback we keep getting is okay, so where are the numbers?
Where are the numbers? And a lot of the numbers that are referenced are not even from this jurisdiction, unfortunately.
There's no concrete data that is coming from Kenya from the continent that would allow us to actually speak to one the solutions that now we are seeking and also the funding. There's a portion of the budget Kenya's budget that is supposed to be going towards mental health.
>> Yeah.
>> WHO recommends 5%. Kenya is allocating less than 1%. There's a gap there.
>> Let me just speak to that and then that's very accurate, but I would say that yes, there is a scarcity of the data, but if again you were to look into the task force, the mental health action plan, they came up with a huge report that has so much data. They literally went round the country collecting data.
There's so much data there, but [clears throat] I believe that we need also more contextual data and also more radical things like clinical trials, things that are being done there like in the West currently they are exploring new medications for postpartum depression that don't include antidepressants. So, medications that are similar to progesterone.
Where are those radical radical studies? However, I'm really playing devil's advocate. There are some amazing things being done by Aga Khan mental health department.
Prof. Twoli is doing fantastic work in terms of looking at the genetics of mental health. Can we isolate the genes that are causing X condition and can we then later think of treating it at the genetic level? Yeah.
>> Let me to add. You've talked of genetics and mental health, which is sorry I'm jumping in because mental health is a field I'm very passionate about. I work in the critical care unit and it's one of the areas where mental health really becomes very very significant not just to the patient but also to the relatives. However, in addition to genetics and mental health, there's another research which is being done by Prof. Sande Nairobi Hospital and a team from I think Washington and it's looking at MRI magnetic resonance imaging and the utility of that in predicting mental illnesses.
And we do talk of you know mental health or mental illnesses being genetic meaning learning within families. So, are we able to use for example MRIs to predict if you're going to get a mental illness.
So in addition to such, you know, ground breaking studies.
Um The reason why we don't publish as much and I wanted to also add to that is Um We or many institutions do not dedicate time for research for their employees.
Which is something we need to advocate for at all levels of uh education or academia. That's that's in my view the biggest impediment.
>> Hm. Thank you. Um okay, Albert has some Okay. I I love that we've gone into into this mode of getting to the why.
Research data are essentially the foundations that we can build a strong health care system on. I mean, by the time Yeah, like we said, we're taking data from so many other jurisdictions, whether it's mental health or other things. So we may not be catering to our needs as well as we think we are. But Albert, please respond before we >> I think also one issue that we have to talk about is the subjects. We have a lot of suspicions from the subjects.
If you go through this process, we've had a lot of proposals, especially like the MRI from United Imaging telling us that we want you guys to talk to your to your patients to give to allow us to get some data so that we can be able to do some more research and work on things that can possibly help us. But everyone is suspicious about it. You see there's the moral part of it, the honesty that the institution has.
>> What reason?
>> So there's a suspicion and there's a lot of pushback from the subjects themselves. So you are the institution, but you don't want to push your patients to do We've had people talk about clinical trials with us, tell us we want to do clinical trials. But every time you try to ask the patients, are you willing to enroll into this trial? It's always no. They're suspicious. You want to sell it to the US, you want to sell it to China and all this. So I think there needs to be a lot of education around it. This thing is for your own good. It's for us because these people need to work on something that can actually help us, you know? They know what is going to genes and look at it.
They look at what are things that are affecting Africans, what can be done, how can we zone it, how can we assist.
So, I think we need a lot of education around clinical trials and research for people to be able to understand.
>> I get that and it it shows in it's a culture thing perhaps, because think about even a while ago people would feel some sort of hesitancy towards like donating blood, little things like that, you know? Or being an organ donor and it volunteering for a clinical trial. So, I think it's also a culture shift, like you said, that needs to happen and we need to do to trust our medical professionals a lot more. Um but I do think it's also a bit of a top-down issue. Let me walk you through. When things are not communicated well, suspicion builds. So, if for example, I hear that, "Oh, my medical data is going to the United States." I'll be Immediately I feel like protecting it for no reason. Doesn't matter that it's aggregated data, it's whatever. I'm just like, "Ah, what are they doing with my data?" So, then if you come to me and you say, "You know what? Actually, we want to potentially study to do MRIs to figure out, you know, if we can predict incidences of mental health and we want to take an MRI of your brain." I'd be like, "For what? So, you can sell it to the States." So, it's a two-pronged problem. Um but to to gain a bit more trust, I think is something that we can also talk about, um building the the trust between the health care professionals and the patients and also caregivers and other people who are involved. And I think that's what we'll focus on a little bit in the next hour as we talk about the money aspect as well. We'll take a really short break, but when we come back, let's talk about all those things, medical advocacy, building the trust, and of course, the disease burden and what it's costing households. Hashtag is Fixing the [music] Nation and TV. We'll be right back after this.
At Signal, let's get into our news fix for the hour. Now, the Kenya Medical Practitioners, Pharmacists, and Dentists Union has given the Kenyan government 48 hours to disclose the details of a reported US-backed Ebola quarantine facility in Laikipia. The union opposed plans to host Americans exposed to Ebola, warning Kenya risks becoming a containment zone for foreign health crises. KMPDU threatened nationwide industrial action if the government proceeds without transparency and public participation. The proposed facility comes amid a regional outbreak that's happening in the DRC and Uganda.
Something that we've been seeing, of course, and keeping track of.
And I'm with the KMPDU.
>> Yeah. Yeah, absolutely. It's I I don't know how to feel about the PSC's response yesterday, and maybe I can just get that one of the doctorates who I will throw this to uh doctorate from Luton Hospital. Given that you're running a health facility, if we happen to have a case of Ebola, is are we opening ourselves up to, you know, a situation we cannot contain? And this is a strain, first of all, that does not have a vaccine whatsoever. And [snorts] uh people, you know, doctors within the space in Uganda have found a way of containing it. They've closed their borders to DRC. Yet here we are saying, "Y'all are welcome. We're very hospitable."
Would we be able to manage this?
>> I can only speak for from a medical point. I'm not a medical doctor, but what I know is that we have professionals who are prepared. I think this is part of the thing that Kenyans needs to understand. Kenyans needs to understand that we have doctors and professionals who are prepared for for this. They may not be, you know, it may not be they don't have the full information, but I think they are able to manage. You know, if someone walks in at Nairobi Hospital or at Luton and have a Ebola, I think we have enough doctors who are prepared for this in terms of knowing what to do. The only thing that I think Kenyans are worried about is that the information part of it. Do we have enough information from the government? What is going on? Are they Do we have cases here? What exactly is going on with the US today? Have they seen something that we haven't seen? So, I think it's an information point of view, but I think we have medical doctors that are able to handle the situation in case that arises.
>> It's a vote of confidence.
>> no. I think I was saying that yesterday. I don't know this Correct me if I'm wrong. My doubt is not in the Kenyan healthcare system, by the way, that we can handle.
It's why are we becoming uh >> No, actually, now as a doctor, so you you've I I like what you've said.
You have no doubt in the Kenyan doctors.
By the way, we have fantastic doctors.
But, what about our system? I think for the last 1 hour we've been talking about systemic gaps.
Suddenly, has the system changed?
>> All of a sudden.
>> You know, so and I mean, if we if we can get a clear it's not coming out very clearly. And as a medical doctor, actually, I served on the frontline during COVID. Dr. Reuben, I don't know if you remember when we had the tents out there.
And we were prepared then. Nairobi Hospital, they gave us the shields, the uh the suits and everything, and then we felt con- confident. We had trainings, we had and we knew we were why we the why The why is so important. We knew we are preventing this COVID from going to affect my mother.
What is this? This doesn't make sense.
We don't feel prepared. I don't understand how a system which has so many gaps is being thrust upon such. So, I am doubtful.
>> And it's good to have that balanced approach because yes, the hardware might be okay, the software is not okay, or vice versa, or both are just not working, and it's not okay. And as we wait to see what Kembi I Due escalates this matter to, and what public participation actually looks like in terms of the setting up of this facility. But, as we were talking with Maryam yesterday, it almost feels like the deal is done. It's I don't know what you all are negotiating about.
>> To be fair, and I'll be very honest, the communication from the CS makes it sound like we're in a negotiating we're in a talking stage, while from the other end it's a done deal.
>> It's done.
>> It's a done deal, and I think it's kind of managing us so that it's not like, "Oh, we didn't do this without, you know, consulting you guys." It's it's a bit of management. But, um I think actually, Dr. Bundi, you found the words because for me um the doubt was Yeah, I I believe in healthcare professionals, so it's not a capacity problem in terms of like individuals or even yeah, the system sometimes. It's just like, yeah, those things that you've mentioned. And also, why why are we allowing ourselves to sort of become like a playground? Anyway, I don't want to get too political. Um there is cooperation and and sometimes you can tell when something is a is a cooperation versus you're kind of just being handed a hot potato and being told deal with it. A hot potato that they don't want to take back home. But, let's get back to our conversation around healthcare financing in Kenya and the disease burden as it stands currently.
Uh we have some questions from the audience that we'll be taking very shortly, but just before that, I wanted to ask the doctaries and um executives on the panel a very quick question.
Chat GPT AI as a whole, is it making us better or worse patients? Really quickly before we get to hear from the audience.
Are we better or worse patients because of AI?
Dr. Crystal, go for it. I see I see I see the wheel spinning. Go for it.
Um I'd say neither nor.
>> Mhm.
>> Uh because, I mean, before AI there was Google, and it was the same debate.
And I do get, you know, sometimes um yes, we do become worse patients because why are you telling me it's just a cold?
And when I googled or when I aired my sister my my symptoms, you know, it was actually lung cancer. Why are you not doing tests to rule out lung cancer?
But um on the alternate side as well, I do think it has helped some people with advocacy because there are people who have recurrent symptoms. So like if you've treated me for a cold six times in the [music] past 3 months and I have my seventh cold and you're telling me it's a cold again and I consulted the internet and it tells me no, at this point maybe it could be this. Then in that and there are people who shared such stories. Then in that case, it becomes something that has helped patients to advocate for themselves. So to the doctor, you know, it might look like why are you bothering me? It's a cold. But yeah, on the inverse, it has assisted some people with advocacy. So finding that balance is what I think is important.
>> For for mental health though, I would say it's making patients worse because we've seen situations where AI has encouraged people in their delusions. And you know, there's one Tik Tok, I think somebody was sharing how they went to AI and told them that they are seeing things and hearing things. And they've told their next of kin about the things they're hearing and the next of kin are not believing them.
They're saying, "Go to the doctor." And AI says that, you know, "That's not right. Your family member should support you. They should try and understand you." And this person is obviously having a psychotic episode.
So AI has also people have used it as their therapist, which of course we understand the limitations because there's a lack of empathy.
I've tried I tried it to use AI as a as a coach and as a therapist.
>> How was that?
>> And I couldn't reach my my therapist said time and I said, you know, let me try. So, I asked as a coach, what would you do? I just felt the advice was very generic.
>> Uh-huh.
>> As opposed to what a human being would have told me. It was very something I would have, you know, not groundbreaking. So, in mental health, I'm a bit iffy.
>> And also seeing how it's really opened up a can of worms cuz everyone is self-diagnosing now and it also points to a gap. And we have to acknowledge the gap being if I feel the cost of going to see a therapist is something I can't meet and I have a free app on my phone that can give me a semblance of comfort to understanding what it is that I'm going through, then it works. So, it still goes back to financing and funding gaps when it comes to healthcare.
>> Dr. Reuben, yes?
>> Yes.
I I I do like that my colleague panelists doesn't want to commit to whether it makes patients better or worse. Um but maybe to throw a spanner in the works, um how how is or how does ChatGPT work?
And I think that's what maybe the patients needs to understand that um what ChatGPT will give you as your diagnosis, as an explanation to the symptoms you put, is based on, you know, just a collection of data, which may not be um correct.
And that to bring in the aspect of empathy that Dr. Bundi has uh brought in.
And and now um my my solution to that is yes, um using ChatGPT or Google for that matter can help a patient understand better that uh they have a problem that needs um a doctor's attention. But not use that to make a diagnosis or maybe to challenge what um a doctor may uh prescribe or advice.
Um, on the other side, doctors are also using, um, AI a lot more.
Um, I'm seeing a lot of AI courses from Harvard to Mayo, all training doctors on how to use AI. Because AI should be an should be an enabler, not the solution to, uh, the doctor, not a solution to the patient. It should be enable us to understand our symptoms better so that even when we are going to see a doctor, we are able to explain better.
That's how I would look at it. I will also not comment if it makes patients better or worse. [laughter] >> A like a tool, again, as always, a tool, not a replacement, not a diagno- yeah.
Okay, I was I was about to say not a diagnostic tool, but you get it.
Something to help, but not to do the actual work. Albert, in your view?
>> I think I think so. I think, uh, we have a lot of challenge when it comes to AI now because, uh, there are other things like the MRI, for example, that typically a radiologist will take some hours to read. I've gone to forums where most countries now, the well-developed countries, are bringing that as part of it. Uh, you're able to get your results in about an hour or two as opposed to when you're doing, uh, 6 hours or 7 hours. So, as the case is, an enabler that has to be there. But, I want to comment about social media in general.
It's just not ChatGPT. I think also one of the things that affects us in hospitals is TikTok. TikTok is even worse than ChatGPT.
I mean, you have patients always taking TikToks. You have some nurses, I think you've seen them in social media, nurses on TikTok with patients. So, generally, we are in an an environment where there's a lot of social media, and we have to handle it that way. You have a patient who is threatening you in social media. If you don't do this to me, I'll I'll post you on social media. I'll do all these things. So, basically, it's a social media challenge that we have, and we just have to navigate around it and find a solution.
>> Right. I thank you for broadening that as well. And you're right, there's a an ethics conversation to be had on on all ends because yeah, threatening if you don't give me this prescription, if you don't do this, I'll I'll post you on on my Tik Tok or my Instagram is very problematic. So is maybe perhaps posting whether it's a patient's personal details or things like that. But then there's the other half where if I'm a nurse and I say come along with me on my 8, 10, 12-hour shift and see what a day in the life of a nurse looks like, it gives you insight into the life of a medical professional.
>> Correct.
>> So it's it's a balancing act. Um I like that you guys have given us such a broad perspective. We're getting to the audience. On the AI question though, I wanted to talk about the feedback loop that AI likes to give. Which is we all love to hear someone say yes, you're right, you're correct.
>> Yeah.
>> Well done, ta-da-da. And how big of a danger it it can also be.
>> Mhm.
>> Because uh you've also seen incidences where people ask like AI, oh I'm sorry, I stabbed my friend, it but they really annoyed me. They're like, you know what, they shouldn't have done that.
>> [laughter] >> It's like, okay, where do we draw the line? But um there's a gentleman in the question in the audience with a question.
>> Uh for the panel before we get back to the financing of our healthcare system.
He's actually dressed in black. But as we talk money matters throughout this half hour, we'll also take questions from the audience. So come up with a swahili you know what to call now and let us know and we'll bring the mic over to you. It's the gentleman with the glasses and the lady next to him as well. Yeah.
>> Okay.
>> Good morning.
>> Morning.
>> My name is Robin Munene Nyaga. I am a nurse. I'm also a founder of a startup where we work with mothers.
And we also focus on postpartum maternal health and anti-natal anti-partum maternal health.
>> Mhm.
>> So my first question goes to our first discussion. We were talking about affordability of care and access. So currently we are having around 42,000 new cancer diagnostic cases.
And out of the 42, almost 70% is advanced. And you know how it feels when you meet those patients. So, what can we do to incentivize these patients to make sure that they can access this care earlier? Then, my other question is to Dr. Bundi.
The nursing ratios to patients, especially in Mathare, are crazy.
Because you can get to a point where there are only two qualified nurses with around 80 to 90 patients. So, what are we doing to ensure that there is health care workers safety? Because we tend to focus so much on patients, but we forget to protect our health care workers.
The other question is, how do we create a system that can be able to accommodate the needs of these mothers from the early stage of maternal care? Because most of these issues arise between the 20th week up to to the 28th week, and they go unnoticed until we get to the postpartum stage where ending up with postpartum psychosis. And when this mother comes, we even affect the attachment of this mother to even the baby. So, how do we create a system that works for them? We may be working on the solution, but how do we even integrate these solutions that we have with the government systems? Because access to those systems and integrating them is also another challenge.
>> Thank you. Maybe let's answer those ones so we don't lose track. I think there's like two for Dr. Bundi, and maybe one can be taken by Dr. Christol. I think around Yeah, yes. Yes. Yes, first one.
>> Yeah, one was on human resources for health because you touched on the nurses. So, let's step back and look at human resources for mental health.
Yeah, in general. So, we know that we have, as we said, one in four people suffering from mental illness in Kenya.
We have a population of about 50 million. So, that puts If we have 150 psychiatrists, let's start with psychiatrists. We have only roughly 150 registered psychiatrists.
If you do that, it means that >> [clears throat and cough] >> if you do that ratio, you can see the the gap. Basically, it's almost like one doctor is managing 380 something thousand patients.
My my math is not good. Mwalimu of math, don't don't come for me. But you can basically see um there is no way even if I'm a very good doctor, there's no way I can service 380,000 patients.
And this is why we pushed for decentralization of mental health services from Mathari Hospital, which was one of the things that we actually did achieve in the task force. So, Kiambu Level 5 Hospital has a psychiatrist. Muranga has a psychiatrist, right? But unfortunately, what we did is we can't successfully decentralize without investing in those smaller facilities in the Level 4 facilities. Because what you find is for example, in Level 4 facilities, they have a psychiatrist, but there's no inpatient facility. So, the psychiatrist goes, does a clinic. If anyone needs admission, they send back to Mathari.
So, that feeder system, Mathari's carrying such a burden um of this system because we are the referral. So, everybody is referring to us, and we can't refer to anyone else. So, that's why our nurses are overwhelmed. That's why the psychiatrist, I can tell you, personally I'm overwhelmed. So, what can we do?
Let's invest in the smaller like I'm calling them smaller, but I mean Level 5 hospitals. Let's equip them. Let them have a good number of nurses at that level and a good number of psychiatrists. So, that's that's why I keep saying we cannot have a mentally healthy nation with less than a cent, which is what we are allocating for mental health. So, of course, we need more funding. But also, we need to invest, decentralize the investment. The other question that you said is what can we do with these mothers? Because we are catching them at when they are very late. So they're they're pregnant, they come later when they are they have postpartum psychosis, and we know how dangerous that is. Babies can die, mothers can take their lives. So, I highly recommend for the integration of mental health units within MCH because 90% of pregnant women, actually it's 95, go for MCH. We've done a good job. So, they'll go for their clinics, they come for their vaccines. So, let's meet them at that point. Let's have mentally mental health clinical officers, nurses, uh medical officers who are capable of screening, and that's that's everything um that can make a huge difference.
Screening for postpartum depression, screening screening for cancer, your question about cervical cancer. So, intensify the screening, and also working with community health workers.
We have so many community health workers, and they know the women who are at risk of developing these uh mental health disorders. So, those are just some of the recommendations I would I would propose.
>> Thank you, Dr. Crystal. Perhaps speak to the the screening questions as well and and and more of a preventative approach especially when it comes to cancer.
>> Okay. So, thank you, Robin, for your question. So, um you mentioned 42 about 42,000 newly diagnosed cancer cases, and your question was how to, you know, catch them before they get to the advanced stages, and how to incentivize early screening. So, um I'd actually structured my question in a way that brings back to my response in a way that brings back to the discussion. And so, I would say um initially at the start we were speaking about, you know, why we have increased numbers that we are diagnosing not just for cancer, but also for the other NCDs, and while we did talk on the fact that we have better technology, we are better able to diagnose that, I think there are other things that we should be cognizant of that cause um you know, that has led to the increased diagnosis is yes, that but also we are now you know, our population is growing.
The more people you have statistically, the more issues you will see within the population. And then uh we have more awareness. More people are coming out speaking about these things knowing that you know, that symptom you're ignoring is not just a symptom, it could be a cancer, it could be an NCD. And then um we also are seeing increased lifestyle risk. So, our lifestyles today, for example, are not what they were 20 years ago as a population. We are more sedentary, our food is more processed, um we're less active, we are consuming more alcohol, we're consuming more tobacco, etc. etc. So, our risks are also increasing and all these cumulatively now lead to the increases in diagnosis. And then because of our poor health-seeking behavior, where we are more um curative than we wait until it's unbearable at home. Um and then now when it comes to now the late diagnosis as well, we go back to the discussion on why we go to the hospital late. So, yes, poor health-seeking behavior, but also funding of health care. And I think Albert had mentioned it, for example, if you have a limited outpatient um cover, you would say, "Let me sacrifice this and let you know, either my spouse or my children uh utilize the benefit more. Uh I'm an adult, I can tough it out."
Um or if you don't have insurance cover, then you're wondering, "Am I paying rent or am I paying for that MRI that I need or that CT scan that I need for diagnosis?" As again, as we continue to postpone these things, you know, cancer is something that grows exponentially.
Like the difference between today and 3 months down the line when you finally have fundraised enough money to get that imaging or that um blood test, you know, you'll have gone up maybe a stage or two or even three. So, um, again, I came across some very interesting statistics that I'd like to share with regards to the out-of-pocket payment for health care. So, it's a bit old. So, as of 2013, I think, um, it says about 45% of, um, total health care costs were being paid out of pocket.
So, and for the other 55% um, was, you know, some form of insurance, whether private, whether public. At 2013, that was still NHIF.
So, um, and then you find that again for this, so we usually say statistics, you know, like we have only 2.4 4% of the country right now that is covered by insurance. Like that's insurance penetration in this country at, you know, 2.44%.
That's a very small number. Um, and that's usually penetration is calculated by the cost of premium. So, what you pay to the insurance fee to be covered. So, when you look at, um, the people who are paying this premium, the people constituting the 2.44% of course, if I pay, for example, I may be covering not just myself, but my family. So, that coverage now comes up to about 25%.
So, it's still a very small number. And within that 24% of the population that's covered, then you still have, you know, the varying my outpatient is 50,000, your outpatient is 300,000. So, the tests that you can access are different.
And then, um, the model that has been, not just in Kenya, but world over for insurance is that um, there's a priority that's given to curative medicine. So, you would find that some things that are more preventive are exclusions or not covered with within your insurance cover. So, as we as this trend has been continuing, we sort of incentivize late diagnosis because if we're not able to pay for, let's say, the vaccine for cervical cancer, we're saying, "Wait till you get the cancer, then we'll pay for the treatment."
And the vaccine is, you know, that like at most, the most expensive one, I think, is like 70,000 a pop.
Uh but if you're treating the cervical cancer, if you're paying for radiation, you're paying for chemotherapy, you're paying for surgery to, you know, remove the tissue, it's going into the millions. And the same thing could be said for colon cancer. If you say you're not paying for a colonoscopy, um then you're paying for colon cancer down the line in the future. And so, these are some of the conversations that we're having within the industry as well. And especially like now from where I sit as head of wellness in Minet, that's a discussion we're having internally. Like, how are we then pushing um the industry as well so that we are not, you know, incentivizing late-stage complications, and not just for cancer because, you know, like renal failure versus early treatment of hypertension, stroke versus early treatment of um cardiac disease. So, um that's where that's where we're headed. And that I think that should be the priority in conversations as far as um prevention and early treatment is concerned.
>> Mhm. Thank you. That was incredibly comprehensive, and thank you so much for that. I'm thinking through our healthcare structures and thinking CHPs have such a large role to play when it comes to preventative healthcare. And maybe that's something also that we should look at. How much funding goes into level one, level two, level three cuz I think a lot could be done to reduce the the financial burden of on going up to level 4 5 6 if we catch things at 1 2 3 or even if we're informing people about lifestyle and then and then and then yeah, doing all this work. But I know there's a like two more questions. Maybe we can take them.
>> There's a question here and it as Dr. Crystal was speaking, I was just thinking about the challenge that is presented to insurance underwriters because then that's another level of financing. You say two less than 3% penetration, but how that is structured more to the formal sector and not the informal sector, but majority of Kenyans and the are within the informal sector. So we are actually excluding them from the insurance conversation which if we're going to have a comprehensive conversation on health care financing, then the insurance model also needs to be re-looked and it has to be challenged based on the reality of where Kenya is right now. Uh you had a question?
>> Morning, everyone.
>> Morning.
>> I'm Faith Nyanchama. I work with Oasis Health Care Group.
Uh at Oasis we're measuring a network of facilities across the country and I can say we are we've started embracing the preventive preventive care uh because we've been able to introduce the wellness packages in all our branches.
Uh but my main question goes to Dr. Crystal uh on the same about regarding the wellness packages.
Um a lot of insurances, yes, they've they've they have that package for the wellness package for a household, but together there are limitations. You get like for a household a spouse and maybe two three kids.
They're being given 30,000 20,000 for most of the insurances, but you get uh this this money is also limited.
There are some limitations that you can only do these wellness for the the spouse and their principal contributor.
And a lot of concern that I've raised from the patients because I work hand in hand with patients on daily basis is once they do these wellness packages, the the deduction is also affecting their outpatient overall outpatient cover. I don't know whether that is what happens with Minet, but I can say for other insurances, it's happening.
And also for the share for the share packages, they've also introduced that, but it's also affecting their general outpatient cover. So, a lot of clients shy away from doing the wellness packages because this package is costing 20,000 and maybe we have only 100,000 for our outpatient. So, how how are you going to work around that to ensure that these people uh our clients are also going to embrace the doing the wellness packages so that we can get these diagnosed at an early early stage. Yes.
>> Uh I'm going to add to your question. I'm not going to try answer your question.
And um as a doctor and also looking at Minet's wellness, um I have a concern and I think you are speaking to it.
You're talking about packages for wellness.
These packages are tests that we do. But is that really what constitutes a wellness? Maybe she could speak to that as well.
>> Um thanks, Faith, and thanks, Dr. Ali.
Uh so, you've taken a few words out of my mouth. Uh but basically um to answer one bit of your question, and I think it ping back it pings back again to what we were talking about when we say you can spend X amount of money. So, um this is a conversation that is had at the point of you know, design when you're designing the benefits package. So, like we said for example, um my out patient could be 50,000.
Dr. Bundi's could be 100,000.
But, there's something within her package, like maybe her wellness is restricted to 20,000. So, she has more out patient than me, but I can use my full 50 for wellness if I wanted within a year. So, that's a conversation that's had between ideally between the underwriter and the client, whether corporate or um individual, at the point of benefit design so that it informs, you know, the um how much risk is being undertaken.
So, that is a mathematical probability question. But, yes, so you will have some covers that have um Usually, you don't have wellness as stand-alone or as full out patient benefit. Usually, it's a sub-limit within your out patient. Uh I hope that's not too much jargon. Basically, it's like I give you 1,000 shillings and I tell you of this 1,000, your budget for nyanya is 100.
You cannot spend 200 on tomatoes. That's basically what the sub-limit means. You have a budget within that amount that's allocated. Now, um Part of why this is the case again is because um if left to the free market, you know, we assume that even in economics, we assume that all players are rational, but they are not. So, somebody will take it as a blank check and run unnecessary tests, etc., etc. But, when it comes to the discussion of wellness packages, I know it's something that um we do sort of to standardize what we are checking or based on a general risk stratification.
But, again, preventive health care does not only happen at the point of a wellness package. So, um if I'm consulting my GP and this is a doctor I've seen for maybe the past 5 years, they're the person that's been seeing my family, they can prescribe relevant blood work or relevant tests that would be screening for maybe a cancer that's not covered within a wellness package. Again, something that we've been having discussions and I look into innovate around, for example, is you'd find from standard wellness packages, they test pretty much the same things. So, if you're doing the same wellness package year on year, yes, you're seeing, you know, like my full hemogram, for example, was normal last year, was normal the year before, but that's um you know, the results of a hemogram are usually valid for up to is it 6 weeks?
So, it's not giving you So, you know, we keep doing it to what benefit?
Every year, I have like a a pap smear in my package.
Standard or a prostate screening in my package. Standard guidelines say that this is something that should be done every 3 to 5 years, depending on your risk profile. So, again, if I'm sticking specifically to this package to this package, there are other, you know, like next year I would want to test for colonic cancer to screen for that. The other year you'd want to screen for a different cancer.
So, I'd not I'd say that, you know, the standard or the wellness packages are not the one-size-fits-all solution.
And so, this preventive care should be a lot more thought or tailoring to specifics should go into the preventive medicine and the wellness discussion than what is standard practice currently.
>> Okay. Well, I'm thinking some of these things are conversations you have when you have a doctor that you are in, you know, constant conversation with, which is a privilege that a lot of Kenyans have. Because then you can say, you know what you did the pap smear last year this year those funds could be used to do this. So hmm I don't know if Filaris there's so many tiny gaps that we need to close in but I know there's a few more questions from the audience we can we can ask >> from this corner.
>> So your name?
>> Franciska.
>> Uh good morning.
I'm a pharmacy student from USIU and actually my question was on the AI topic that you just discussed on. I feel like AI's a phenomenal entity that has taken the space of our generation so far. It has both its positive and its negative especially in the health care system but I feel like sometimes we've not seen it as a source of data like it tells us something about especially where health care is directed which is our patients.
And I feel like the common mwananchi is not really knowledgeable about their health or their body. So they go to a site to a place where they know that they can easily get information because maybe they don't feel like their doctor gives them sufficient or the health care officers don't give them sufficient sufficient knowledge about their health or about their body or what they're they're going through. So I feel like my question is do you think we have done enough to inform the common person without our many jargons about what is actually their health? Is it sufficient knowledge so that they don't think that I don't really get as much knowledge from the doctor or from the pharmacy? So if I go to a pharmacy I'll just be given a drug and they'll be like take this one times three and I move but I'm not really getting the sufficient knowledge that I need and I feel like that's like a gap. So anyone can answer this do you feel like there is sufficient knowledge being passed to the common man that they know about their health of.
>> Allow me to start and um I think I'll agree with you on uh that fundamental um aspect about communication between a doctor and um a patient.
Um quite often and um being in a tertiary hospital, uh we do get many referrals and um unfortunately, the patient is scarcely aware of their condition.
Um we did talk about cancer late diagnosis. You find quite a number are not aware of how advanced their condition is.
And um it cuts across all disciplines, not just uh cancer.
We need to learn as doctors to communicate better with our patients.
Um the days of uh you know doctors being small gods is is gone.
And uh it's basically with the era of communication and the era of you know increased access to alternate sources of um uh information.
Um I did like um the comments by our host and that that is in regard to uh continuity of care because that is also a big gap in our system as it is now.
If you move from you know your village, we tend to use West Pokot quite often and and you move to Nairobi, what are the chances that your data is going to be integrated or to to be accessible to the doctor who is going to attend to you here in Nairobi? They're going to rely on your memory and what you're able to give.
I know of course there are efforts um through the digital health uh initiatives by MOH to link you know uh patient's data across all sectors. But, that is still not going to be the solution.
I believe the suggestion of linking individuals to doctors in what is a primary health care kind of setup, where these doctors take care of your basic needs, and then escalate or refer you upstream, when you need specialized tests, when you need specialists. That is the model probably should approach. And it has been tested and it has really survived the test of time. For example, in the NHS, NHS is quite often referenced as a good public health system.
There you have GPs, and as a resident, you must be attached to a GP.
So, that GP is the doctor who is going to manage your basics, and escalate, you know, push you upwards towards specialists, if need be. That way you also get better information, because you are dealing with probably one doctor or, you know, a doctor working in one institution where access to your data is easier.
>> All right. Um, we'll come back to the audience in just a little bit. Okay, one last one for Lars. Okay, stop.
>> Um, good morning.
My name is Musanga. I'm a creative and a mental health advocate.
Um, my question is to Dr. Bundi, and I think it's connected to what she was asking. How much data or information is out there for the public to um, clearly probably know when they need to go in for mental health checkup.
Sorry.
How much information is there for people to know that they need to go out there and you know, get that check-up. And you know, it's very expensive right now to get psychological or psychiatric help. And from my experience, what has happened to me was is that for the last 6 years, every year there's probably something new that a different psychiatrist or psychologist has told me about what I've been experiencing and it's been very confusing.
Some of it is my own fault because um there's a there's a disconnect between especially now that because we are a Christian nation, there's a disconnect between religion and psychol- psychology. So, I was misdiagnosed because of coming with religious terms into the psychological space and you know, that gave that made me become um skeptical to what what is being offered.
So, in terms of AI and social media, that's why we go there. It's because we want to be sure that we're being rightly diagnosed. So, what what do you think is possible to be done especially for people to just know that um what is for example, bipolar is the most misdiagnosed from my experience.
What does that look like and um and and how can how can I be very sure that I'm being treated for the right thing? Thank you.
>> All right. Thank you so much.
>> I think that's a three in one.
>> Yeah, it's a three in one. And then I also ask Albert to tap into that when you're when you're done with the with what that process looks like from a private health care facility vis-a-vis for example, Mother and National Teaching and Referral. Yeah.
>> So, the first question was how how many people are actually being reached in terms of awareness. So, remember we I keep saying one in four people have got a mental illness in Kenya. Out of that one in four, only 75 uh up to 75% don't end up getting the help they need until it's very dire.
So, that shows you the gap. People are not as informed. So, then the next question is whose responsibility is it to bring up the awareness?
>> [music] >> And I wager that at the front seat of advocacy has to be the clinicians.
So, it has to start with us telling being there giving the messaging.
This is what depression looks like. This is what you do when you're feeling unwell. This is who you go to. This is a psychiatrist. This is how you get to Mathare. We have to be in the driver's seat and that's why I'm I do what I do on social media, um TikTok because if we don't do that, we're going to have people who are not qualified giving this information. Is AI bad? No, but uh connecting with what you had asked, I don't encourage for mentally ill patients especially to use it as their guidance and as their check and balance for their doctor. So, I I believe a doctor or a psychiatrist who uses AI is phenomenal. So, I can tell you about your condition and then I can give you a printout with a few more details. And actually um uh the in the NHS, we've got the nice guidelines. They've created guidelines which even I as a clinician can print.
Maybe we need locally uh appropriate Swahili versions that we can be printing out quickly. You just quickly generate it to fit your context of your patient, print it out and give it to them. But I in the in the AI is only as good as what you feed it. If I tell AI I'm having flank pain, it's very different uh it'll give me different results from if I tell them I have lower abdominal pain. Those are two different things. One, it might tell me I'm having an appendicitis. The other one it might tell me I'm having an ectopic pregnancy. So as a patient, you're not going to be able to know.
>> Yeah.
>> You're not going to be able to know that too. About being misdiagnosed, the journey of of mental health is very fluid. Today you might come in with insomnia. After 6 months your doctor might realize actually this is depression. After a year and a half it might be bipolar two.
It doesn't mean if your doctor is a good doctor that they're lying to you. But that's the nature. Sometimes things start off in postpartum as postpartum depression. Then you follow this mother up and you realize actually this was the beginning of a bipolar mood disorder. So my thing is have a relationship with your doctor and if you feel that you're not getting what you want rather than go to chat GPT, get a second opinion, even a third, fourth, fifth opinion. Yeah. I don't know if those are a third question in there.
>> I think it's covered. Yeah.
>> It covers.
>> Yeah, I think it covers everything.
Let's hear from >> I I think mine will come from a private institution point of view and I want to look at it in terms of affordability and cost.
I think most of us will accept that when you go for insurance when you're buying your medical insurance you don't look at it in terms of I might need mental health.
So you go you buy your out patient but how much of that can you actually go to a psychiatric with? You're always capped. You're told you can only do it once or twice. So most people have to do it out of pocket. Now how many of us can afford out of pocket? Not. So you have so many sessions that you have to do. So people fall back on this. You find that guys are not able because not all of us can go to Mathari or go to public hospitals. We don't even have the numbers. You're not able to go there.
You don't have the time. So I think it's also time that maybe insurance companies and even SHA come up with programs and packages that people can actually buy into and get that. One of the things that are actually right now is affecting the world is autism for example. Autism affecting children below age of five, young people. You see them a lot. But most parents have to pay this from their pocket. You talk about paying 30 or 40,000 per month for counseling for your for your kids. How many people can afford that? Insurance are not providing for us packages for that. The government is not providing for us packages for that. So you end up having a situation where you have all these people who are not able to access access health care because they're not able to afford. So I think maybe a broader conversation should be things that are not basically, you know, things that to do with counseling, psychiatric. How do we handle them? Do we handle them as normal things within our package or do we come up with different packages for them so that you're able to afford and have more people within those programs to help.
But also there's also one thing that we have, you know, we have so many mental health programs that happen across the country. I think we had a mental health month last time and we said most institutions give counseling for free.
So these are opportunities for people to actually come out and look for opportunities for them to get counseling in those situations. Yeah, thank you.
>> Okay. Sorry to dominate. Mental health >> No, yeah, please.
>> I think it's an area area of passion of study of practice.
Yeah. The idea of it becoming as a separate package is it's it's kind of makes it seem like it's not actually health. And we we keep saying no health without mental health. I think we need to understand that for example with diabetes, it's so comorbid with depression. A lot of people who have diabetes will at one point develop depression. HIV, TB, very comorbid.
Along the line, you know, we get anxiety, we get depression. So even with NHI with SHA, we need to have an outpatient cover for mental health.
Currently, we are on SHA is only covering in So, what if somebody is fairly stable? I think the gentleman was describing he's mostly an out-patient. Uh he goes there for out-patient, yeah? For therapy, to see a psychiatrist. What if they allowed people opt in, like the way we see some people pay for only out-patient, or you pay for only in-patient? Cuz you find somebody's contributing to SHI and has never been admitted year in, year out, and then they can't see the therapist or psychiatrist, yet they're paying for the SHI. So, can we find a way, especially for the younger people, before you know, it'll be more preventive, before they become, you know, very extreme, can we allow them to just have out-patient and opt out of the in-patient? That would be perhaps a way to look at it.
>> Uh yes, uh I do agree with Doc. And I think this comes back to what uh we've also discussed earlier, that if you're not um like the layperson, if you're not aware of how insurance works, how to advocate for yourself, how to say, um I don't want in-patient, I just want out-patient, because that's also something that's available at the moment, and even within that out-patient, pushing back and saying, "Okay, I'm seeing that you have this allocated for this. Can I have it higher? And what are the implications of that?" If you if if we don't have that knowledge out there in the public, then we'll continue to have those limitations that are not insurmountable. You know, there's a solution to that. We just don't know that we can access that solution. And then I think also cognizant with what um Albert has said, um maybe just to also put it out there that for what we are doing as Minet has said, to bridge that gap for having We do have actually um counseling center. So, for everybody that's with us for their health cover, for example, we do have a toll-free line that gives free therapy. And for children on Saturdays, they can be brought over to me the center for free therapy and so we do that so that even our clients are not having that struggle of balancing therapy is coming out of my outpatients my outpatients is getting depleted da da da da da da so for our schemes for our you know both corporate and individuals they do have access to that.
>> Okay, just as we're about to wrap up the conversation I wanted to end with at least you've spoken to it Dr. Crystal but I want to hear from Dr. Ruben Dr. Vundi as well as Albert on the advocacy work that you're doing in your spaces for health care financing for the things that are of interest or passion to you and your patients. Let me start with Dr. Ruben.
>> Thank you. Um health care financing will remain a big challenge.
It is in our country it is globally and maybe to give us a synopsis since COVID-19 a lot has happened in the health care financing um area or sector that I would say has reduced what is available both out of pocket and even from private insurance and even looking at you know public insurance such as sham and the conversation across all sectors whether it's the hospitals the individual patients the payers insurance is how do we reduce the cost of health care because eventually that determines how much of your earnings you're going to dedicate to health care.
Um we have to look at what is contributing to the increase in cost of health care and that's the cost of inputs.
We don't manufacture much we import so it's probably one area we can intervene quickly.
Of course, with a lot of political goodwill. Because the more you manufacture, the cheaper it comes and it eventually it passes on to the patient.
Of course, strengthening SHA and probably aligning SHA better as has been described, for example, to obtain opt-out if you if if if you want to. That is another area because um there are people who have never used SHA for the in-patient, but they need it for out-patient. So, why not? And even for private insurances, that is another area to look at.
Um three, and we didn't mention that majority of our population is in the informal sector.
I got a slightly different figures when it comes to private insurance financing Kenya between 2 to 5% and for public, 25 to about 39%.
So, it tells you by all means less than 60% of Kenyans are not insured. And we see that quite often and unfortunately, it bites harder when a patient is admitted in a critical care unit, they need a major surgery, they have a major diagnosis. So, we end up going back to, you know, Harambees as we commonly know them. And that is fundraising. And there are hundreds and hundreds of WhatsApp groups that are doing that now.
Um public insurance is the most affordable as it is now.
So, I would encourage and I've seen even some governors in this country, uh you know, paying up in mass for their, you know, constituents to get you know, that kind of public insurance. And it works in quite a number of situations. I'll talk about surgery for example and there are good benefits you will get by being um a paid up member of Sham.
Secondly, there's the aspect of home grown insurance and these insurances can be tied up for example to circles. I know a good number of us here belong to circles and probably it's the high time we thought of how do we integrate medical insurance with um other aspects of you know financing. Cuz most of us belong to a circle somewhere. Can we bring those or can we bring these ideas into circles where you get a cover through your circle either negotiated with a provider. I know Dr. Crystal would be happy to hear that but of course it can also be individually sought.
>> All right. Thank you so much Dr. Reuben.
Let's hear from Dr. Vundi and Albert real quick on the on the same matter of the advocacy that you're doing in your spaces then we'll we'll wrap up the conversation with just 30 seconds with Dr. Crystal.
>> No problem. So advocacy for me I have taken it up very personally at Mathare where I speak up and I noticed that whenever you are in any offices high up there all they want is the data. So and there's so much data that has been done. There's a business investment case for mental health that was done 2021 showing that mental health cost Kenya about 60 billion annually. So whenever I'm in spaces I throw around these numbers because those costs are there. By the time a mother is going into postpartum psychosis I mean the repercussions for the entire family are financial. They're tangible and of course there are the intangible ones. So I always advocate also the point of the the patients.
Mathari does a lot of advocacy. We wave a lot of patients, the ones who truly they come and you can see this person has nothing. This person has nothing. In emergency situations, I believe that Kenyatta Hospital has under Shadd, they've got an emergency cover. Such that yes, even if you're not covered outpatient for Shadd and you end up in Kenyatta and it's an emergency, you will be treated. So, there are things that are working, but as a as the doctor, sometimes we have to advocate cuz you'll see a patient who even doesn't know about this, for example, the emergency Shadd cover. Yeah.
>> Thank you so much and it's really good to know that because we often don't think of mental health emergencies as emergencies, but it's good to know even from the KNH perspective and at Mathari what's happening. Albert, very briefly, we're meant to be running out of time, so I'll ask you to be brief. Yes.
>> I think my advocacy is more is about the private institutions to get their payments on time. I think that's the most important thing because you're not able to provide health care if you don't have the money.
Ruben will tell you how much they're owed by Shadd and by providers. If we were able to be more, you know, more upfront when it comes to our payments, it would be much easier because I can only provide what I'm able to afford and that affordability comes from me being able to pay my doctors, buy the drugs, and provide for the patients. So, I think it's high time that we push more so that we can be able to be in business and provide for for our patients.
>> Thank you so much. Dr. Crystal, you had already spoken to your advocacy work, so please allow me to end it there. We're completely out of time. We have to go, but thank you so much for sticking with us. Thank you so much, Albert. Thank you, Dr. Bundi, Dr. Crystal, Dr. Ruben.
And to our amazing audience here and to you fixers watching at home. We'll be back Monday 6:00 to 10:00 a.m. For myself, Mariam Bishar, Felaries Wambui, and Eric Latif in absentia to come Monday. Have an amazing amazing weekend.
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