Kenyan health workers may be gearing up for a second strike in less than two months. Strained health budgets in countries across eastern and southern Africa could lead to this kind of industrial action becoming more common and workers are fighting to balance their rights with those of their patients.

A March agreement between government and the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) put an end to a 100-day strike by doctors and nurses that paralysed Kenya’s public health sector. As part of negotiations, the government agreed to recognise the union and grant doctors salary increases of between 40% and 50%. The health ministry also vowed to implement a 2013 deal that promised more public sector jobs and a 2% annual increase in funding for local health departments within 60 days.

But almost half of this time has lapsed and doctors have still not been paid, says Alex Thuranira, secretary general of the Nairobi branch of KMPDU. According to Thuranira, more than 1 400 qualified local doctors remain unemployed.

He argues that empty promises may force the union to prepare for a second round of strikes.

“There is still time for the government to act, but if they have not done anything when the 60 days are up – expect a crisis,” he warns.

Have skills, will travel
Considered as essential service providers, health workers are legally prohibited from striking in many countries, including Kenya, Zimbabwe and South Africa. But tight budgets and dire working conditions have resulted in industrial actions by these workers in all three countries in the past decade.

In February, Zimbabwean doctors contested the country’s shrinking health budget and demanded a salary increase of almost 150% during a three-week strike. Doctors returned to work before their demands were met in an effort to curb rising deaths as a result of the strike.

Government also agreed to create 260 new posts in the health system to accommodate new junior doctors. But these posts have only been funded until the end of 2018, according to Zimbabwe Hospital Doctors Association president Edgar Munatsi.

Munatsi says health care is still not a priority in Zimbabwe.

In 2001, African Union countries agreed to allocate at least 15% of national budgets to health as part of the African Union’s Abuja Declaration. Zimbabwe allocates less than 7% of its national budget to health. The department received $281.9-milion as part of the 2017 budget, but Minister of Health David Parirenyatwa reportedly told senators in February that he needed $1.3-billion annually to fund health services.

Munatsi argues the country has to prioritise health or risk losing doctors to better pay and working conditions in neighbouring countries such as Botswana, Namibia and South Africa.

Munatsi says government needs to create opportunities for doctors to develop in the country. Currently, new medical graduates who have completed state-mandated internships cannot be absorbed into the system to specialise.

Where to from here?
A lack of opportunities for recent graduates is also part of Kenyan doctors’ frustrations.

In 2013 Kenya’s health service was decentralised in an effort to increase access to health care. Health service delivery became the responsibilities of local counties, while policy and capacity building remained in the hands of national government.

Now, doctors are being governed by counties that do not understand the importance of human resources in health care, argues Nelly Bosire, a former KMPDU official.

Thuranira alleges the decentralised system of government also makes doctors vulnerable to discrimination in a country in which ethnicity is often used to further political agendas.

Thuranira explains: “Before devolution, doctors who completed their internships would be posted at a specific hospital. Now, doctors apply to a county that could reject your application based on ethnicity, leaving many doctors jobless.”

Health workers warn this could be behind the country’s health worker shortage.

Trauma doctor Onyimbo Kerama remembers his time as one of two doctors in a public hospital in Kenya where he was responsible for 100 patients daily.

He explains: “There was a pregnant mother who came to the hospital. The distance she had travelled was shocking.

“She did not want a caesarean section and there weren’t any doctors to help her give birth. By day three ­– the child was dead. All we could do was make sure the mother was fed and comfortable.”

Kerama chose to leave Kenya because of poor working conditions and now practices in the Democratic Republic of the Congo.

Making the best of a bad situation
The Kenyan government allocated just over $588,8-million to health in its 2016/17 budget. This constitutes just over 3% of the country’s national budget. Although health budgets increased by 2,2% from the previous year, Bosire says it is not enough to address the management and human resource crises facing Kenya’s health sector.

The Zimbabwean and Kenyan ministries of health could not be reached for comment.

The conditions fuelling recent strikes are unlikely to change but the South African Medical Association (Sama) says a minimum service agreement to allow doctors to provide a basic package of medical services while striking could help workers keeping patients safe while advocating for their rights.

South Africa’s 2009 health worker strikes brought the public sector to a standstill in part because the country had failed to implement a 2007 agreement called the Occupation Specific Dispensation, to increase the salaries of specialist health workers. As part of negotiations, Sama was adamant that the health department concede to a minimum service agreement.

But Sama chairperson Grootboom says the government did not entertain the conversation.

Grootboom explains: “Doctors are advocating for their patients, not only for themselves. There’s always a tension between your responsibility as a doctor and your rights as a citizen.”

Health care workers eventually returned to work after the national health department agreed to pay salary increases promised to workers under the Occupation Specific Dispensation.

South African national health department spokesperson Popo Maja says such an agreement would have to be legislated. He says unhappy doctors should not strike, but rather opt for mediation and arbitration by an independent commissioner or approach the courts.

Russell Rensburg is the health systems and policy manager at the ngo Rural Health Advocacy Project. He says South Africa needs a minimum service agreement to protect patients during future negotiations.

Rensburg warns that the country’s next labour dispute will likely come as a result of austerity measures.

In January he told Bhekisisa that while provincial health budgets have almost doubled in the past 15 years, they have not kept pace with the rising cost of employee compensation. He argues that this has led to fewer health posts as provinces look to contain costs through official or unofficial hiring freezes.

Rensburg warns South Africa’s health budget will not be able to accommodate further increases for health workers.

‘We are tired of presiding over death’
Meanwhile, as tensions mount in Kenya and clinicians question whether another strike will happen, the country currently lacks the kind of minimum service agreement needed to safeguard patients.

Nonetheless, the KMPDU’s secretary general says the union will push for a minimum service agreement if the strikes continue.

Thuranira says strained negotiations during the 100-day strike have left government sceptical of any suggestions from the union, making this potentially life-saving agreement unlikely.

KMPDU’s Nelly Bosire says that health workers had a minimum service agreement in 2011 but that striking doctors felt it undermined efforts. “We are dealing with a cold-hearted government. If they think they can cheat the public into thinking some level of service is provided, the industrial action will have no effect.”

Bosire says a strike is always the last resort. “It hurts to know one of my patients couldn’t access her chemotherapy because of the strike. It’s not about the money, but about a functioning work environment. We are tired of presiding over death.”

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