Nurses in Kenya are threatening to strike, protesting that the government had failed to increase their salaries in spite of an agreement which ended a five-month strike last year. If they strike this would be the second time in two years and it could create another public health crisis because of the huge role that nurses play.
Kenya's almost 16,500 nurses work across all levels of health care; from primary care dispensaries and clinics to major hospitals. In some settings they may be the highest qualified, or only health professional, there. This means they provide essential public health prevention, health treatment and emergency services.
My colleagues and I put together a report for the recent world innovation summit for health. We worked with a team of experts to review global evidence and explain why to quickly, and cost-effectively, expand universal health coverage, there must be proper investment in nurses.
Nearly one billion people around the world can't access or afford basic health care. At about 21 million strong, nurses make up half of the health workforce. If they are properly resourced and empowered, they could help to quickly spread universal health care, expanding services to under-served communities.
One of President Uhuru Kenyatta's "four pillars" is universal health care. Ksh44.6 billion (about USD$420million) was allocated into the sector so that all Kenyans could have access to critical health care services.
But unless proper investment is made in the workforce, it won't work. While increasing allowances is important, nurses must be empowered to reach their full potential. Also worrying is the recent redrafting of the Kenyan Health Act which limits the leadership potential and opportunities for nurses within the public health system.
Kenya currently has about 1.6 practicing nurses to 1,000 people, significantly less than western countries like Canada (9.8) and Australia at (12.9). Not enough nurses are joining the force, about 600 leave the country each year and many are retiring, or close to retirement.
Their low numbers mean they often attend over 100 patients per day, and in many rural health centres they are the only professional care available. And yet they could offer a solution to Kenya's challenges of making health care accessible and affordable.
There are three reasons to invest in nurses and midwives:
By investing in nurses, Kenya can quickly expand quality medical services because of the availability of nurses.
Doctors are important members of the health care team but there's not enough of them to make a major impact on the rapid scale-up of universal health care. In Kenya there's 1.6 nurses and midwives for every thousand people, while just 0.1 doctors. Nurses and midwives are able to provide care of equal value to doctors when it comes to the basics of primary health care prevention and follow-up. This includes prevention, early detection and support for longer term chronic disease.
To take advantage of this, Kenya must adopt a strategy that combines investment in nurses with changes in service delivery and practice. Investment would mean more people go into nursing schools, graduate nurses get full employment and there are increased pathways for upgrading the current nursing workforce. For instance programmes, like the one we offer at Aga Khan University, which allows nurses to upgrade their qualifications while still working.
Changes in service delivery would include the creation of more nurse-led clinics, and more specialist nurses and midwifery services.
Because there are at least three times more nurses and midwives than doctors, it will be more cost-effective for Kenya to increase their skills.
There is enormous potential for nurses to expand their scope of practice through task-sharing with doctors. One study in the report estimates that some nurses can complete approximately 70% of a general practitioner's workload. This would free up doctors so they can attend to patients that need more intensive medical care.
High quality expansion involves moving nurses and midwives into more advanced, speciality roles.
There is evidence that an approach centred on nurses and patients will have a positive impact on access and satisfaction. Studies show that nurses generally achieve equivalent health outcomes as doctors for long-term non-communicable diseases management.
Nurses often also score higher for patient satisfaction and for treatment adherence. Patients are more likely to return for follow-up appointments and take prescribed medicines. Because they have so much contact with patients, nurses are well-positioned to provide simultaneous health-promotion and disease prevention advice. They also take on roles in coordinating and supporting teams of primary health care workers.
These factors all give a powerful case for why, in order to achieve universal health care, governments must invest in their nurses.