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Customers, Not Patients: The Nairobi Women’s Hospital Saga

15 min read.

How did a hospital dedicated to women’s health end up being managed like a cut-throat business where those seeking medical attention are treated like customers rather than patients, and where the bottom line is more important than healthcare?

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Customers, Not Patients: The Nairobi Women’s Hospital Saga
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From Nairobi, Dr. Felix Wanjala texts the following on a work Whatsapp group: “Team, let’s ensure we don’t let the team down…let’s meet our target.”

Without context, this might appear like a harmless motivational speech from a boss to his subordinates. But the context here is this: Dr. Wanjala is the CEO of Nairobi Women’s Hospital (NWH). In the message immediately before that, he had forwarded a text listing the admission numbers across all the hospital’s branches in the country. “We have the numbers as follows at this hour,” the CEO wrote to his employees, and then listed admissions totaling 288 across the hospital group.

The target, and the context of the war cry not to let the rest of the team down, he went on, was to have 22 more admissions. To do this, the CEO recommended that his team, based at one of NWH’s two branches in Nakuru (called Nakuru Hyrax), “start with looking for referrals”, not miss “any opportunity”, and be “very vigilant in casualty.

In multiple texts covering different days in 2017 and 2018, the Whatsapp group resembled a trading floor, with Dr. Wanjala and his Chief Operations Officer, Eunice Munyingi, pushing employees to work harder to increase admissions. On the first day of July, for example, Eunice wrote in reply to the nurse in charge of the hospital chain: “Let us increase speed 2 admissions against 13 discharges at this hour not good.”

Two minutes later, the CEO added, “It’s our striking time. Let’s intensify our effort…replace all discharges by 6pm.”

Five days later, at 7:28 p.m., the COO told to the Nakuru branch staff to “get 3 admissions by 9pm.

Several interviews with whistleblowers describe a corporate culture of being pushed to meet admission targets. “Although it was not said explicitly,” one former member of the NWH said, “the implication was that doctors and nurses in particular had to find reasons to admit patients to meet the hourly and daily targets, even if those reasons were an absolute lie.”

Another added that there was a financial reward paid to clinical officers for each admission; but they still had to write down why they were admitting each patient. This meant they had to get creative to meet targets, both personal ones and those of their employer.

Origins

Founded two decades ago by a young gynaecologist called Dr. Sam Thenya, Nairobi Women’s Hospital began with a unique specialisation. The focus of its first branch in Hurlingham was solely obstetrics and gynaecological services, meaning its primary clients were women. It became particularly known for its Gender Violence Recovery Center (GVRC), a charitable arm that serves survivors of sexual and domestic violence.

I was working in a hospital and I had pitched this idea to the CEO of that hospital, but he wasn’t very keen on the idea of taking in abused women for free,” the hospital’s founder told Business Daily in November 2016.

One time he told me that if I thought the idea would work then I should go ahead and open my own hospital because it wasn’t going to work at that hospital and right there I thought to myself, ‘Why not?’”

So at the age of 31, Dr. Sam Thenya took up his boss’s challenge.

The thing that drove him to start the hospital when he had no money, he told the interviewer, was a “certain trigger, madness or passion”. His singular goal, despite the challenges almost as soon as he started, was to build one of the most familiar, respected private hospitals in the capital city.

“Although it was not said explicitly,” one former member of the NWH said, “the implication was that doctors and nurses in particular had to find reasons to admit patients to meet the hourly and daily targets, even if those reasons were an absolute lie.”

For the hospital to survive without taking in more investors or money, it needed to scale up fast, and build solid revenue streams that included donor funding for its GVRC charity. It also had to wade through the rough early 2000s, as Kenyan systems tried to reset themselves.

In 2003, for example, the hospital’s banker, Daima Bank, collapsed. Dr. Thenya, still in the early years of his project, heard the devastating news while he was fuelling his car at a petrol station. “We had just issued suppliers cheques,” he said in the interview.

Despite such and other challenges, Dr. Thenya and the hospital he built surged on.

He transformed from a practising gynaecologist to an entrepreneur. He also sold the hospital for a fortune, and was on his way out as the founding CEO. Although he stayed on after resigning as CEO, his armophous role as Director of Strategy didn’t mean much.

In a scenario that exemplifies the fine line between private healthcare as a business and a service, Dr. Thenya had to fight with politicians, including President Uhuru Kenyatta, and technocrats who had demanded the release of patients (alive or dead) over bills.

Once, he told the interviewer, the President called him and told him someone had sent him an e-mail that the body of his/her mother was being held hostage by NWH over unpaid bills.

Sam, what do we do?” the President asked.

Your Excellency, the bill has to be paid,” Dr. Thenya answered.

After the President said he would pay the bill, and asked the body be released while he did it, Dr. Thenya replied, “I need some proof of payment of some pre-payment today.

If you want me to release it today,” he went on, “then pay today.”

By this point, a lot had changed.

Born in Nyakihai, Murang’a, in 1968, a much younger Sam Thenya had wanted to be a pilot. But he became a doctor instead. As a young doctor in training, he led a strike at Nyeri Provincial General Hospital in the early 1990s. The issue, which was fixed because of the strike, was bad working conditions for medical practitioners.

I am not one who stands by and watches things deteriorate,” he told an interviewer in 2011.

What finally drove him to ask his boss to start a wing for victims of sexual violence, and doing it himself when he was challenged, was meeting the victim of a brutal gang rape. Battered, violated, and in need of urgent medical care, she did not have money to pay for admission.

I paid for her admission and closely monitored her progress.”

The past

As a young doctor, Dr. Sam Thenya was unstoppable in his mission to build Nairobi Women’s Hospital. In October 2000, a hospital called Hurlingham Hospital was on auction for unpaid debts. Dr. Thenya approached the auctioneers with a promise to buy the hospital. It was an attractive deal for both sides: the auctioneers would get rid of an asset few can or want to buy, and the young doctor could build a hospital from scratch.

But there was one problem, a big one. He had no money.

The most he could raise was half a million shillings, which he did by selling his wife’s car. He needed 17 million more, so he got other investors to put in the money and take a share of the repainted hospital’s ownership.

In the world of modern finance, this seemingly brilliant financing strategy has a name. It is called a leveraged buyout (LBO). It works exactly how Dr. Thenya did it: you buy a company by taking in debt and giving up equity, which means you do not need a single coin to start whatever enterprise you want to start. The assets of the thing you are buying, with money that is not yours, serve as the collateral in case the enterprise doesn’t prosper.

The most famous LBO in the world is the hostile takeover of an American company called RJR Nabisco. In 1989, the executives of the conglomerate, which sold tobacco and food products, including the world famous Oreo cookies, started an unstoppable process to acquire the entire company at $75 a share.

The events that followed that ignition are covered in Barbarians at the Gate: The Fall of RJR Nabisco, book (and movie) written by two American journalists. It covers the executives’ plan to buy out other shareholders, and the marathon that began when other groups of people joined in on the race to acquire one of the biggest companies in the world. One of them finally won, by offering a price higher, by $15 a share, than the management team’s offer.

But the best of this story is that none of them, even the executives who wanted to buy a company for $25 billion, actually had the money. They didn’t need to. In the great game of modern finance where money is an idea, one person quoted in the book says, you need more money to start a shoeshine store than you do to buy a 2 billion-dollar company.

The gist is to start what is called, in modern finance, a fundless fund –simply a corporate body that on the one hand promises to and negotiates to buy something, while asking for money from those who have it to complete the deal. For investors with vast amounts of money on hand, this is an investment for which they expect to see profits.

In the world of modern finance, this seemingly brilliant financing strategy has a name. It is called a leveraged buyout (LBO). It works exactly how Dr. Thenya did it: you buy a company by taking in debt and giving up equity, which means you do not need a single coin to start whatever enterprise you want to start.

Dr. Thenya gave up 40 percent of NWH’s ownership to the investors who gave him the $50 million (in total) to buy the assets of Hurlingham Hospital, and to repaint it afresh as Nairobi Women’s Hospital. As the new hospital grew on the back of its reputation as a niche healthcare provider, Dr. Thenya progressively bought out the investors, and by the late 2000s, owned the entire thing.

As they left, presumably after making a profit, Dr. Thenya expanded his enterprise just in time. The 2008 financial crash was wreaking havoc in Western markets, starting first in the mortgage industry and eventually spreading its tentacles to the heart of multiple economies. For private equity funds, which had had their best years right before the crash, it was time to find other markets to play in.

In 2009, Dr. Sam Thenya acquired Masaba Hospital in Adams Arcade, and turned it into the second Nairobi Women’s Hospital branch. By the end of the next decade, there would be a total of nine Nairobi Women’s Hospitals: four in the capital city and the metropolis; two in Nakuru; and one each in Naivasha, Meru, and Mombasa.

From a single hospital in Hurlingham, Nairobi Women’s Hospital was one of the fastest-growing hospital chains in Kenya by the mid-2010s. But things had changed. In the first decade, Dr. Thenya had quit practising to concentrate on the business side of his hospital.

I realised that I was not giving my patients full attention because I was often caught up in strategy meetings,” he said in later years, “[so] I had to choose between expanding the hospital and practising.”

And in several transactions beginning in 2010, he had progressively sold his ownership stake in the hospital to the successor of leveraged buyouts in modern finance; a similar but differently named structure called a private equity fund.

The present

private equity (PE) firm is a leveraged buyout by another name, with very few significant differences. Simply, you get money from wealthy individuals and organisations, such as pension funds and charities, and buy attractive companies. Then you restructure them by cutting costs, expanding as fast as possible, extracting as much revenue as you can, and then selling them for a profit.

The basis of this model of financing is to buy and sell, as opposed to keeping an investment in perpetuity. So PE firms strip their new companies of any sellable assets, change the management, reduce costs by firing professionals and employing cheaper labour, pay executives bonuses for meeting targets, and once the company is attractive enough on paper, sell it to someone else. That new buyer is often just another PE firm.

In the complicated structures of global commerce, private equity funds are used to finance rapid expansion, which increases the value of the assets. Investors, who include funds of funds, where one investment fund invests in another investment fund, expect a return in investment. And investment funds get money by promising exactly that.

PE funds themselves make money in two ways: by charging an annual management fee of the money they have been trusted with, calculated as a percentage, and by taking a cut of the profits they make when they sell the companies they buy. So their primary motivation is to get more investor money, and to restructure companies as fast as possible to attract a higher price than they bought it for.

One of the things PE funds do when they acquire a company is to transition it from a founder-run company into a corporate body that can attract a higher price. This is exactly what happened at Nairobi Women’s Hospital from the first funding round in 2010, where Dr. Sam Thenya’s ownership systematically reduced as the new owners’ ownership stake increased.

In the midst of the “Africa Rising” narrative, and from the ashes of the 2008 global crisis, billionaires and institutional investors in the West turned their investment focus on Africa. The continent’s young population offered an attractive proposition for profit-making ventures; it was expected that not only would these younger Africans be richer than their parents, and willing to spend more on everything, but that there were no modern legal or regulatory structures in place to halt corporate raids of existing companies. And by the time they came, several rounds of investors would have already made enough profits.

In 2010, Dr. Sam Thenya got $2.66 million for part of his stake in the hospital. The buyer, The Abraaj Group, which would collapse in 2018 amidst investigations that its founder and executives had stolen investor funds, was founded by a Pakistani based in Dubai. In addition to Nairobi Women’s Hospital, it also acquired all or parts of other Kenyan companies: Java House (100%); Brookside Dairy (10%); and Seven Sea Technology (21%).

But its most prominent purchases were in private healthcare, where it bought 18 clinics and 10 major hospitals. In addition to its stake in Nairobi Women’s, it also bought part of Avenue Group Hospital, Ladnan Hospital, and Metropolitan Hospital.

Three years later, Abraaj bought more of Nairobi Women’s with a partner PE firm called Swedfund. The Swedish government describes Swedfund, which it funds and owns, as a “development financier and development cooperation actor”; but it works in basically the same way privately-owned PE firms do.

The objective of the Africa Health Fund is to increase access to affordable and quality health-related goods and services for those at the bottom of the income pyramid,” Swedfund said in a press release dated 22nd November 2013. “At the same time it hopes to provide investors with good long term financial returns.

This dual-purpose fit into Dr. Thenya’s founding principles, which had been to build a hospital that offered services to abused women for free, while offering other medical and surgical services at a fee. Swedfund, which said it “put a high emphasis on environmental, social and governance issues”, and other investors were investing in the hospital to fund its expansion.

In 2010, Dr. Sam Thenya got $2.66 million for part of his stake in the hospital. The buyer, The Abraaj Group, which would collapse in 2018 amidst investigations that its founder and executives had stolen investor funds, was founded by a Pakistani based in Dubai.

From a single branch, Nairobi Women’s Hospital had expanded to three hospitals: one in Adams Arcade founded in 2009, another in Ongata Rongai founded in 2011, and the Nakuru branch which followed a year later. It also had two medical centers in Kitengela and Eastleigh, both opened in 2012, and two more branches, in Mombasa and Kisumu, on the way.

This was all, the Swedish state investor said, “part of a the grand plan to expand further in the country and the Eastern African region by 2016; and subsequently into the rest of Africa.”

The thoroughfare

While the source of Swedfund’s finances is obvious, the source of The Abraaj Group’s funds is a more interesting story because it led to its death in 2018, and the arrest of its top executives.

Because PE funds run multiple projects at any one time, they structure them as independent funds with their own fund managers. The specific one that invested in private healthcare in Kenya beginning in the late 2000s was called The Abraaj Growth Markets Health (Africa) Fund. It got its $1 billion to invest in Kenya and other countries from multiple sources, the most prominent being the Bill & Melinda Gates Foundation and the World Bank’s private equity fund, the International Finance Corporation (IFC).

The second deal, which reduced Dr. Thenya’s ownership even further, was worth $6.5 million.

The Dubai-based Abraaj Group, founded a year after Dr. Thenya started Nairobi Women’s, was a renowned investor in multiple sectors across the continent. By the time it collapsed in 2018 amidst a dispute with its investors, the Bill & Melinda Gates Foundation had initiated an audit into how its money in the healthcare fund had been used; it had invested an estimated Sh320 billion in 80 transactions across Africa.

Through the fund, part of which the PE firm’s founder, a Pakistani man called Arif Naqvi, was accused of misusing, Abraaj owned private hospitals in Kenya, Nigeria, and Pakistan. In April 2018, around the same time the screenshots of the Nairobi Women’s Hyrax Whatsapp group were revealed, Naqvi was arrested in Britain on a US warrant.

Naqvi had resigned from Abraaj the month before investigators found evidence that he had defrauded investors in two ways: by inflating the price of assets, which included Nairobi Women’s Hospitals and several other Kenyan private healthcare providers, and misappropriating the fund.

The scandal made headlines around the world, as many other similar investment structures had ridden on the Africa Rising wave and bought many companies, in many countries, on the continent. Meanwhile, The Abraaj Group was closed and its assets stripped for parts by other PE firms. A British firm took over its stakes in Brookside Dairy and Java; an American PE firm called TPG acquired the healthcare fund, which counted among its assets several Kenyan hospitals. TPG then renamed the fund the Evercare Health Fund to avoid the negative reputation of its former name and manager.

These high finance events and deals all took place outside of Kenya, but in the end TPG owned Nairobi Women’s Hospital and several other private hospitals in the country.

Meanwhile, Arif Naviq remains in the UK, and not by choice. Last May, after he had spent a year in custody, he was granted a record $20 million bail. By October, he was also being investigated for bribing Pakistani politicians.

While this complicated game of international finance was happening, the private hospitals in Kenya were still operational, and still working to make profits for the fund, as their investors sorted a new PE firm to “buy” and run them.

In a text forwarded to the Nakuru Hyrax staff on 11th September 2018, CEO Dr. Felix Wanjala outlined the revenues so far, and the targets he expected them to contribute during the course of that day. The Nairobi Women’s Hospital group was making Sh12.81 million a day against a target of Sh15.47 million, and cumulatively was Sh33 million off a total target of Sh170 million.

Team this revenue is too low for the numbers that we have, are we billing,” he posed to the staff.

The shift from Dr. Thenya’s ownership and leadership to the PE funds had launched what was typical corporate behaviour after acquiring a new asset. Nairobi Women’s Hospital had, over time, stopped hiring medical officers (MOs), professionals in waiting who are mostly post-graduate students, to serve outpatient patients. It had instead turned to hiring young clinical officers (COs), who (at the time) only had a diploma earned after three years of training, to do the job.

To staff its rapid expansion, Nairobi Women’s was now depending on COs to serve patients who were not already admitted in the hospital. It was also encouraging them, according to multiple insiders, to meet admission and revenue targets, which were analysed every hour of every day, day and night. While the hospital still hired specialists, it hired less than it required (because MOs demand better salaries) and gave clinical officers the job of determining which patient needed to be admitted. It also gave the COs a financial incentive, at one point 710 shillings per patient they admitted.

This structure meant that while COs would find and push for admissions, even (and especially when) they were unnecessary, more qualified medical officers would only encounter the patients when they had already been admitted, and were already paying for the bed, food, tests, and medicines. They were already, in lingo used frequently in the leaked Whatsapp group messages, customers.

Nairobi Women’s Hospital had, over time, stopped hiring medical officers (MOs) to serve outpatient patients. It had instead turned to hiring young clinical officers (COs), who (at the time) only had a diploma earned after three years of training, to do the job.

Once they were in the hospital, the top management of Nairobi Women’s encouraged the staff, everyone in the Whatsapp group, medical and non-medical staff included, to keep them admitted for longer.

In another text, for example, CEO Dr. Felix Wanjala asked his staff “how did we end up at 18 discharges from 10 planned.” The text included an emoji of a sad face, suggesting he was unhappy with the situation. His COO, Eunice Munyingi, then asked someone called Victoria to answer the CEO. Victoria then passed the question to two other people, before the CEO responded “Vikki calm down…we expect better performance in future. Obviously this is not good for us.”

Medical officers and other specialists who worked at Nairobi Women’s at the time describe multiple instances of being pushed to keep patients for longer than necessary. In a text sent at 8:04 am on 11 November 2018, COO Eunice Munyingi told the staff to “lock discharges at 7” and to “…kindly start now.

This meant that if you were admitted at this particular Nairobi Women’s Hospital, and should have been released to go home, the decision of whether to let you go was based on revenue and admission targets, not on your health. In the texts, the senior executives ask staff to post hourly updates of the branch’s status, specifically how many people are being served and how much money was made, and cheer them on in language a media practitioner described as “better suited for a trading floor than a hospital management team”.

Courtesy of SHOWTIME

The comparison to a trading floor is poignant, because insiders describe an internal system that fits the script of the popular TV series Billions, with a CEO-COO dynamic similar to that of the characters Bobby Axelrod and Mike “Wags” Wagner in the show.

The similarities with a fictional TV show do not end there because the two characters run a ruthless private equity firm that buys companies, restructures them by any means necessary, legal or otherwise, and sells them over for a profit.

Like a PE firm and any modern enterprise, the top management of Nairobi Women’s also kept tabs on its reputation online. In one screenshot from 2017, the then clinical services in-charge, Victoria Wawira, posted a screenshot of a Facebook post written by a woman who had commented on their hurry to admit her child. Whenever she took her daughter to the hospital, “…The doc sees her and immediately its admission no second thought about medication,” she’d written on a Nakuru Country Mums group on Facebook.

In follow-up messages, Victoria told two clinical officers that the post was “trending on FB” and that they should “vet admissions”. In any other context, this would mean that the two COs should make sure they were admitting only patients who needed to be admitted. But in this particular context, it meant one thing – that they should check that they didn’t admit potentially problematic patients who would be suspicious of the need for them to move from outpatient to inpatient.

Medical officers and other specialists who worked at Nairobi Women’s at the time describe multiple instances of being pushed to keep patients for longer than necessary. In a text sent at 8:04 a.m on 11 November 2018, COO Eunice Munyingi told the staff to “lock discharges at 7” and to “…kindly start now.

Bad publicity meant not just harm to the hospital’s reputation, but it could also hurt the bottom line if future buyers, well-meaning investors, and nosy reporters found the posts and figured out how Nairobi Women’s was achieving its spectacular service and revenue targets.

The chaos, and reasons why we seek medical attention, meant patients caught up in this great game of corporate greed, and trusting their doctors to know what was best to restore their health, did not know better. They would have sell assets, sacrifice savings, hold fundraisers both online and offline, and do whatever was necessary to pay their hospital bills, without ever knowing that they had been unsuspecting victims of the vagaries of modern finance, and the focus on Africa that followed the 2008 financial crisis.

In Part II, the author examines how we let this happen, how other hospitals do it too, and how other countries have warded off the barbarians at the gates.

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Owaahh is the pseudonym of a blogger based in Nairobi

Politics

It’s a Nurses’ Market Out There, and Kenyans Are Going For It

Nurses are central to primary healthcare and unless Kenya makes investments in a well-trained, well supported and well-paid nursing workforce, nurses will continue to leave and the country is unlikely to achieve its Sustainable Development Goals in the area of health and wellbeing for all.

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It’s a Nurses’ Market Out There, and Kenyans Are Going For It
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Nancy* is planning to leave Kenya. She wants to go to the United States where the nursing pastures are supposedly greener. I first met Nancy when the country was in the throes of the COVID-19 pandemic that tested Kenya’s healthcare system to breaking point. She was one of a cohort of recently graduated nurses that were hastily recruited by the Ministry of Health and thrown in at the deep end of the pandemic. Nancy earns KSh41,000 net with no other benefits whatsoever, unlike her permanent and pensionable colleagues.

When the then Labour and Social Protection Cabinet Secretary Simon Chelugui announced in early September 2021 that the government would be sending 20,000 nurses to the United Kingdom to help address the nursing shortage in that country, Nancy saw her chance. But her hopes were dashed when she failed to raise the KSh90,000 she needed to prepare and sit for the English language and nursing exams that are mandatory for foreign-trained nurses. Nancy would also have needed to pay the Nursing Council of Kenya KSh12,000 for the verification of her documents, pay the Kenya Medical Training College she attended KSh1,000 in order to get her exam transcripts, and apply for a passport, the minimum cost of which is KSh4,550 excluding the administrative fee. Nancy says that, contrary to then Health Cabinet Secretary Mutahi Kagwe’s disputed claims that a majority of applicants to the programme had failed the English language test, most nurses simply could not afford the cost of applying.

Of the targeted 20,000 nurses, the first 19 left Kenya for the UK in June 2022. But even that paltry figure represents a significant loss for Kenya, a country where the ratio of practicing nurses to the population is 11.66 per 10,000. The WHO considers countries with less than 40 nurses and midwives for every 10,000 people to not have enough healthcare professionals. Nearly 60 per cent of all healthcare professionals (medical physicians, nursing staff, midwives, dentists, and pharmacists) in the world are nurses, making them by far the most prevalent professional category within the health workforce. Nurses offer a wide range of crucial public health and care services at all levels of healthcare facilities as well as within the community, frequently serving as the first and perhaps the only healthcare provider that people see.

Kenya had 59,901 nurses/midwives in 2018, rising to 63,580 in 2020. Yet in 2021, Kenya was proposing to send almost a third of them to the UK to “address a shortfall of 62,000 in that country”.

The growing shortage of nurses in the UK has been blamed on the government’s decision to abolish bursaries and maintenance grants for nursing students in 2016, leading to a significant drop in the number of those applying to train as nurses. Consequently, the annual number of graduate nurses plummeted, reaching the current low of 31 nurses per 100,000 people, below the European average of 36.6 and half as many as in countries like Romania (96), Albania (82) and Finland (82). Facing pressure to recruit 50,000 nurses amid collapsing services and closures of Accident & Emergency, maternity and chemotherapy units across the country, the UK government decided to once again cast its net overseas. Established in 1948, the UK’s National Health Service (NHS) has relied on foreign healthcare workers ever since staff from the Commonwealth were first brought in to nurse back to health a nation fresh out of the Second World War.

The UK government’s press release announcing the signing of the Bilateral Agreement with Kenya states that the two countries have committed  “to explore working together to build capacity in Kenya’s health workforce through managed exchange and training” and goes as far as to claim that “with around only 900 Kenyan staff currently in the NHS, the country has an ambition to be the ‘Philippines of Africa’ — with Filipino staff one of the highest represented overseas countries in the health service — due to the positive economic impact that well-managed migration can have on low to middle income countries.”

It is a dubious ambition, if indeed it has been expressed. The people of the Philippines do not appear to be benefiting from the supposed increase in capacity that the exchange and training is expected to bring. While 40,000 of their nurses worked in the UK’s National Health Service last year, back home, according to Filipino Senator Sonny Angara, “around 7 of 10 Filipinos die without ever seeing a health professional and the nurse to patient ratio in our hospitals remains high at 1:50 up to 1:802”.

Since 2003 when the UK and the government of the Philippines signed a Memorandum of Understanding on the recruitment of Filipino healthcare professionals, an export-led industry has grown around the training of nurses in the Philippines that has attracted the increased involvement of the private sector. More nursing institutions — that have in reality become migrant institutions — are training nurses specifically for the overseas market, with the result that skills are matched to Western diseases and illnesses, leaving the country critically short of healthcare personnel. Already, in 1999, Filipino doctors had started retraining as nurses and leaving the country in search of better pay.

It is difficult, then, to see how the Philippines is an example to emulate. Unless, of course, beneath the veneer of “partnership and collaboration in health”, lies the objective of exporting Kenyan nurses with increased diaspora remittances in mind – Kenyans in the UK sent KSh28.75 billion in the first nine months of 2022, or nearly half what the government has budgeted for the provision of universal health care to all Kenyans. If that is the case, how that care is to be provided without nurses is a complete mystery.

Already in 1999, Filipino doctors had started retraining as nurses and leaving the country in search of better pay.

For the UK, on the other hand, importing nurses trained in Kenya is a very profitable deal. Whereas the UK government “typically spends at least £26,000, and sometimes far more, on a single nurse training post”, it costs only £10,000 to £12,000 to recruit a nurse from overseas, an externalization of costs that commodifies nurses, treating them like goods to be bought and sold.

However, in agreeing to the terms of the trade in Kenyan nurses, the two governments are merely formalizing the reality that a shortage of nurses in high-income countries has been driving the migration of nurses from low-income countries for over two decades now. Along with Ghana, Nigeria, South Africa and Zimbabwe, Kenya is one of the top 20 countries of origin of foreign-born or foreign-trained nurses working in the countries of the OECD, of which the UK is a member state.

Faced with this reality, and in an attempt to regulate the migration of healthcare workers, the World Health Assembly adopted the WHO Global Code of Practice on the Recruitment of Health Personnel in May 2010. The code, the adherence to which is voluntary, “provides ethical principles applicable to the international recruitment of health personnel in a manner that strengthens the health systems of developing countries, countries with economies in transition and small island states.”

Article 5 of the code encourages recruiting countries to collaborate with the sending countries in the development and training of healthcare workers and discourages recruitment from developing countries facing acute shortages. Given the non-binding nature of the code, however, and “the severe global shortage of nurses”, resource-poor countries, which carry the greatest disease burden globally, will continue to lose nurses to affluent countries. Wealthy nations will inevitably continue luring from even the poorest countries nurses in search of better terms of employment and better opportunities for themselves and their families; Haiti is on the list of the top 20 countries supplying the OECD region.

“Member States should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers.”

Indeed, an empirical evaluation of the code four years after its adoption found that the recruitment of health workers has not undergone any substantial policy or regulatory changes as a direct result of its introduction. Countries had no incentive to apply the code and given that it was non-binding, conflicting domestic healthcare concerns were given the priority.

The UK’s Department of Health and Social Care (DHSC) has developed its own code of practice under which the country is no longer recruiting nurses from countries that the WHO recognizes as facing health workforce challenges. Kenya was placed on the UK code’s amber list on 11 November 2021, and active recruitment of health workers to the UK was stopped “with immediate effect” unless employers had already made conditional offers to nurses from Kenya on or before that date. Presumably, the Kenyan nurses who left for the UK in June 2022 fall into this category.

In explaining its decision, the DHSC states that “while Kenya is not on the WHO Health Workforce Support & Safeguards List, it remains a country with significant health workforce challenges. Adding Kenya to the amber list in the Code will protect Kenya from unmanaged international recruitment which could exacerbate existing health and social care workforce shortages.”

The WHO clarifies that nothing in its Code of Practice should be interpreted as curtailing the freedom of health workers to move to countries that are willing to allow them in and offer them employment. So, even as the UK suspends the recruitment of Kenyan nurses, they will continue to find opportunities abroad as long as Western countries continue to face nurse shortages. Kenyan nurses will go to the US where 203,000 nurses will be needed each year up to 2026, and to Australia where the supply of nursing school graduates is in decline, and to Canada where the shortage is expected to reach 117,600 by 2030, and to the Republic of Ireland which is now totally dependent on nurses recruited from overseas and where working conditions have been described as “horrendous”.

“Adding Kenya to the amber list in the Code will protect Kenya from unmanaged international recruitment which could exacerbate existing health and social care workforce shortages.”

Like hundreds of other Kenyan-trained nurses then, Nancy will take her skills overseas. She has found a recruitment agency through which to apply for a position abroad and is saving money towards the cost. She is not seeking to move to the UK, however; Nancy has been doing her research and has concluded that the United States is a much better destination given the more competitive salaries compared to the UK where nurses have voted to go strike over pay and working conditions. When she finally gets to the US, Nancy will join Diana*, a member of the over 90,000-strong Kenyan diaspora, more than one in four of whom are in the nursing profession.

Now in her early 50s, Diana had worked for one of the largest and oldest private hospitals in Nairobi for more than 20 years before moving to the US in 2017. She had on a whim presented her training certificates to a visiting recruitment agency that had set up shop in one of Nairobi’s high-end hotels and had been shortlisted. There followed a lengthy verification process for which the recruiting agency paid all the costs, requiring Diana to only sign a contract binding her to her future US employer for a period of two years once she had passed the vetting process.

Speaking from her home in Virginia last week, Diana told me that working as a nurse in the US “is not a bed of roses”, that although the position is well paying, it comes with a lot of stress. “The nurse-to-patient ratio is too high and the job is all about ticking boxes and finishing tasks, with no time for the patients,” she says, adding that in such an environment fatal mistakes are easily made. Like the sword of Damocles, the threat of losing her nursing licence hangs over Diana’s head every day that she takes up her position at the nursing station.

“The nurse-to-patient ratio is too high and the job is all about ticking boxes and finishing tasks, with no time for the patients.”

Starting out as an Enrolled Nurse in rural Kenya, Diana had over the years improved her skills, graduating as a Registered Nurse before acquiring a Batchelor of Science in Nursing from a top private university in Kenya, the tuition for which was partially covered by her employer.

Once in the US, however, her 20 years of experience counted for nothing and she was employed on the same footing as a new graduate nurse, as is the case for all overseas nurses moving to the US to work. Diana says that, on balance, she would have been better off had she remained at her old job in Kenya where the care is better, the opportunities for professional growth are greater and the work environment well controlled. But like many who have gone before her, Diana is not likely to be returning to Kenya any time soon.

*Names have been changed.

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Why Azimio’s Presidential Petition Stood No Chance

In so far as the court had nullified the 2017 elections, the evidential threshold required for any subsequent electoral nullification was going to be substantially high for any petitioner.

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Even before the 9 August general election, it was expected that the loser of the Kenyan presidential contest would petition the Supreme Court to arbitrate over the outcome. Predictably, the losing party, Azimio La Umoja-One Kenya Coalition, petitioned the court to have William Ruto’s win nullified on various procedural and technical grounds. Azimio’s case was predicated on, among others, three key allegations. First, that William Ruto failed to garner the requisite 50 per cent plus one vote. Second, that the Independent Electoral and Boundaries Commission (IEBC) chairman Wafula Chebukati had announced the outcome without tallying and verifying results from seven constituencies. Finally, that the commission could not account for 250,000 votes that were cast electronically.

As we know, Azimio lost the case as the judges dismissed all the nine petitions that the party had filed, unanimously finding that William Ruto had won fairly.

Adjudicating electoral fallouts

Since its inception in 2010, the Supreme Court has played a decisive role in adjudicating fallouts linked to contentious presidential politics in Kenya, with the court deliberating on the outcome of three out of the four presidential elections held after its inauguration. Prior to this, the losing party had no credible institutional mechanism of redress and electoral disputes were generally resolved through mass political action (as in 2007) or consistent questioning of the legitimacy of the winner (as in 1992 and 1997).

The Supreme Court’s presence has, therefore, been crucial in providing losers with an institutionalised mechanism to channel dissent, with the court operating as a “safety valve” to diffuse political tensions linked to presidential elections. It is, hence, impossible to conceive of the relatively peaceful elections held in 2013, 2017 and 2022 without the Supreme Court whose mere presence has been key in discouraging some of the more deadly forms of political rivalry previously witnessed in Kenya.

Relentless petitioning

While the Azimio leadership were right to petition the court in the recent election, first because this successfully diffused the political tensions among their supporters, and second because the court was expected to provide directions on IEBC conduct in future elections, it was clear that Raila Odinga’s relentless petitioning of the court in the previous two elections, and the nullification of the 2017 elections, was in essence going to be a barrier to a successful petition in 2022.

In so far as the court had nullified the 2017 elections, the evidential threshold required for any subsequent electoral nullification was going to be substantially high for any petitioner. The relentless petitioning of the court and the nullification of the 2017 elections had in essence raised the bar for the burden of proof, which lay with the petitioner(s) and, therefore, reduced the probability of a successful petition.

The Supreme Court’s presence has been crucial in providing losers with an institutionalised mechanism to channel dissent.

The reason for this is both legal and political. Legal in the sense that the IEBC is expected to conduct the elections under the law, which, among other issues, requires that the electoral process be credible and the results verifiable before any certification is made, otherwise the election is nullified, as was the case in 2017. It is political because the power to select the president is constitutionally, hence politically, delegated to the Kenyan people through the ballot, unless electoral fraud infringes on this, again as was the case in 2017.

The court in its deliberation must, therefore, balance the legal-political trade-off in its verdict in search of a plausible equilibrium. For instance, while the majority of Azimio supporters had anticipated a successful petition based on the public walkout and dissent by the four IEBC commissioners, it seems that the decision to uphold the results displayed the court’s deference to political interpretation of the law by issuing a ruling that did not undermine the Kenyan voters’ right to elect their president.

While the settlement of legal-political disputes by a Supreme/Constitutional court is a common feature across democracies, and continuously being embedded in emerging democracies like Kenya, it does seem that in this election, the political motivations for upholding the vote outweighed the legal motivations for nullifying it. In essence, the court demonstrated its institutional independence by ruling against the Kenyatta-backed Azimio candidate due to insufficient evidence.

Supreme Court power grab 

A counterfactual outcome where the evidential threshold for the nullification of presidential results is low would foster a Supreme Court power grab, in lieu with the 2017 nullification, by marginalising the sovereign will of Kenyans to elect their president.

In many ways, nullification of the results would also have incentivised further adversarial political behaviour where every electoral outcome is contested in the Supreme Court even when the outcome is relatively clean, as in the case of the 2022 elections.

It is this reason (among others) that we think underlined the Supreme Court justices’ dismissal of Azimio’s recent petition. The justices ultimately dismissed the evidence presented by the petitioners as “hot air, outright forgeries, red herring, wild goose chase and unproven hypotheses”, setting a clear bar for the standard of evidence they expect in order to deliberate over such an important case in the future.

In essence, the court demonstrated its institutional independence by ruling against the Kenyatta-backed Azimio candidate due to insufficient evidence.

Since the earth-shaking nullification of the 2017 elections, the Supreme Court transcended an epoch, more political than legal by “invading” the sovereign space for Kenyans to elect their president, thereof setting a precedence that any future successful petition to contest a presidential election requires watertight evidence.

In a sense, Azimio were victims of Odinga’s judicial zealotry and especially the successful 2017 petition. In so far as the evidence submitted to the Supreme Court by Azimio in 2022 was at the same level or even lower than the 2017 base, their case at the Supreme Court was very likely to be dismissed and even ridiculed as the justices recently did.

The precedent set by the 2022 ruling will, actually, yield two positive political outcomes. First, it will in the future weed out unnecessary spam petitions that lack evidence and rather increase needless political tensions in the country. Second, it has signalled to future petitioners, that serious deliberations will only be given to petitions backed by rock-solid evidence.

Missed opportunity

From the recent ruling, it is evident that the judgement fell far below the precedent set in 2017. The 2017 Supreme Court ruling that the IEBC should make the servers containing Form 34A publicly available, was crucial in improving the credibility of the 2022 elections, by democratising the tallying process. At a minimum, the expectation was that the justices would provide a directive on the recent public fallout among the IEBC commissioners with regard to future national tallying and announcement of presidential results.

By dismissing the fallout as a mere corporate governance issue, the justices failed to understand the political ramifications of the “boardroom rupture”. What are we to do in the future if the IEBC Chair rejects the results and the other commissioners validate the results as credible?

Additionally, by ridiculing the petitioners as wild goose chasers and dismissing the evidence as “hot air”, the justices failed to maintain the amiable judicial tone necessary to decompress and assuage the bitter grievances among losers in Kenya high-octane political environment.

In a sense, Azimio were victims of Mr Odinga’s judicial zealotry and especially the 2017 successful petition.

The Supreme Court ought to resist the temptations of trivializing electoral petitions, as this has the potential of triggering democratic backsliding, where electoral losers might opt for extra-constitutional means of addressing their grievances as happened in December 2007. It is not in the petitioners’ place to ascertain whether their evidence is “hot air” or not, but for the court to do so, and in an amiable judicial tone that offers reconciliation in a febrile political environment.

The precedent set by the 2017 ruling that clarified the ambiguities related to the IEBC’s use of technology to conduct elections, set an incremental pathway towards making subsequent elections credible and fair, and increased public trust in the key electoral institutions in Kenya.

The justices, therefore, need to understand that their deliberations hold weight in the public eye and in the eyes of political leaders. Therefore, outlining recommendations to improve the IEBC’s conduct in future elections is a bare minimum expectation among Kenyans. In this case, while they provided some recommendations, they failed to comprehensively address the concerns around the walk-out by the four IEBC commissioners.

At the minimum, chastising the IEBC conduct was necessary to consolidate the electoral gains made thus far but also recalibrate institutional imperfections linked to how elections are to be conducted and, especially, contestations around the role of the commissioners in the national tallying of results in the future.

This article is part of our project on information and voter behaviour in the 2022 Kenyan elections. The project is funded by the Centre for Governance and Society, Department of Political Economy, King’s College London.

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GMOs Are Not the Only Answer

In a country where agricultural production is dominated by smallholders, the decision to allow genetically modified crops and animal feeds into Kenya as a means of combatting perennial hunger ignores other safer and more accessible alternatives such as Conservation Agriculture.

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Newly elected President William Ruto has, to use a much abused expression, hit the ground running. I am, however, not certain that he is running in the right direction. On 3 October 2022, during the second meeting of his recently (and unconstitutionally) constituted cabinet, Ruto announced that his government had authorized the cultivation and importation of genetically modified crops and animal feeds, sweeping aside the grave concerns raised by Kenyans and lifting a ten-year ban with the stroke of a pen.

The decision was made at a time when Kenya is facing the worst drought in four decades that has left over four million people facing starvation. According to President Ruto, the adoption of GMOs is the solution to the recurring cycles of drought and famine that Kenyans have been increasingly experiencing.

I shall not go into the merits and demerits of what some call Frankenfoods here. However, it seems to me that Ruto’s decision is driven solely by the political imperative to bring down the price of maize through cheap imports of GM maize following the withdrawal of the maize subsidy.

Already, back in November 2018, the Route to Food Initiative (RTFI), the Kenya Biodiversity Coalition (KBioC), the Africa Biodiversity Network (ABN) and Greenpeace Africa had issued a joint statement raising “concerns over recent disconcerting developments in the country, that [suggest] the Government has made [a] unilateral decision to adopt genetically modified crops”, and adding that “an all-inclusive nationwide discourse through public participation, which addresses whether the technology is appropriate for us, is being circumvented”.

The group also voiced their suspicion that the report of the Task Force to Review Matters Relating to Genetically Modified Foods and Food Safety that was set up by the Ministry of Health in 2013 was being withheld because it was against the adoption of GM foods. This suspicion may well be founded since, in making the announcement, State House said that the decision to lift the GMO ban was “made in accordance with the recommendation of the Task Force”, while failing to make the so-called Thairu report—which was submitted in 2014—available for public scrutiny.

The cabinet said that in reaching its decision to lift the ban it had also referred to reports of the European Food Safety Authority, among others.

The European Union’s policy on GMOs “respects the right-to-know by ensuring clear labelling and traceability of GMOs. This requires reliable methods for the detection, identification and quantification (for authorised GMO) in food, feed, and the environment”. There is zero tolerance for unapproved GMOs and stringent regulation of products originating from or containing GMOs.

A detailed risk analysis and the availability of a validated method for locating, identifying, and quantifying GMOs in food or feed are prerequisites for authorization. For any GM launch, biotech businesses that want to market their product in the EU must submit an application. A very precise way of detecting each unique GMO is included in the application dossier.

The terms of reference of the government’s GMO task force included, among others, assessing Kenya’s infrastructural capacities to monitor genetically modified products in the country; assessing the adequacy of qualified human resource capacity to monitor research, use and importation of genetically modified products into the country; and recommending approval procedures for imports of GM foods.

If we are to look only at the procedures established by the National Biosafety Authority for the importation of GM products into the country, then we may conclude that Kenya lacks the infrastructural and qualified human resource capacity to monitor their research, use and importation. In effect, an entity wishing to import a GM product into the country is merely required to provide the particulars of the supplier, the nomenclature of the GMO, proof that the GMO has been registered in the exporting country, its use in the country of origin, its intended use in Kenya, a summary risk assessment, methods and plans for safe handling, storage, transport and use, and the emergency response foreseen in the event of an accident with the GMO. The second of the two-page the application document is reserved for the applicant’s signature before a commissioner for oaths, a magistrate or a judge. Means of detection of GMOs are not mentioned.

It would seem then that Ruto’s government has fully devolved the responsibility for Kenya’s biosafety and biosecurity to the authorities of foreign nations. This is very frightening when you consider, for example, that the European Union Regulation EC304/2003 allows EU companies to produce and export to other countries pesticides that are banned or restricted in the EU. This double standard is the reason why active ingredients which have been withdrawn in the EU find their way to Kenya, poisoning our bodies and our environment, and destroying our biodiversity.

Maize is not the only ugali

The lifting of the ban on GMOs may have sounded the death knell for Kenyan small-scale maize growers; GM maize is to be found on the international markets at prices that defy all competition, which will now prove to be a boon for well-connected maize-importing cartels.

But maize, a staple in the majority of Kenyan households, is a relatively recent arrival on our national menu, becoming a major staple during the First World War when disease in millet led to famine.

As Noel Vietmeyer observes in the foreword to the first volume of Lost Crops of Africa,

“Lacking the interest and support of the authorities (most of them non-African colonial authorities, missionaries, and agricultural researchers), the local grains could not keep pace with the up-to-the-minute foreign cereals, which were made especially convenient to consumers by the use of mills and processing. The old grains languished and remained principally as the foods of the poor and the rural areas. Eventually, they took on a stigma of being second-rate. Myths arose—that the local grains were not as nutritious, not as high yielding, not as flavorful, nor as easy to handle. As a result, the native grains were driven into internal exile. In their place, maize, a grain from across the Atlantic, became the main food from Senegal to South Africa.”

But with initiatives such as the Busia County Biodiversity Policy, which recognises the role that biodiversity can play in addressing food insecurity, the tide is turning and Kenyans are rediscovering and embracing the culinary habits of our forebears. You would think then that the GMO decision will not, in the main, affect the choices we make in the foods we consume. That those of us a tad squeamish about eating foods that have been genetically interfered with can opt out.

Were it that simple.

Many Kenyans are unaware that the Seed and Plant Varieties Act Cap 326 of 2012 prohibits farmers from sharing, exchanging or selling uncertified and unregistered seeds. Yet, to mitigate against the effects of perennial droughts and the escalating costs of hybrid seeds, community seed banks have been conserving indigenous seeds—that are demonstrably more climate-resilient—for sale during the planting season, in contravention of the law and at the risk of a one million shilling fine, or two years’ imprisonment, or both. Criminalising a system through which small-scale farmers acquire 90 per cent of their planting material does not augur well for Kenya’s food security, or for our biodiversity. Small-scale farmers are fighting back, however, with a group from Machakos recently going to court to challenge the legislation. It remains to be seen who between David and Goliath will prevail.

But maize, a staple in the majority of Kenyan households, is a relatively recent arrival on our national menu, becoming a major staple during the First World War when disease in millet led to famine.

What is clear is that Kenya’s David, while remaining impoverished over the decades since independence, is the mainstay of the country’s agriculture in terms of productivity. The Economic Survey (2021) of the Kenya National Bureau of Statistics reports that,

“The share of marketed agricultural output for small farms increased marginally to 73.3 per cent in 2020. This is a reflection of the continued dominance of the smallholder sector in the marketing of agricultural produce during the year under review. The value of sales through small farms increased by 9.4 per cent from KSh 341.4 billion in 2019 to KSh 373.6 billion in 2020. Similarly, the value of sales by large farms increased by 8.9 per cent from KSh 125.0 billion in 2019 to KSh 136.1 billion in 2020.”

The survey defines large farms as those above 20 hectares.

The small-holder has consistently outperformed the large-scale farmer despite government policies that have since the 70s viewed smallholders as without agency beyond adopting technologies that are presented as capable of transforming agriculture and building livelihoods. The adoption of GMOs is likely to be yet another of these technologies that, together with unjust seed legislation, will increase rather than decrease Kenya’s food insecurity.

President Ruto worries about food insecurity but fails to consider the very ready solution available to his administration and recommended in the Agricultural Policy (2021) of the Ministry of Agriculture, Livestock, Fisheries and Cooperatives, namely, conservation agriculture.

The Food and Agriculture Organisation (FAO – also quoted in Ruto’s decision to lift the GMO ban) recommends conservation agriculture as it is a sustainable system of production that conserves and enhances natural resources; enhances biodiversity; assists in carbon sequestration; is less labour and fertilizer intensive; improves the health of soils; and increases yields over time.

Criminalising a system through which small-scale farmers acquire 90 per cent of their planting material does not augur well for Kenya’s food security, or for our biodiversity.

The very promising results obtained among the small-scale farmers that have adopted the system following training under the FAO beginning in 2015 show that the government would do well to promote conservation agriculture among smallholders as a means of mitigating both against food insecurity and the effects of climate change, rather than hastily reaching for GM technologies that the country is ill-equipped to safely handle.

But clearly, the president is not on the same page as his Ministry of Agriculture and so, like others, I can only conclude that Ruto’s lifting of the GMO ban is for the benefit of the seed multinationals and their clients, the large-scale farmers who have taken over most of the productive land to grow cash crops for export, leaving small-scale farmers to exploit marginal lands for the production of food crops for local consumption. And for the benefit of maize-importing cartels.

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