By our Correspondent
A report by the Committee on Health of the Machakos County Assembly has confirmed the sad status of Machakos L5 Hospital.
The report is the outcome of hospital visits, interviews with hospital staff, Chief Officers anf doctores managing the facility.
The report was tabled on the floor of the assembly and adopted. It amounts to an indictment of the Wavinya Ndeti's approach to provide healthcare to the residents of Machakos County.
The Anchor now presents excerpts of the report verbatim.
8. Honorable
Speaker, during a Committee meeting held 12th February, 2024 it was
brought to the attention of the Committee on the public outcry about the poor
status of Machakos Level 5 Hospital. This was backed by letters circulated in social
media purported to be originating from Doctors and the Medical Superintendent
of the said Hospital. (Annexure 1, 2 and 3)
9. The
following was set out as the matters to be considered and investigated on
during the site visit and engagement with the Management of Machakos Level 5
Hospit
3.1 Site
Visits
10. Honorable Speaker, the Committee
conducted impromptu visits authorized by the Speaker pursuant to Standing
Order 162 (Annexure 4 ) to the facility on 15th
and 20th February, 2024 and the following were the
observations;
3.1.1
Intensive
Care Unit (ICU)
11. The Committee interrogated the nurse
in-charge of the ICU who stated that the bed capacity is six. However as at the
time of this visit only four beds were being used because the staffing levels
of nurses in the ICU was not enough. The ICU Department has twenty six nurses
working in shifts. One patient in ICU is supposed to be manned by six nurses working
in shifts.
12. The Hospital has a two bed capacity
High dependency Unit (HDU) which at the time of this visit was not operational
because of shortage of nurses. It was further reported that in an ideal
situation, a patient in HDU is supposed to be handled by eight nurses working
in shifts.
13. The Committee was informed that when
the ICU is overwhelmed with patients, referrals are made to Kenyatta National
Hospital or Private Hospitals depending on the patients/kins’ preference.
14. The nurse in charge of the ICU
acknowledged that letter (Annexure 1) was known to him and was
the true status of the ICU as at 24th January, 2024. The ICU had
stock-outs of heat and Moisture Exchangers (HME) and bacterial filters,
Bacterial filters for the ventilators, catheter mounts, perfusor lines and
blood gas analysis. The breathing circuits’ wipes had broken down and needed
replacement. He however stated that new
breathing circuits were later traced in the maternity theatre.
15. It was reported at the time this
letter was written, the ICU had stayed for two weeks without supplies with an
admission of only one patient. During this time when stock outs were
experienced, patients were being referred to other Hospitals.
3.1.3 Status of the Theatre
16. The
Committee had an engagement with the Head of General Surgeons, who confirmed to
be the author of letter (Annexure 2) dated 29th
January, 2024. He further confirmed that the contents of the letter addressed
to all Heads of Departments and copied to the Medical Superintendent on frequent
disruption of essential theatre supplies were known to him and was a true
reflection of the status of the theatre as at the time the letter was done.
17. As
at the time of this site visit, the Doctor further highlighted to the Committee
that supply of essential theatre commodities was still erratic.
18. Patients
were being told to purchase such theatre supplies from outside the facility
whenever they were out of stock. Some would purchase while others would opt to
have their patients transferred to private hospitals within the town. Those who
could not afford to purchase would wait until restocking is done.
19. The
Doctor reported that the common theatre commodities whose supplies are not
consistent were gloves, sterile drapes, sterile gauzes and sutures.
20. He
further acknowledged that laundry for theatre was recently being done from
Kangundo Level 4 Hospital since the Laundry Machines at Machakos Level 5
Hospital had broken down.
3.1.4 Availability
of Hospital Supplies (Pharmaceutical and non- Pharmaceutical)
21. The
Committee held a discussion with the Head of Pharmacy on hospital supplies
especially pharmaceuticals.
22. He
indicated that the facility consumes approximately Kshs. 30M on drugs, Kshs.
30M on laboratory reagents and Kshs. 10M on Imaging Supplies quarterly.
23. He
further reported that during the second quarter of the currently Financial year
(October, November and December, 2023) the hospital had ordered supplies from
KEMSA worth Kshs. 20M and from MEDS worth Kshs. 10M. Out of this order, a
consignment worth Kshs. 15M and Kshs.9M was received from KEMSA and MEDS
respectively in the month of January. This is because payments for MEDS are
made upfront whereas those for KEMSA are made after delivery. However KEMSA
cannot supply until the previous payment has been done.
24. The
Committee was informed that lack of funds occasioned delay of these critical
hospital supplies and to bridge the gap, the hospital has been engaging local
suppliers who currently were not being promptly paid.
25. He
acknowledged that supply of pharmaceuticals and non- pharmaceuticals in the
Hospital wa erratic and this was inconveniencing all the Departments and the
patients.
26. The
Committee made visits to the non- pharmaceuticals store and noted that most of
the cartons were empty. The nurse in charge reported that most of the
commodities were out of stock and more especially clean gloves. Out of an order
of one thousand pairs of clean gloves from the outpatient Department, only one
hundred pairs were available. This meant that patients will have to buy gloves
from outside to supplement the deficit.
27. The
Committee further had an engagement with the Officer, in-charge of Procurement
in the Hospital who stated that acquisition of bulk commodities and equipment
was done by the Director of Procurement in the entire Department of Health. The
In-charge of procurement in the facility reported that she only dealt with
emergency commodities of amounts less than Kshs. 50,000 per item per year
through requests of quotation from prequalified suppliers. The Hospital has
accrued approximately Kshs. 2M pending bills from suppliers of the emergency
commodities since last year. She was also charged with the responsibility of
receiving delivered commodities and issuance to the user Departments.
3.1.2 Mortuary
28. The Committee interrogated the
Officer in-charge of Public Health in the facility who confirmed that in the
month of October, November and Part of December, 2023 the Mortuary at Machakos
Level 5 had been closed to pave room for renovations.
29. The renovations were done on the
super structure and not the chambers. This included plastering, partitioning,
cold room, Toilets, Offices and Doctors’ rooms. The walls were dilapidated
before the renovations and were losing coldness hence compromising the
preservation aspect of the mortuary.
30. Before the closure for renovation,
the Public Health Department had made an application to the court to conduct
mass burial of thirty one (31) unclaimed bodies which was granted. As at the
time of renovations the Mortuary had four bodies. During the renovations, the
Hospital wrote a letter to notify the police of non-admission of bodies but a
public notice was not done.
31. The Officer was neither aware
whether inspection and acceptance had been done on the renovated part nor
handing over of the project. He however confirmed that the contractor had
exited the site.
32. He further brought to the attention
of the Committee of the body of a suspected thief who had been burned at Kenya
Israel in January and clarified that it was not brought at Machakos Level 5
Mortuary but instead taken directly to Kathiani Level 4 Mortuary.
33. The Committee visited the mortuary
and noted that it was operational with three chambers holding six bodies each;
only one chamber was under renovation. A public notice had been placed on the
notice board to inform the members of public of resumption of services. The
Mortuary has a capacity of twenty four and the occupancy as at the time of the
visit was thirteen.
34. The Public Health officer further
notified the Committee that post mortem services were not being offered in the
mortuary because of lack of a post mortem kit whose requisition had been raised
severally.
3.1.5 Status of the Laundry Unit
35. The
Committee held a discussion with the hospitality Officer in- Charge of the
Laundry Unit who confirmed that in the month of December, 2023, the Hospital
received four new laundry machines which included; one sluicing machine, two
washing machines and one calendar (Ironing machine). These replaced the old
machine which would frequently break down and tear linen as it washed.
36. Installation
of the new machines started in January, 2024 which included mounting, wiring
and plumping and was done by the Hospital maintenance team in conjunction with
the supplier.
37. The
hospitality Officer reported that disruption of laundry services occurred when
the old washing machine was un- installed and replaced with one of the new
washing machines. The new washing machine started overheating and the heater
had to be removed. Linen was therefore taken to Kangundo for laundry. Laundry
services have since resumed at the facility.
38. The
Committee was informed that the Inspection and Acceptance Report had not been
done The Committee further interrogated the Bio- Medical Engineer who further
stated that the manual book for the laundry machines was in Chinese Language
but plans were underway to have an English version availed. He added that the
Machines did not have a brand name hence difficult to compare their maintenance
with other machines. The hospital staff operating the machines had not been
trained.
39. The
Committee visited the laundry unit and was impressed by its operations despite
the initial installation challenges. As at the time of this visit all the newly
installed machines in the laundry unit were working. The hospital linen was
however old, stained and torn.
3.1.6 Status of the Catering Unit
40. The
Committee interrogated the Hospitality Officer in- Charge of the Catering Unit
who confirmed that the contents of letter Annexure 3 dated 25th
January, 2024 and signed by the Medical Superintendent was a true reflection of
the food stock of the hospital as at that date.
According to the letter, the framework supplier of food stuffs in the
hospital was adamant on supplying food owing to delayed payment since
September, 2023. She however confirmed that patients have never missed a meal.
41. She
highlighted that orders are done quarterly and forwarded to the Department of
Procurement. Approximately Kshs. 9M per month was adequate to cater for
perishables, dry foods and cooking fuels.
42. The
Committee was informed that in the month of October and November, 2023 supply
of food rations was sufficient and dry stuffs were supplied enough for a month.
The supplier would supply perishables every Monday and Friday which are market
days for Machakos town Market.
43. Currently
the supplies were unpredictable and there are days she gets to office at 8.00am
without food stocks for lunch and dinner meals for that day. On these days, the
lunch meals are served at 2.30pm. Diabetic patients were being served with
porridge as they wait for the meal. The Committee interrogated some patients
and it was confirmed that meals were being delayed.
44. The
Committee also visited the main kitchen and noted that it was under renovation
since last year October. A temporary kitchen was being used in the meantime.
The scope of works for the renovation of the kitchen included drainage, painting,
cold rooms, store, partitioning of washrooms and ceiling. The Committee noted
that when the rains came, the roof leaked destroying the already renovated ceiling.
As at the time of this visit the contractor was not on site. Works on the
stores and cold rooms had not commenced.
45. The
Committee made a check-up of the food store and the available food was two bales of maize
flour, five bales of wheat flour, six cartons of tea leaves and two cartons of
blue band. The store had sufficient perishables (fruits and vegetables) but the
cereals store was empty.
3.1.7 Revenue Collection in the
Facility
46. On
revenue Collection, the Committee was informed that in the month of November,
2023, Kshs. 11,467,000 was collected. This included 61% from outpatient and 39%
from inpatient. A breakdown of the outpatient collection showed that Kshs. 2M
was collected from Laboratory Services, Kshs. 1.6M from Imaging Services, Kshs.
1.2M from pharmacy and Kshs. 1.6M from consultations. In the month of December,
2023 the hospital collected Kshs. 9.4M which included 56% from Outpatient and
44% from inpatient. These fees and charges are paid through MPESA to the
hospital account and later swept to Family Bank Account. The hospital has no
authority to spend the monies collected at the facility.
47. The
hospital Admistration reported that during the second quarter of the FY
2023/2024 the facility got a plough back of Kshs. 5M which was received in the
month of October, 2023 whereas in the month of January, Kshs. 5.5M was received
to cover the third quarter. These funds are utilized in the form of imprest to
cater for operations of the hospital. This includes fueling of ambulances and
purchase of emergency hospital commodities. The hospital Admistration stated
that the monies received as plough back were very little and not able to
sustain the hospital.
3.2 Minutes from meeting of Consultants.
48. Honorable Speaker,
the Committee was supplied with copies of minutes from meetings of Consultants
which had highlighted various issues (Annexure 5 and 6)The Committee
deduced the following from the minutes;
Minutes of 15th November, 2023
49. The
committee noted from the minutes that the County Government has adopted the
facilities improvement financing Act, 2023 that was recently passed by the
senate and whose operationalization was to start from 1st December,
2023.
50.
The Committee noted the FIF collection
from 10th September to 15th November:
i.
Outpatient-Kshs.13,5112,266.68
ii.
Inpatient- Kshs. 8,212,212.91
iii.
Total collection - Kshs. 21,724,383.59
51. On
average outpatient revenue collection accounted for was at 62.2% of total
revenue collection while inpatient accounted for 37.8%.The committee observed
that the consultants had unanimously agreed that the hospital was not reaching
its full potential in revenue collection.
52.
That the malfunctioning of the
Laundry Unit, poor state of linen and lack of key supplies had been discussed
during this consultants meeting.
Minutes
of 17th January, 2024
53. The
Committee appreciated that there was automation of health records-launch of new
Health Information Management system for both inpatient and outpatient services
which was a great boost to service delivery.
54. The
Committee noted the following challenges as discussed by the consultants;
i.
Staff exodus resulting in acute staff shortage
especially nursing
ii.
Security lapses in the vicinity of the
hospital.
iii.
Low staff morale due to lack of
implementation of collective bargaining agreement (CBA) and public service
policies.
iv.
Shortage of electronic infrastructure like
computers
v.
Under equipped departments like dental
which has resulted in increased referrals to Kenyatta National Hospital
vi.
General poor and old buildings with
inadequate space to accommodate expansion of services.
55. The
committee noted from the minutes that
the hospital level of operation was at 10% mainly because critical Departments
such as laboratory, radiology, ICU, renal and pharmacy departments were still
struggling with commodity stock outs causing demotivation and lethargy of
staff.
3.3
Meeting with the Chief Officer, Medical Services
56.
Honorable Speaker, Article 195 (1) of the
Constitution of Kenya, 2010 stipulates that “A County assembly or any of its Committees
has power to summon any person to appear before it for the purpose of giving
evidence or providing information.
57.
Section 39(2) of the County Governments
Act, 2012 states that “A committee of the county assembly may require a member
of the executive committee to—
(a)
Attend or appear before the committee; and
(b)
Answer any question relating to the member’s responsibilities.
58. Further
Section 18 (1) of the County Assemblies Powers and Privileges Act, 2017 states
that “a County Assembly or its Committees may invite or summon any person to
appear before it for the purpose of giving evidence or providing any
information, paper, book, record or document in the possession or under the
control of that person and, in this respect, a County Assembly and its Committees
shall have the same powers as the High Court as specified under Article 195 of
the Constitution.
59. The
Health and Emergency Services Committee invited the Chief Officer, Medical
Services for a meeting on 6th March, 2024 through a letter Reference
No. (MKSCA/ PCS/CMM/HES/VOL.13/25) dated 26th February, 2024. The
Chief Officer stated the following in regard to the status of Machakos Level 5
Hospital;
60. That
supplies of pharmaceuticals, non- Pharmaceuticals and food rations is
inconsistent in Machakos Level 5 hospital and across all hospitals in the
County. This is occasioned by inadequate budget allocation on vote lines of
such supplies. For instance in the current FY the budget for purchase of
pharmaceuticals and non- Pharmaceuticals in all Hospitals in the County is at
Kshs. 236M. As at the time of this meeting, the Chief Officer reported the
budget had been exhausted and had put forth a request to have an additional
Kshs. 123M in the second supplementary budget.
61. He
stated that 70% of these hospital supplies go to level 3 and 2 hospitals which
do not collect much revenue. He further stated that the ideal budget for
pharmaceuticals and non- Pharmaceuticals in all Hospitals across the County in
Financial year should be Kshs. 800M. As at the time of this meeting, the Chief
Officer confirmed that most of the supplies in the hospital were out of stock.
62. On
revenue collected in Machakos Level 5, the Chief Officer highlighted that
during the first half of FY 2023/2024 the hospital collected Kshs. 106M even
when all the Departments were not operating optimally. He informed the
Committee that if this amount was to be utilized within the facility as provided
for in the Facility Improvement Financing Act, 2023 much pressure on supplies
would be relieved.
63. All
the revenue collected at the hospital was banked via MPESA paybill to family
bank. He however reported that he was not a signatory of the account and had no
access to the funds collected.
64. NHIF
claims for Machakos Level 5 Hospital according to the Chief Officer goes to the
County Revenue Account (CRF).
65. On
staffing of the hospital, the Chief Officer acknowledged that shortage of staff
across all cadres was a big challenge affecting service delivery in Machakos
Level 5 Hospital and all other hospitals in the County. This had been
occasioned for mass exodus of nurses in pursuit of greener pastures outside the
Country and non- replacement of medical personnel who exited service due to
natural attrition. He however informed the Committee that recently an
advertisement had been made to fill ninety one (91) positions which were still
not enough.
66. On
the status of the mortuary, the Chief Officer appreciated that most of the
cooling machinery were old and inefficient. This meant that routine maintenance
had to be done and was expensive since some spare parts of such old machinery
were not locally available. He proposed that the County can consider building a
modern funeral home.
67. He
further stated that the current mortuary at Machakos Level 5 Hospital did not
have space to accommodate post mortem services and such can be considered when
proposing for a modern funeral home. He also acknowledged that public notice
was not done when the mortuary was closed during renovation which was an
oversight on the Administration of the Hospital.
68. On
the Laundry Unit, he confirmed that it was operational. He stated that when the
Committee visited the facility, personnel working in the laundry unit had not
been trained on operations of the Machines and used to overload the machines
hence the overheating. He however confirmed that the supplier had since trained
them and availed an English version manual. Handing over of the machines was
yet to be done and was planned to take place after the biomedical engineers had
been inducted on the use of the machines. The Chief Officer acknowledged that
the hospital linen was torn and old hence the need to have it replaced. A
budget of Kshs. 30M would be ideal to cater for linen and patients’ gowns in
Machakos Level 5 Hospital and all Level 4 Hospitals.
69. On
the food rations, the Chief Officer stated that the supplies were erratic owing
to delayed payments of the suppliers and exchequer releases. He however
highlighted that patients at the hospital have never lacked a meal.
70. On
renovations works on the main kitchen of the hospital, the informed the
committee that the scope of works did not include roofing of the kitchen and no
payment had been paid on the works. Works were ongoing according to the Chief
Officer.
71. On
why the hospital did not have a medical superintendent, the Chief Officer
stated that there was a proposal to have a Chief Executive Officer (CEO)
managing the Hospital. Currently the hospital was being manned by Deputy
Medical superintendent Officer.
72. Honorable Speaker,
from the above observations drawn from the site visit, minutes of hospital
consultants and discussion with the Chief Officer, Medical Services, the
Committee made the following findings;
73. That
Machakos Level 5 Hospital has an acute shortage of staff across all the cadres.
This has led to service delivery at the facility being poor. Some critical Departments
like the ICU and HDU have had to scale down on their admissions because of
shortage of nurses. This has also greatly affected the quality and promptness
of medical care.
74. There
is no functional and competent County Directorate of health as provided for in
the Health Act 2017. Most directors are in acting capacity and the substantive
ones had been transferred to other areas under unclear circumstances.
75. Supply
of pharmaceuticals and non- pharmaceuticals in Machakos Level 5 Hospital is
very erratic despite it being the referral Hospital of the County. This was
affecting the less fortunate especially who those who required theatre services
and could not afford to purchase the much needed theatre commodities from
outside the hospital or get transferred to private hospitals. The hospital can
operate smoothly with a budget of Kshs. 70M per quarter to cater for drugs,
imaging and laboratory commodities.
76. When
renovations were being done at the Machakos Level 5 Hospital Mortuary, closure
was done without informing members of public. As at the time of the site visit,
the mortuary had been re-opened. The capacity and standards of the Mortuary
however do not meet the current market demand of funeral homes. Post mortem
services were not being conducted at the mortuary because there was no post
mortem kit. All of deaths with police cases requiring post mortem services had
to be transferred to private funeral parlors. This in itself was a loss of
revenue.
77. The
new Laundry Unit is working well despite the initial installation challenges.
However the laundry Machines are being used even before the inspection and
acceptance report has been done and commissioned. This poses a risk especially
on who is responsible incase a breakdown happens.
78. That
the hospital linen and patients’ gowns are old and torn. Besides not having
replacement of the linen done in the recent past, the old washing machine had
contributed in worsening the state of the hospital linen.
79. The
supply of food rations is inconsistent and there is a high risk of patients
missing meals. The hospital can comfortably operate with a budget of Kshs. 27M
per quarter on perishables, dry stuffs and cooking gas.
80. The
renovations works of the main kitchen seems to have stalled with the contractor
not being on site. The roof of the kitchen is leaking. Priority has to be given
to the roof before repairing the ceiling.
81. The
amount ploughed back to the hospital is way too low compared to the amount
collected in the hospital. The ratio of the amount ploughed back to the amount collected
can be equated as 0.2:1. If the
hospital can collect an approximate of Kshs. 10M per month with the current
inconsistent supplies is a clear indication that when all supplies are well
stocked, a double output on revenue can be realized.
82. The
Department of Health and Emergency Services has never operationalized the
Facility Improvement Financing Act, 2023 enacted by the senate which provides for collection, management and Administration of charges and
monies collected in hospitals.
83. Honorable
Speaker, based on the above findings, the Committee makes the following
recommendations;
84. The County Government should consider
apportioning some additional funds to start a phased program of recruiting
medical personnel in the Department of Health and Emergency Services. The
County Public Service Board should prioritize recruitment process for any
pending advertisement in the shortest time possible.
85. Sufficient budget should be allocated for the
purchase of pharmaceutical and non- pharmaceutical supplies. Lack of these
basic and very essential commodities entirely impact negatively on service
delivery in the hospital and ultimately affect residents of the County who
cannot afford medical services in private hospitals. At least Kshs. 70M should
be allocated to the Hospital per quarter to cater for drugs, imaging and
laboratory commodities.
86. In
future when the Department of Health and Emergency Services intends to close
certain units in the Machakos Level 5 Hospital or any other public hospital
within its jurisdiction a public notice should be issued on such disruption of
services through the Kenya gazette and other media platforms. Reopening and
resumption of such services should also be notified to the public.
87. The
County Should also set aside funds for construction of a modern state of art
funeral home with a 100 body capacity well equipped with a post mortem kit and
a chapel. Further, the non- functional chambers in the current mortuary should
be operationalized and modernized to cater for the police cases and unclaimed
bodies.
88. Training of biomedical engineers and handing
over of the Laundry unit to the Hospital should be fast tracked the soonest.
This is in line with the Public Procurement and Disposal Act.
89. Kshs.
30M should be factored in the budget for the FY 2024/2025 for purchase of
hospital linen and gowns. This linen and gowns will specifically be for
Machakos Level 5 and all the level 4 hospitals in the County.
90. Accrued
debts of the food rations suppliers should be paid within the next thirty days
(30). Since the County is in the budget making process according to the Public
Finance Management regulations, sufficient budget should be allocated for
purchase of food rations in the hospital. At least Kshs. 27M should be
allocated per quarter on perishables, dry stuffs and cooking gas for Machakos
Level 5 Hospital.
91. Scope
of works for renovation of the main kitchen should be revised to include repair
of the roof. The contractor should also be urged to hasten the renovations
works because hygiene of the makeshift kitchen is not to the required WHO
standards.
92. The
Health Department should be restructured by establishing the directorates as
described in Health Act, 2017 and the posts in acting capacity to be filled
competitively to provide the necessary technical advice required. Mandatory Directorates
that should be established are; medical services, nursing, pharmaceutical
services, public health and administrative services.
93. Machakos
level 5 Hospital to be converted to a co-operate headed by a Chief Executive
Officer competitively sourced by County
Public Service Board and a fully functional
hospital board of management with such powers and responsibilities as outlined
in the recently enacted Facility Improvement Financing Act,2023. Machakos level
5 Hospital to be considered as a procuring entity with end to end procuring
rights to arrest the lengthy procedures which comes with delays and that for
the purpose of budgeting Machakos Level 5 Hospital should be budgeted
independently.
94. Implementation
of the Facility Improvement Financing Act, 2023 is bestowed with the CECM,
Department of Health and Emergency Services. This Act will ensure monies
collected in all county hospitals are banked and managed within such hospitals.
It will also facilitate creation of hospital boards and Facility Committees to
oversee management of monies collected in hospitals. The Committee directs the
CECM to formulate regulations and forward them to the Assembly for
consideration and approval. The Committee further directs that the CECM
appraises this house with the implementation status of the said act fourteen days
from the approval of the said regulations.
6.0
CONCLUSION AND ACKNOWLEDGEMENT
95. Honorable
Speaker, allow me to acknowledge the Department of Health and Emergency
Services for the response given and proposals given for the management of
Machakos Level 5 Hospital. I wish to appreciate the Health and Emergency
Services Committee members for their dedication during site visits, committee
sittings and compiling of this report. Honorable Speaker, the Committee
expresses gratitude to the Office of the Speaker and that of the Clerk to the
County Assembly for the continuous and relentless support received as it
discharged its oversight mandate. It is therefore my duty, on behalf of the
Health and Emergency Services Committee to table this report and recommend it
to this honorable house for consideration and adoption.
Thank you Honorable Speaker."
