Dollarman Fatinato

Why is strengthening lower tier services central to easing pressure on KNH?

Kenya’s health system has been dogged with numerous challenges, key among them being the poor, health referral systems across the various levels of care, which affects the overall performance of the health system and contributes to negative health outcomes. Nairobi is among the counties that host national referral hospitals including Kenyatta National Hospital (KNH). Where citizens seeking medical care often bypass lower-level facilities and seek care directly at referral care hospitals for illnesses that could easily be treated at the lower tier. Health systems, not just in Kenya but across the world, are hierarchical, starting with primary care, secondary care facilities, and the highest level of care, consisting of tertiary level facilities that provide highly specialized services.


Nairobi Metropolitan Services (NMS) director-general Mohammed Badi, on 12th May, announced plans to close KNH for walk-in patients only to attend on referrals by July 2021. This is a commendable move towards implementing The Kenya Health Policy 2012–2030 which identifies the need to strengthen the referral system in Kenya as a way of improving efficiency in the health system and improving patient outcomes, however, it requires a cautious and systemic approach before its effect especially at this time when the nation is facing a critical health crisis necessitated with the heavy burden of COVID19.


The right to the highest attainable standard of health is a fundamental human right. Central to this right in the delivery of health care in a hierarchical health system is the existence of a well-functioning referral system that allows for seamless continuity of care across different tiers. The enforcement of this may prove to be counterproductive if not well planned and actualized. Considering the high number of patients KNH serves including street men, women, and children who are reported to only rely on  KNH and Casino health facility in accessing free healthcare. The two months period before blocking walk-in patients from accessing care at the referral facility is not adequate to put adequate measures for referral adherence in place.


The implementation of this requires a participatory approach of all state and non-state actors in the health sector including health management teams at different sub-counties, to increase the use of services at lower levels of the health care system and reduce self-referral to higher levels of care. Before this, NMS must also strengthen service providers’ capacity to provide not verbal but written referral at each healthcare system level. The ability to transfer clients and specimens between the different levels of the health care system and public education are other key aspects that the metropolitan area leadership should consider closely.


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