Health worker strikes: are we asking the right questions?
Authors: J K Muma Nyagetuba, Mary B Adam
Journal: The Lancet Global Health (2019)

Strikes by health workers pose a recurring and substantial non-epidemic non-conflict insult to provision of health service delivery across Africa. In The Lancet Global Health, Gerald Ong'ayo and colleagues analysed the effect of strikes on mortality in Kilifi county in Kenya.1Ong'ayo G Ooko M Wang'ondu R et al.Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis.Lancet Glob Health. 2019; (published online May 22.)http://dx.doi.org/10.1016/S2214-109X(19)30188-3Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar They used population-based mortality data obtained from the Kilifi Health and Demographic Surveillance System (KHDSS), which were gathered over a 7-year period (2010–16). In-hospital and community mortality rates during six different strikes (duration 9–42 days) were tallied, including one 14-day period during which time both doctors and nurses were on strike. No change in the mortality rate during strikes was noted (adjusted rate ratio [RR] 0·93, 95% CI 0·81–1·08; p=0·34). Ong'ayo and colleagues' findings accord with those of similar studies in several high-income regions. Yet, a key difference is that emergency services continued to be provided during most of the strikes in high-income settings, but not in the Kenyan study. Despite the pronounced reduction in availability of services during strikes at Kilifi Community Hospital (a level 4 referral facility in the KHDSS), the mortality rate remained unchanged. This result is especially noteworthy with respect to neonatal mortality, which represented 9% of all deaths in the sample (including deaths from neonatal pneumonia, birth asphyxia, neonatal sepsis, prematurity, and congenital malformation). Neonatal deaths, particularly from birth asphyxia (3% of all deaths in this sample) are particularly vulnerable to availability of health workers in the first 5 minutes of life. Yet, with more than 68% of all births recorded in the KHDSS being facility-based in 2016, neonatal mortality was unchanged (age <1 month, adjusted RR 0·97, 95% CI 0·69–1·37; p=0·88). Why was the mortality rate unchanged between strike and non-strike periods? Ong'ayo and colleagues suggest several plausible reasons, including ongoing care provided by doctors from the KEMRI-Wellcome Trust Research Programme in the paediatric high-dependency unit, the relatively short duration of strikes, possibly reduced exposure to hospital-acquired infections, and services provided by private or faith-based facilities that might have filled the gap. Based on our own experience at Kijabe Hospital over this same period, strikes in the government sector caused overwhelming increased demand beyond the capacity of private facilities. Therefore, services provided by private and faith-based facilities are unlikely to be the reason for the unchanged mortality rate. This reason is especially true for poor populations, who might not be able to afford to attend private or faith-based facilities, despite care being substantially subsidised at faith-based facilities—the next level up in financial affordability. These results could point to issues surrounding the quality of care available to Kenyans at government facilities. A paucity of drugs and minimum necessary equipment,2Martin GH Pimhidzai O Service delivery indicators: Kenya.http://documents.worldbank.org/curated/en/106261468285022553/pdf/903710WP0Box380IC00SDI0Report0Kenya.pdfDate: July, 2013Date accessed: April 30, 2019Google Scholar in addition to insufficient ratios of doctors and nurses to patients, legitimise complaints made by health worker unions. But, do these complaints represent sufficient reason to cease caring for patients? Longer strikes that took place during 2017—the 100-day doctor strike and the 151-day nurse strike—make the question all the more important to address.3Adam MB Muma S Modi JA et al.Paediatric and obstetric outcomes at a faith-based hospital during the 100-day public sector physician strike in Kenya.BMJ Glob. 2018; 3: e000665Crossref PubMed Scopus (19) Google Scholar, 4Irimu G Ogero M Mbevi G et al.Tackling health professionals' strikes: an essential part of health system strengthening in Kenya.BMJ Glob. 2018; 3: e001136Crossref PubMed Scopus (50) Google Scholar How can Kenyan health workers trust a government health system that leaves them so under-resourced? How does the Kenyan public trust health workers who are willing to put down their tools? The recurring strikes by health workers point to questions of trust even more than questions about the effect on outcomes such as mortality during strike periods. The trust issue brings to the surface fundamental questions about the nature of the relationship between health workers and the patients they serve and the nature of the relationship and responsibility of the government to its citizens, particularly in a country where the constitution declares that every citizen deserves the highest level of health care. Trust, or lack of trust, has been shown to affect medical outcomes ranging from uptake of Ebola virus disease preventive behaviours,5Vinck P Pham PN Bindu KK Bedford J Nilles EJ Institutional trust and misinformation in the response to the 2018–19 Ebola outbreak in North Kivu, DR Congo: a population-based survey.Lancet Infect Dis. 2019; 19: 529-536Summary Full Text Full Text PDF PubMed Scopus (257) Google Scholar improved vaccinations, use of medical care, and adherence to treatment.6Ozawa S Sripad P How do you measure trust in the health system? A systematic review of the literature.Soc Sci Med. 2013; 91: 10-14Crossref PubMed Scopus (166) Google Scholar Trust is a relational notion and it operates at both the individual, institutional, and governmental level.7Gilson L Trust and the development of health care as a social institution.Soc Sci Med. 2003; 56: 1453-1468Crossref PubMed Scopus (652) Google Scholar, 8Lee PV Berwick D Sinsky CA Building trust between the government and clinicians: person to person and organization to organization.JAMA. 2019; (published online April 10.)DOI:10.1001/jama.2019.4499Crossref Scopus (8) Google Scholar, 9Lee TH McGlynn EA Safran DG A framework for increasing trust between patients and the organizations that care for them.JAMA. 2019; 321: 539-540Crossref PubMed Scopus (43) Google Scholar Trust in doctors is falling globally; the reasons cited in a study in 23 countries include commodification, conflicts of interest, and risk of unmet care needs.10Huang EC-H Pu C Chou Y-J Huang N Public trust in physicians: health care commodification as a possible deteriorating factor—cross-sectional analysis of 23 countries.Inquiry. 2018; 55 (46958018759174)Google Scholar All three factors are probably present in Kenya. Has a marketplace mentality and a worker rights-oriented approach replaced a covenantal relationship with a contractual one? Do doctors and nurses have a duty to care? Can they be trusted? Trust is essential for both contractual and covenantal relationships to work. But a covenantal relationship—exemplified in the Hippocratic tradition whereby the welfare of the patient is placed above the doctor's needs—is radically different from a contractual relationship. Strikes are a symptom of a predominantly contractual view of the relationship between patients and health workers. Therefore, industrial action might be implemented with insufficient attention to the risk of unmet care needs, and trust will be damaged—even if mortality rates remain unchanged. Rebuilding trust is essential to moving forward. It will require far more than increasing medical technical expertise. Rebuilding trust will require a reconsideration of what it is to be human and what it means to care. We declare no competing interests. Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysisThe brief strikes by health workers during the period 2010–16 were not associated with obvious changes in overall mortality in Kilifi. The combined effects of private (and some public) health care during strike periods, a high proportion of out-of-hospital deaths, and a low number of events might have led us to underestimate the effect. Full-Text PDF Open Access