By Samwel Doe Ouma
@samweldoe
Bernard Kabotho, a resident of Mathare slum sustained injuries after being knocked off the pavement by an overlapping Matatu -a minibus public service vehicle- that was in a rush to beat the 7pm curfew. The driver did not stop.
A good Samaritan on a motorbike who saw the incident happen brought him to the MSF trauma room in Mathare, which was just a few hundred metres from the scene.
“The matatus are always in a rush, and it’s worse in the evening these days as they try to make their last coin just before the 7:00 pm curfew,” he says.
Agnes’ is ushered in at MSF Lavender clinic around 8:30 pm, her 18-month-old daughter, Joy, screaming in her arms. Joy got burnt by hot water in the hands and part of the face.
Agnes was cooking in their single-room house when the child stumbled upon a cup of hot water she had just scooped out of the pot to continue making their ugali for dinner.
“It was past the evening curfew and I was worried about what to do. Since we don’t live far from this clinic, I decided to walk. I was afraid of the police but then I could not let my baby hurt until morning.
The outbreak of Covid-19 occasioned the adoption of containment policies to limit the spread of virus such as lockdowns and travel bans which directly affected access to healthcare facilities especially after the curfew hours.
According to Dr. Ceciliah Gakiki, Medical referent Medicines Sans Frontiers (MSF) Mathare Project, the curfew orders missed key priorities issues in addressing access to care for persons living with chronic ailments, patients who required immediate life-saving response – ‘Emergency Care’- who in normal days would use alternative transport such as taxis and motorbikes who are now all forced to request for ambulance transport to maneuver the curfew and police roadblocks to access care.
“We are experiencing overuse of ambulances as a result of higher demand of services especially past the 7pm to 5am curfew hours this has overstretched our resource allocations and going forward it is not going to be sustainable,”
The increase in demand she says means that for the organization to maintain delivering and maintain delivery of services there has been increased operational cost in terms maintance of vehicles, increased deployments of staff especially at night and increase use of personal protective equipment’s.
According to Fred Majiwa, St Johns ambulance communication officer, economic impact of COVID-19 pandemic has not spared even the ambulance providers because their traditional ways of funding ambulances through income generated from training and standby services at events have dried up, yet our service is essential.
As transport plays a vital role in enabling access to healthcare, complexities brought about by night travel bans is directly impacting on ambulance service providers since the demand for their service is now more than doubled after the curfew hours.
Majiwa urges the government to compensate all the ambulance providers supporting the healthcare system to ensure they can sustain their service during this critical time.
Dr Ceciliah explains that, between the months of March and April MSF Mathare project has responded to overwhelmingly increased number of calls never witnessed before with obstetric patients calls more than doubled up from 98 to 209, as pregnant women struggle to find means of transport after curfew hours.
The increase in numbers, She attributes to lack of alternative transport with taxis or public service vehicles prohibited from operating after curfew, not even the boda boda (motorcycle taxis) that people use in informal settlements.
MSF Mathare project emergency rescue services operates three ambulances 24 hours and covers areas of Mathare slums, Easleigh, sections of Majengo slums and Huruma.
St. John Ambulance the only public emergency service provider in Kenya has only sixteen ambulances across the country.
The Covid-19 crisis has increased the demand for ambulance services in Nairobi as they are not only used to transport people who have fever like symptoms and or had a travel record to any of the countries affected by the virus, either to the medical facilities or quarantine centers after testing and check-up at the airport but also seen as a safer means to reach hospitals past curfew hours.
While there is a rising demand for ambulance services because of the travel ban and Covid-19 cases which requires patient to be transported to facilities using the ambulances. The already existing burden of diseases mostly handled by public health facilities are challenged as they do not have adequate patient transport systems and, where available, they are broken down and not in use due to lack of maintenance.
The public funded ambulances and utility vehicles in most of the public hospitals also faces inadequate funding and budgetary allocation.
Across Kenya, a significant decrease in access and utilization of health services has been on the sharp rise something health experts attributes in part to Covid-19 containment orders like excessive hand wash requirements at health facilities coupled with the travel restrictions which took effect in Kenya in late March this year.
“For most of emergency cases timely diagnosis, appropriate pre hospital identification, direct delivery to appropriate health care provider allows for early intervention which leads to better outcomes,” Dr Ceciliah said adding that “the Covid-19 crisis have also changed a lot about how we work, most of the emergency rescue work are now done at night.”
According to Dr. Ceciliah, MSF emergency response call center have been receiving a lot of calls from chronic ailments patients with acute worsening of their conditions for transportation increasing the need for medicalized ambulances during the curfew hours.
Disruptions in transport has established that the government missed key priorities in addressing access to care as patients with chronic conditions are not accorded easily accessible and safer transport modes for their vital hospital appointments who most of the times have to use public transport to access care.
According to Dr Catherine Karekezi, chair NCD alliance Kenya, transport restrictions have hindered access to care for people living with chronic ailments.
While Dr Benard Gitura of Kenya Cardiac Society emphasis the urgency of providing emergency response to acute cardiovascular event cases. “Acute cardiovascular emergency requires to be attended to as soon as possible,” he said.
“The first four hours of the response is called the golden hour-if proper first aid is given the victim will have the greater chance of survival,” Mr. Majiwa added.
Dr Ceciliah explains that the ambulances also faces difficulties in transferring People with respiratory symptoms who may be labelled as suspected COVID-19 patients.
She says for example patients exhibiting symptoms like chest pain, breathing difficulty, altered level of consciousness, sudden numbness, or paralysis of the face or limb are facing a lot of blocks from facilities as facilities receiving them are hesitant to take Covid-19 similar complications making turnaround time to be very long.
Fraught in good times, long-term care decisions have become even more agonizing in the pandemic era.
World Health Organization has called on countries to ensure continuity of essential health systems service deliveries and mitigate the risks of collapse of some of the essential services.
Although according to NCD Alliance Kenya most of the chronic ailments patients who requires specialized treatments in Nairobi are accorded a pass to travel around, especially for health purposes that counts as an essential service which has eased their movement to access the capital city considerations about the broader ramifications of those restrictions like emergencies were often overlooked.
The critical linkage towards ensuring appropriate health coverage in the population is a reliable transport service. In Kenya patient transportation to health facilities include– ambulances, utility motor vehicles, and other appropriate transport services.
Ambulances, specially designed vehicles equipped to provide transportation for low risk patients to patients with complex transport requirement from home to hospital or between health care providers.
While ambulance services providers have strict protocols to prevent the spread of Covid-19, there is already public stigma associated with ambulances as they are used in contact tracing and transporting Covid-19 patients
“It will be harder to regain public confidence on the safety of ambulances services when community acquired infections would be on a steep rise,” She noted.
While Dr. Waiyaya Ema a medical advisor for Momcare an initiave providing innovative transport to pregnant women in Nairobi and western Kenya affirms that ambulance services staff and paramedics are properly trained on infection prevention guidelines and can handle both patient safety and their own safety.
As community acquired infections is projected to scale up public perception on the safety of ambulances may also change, Dr Ceciliah noted.
The emergency rescue team crucially rely on the availability of personal protective equipment’s (PPE) to protect patients and staff from the risk of infection and with the global shortage of protective material especially the N95 masks organizations operations maybe crippled and even forced to shut down including emergency, lifesaving activities.
Poor transport fleet management.
Uncoordinated transport management framework in the health sector and Irregular maintenance and repairs of motor vehicles is a perennial challenge to most of ambulance services.
According to Geoffrey Majiwa, communication officer St. Johns Ambulance, there is an important component missing in the current system, and one that will be needed in the long-run, a body to regulate the ambulance services in the country.
He says that as compared to many countries with proper emergency systems in place, there is a single emergency number 999 which play a major role in managing emergencies in Kenya be it fire rescues, crime and road crashes.
There is a fragmented system in place to attend to the emergencies in the country. Although different Hospitals in the country provide different telephone numbers for their ambulances. The existing fragmented system falls terribly short of meeting the demand.
Poor health literacy to navigate the health system is also a factor in underutilization of ambulance services as most members of the public are not aware how they can call an ambulance when they need one.
There is still a great shortage in the number of functional ambulances as per the KEBS standards in the country making the referral systems hard to succeed.
Furthermore, the ambulances are not well maintained and lack appropriate equipment and hence end up being transport vehicles and not referral vehicle.
Both prehospital care and hospital transfers in most of the time becomes be very tedious to most patients with some ending up dying because of avoidable delays.
Kenya Health Master Facility List, 2019 shows that the number of public health facilities were 5,277 48.4 percent while private facilities were 5,624 51.6 percent mostly medical clinics, maternity homes and nursing homes.
Despite the growth in the number of health facilities in the country, there are imbalances in geographic distribution
While several emergency services do exist, they are usually fragmented and operate on their own.
According to Dr Waiyaya, group to assist pregnant mother to reach health facilities during curfew hours, there is no set policy guideline for ambulance service, and recommends system wide thinking that will include all kind of care especially during the covid-19 period.
In the absence of such regulation, it is unlikely for existing providers to maintain highest standard of professionalism and risk mitigation against COVID-19 as well as other infectious diseases.
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