Setting Up, Part 2
I intended to blog once a week, and wondered if I would have material to blog about that often...I is now week three since I returned to Kenya, and I have not had time to blog! Obviously a lot has been going on, but I will try to catch you up.
I returned to Nairobi in mid-January, and spent my initial time in meeting with people who know what they are talking about with businesses, building clinics, running clinics, and medicine in general in Kenya. I can’t stress enough how important having contacts with people is in this environment, and how much of a joy it is to have them offer their help.
I started with a meeting with Richard Kerich, a long-time acquaintance with whom I had a “black milk” encounter several years ago. It’s a great story and a Kalenjin thing, but I won’t go into that here. He used to be the head of the National Health Insurance Fund (NIHF), the Kenyan government insurance program, so he was very helpful in helping me understand the insurance landscape and where a Mission medical clinic would fit in. It turns out it will fit quite well. Kisumu, where the clinic is planned, is part of a pilot government program to give everyone a health card, instead of having them buy the insurance, and seeing if there can be a cost saving by having people get preventative and acute primary care before illnesses progress to where they need to be hospitalized- the essence of Family Practice and the goal of our clinic!
He also now runs a consultant inn business that helps establish medical clinics, so he gave me a lot information about personnel pay scales, as well as a step-by-step plan for identifying a location, partitioning the building, equipping the facility, staffing the facility according to government requirements, and applying for all of the licenses.
These include, in step-wise fashion:
County Government License to operate
Public Health License
Medical license for the facility ( rides on my medical license)
Laboratory license
Pharmacy license
Radiology license, if desiring to have on-site radiology services.
Richard then gave me the contact of Noor Majid, the man they use for getting facilities set up, and had his assistant send me a complete prospectus of a project they had recently been involved with setting up 10 clinics in Nairobi. That allowed me to get a very accurate estimate of what we would need to get the running for the first 6-12 months, using real figures. Richard was incredibly helpful, and took a large part of very busy day to introduce me to healthcare in Kenya.
The next meeting was with Dr. Tamer Mikhail and his wife Dr. Sherry Eskander. They are both working at the Coptic Hospital in Nairobi, a Mission hospital system that is well known for quality medical care. I was given Dr. Eskander’s contact by Karim Hanna, whom I met through the Global Medicine interest group of the American Academy of Family Practice. They were very helpful in sharing with me about the mission hospital experience in general, and with specifics of the Kisumu region in particular. They were kind enough to offer contacts with whom I could set up a possible clinical experience while I am here. I was looking to work at Jaromogi Oginga Odinga Referral and Teaching Hospital, but had not confirmation from them yet, so it was comforting to know there might be options if that did not work out! Again, they gave me the better part of their morning, and were very kind. They will definitely be a good resource.
The next meeting was with Mr. Majid. He is married to an American lawyer who is working on women’s prison issues, and her father is doctor who volunteers at a Mission hospital here in Kenya, so the family has a heart for Mission work. He also works for a company called Bliss, which has set up a hundred or more clinics in Kenya. He does the building preparation so it meets the standards for government inspection, and manages the logistics of the practices. He was very helpful in terms of specifics on costs on building preparation, and how the NGO and government programs for vaccines, HIV and TB work with clinics, costs of IT, and the nitty- gritty of practice management, like waste disposal. As everyone I have met has, he said he would be glad to volunteer his time to look over our building once we have it, and give us specifics on required specifications, etc. He will definitely be a huge asset, and he volunteered his wife’s legal skills, if needed, but I guess that would be something she might have some input on, if the need arises.
After exhausting my contacts in Nairobi, I traveled across to Kisumu. I next met with Maurice and Jane Owuor. Jane is the daughter of Jane and Austin Odicoh, good friends who are church leaders in Bonde. Maurice and Jane are running a successful clinic and hospital practice in Ahero, just East of Kisumu, called the Ahero Medical Clinic. Jane was actually sick with malaria, and was receiving IV medication in her own facility!
Maurice gave me the tour, and had me accompany the Clinical Officers on rounds. It is an outpatient and inpatient facility. I was not licensed to practice medicine yet, but I did answer questions about management in cases where they thought I could be of help. Maurice then sat down with me to talk about the way their facility works.
I might explain first the hierarchy associated with medical practice in Kenya. Consultant Doctors are the top tier, but very scarce in Kenya. Those who be doctors who have completed a residency. A doctor that has been through medical school and completed a year of internship is called a Medical Officer. Clinical Officers are similar to a Physicians Assistant Nurses are the next tier, and can operate very independently, like the Nurse Practitioners in America.
Maurice is a Medical Officer, and Jane is the manager of the clinic. He has 4 Clinical Officers (COs) working under him. They see patients in the clinic, and refer any hard cases to him for evaluation and treatment. He also reviews all of the charts. He rounds with the COs, and is called to see patients as needed. They have a laboratory, run by a Lab Technician, and a Pharmacy, run by a Pharmacy Tech. The lab, the pharmacy and the techs all have to registered with the government. They do not have radiology yet, so if they need an x-Ray or ultrasound, they refer them to a bigger hospital, or one of the private radiology service providers (who of course vary in competence depending on their price) that dot the landscape, The medicine is basic, often involving empiric treatment for things, because diagnostic testing is too expensive or unavailable. They do give much needed care locally, and even are given step down referrals from the bigger hospitals in Kisumu at times.
Maurice and lab tech at Ahero Medical Center
I did also find out that the testing and treatment for HIV is free of charge and is largely done by government and NGO technicians who are in the clinics, so when a patient needs testing they are referred to the in-house technician that the clinic gives space to operate in the clinic. TB is also referred out for treatment, which is free, and vaccinations are given in the clinic, but are provided by the government also. That means we don’t have to reinvent the wheel in terms a lot of these programs. It is good to see so many of these initiatives making a real impact in the lives of the people here. The vaccination schedule is different than what I am familiar with, but most of the same vaccinations are given, with the exception of BCG(tuberculosis vaccine).
Maurice also shared with me their growth from a rented building to start with, growing to where they were able to invest 4,000,000 Kenyan Shillings, or $40,000, to buy land and build the clinic, after 4 years. That was seven years ago, and now they have expanded to an inpatient facility with male, female, maternity and pediatrics wards. They put the capital they had into the building, and then borrowed money for the equipment, so they could use the equipment to generate the revenue. Our goal is to not go into debt at all, but it certainly put the importance of having the physical structure as the focus at first. He shared a list of essential drugs that we can dispense as a “dispensary”, if we do not have a pharmacy technician at first.
Maurice was very helpful in describing the payment systems, what the average payment from the NHIF was per patient, and the names of groups that help Mission clinics with medications and equipment. I am convinced that Maurice and Jane will be invaluable resources as the time goes on. And Jane seemed to fully recover from her malaria.
Back in Kisumu, Eric Odida set up a meeting with Dr. Luci Ojuwong, the past Secretary of Health for Kisumu. He was able to give us the information on what would be required for our licenses, and then decided we should just meet with the current Secretary, Dr. Dickens Onyongo. He gave him a call, and found he was having a seminar in the very hotel we were meeting in, so Dr. Onyongo left the seminar and came down to meet us. He seemed very supportive of the project, and was sure there would be no problem with licensing when we got ready to do so. He gave a rundown on the regulations we need to be aware of, and what authorizations we would need if we decided to build instead of rent.
Dr. Onyongo
While I was gathering all of this information, I was also waiting for my letter from JOORTH so that I could get my license. I got that from the hospital on a Thursday, and on Friday returned to Nairobi (only a 7-1/2 to 8 hour bus ride) to the Medical Board office. Winnie Owino was there this time, and confirmed that my file had indeed been lost last time, but I had electronic copies of everything, and with those copies and the letter, she went away for about 15 minutes and came back with my Medical license! It was a breath of fresh air to have someone working so efficiently. I will need to get my license modified when I start in the clinic, but she assured me I could just come back and she would get it all done.
I went ahead and stayed in Nairobi so I could meet with the congregation in Nakuru on Sunday. They meet in Tabitha Omedo’s home, and it was good to see everyone there again, and to meet some new people too.
It turns out, in order to of get registered, you have to have a local (ie Kenyan) Director, which Eric kindly stepped in as, and to get the business lisenced, you have to have $100,000 in a bank account. Brian Mundy, the ARM treasurer, sent me a message that there is now $100,500.00 in the MSMHC account! We have surely been blessed with the right amount at the right time!
With my license now firmly in hand, and several copies made “just in case”, I returned to Kisumu to finish the last step of the registration process. I went back to Barclays to speak with Ronald Mokaya about my progress. He sat down with me to walk me through the registration, answering questions as we went. He then sent me the actual statute about registration, so I wouldn’t get tripped up again, which was extremely helpful also.
The last hurdle was paying for the application. It required me to use M’pesa, but it kept getting rejected, saying that the business didn’t match my payment. I finally figured out that I needed to pay 7,540 shillings instead 754 shillings, which meant a trip to the M’pesa shop, but soon enough that hurdle was overcome, and so now we are waiting on the governmental review.