Health care is notoriously expensive in the U.S., but rarely in my general surgical training have my patients had to grapple so viscerally with the financial implications of their illnesses in the acute setting. In Kijabe, I see this play out daily. The pedestrian hit by a matatu who is so preoccupied with his emergency room bill that he is unable to concentrate on our physical exam to diagnose his pelvic fracture. The septic newly diagnosed diabetic man with a massive back abscess who spends the night in the clinic waiting room instead of upstairs in the ICU because he doesn’t yet have the deposit for his hospital admission fees. The fresh motorbike trauma patient with abdominal pain and potentially undiagnosed solid organ injury who leaves our ER against medical advice for another facility where she believes CT scans to be less expensive. The elderly woman with dysphagia and biopsy-proven esophageal cancer who delays getting a staging CT scan or endoscopic stent placement for months or even years while her family crowd-funds the next step in her care. Maybe my patients in the U.S. are making similar life-or-death decisions based on financial calculations, but it doesn’t happen in front of me.
The National Health Insurance Fund (NHIF) started about 4 years ago to offer free insurance coverage to all Kenyan citizens. Kijabe Hospital fees are out of reach for >70% of the population, so NHIF coverage is critical to the hospital’s mission of caring for patients while remaining financially viable and sustainable. In recent weeks, NHIF abruptly stopped covering surgeries and maternity fees at mission hospitals across the country, including Kijabe. This crisis has translated into lower surgical case volumes, fewer training opportunities for my Kenyan resident counterparts (i.e., the next generation of surgeons in East Africa), and a growing number of patients not getting the operations they need in time. Watsi, an international crowd-funding platform, and Friends of Kijabe (https://friendsofkijabe.org/) are two ways people can help.
Costs affect patient outcomes in innumerable ways. Approximately 40% of breast cancer patients cared for at Kijabe are HER2+ and would receive a survival benefit from a targeted course of Herceptin therapy. Yet at a cost of $27,000, this treatment is out of nearly everyone’s reach. For comparison, in the nearby city of Naivasha, most of the local population works for a company that produces fresh-cut roses for the European market. They make $70 per month. A recent Lancet Commission on global surgery determined that 25% of people who have a surgical procedure incur financial catastrophe as a result of seeking care – although this proportion is probably far higher in Kenya.
For the past seven years, I have lived the daily luxury of not thinking about costs for 99.99% of my medical decisions. The luxury of doing the right thing for patients, regardless of cost implications or their ability to pay. Is this wrong?