An Exciting New Voice in Family Medicine and a Consultant in Global Health and Health Systems Strengthening.
Dr Mercy Wanjala is a graduate of the University of Nairobi School of Medicine, she holds a Master of Comprehensive General Medicine from the University of Medical Sciences of Havana, and an MBA in Healthcare Management at Strathmore University Business School.
She currently works at the County Government of Embu Health Department as a Family Physician and Primary Healthcare Coordinator. She has held prominent positions, including Head of Primary Health Care, Embu County and National secretary for the Kenya Association of Family Physicians. She sits on the National technical Working Group on Primary Health Care and the Technical Group for National Cancer Strategic Information, Research, Registration and Surveillance. She served as a visiting Lecturer in Primary Health Care in Global Health at the University of Global Health Equity-School of Nursing and as part-time lecturer in Health Services Leadership at Kabarak University Department of Family Medicine. She held leadership roles in the Africa Forum for Primary Health Care, WONCA Working Party for Quality and Patient Safety, WONCA Working Party on Rural Practice and Women in Global Health Kenya Chapter. In 2023 she won the Young Family Doctors Rising Star Award from the Africa Region of the World Organization of Family Doctors (WONCA) and the WONCA Sydney Conference Full Scholarship.
Watch the video of the interview below or on Youtube
Listen to the Podcast on all the major platforms
“Ever since I was a little girl, I always knew somehow that I wanted to be a doctor. Whether it was because of my compassion for the suffering of others or a drive to just save people and make them okay…”
Today I’m talking to Mercy Wanjala… First, let’s take you back to the very beginning. Tell me how you got interested in medicine.
Mercy Wanjala: Ever since I was a little girl, I always knew somehow that I wanted to be a doctor. Whether it was because of my compassion for the suffering of others or a drive to just save people and make them okay, I always wanted to be a doctor. So, all my life I’ve structured my education and my pursuits towards becoming a doctor. And, finally that happened in 2008 when I joined the University of Nairobi and did my undergraduate program in medicine, and graduated with a Bachelor of Medicine and a Bachelor of Surgery.
DMacA: Tell us about medical school.
MW:  Unfortunately for me, I didn’t get directly to medical school with the required 48 points. But there is another system called the parallel system, where they give you a second chance to get into medical school and that’s how I got into medical school at the University of Nairobi. And medical school was quite different from high school because high school was, I would say, a little easier because it was mostly testing recall, not testing understanding and critical thinking. And that is what medical school was testing. So it was a bit different. And it was tough, especially the first year because we had anatomy where, first of all, you had to get used to living with a cadaver, maintaining it, taking care of it, and then dissecting it from foot to head. That was a new experience for me but a valuable one.
We had to get used to a lot of reading and staying up all night. Most of the time I used to sleep maybe for 2 to 4 hours because, unfortunately, I could not get a hostel in the school because I was a parallel student and I had to live at home. This meant I had to get two busses just to get to school so I didn’t have much time to study and to sleep. It was quite tough in the first year, especially the foundation subjects around medicine; physiology, biochemistry and anatomy. It was constant reading and constant studying and constant dissecting to make sure you knew your anatomy. And, every week we had what we called progress assessment tests, which you had to pass. It was tough.
DMacA: Â Had you any experience of family medicine then as an undergraduate?
MW: No. We had zero exposure to family medicine because family medicine had not yet developed or matured to that level. We were exposed to various disciplines in medical school rotating through specialties like surgery, anaesthesia, ophthalmology, visiting all those disciplines and specialties, but not family medicine. We didn’t even know what family medicine was or if it existed. So as an undergraduate I had zero exposure to family medicine.
“Learning about all the systems, it seemed people had no place there as we had become subspecialized and over medicalized to a point that we were thinking about body parts. We were thinking about how to fix them, but not the person the parts belong to.”
DMacA: You qualified in medicine and then you went to Cuba. Tell us how that happened.
MW:Â After I qualified, I was posted to a county called Embu county, its peri-urban urban county but with a large rural area. I worked there for about five years and then this opportunity came up where the President created an initiative of training 50 family doctors in Cuba because he had gone there, had seen the system, thought it was a very good system, and he wanted to bring it back to Kenya. There was an intergovernmental agreement between Cuba and Kenya that 50 doctors could go and train in family medicine, and that 100 specialists would come and supplement the gap in Kenya at the time.
At first I wasn’t really for it but what attracted me was that once I read about Cuba and what it had to offer, I remembered the reason why I became a doctor.  I had been doing an MBA program in healthcare management where we were learning about different health systems and one of the systems we learned about was the Cuban system. Learning about all the systems, it seemed people had no place there as we had become subspecialized and over medicalized to a point that we were thinking about body parts. We were thinking about how to fix them, but not the person the parts belong to. So for that reason, I thought to myself, I need to go back to general practice, that’s the reason I became a doctor -looking after families. That was on my mind. So when the opportunity came to go to Cuba, I thought this could be a good opportunity for me to get back to that. It was one doctor per county, I applied and I got the position from my county to go to Cuba.
DMacA:Â Tell us about medicine in Cuba.
MW: Wow, where to start!  Cuba has this program that they call the family doctor and nurse program, which is the basis of their primary care system. You have a family doctor and a nurse taking care of a population of about 1000 to 1500, maximum. All these patients are empannelled and  are the responsibility of this basic work team. The basic work group is part of a conglomerate of what they call consultorios. This is like a small clinic where the family doctor and the family nurse see their patients.
And then we have the polyclinic, which links all these consultorios together and is a sort of hub that offers superior diagnostic capabilities that are not available at the consultorio. It also offers aged care. There are 10 to 12 consultorios linked to that polyclinic and that polyclinic is called a health area. So the polyclinic plus those 10 to 12 consultorios form one health area and everyone who lives within that area is linked to that polyclinic. That polyclinic is also linked to secondary care, whether there’s an institute or a particular hospital.
If any patient within that health area needs secondary care, they go through the polyclinic and to a specific hospital that polyclinic is linked to. What is most fascinating is what the basic work team does. That’s what I came to learn and people have a term for it, they call it Population Health Management. But, in Cuba it was about the control of different things within the population. It was mostly focused on preventive and health promotion activities rather than curative.  We would start, first of all, by knowing your whole population, that means that within one year you plan that each member or each family is visited once in their home and they come once to the consultorio for a consult with the family doctor.
The second step is called dispensarization, where you have to classify your whole population according to their health status. And, once you do that, you plan their care based on their health status, looking first at the individual health status and then the family health status. And that is how you plan their care.
Then there were a number of different programs for everybody from the time they are a neonate, to the time they age, to the time that they are dying. We had a program for all of that and for everyone in the community. The second thing that was fascinating was that the basic work team had to focus on socio economic determinants of health. Â Part of the assessment was the functionality status of a family and to classify it as a healthy family that is functional, moderately functional or dysfunctional.
Once you classify the family you know which families are at risk and which families you need to pay attention to in terms of their dynamics, how they relate to one another, and how they relate to the society around them. So care went beyond medical, it went beyond clinical, to the socio economic determinants of health. If you found someone in a family or in the community that is economically deprived, you would then connect them to social services where they get their food, shelter, their clothing and everything else that they needed, including their medication. It went beyond just clinical and medical care to addressing the socioeconomic determinants of health, understanding that 70% of health and health care is based on behaviour. We did a lot of behavioural intervention and behavioural care, and also empowering the community around different behaviours that they needed to adopt to remain healthy.
“Changing that mindset that has been frozen and solidified for 40 years as providing basic services and low cost interventions to move to comprehensive services with a team headed by a family physician is going to be quite the uphill struggle and challenge.”
DMacA: Were you able to bring that back to Kenya and how did that relate to the Kenyan health system?
MW: Â We are trying to bring that back to Kenya but I will admit that it has been a struggle. Â First of all, changing the mindset of a system that is set on diseases is very difficult because, for ages, the Kenyan health care system has been based on vertical programs such as on reproductive and maternal and child health, HIV and Aids and TB, with different programs being managed differently by different people.
It is difficult to change that mindset to say, we can actually do this better. We can move to prevention and promoting health within the community so that we never have to get to this place. It has been a difficult and an uphill journey. A few of my colleagues have managed to implement just a little bit of what we’ve learned in their counties but it is still an uphill struggle considering also that family medicine had not matured to a level where this would be easy to implement in the country. We are still at the stage where we are advocating for family medicine and family physicians in Kenya, where we are telling people why family physicians are the primary care level. Because in Kenya, primary care was a not a concept but a level of care starting with dispensaries, then to health centres, and then the community health services. That was considered primary care.
The tragedy is that while people talk a lot about the 1978 Alma-Ata report, nobody quotes the 1979 Conference on Health for All by 2000, funded by the Rockefeller Foundation, that told low and middle income countries, including Kenya, that you cannot afford primary care as comprehensive as it is in the Alma-Ata declaration, you can only afford basic services, low cost interventions. So for 40 plus years, Kenya focused on low cost interventions, basic services, which we call the GOBI-FFF, which is growth monitoring and evaluation, immunization, education of girls, food fortification amongst others, and that is what people have considered primary care for a long time. Changing that mindset that has been frozen and solidified for 40 years as providing basic services and low cost interventions to move to comprehensive services with a team headed by a family physician is going to be quite the uphill struggle and challenge.
DMacA: Â Your other interest is in global health. Talk to us about that.
MW: As I was doing my studies in Cuba, I was looking for, what you might call, a community of practice. I wanted to see which people are advocating for primary health care in Africa and then also globally, and which organizations I can join to find my voice and find my place. So I joined organizations like the Africa Forum for Primary Health Care, WONCA, (World Organization for Family Doctors), the World Medical Association, amongst others where I learned how to advocate for primary care-  what is primary health care, what are the concepts, what are we advocating for when we talk about quality primary care. So, that’s how I found myself joining the global space and finally found myself, now as the executive coordinator of the Africa Forum for Primary Health Care, leading various initiatives to strengthen family medicine and primary care in the Africa region, and also with WONCA where I’m involved in different working parties, still advocating for quality primary care.
“I built my capacity on quality improvement and quality improvement techniques, learned how to coach people through quality improvement initiatives, and also developed my leaderships skills in terms of leadership and organizing for quality improvement.”
DMacA: Â As part of these various leadership positions, you have another role, working with IHI (Institute of Health Improvement).
MW: Â When I was in Cuba, I applied for the Institute of Health Improvement (IHI) Open School, which was looking for what they call ambassadors for quality of care. So I applied and I got in and I started working with them as one of the ambassadors for the IHI Open School. What we did was, after learning the principles of quality improvement in health care, we would support different chapters of IHI Open School around the world in different quality improvement initiatives. Being the only coach who spoke Spanish I got connected to a group in the Universidad de Santander, which is a group in Colombia that was doing a lot of quality improvement initiatives and wanted to integrate the IHI courses into their curriculum for family doctors or family residents and for undergraduate students.
I got that opportunity to work with them, learn about the Colombian health system and see how they integrated it. They’re doing a lot of work in quality improvement in primary care through IHI. That was a good thing for me because I built my capacity on quality improvement and quality improvement techniques, learned how to coach people through quality improvement initiatives, and also developed my leaderships skills in terms of leadership and organizing for quality improvement.
DMacA: And finally, let me ask you, about your work in Futures
MW: That is another place where I found a way of integrating some of the things I’ve learned in Cuba. Its a consultancy firm where I consult in terms of health systems strengthening. With that firm we have done some work within the health care system in Kenya, things like adopting global health standards for health promoting schools, because one of the things I had learned in Cuba was school health was part of primary care and a very fundamental part. Working on that project was very important for me just to ensure that our schools are healthy. Other projects that we’ve worked on include, of course, community health services, strengthening community health services. It is also important for me to integrate some of the things we had learned about community empowerment and community engagement in Cuba, which is a fundamental part of primary care. The work with Futures is consultancy, and that is another way I’ve found to integrate some of the principles I’ve learnt into the policies that we are developing in Kenya.
DMacA: It’s been an absolute pleasure talking to you, I’ve learned so much. Thank you very much for sharing your knowledge of Kenyan health care, Cuban health care and your view of the future. Thank you very much indeed.
