The other night, a man came to the health center. The only nurse, Stephen Sangara, works eight hours per day and then sleeps on the premises. But he’s on call 24 hours a day, every day. The man awoke him, shouting in the night. Mr. Sangara came to the gate and opened it. The man is standing there with his son who has a bean stuck in his nose.

Immediately to the patient’s right is a wall-sized painting of his rights. Though he can’t read them, because they’re in English (Ministry of Health loves looking Westernized), he fully understands them.

Mr. Sangara opened his office and asked the man for payment (40/=, ~$0.50). The man said he had nothing, but he’d get it later (which he never did). In the exchange, he was rude to Mr. Sangara partly because he had to wait for him to wake up. And according to the Rights Mural, he has the ”Right to timely services” and the “Right to Optimum Care by qualified health Care providers.” His rights are clear, are extensively listed, customer obligations notably omit payment. He was annoyed in being asked to pay; paying for medical service is not mentioned as a customer obligation.

For reasons that are beyond the scope of this blog, the Ministry of Health (MOH) cannot reliably keep its health facility operating optimally. There is never enough staff, so wait times are very long in most MOH clinics. The supply of medical personnel comes from Nairobi and is doled out according to need. And the need is always too great.

Medication resupply shipments come in with random supplies at random intervals. They’re supposed to come every three months, but sometimes it’s five months between shipments. They’re supposed to be filled with medicines based on patient loads, but it seems quite random (we have about 40,000 condoms and almost no antibiotics).

So health facilities have two options. The first option is to violate customer rights #1 and #2, the right to “Optimum service” by not providing the drugs patients need and the right to “Timely service” by not having sufficient staff. This is what most clinics are forced to do. The other option is to add a customer obligation: the obligation to “Share in the cost of treatment.”

Those who chose the second option begin acting like private clinics. They buy medications from local pharmacists (which are always in stock) and sell them at a premium. The premium then goes to hire casuals, nurse assistants and clerks to help with patient management.

But when they sell drugs, people are angry. Even one of our good-hearted entrepreneurial boda drivers felt cheated when he was charged for medicines beyond the flat (subsidized) government rate. He went on and on about how they were very “funny” (devious) people at the hospital. The very people who used a bit of business sense to provide better treatment to their patients are perceived by the community as cheaters. Because, after all, people have a right to optimum service. And you shouldn’t have to pay for rights.

Maybe free healthcare for all should be the goal. We (theoretically… maybe… I hope) can afford it in the West. But Kenya’s not there yet, even counting foreign aid. So in the meantime, most government clinics have chosen to do their best to provide decent service to as many as they can, bearing the scorn of those who feel their rights have been violated.

Nuru aspires to sustainability. That means that we want our programs to be running full-steam without extra Western money within 5 years. And the “Healthcare is a right” worldview makes sustainability extremely difficult in the absence of a reliable well-funded government system. Every price increase, every user fee, every shilling asked for at a clinic is a perceived violation of rights.

People here have been told all their lives that healthcare is and should be a handout. Nuru’s No-Handouts ambition is confronting that view head-on. Our next major step is figuring out a mechanism for doing that. Do we increase fees at the clinics? Do we try to offer private options? Can a health plan or insurance plan be a financing mechanism? The real question is: do people value healthcare as something valuable enough to be paid for? Or are they satisfied in accepting whatever the government can hand out? And, an even harder question, if they see it as valuable for themselves, would they be willing to contribute so that the less fortunate can have it?

Is there a fundamental human right to healthcare? Let’s leave that to the philosophers (or me on my personal non-Nuru affiliated blog). But from the perspective from one on the ground, the idea that healthcare is a right has proved to be a significant obstacle to actually providing it.