Nine out of ten Level 4 hospitals in Kenya have no intensive care unit (ICU) or high dependency unit (HDU), exposing a critical gap in the country’s emergency medical system.
This forces patients requiring critical care to be referred to Level 6 hospitals, straining the resources of these national tertiary facilities with cases that should have been stabilised at the county level.
A report by Auditor-General Nancy Gathungu found that 90 percent of Level 4 hospitals and 33 percent of Level 5 hospitals lack ICU or HDU facilities, a direct violation of national health regulations that mandate these facilities at all county referral hospitals.
The Kenya Medical Practitioners’ Hospital Checklist for Categorisation of Health Institutions requires Level 4 hospitals and above to have HDU and ICU to offer critical emergency care. The regulations specify that Level 4, Level 5, and Level 6 hospitals must have 6, 12, and 24 functional ICU beds, respectively.
The audit found that none of the 33 sampled Level 4 hospitals met the minimum requirement for ICU bed capacity.
Out of 15 sampled Level 5 hospitals, only Coast General Teaching and Referral Hospital had met the mandatory 12-bed requirement.
‘Interviews and physical verification in the sampled hospitals revealed that 30, representing 90 percent out of 33 Level 4 hospitals, and five, representing 33 percent, out of 15 Level 5 hospitals did not have ICUs and HDUs, respectively,’ said Ms Gathungu.
Meanwhile, the few ICUs that exist are most understaffed, with too few nurses trained in critical care to safely manage patients requiring continuous monitoring and specialised treatment.
The report attributes the ICU shortage to a fundamental governance failure, including counties lacking ring-fenced budgets for emergency medical care.
“Counties do not have ring-fenced emergency medical care budgets. Funds for emergency care are mixed with other health expenditures, and even hospitals lack specific budget lines for emergency services,’ the audit stated.
This financial structure has left hospitals unable to meet mandatory requirements for ICU beds, train nurses in critical care, purchase or maintain ventilators, or stock specialised drugs and equipment required for ICU patients. The audit found that 90 percent of Level 4 hospitals lack piped oxygen systems, a basic requirement for intensive care.
The audit further found a lack of step-down units, the intermediate care wards where patients transition out of intensive care, meaning they are often moved straight from the ICU to general wards or stay in the ICU for recovery, limiting the already small number of ICU beds available.
“Due to a lack of functional HDU beds, patients would be moved from the ICU directly to the wards or be retained at ICU for recuperation; this further limits the availability of already strained ICU bed capacity in the hospitals,” Ms Gathungu stated.
According to the Kenya Master Health Facility list by the Ministry of Health, there were about 358 Level 4 hospitals and 14 Level 5 hospitals in the country as of 2022.
Level 4 hospitals are sub-county hospitals that serve as primary referral facilities, while Level 5 hospitals are county referral hospitals providing more comprehensive secondary referral services, including internship programmes for medical staff and serving as training centres for paramedical professionals.