What’s happening to Kenya’s first generation born HIV-positive?

On May 30, 2012 I posted an article under the title ‘What’s happening to Kenya’s first generation born HIV-positive? As Kenya observes 2015 World AIDS Day today this question remains as relevant as when it was put up.

To what extent are the issues facing that generation better defined and addressed today? Among the challenges earlier mentioned were the following: Emotional problems- especially coping with the late discovery that they are HIV positive; their care considering many of them are orphaned; fear of stigma which may interfere with their adherence to drugs, etc, etc.

“Society forces me to live two lives, one of which – the one where I’m honest about my status – I have to keep completely secret from the other one. It’s partly because I have to live this life of shame and secrecy that I find it so hard to take my meds….I’m angry about the stigma in society that makes me have to lie about my status”.

When can a strike action by health professionals be deemed ethical? Japheth Mati

Kenya National Union of Nurses calls off Monday strike

http://www.nation.co.ke/news/Kenya…of…/-/index.html

The epidemic of health workers’ strikes that has gripped Kenya in the last few years raises questions as to the government’s commitment to ensure the fulfilment of ‘Right to Health’, as constitutionally guaranteed. At the same time, Kenya’s health care professionals cannot extricate themselves from their ethical obligation, from the solemn oath they took at graduation, which requires that the patient’s interest always comes first. Neither nor can they disengage from the unwritten contract that is established every time a doctor accepts to take care of a patient.

The Constitution of Kenya (2010) in Article 41(2) states: “Every worker has the right (a) to fair remuneration; (b) to reasonable working conditions; (c) to form, join or participate in the activities and programmes of a trade union; and (d) to go on strike”. Thus, the Bill of Rights guarantees the Kenyan worker the right to go on strike. However, whenever it has involved health care providers, a strike action has elicited both ardent support and fervent opposition, this depending on whose opinion is sought. On their part, health care professionals find themselves confronted by a complex ethical dilemma- including the interpretation of the universal principle that “the patient’s interest always comes first” and the unwritten contract that is established every time a doctor undertakes to take care of a patient.

From the medical ethics perspective, it can be argued that doctors on strike still remain ethically bound to attend to emergency services in order to ensure no one dies or suffers permanent damage as a result of their withdrawal of services. They can stop attending to new non-emergency cases, but must continue the care of in-patients, discharging them only when they are better. The ethics of medical practice forbid doctors from abandoning patients in the middle of their treatment; the onus is placed on the doctor to arrange proper referral of the patient to another doctor of equal or greater skill than her/himself. Ideally, doctors who abandon their patients because of a strike action risk sanctions by professional regulatory bodies, e.g. the Medical Practitioners’ and Dentists’ Board.

Just as employees in any other industry, health care providers—including doctors, clinical officers, nurses, midwives, and others—are indisputably entitled to a voice in the terms of their employment.  However, they are also providers of an essential public service, much like fire-fighters and police officers.  Frequently, availability of their services becomes a matter of life and death, for many. Why, then, have doctors’ and other unionized health care workers’ strikes become so commonplace in recent years?

Strikes by health professionals remained unknown in Kenya until the 1970s, but even then these tended to be isolated and short-lived. My generation of doctors had proceeded through training that overly stressed the vocational nature of our profession, to the extent that we had come to believe nothing should ever detract us from our healing mission. Not even the many hours we were made to work, or the meagre wages we endured!

But it would be utter dishonesty on my part not to admit that living conditions have changed a lot since then. The cost of living was then much lower; the shilling’s purchasing power was at its all-time best since Independence. Doctors were respected, felt appreciated and were able to mingle with former college mates in clubs and other social gatherings without any sense of pecuniary embarrassment. Doctors and nurses were housed decently, and comfortably, close to their place of work. Also, unlike the situation today, cars were within easy reach of junior doctors. Within the hospital, systems worked more efficiently. Cancelling of an operation theatre list because of lack of this or that was then something unheard of. The Pharmacy dispensed almost all the drugs we prescribed and could quickly source any that were not in stock at that moment.

In the ongoing dispute, health workers have complained of delayed promotions, low salaries, and delayed salaries. According to the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPPDU) more than 2,000 doctors have resigned, most of them because of delayed promotions. To what extent these complaints reflect inefficiency in the performance of the devolved system of government remains to be established. What is clear however, is that in the affected counties, services in most hospitals have been seriously disrupted leaving many sick persons including mothers and children, with no choice but to go home, or for those with means, to seek care in private hospitals.

Generally, medicine in public service is practiced through a kind of triumvirate system which involves governments, health institutions and health care providers; just how smoothly the three entities work together determines how successful they are in meeting their moral obligations to the sick. Strike action normally arises from failures on all three sides: failure on the part of the government (employer) to act in accordance with its stated policy recognising the importance of health care (=prioritisation), failure on the part of health institutions to provide suitable work environment for optimal provision of health services, and failure on the part of health care providers to consider seriously their duties and obligations to patients and the profession. Kenyan health workers have often expressed discontent with the health care system and management. Doctors and nurses have often complained of shortages of staff, equipment, drugs and supplies in health facilities. This is a common cause of job dissatisfaction among them.

Doctors like everybody else want a decent life for themselves and their families; they want to educate their children and save for a comfortable retirement. They want recognition and good working conditions and an environment that is conducive to self improvement. They want to be appreciated, especially the nature of their work, which is often fraught with many health risks to themselves and their families- think of the many contagious diseases they have to handle; think of the deadly Ebola.

When can a strike action by health professionals be deemed ethical? Considered from a utilitarian perspective, a strike action may be justifiable if there is evidence of greater long-term benefit to health workers’ welfare, improved health care delivery system, and most of all, an enhanced quality of health care for the public. In fact this has been the justification advanced for many of the strikes by health workers, not just in Kenya. To many well-meaning people a strike action that is focused on improving the quality of health care- improved infrastructure, better staffing, drugs and supplies, etc., and especially if it is likely to stem the steady outflow of qualified health professionals from the public service (and the country as a whole), is justifiable and worth support. They’ll see such an action as bringing common good for the majority of the people.

 

When can a strike action by health professionals be deemed ethical? Japheth Mati

The epidemic of health workers’ strikes that has gripped Kenya in the last few years raises questions as to the government’s commitment to ensure the fulfilment of ‘Right to Health’, as constitutionally guaranteed. At the same time, Kenya’s health care professionals cannot extricate themselves from their ethical obligation, from the solemn oath they took at graduation, which requires that the patient’s interest always comes first. Neither nor can they disengage from the unwritten contract that is established every time a doctor accepts to take care of a patient.

The Constitution of Kenya (2010) in Article 41(2) states: “Every worker has the right (a) to fair remuneration; (b) to reasonable working conditions; (c) to form, join or participate in the activities and programmes of a trade union; and (d) to go on strike”. Thus, the Bill of Rights guarantees the Kenyan worker the right to go on strike. However, whenever it has involved health care providers, a strike action has elicited both ardent support and fervent opposition, this depending on whose opinion is sought. On their part, health care professionals find themselves confronted by a complex ethical dilemma- including the interpretation of the universal principle that “the patient’s interest always comes first” and the unwritten contract that is established every time a doctor undertakes to take care of a patient.

From the medical ethics perspective, it can be argued that doctors on strike still remain ethically bound to attend to emergency services in order to ensure no one dies or suffers permanent damage as a result of their withdrawal of services. They can stop attending to new non-emergency cases, but must continue the care of in-patients, discharging them only when they are better. The ethics of medical practice forbid doctors from abandoning patients in the middle of their treatment; the onus is placed on the doctor to arrange proper referral of the patient to another doctor of equal or greater skill than her/himself. Ideally, doctors who abandon their patients because of a strike action risk sanctions by professional regulatory bodies, e.g. the Medical Practitioners’ and Dentists’ Board.

Just as employees in any other industry, health care providers—including doctors, clinical officers, nurses, midwives, and others—are indisputably entitled to a voice in the terms of their employment.  However, they are also providers of an essential public service, much like fire-fighters and police officers.  Frequently, availability of their services becomes a matter of life and death, for many. Why, then, have doctors’ and other unionized health care workers’ strikes become so commonplace in recent years?

Strikes by health professionals remained unknown in Kenya until the 1970s, but even then these tended to be isolated and short-lived. My generation of doctors had proceeded through training that overly stressed the vocational nature of our profession, to the extent that we had come to believe nothing should ever detract us from our healing mission. Not even the many hours we were made to work, or the meagre wages we endured!

But it would be utter dishonesty on my part not to admit that living conditions have changed a lot since then. The cost of living was then much lower; the shilling’s purchasing power was at its all-time best since Independence. Doctors were respected, felt appreciated and were able to mingle with former college mates in clubs and other social gatherings without any sense of pecuniary embarrassment. Doctors and nurses were housed decently, and comfortably, close to their place of work. Also, unlike the situation today, cars were within easy reach of junior doctors. Within the hospital, systems worked more efficiently. Cancelling of an operation theatre list because of lack of this or that was then something unheard of. The Pharmacy dispensed almost all the drugs we prescribed and could quickly source any that were not in stock at that moment.

In the ongoing dispute, health workers have complained of delayed promotions, low salaries, and delayed salaries. According to the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPPDU) more than 2,000 doctors have resigned, most of them because of delayed promotions. To what extent these complaints reflect inefficiency in the performance of the devolved system of government remains to be established. What is clear however, is that in the affected counties, services in most hospitals have been seriously disrupted leaving many sick persons including mothers and children, with no choice but to go home, or for those with means, to seek care in private hospitals.

Generally, medicine in public service is practiced through a kind of triumvirate system which involves governments, health institutions and health care providers; just how smoothly the three entities work together determines how successful they are in meeting their moral obligations to the sick. Strike action normally arises from failures on all three sides: failure on the part of the government (employer) to act in accordance with its stated policy recognising the importance of health care (=prioritisation), failure on the part of health institutions to provide suitable work environment for optimal provision of health services, and failure on the part of health care providers to consider seriously their duties and obligations to patients and the profession. Kenyan health workers have often expressed discontent with the health care system and management. Doctors and nurses have often complained of shortages of staff, equipment, drugs and supplies in health facilities. This is a common cause of job dissatisfaction among them.

Doctors like everybody else want a decent life for themselves and their families; they want to educate their children and save for a comfortable retirement. They want recognition and good working conditions and an environment that is conducive to self improvement. They want to be appreciated, especially the nature of their work, which is often fraught with many health risks to themselves and their families- think of the many contagious diseases they have to handle; think of the deadly Ebola.

When can a strike action by health professionals be deemed ethical? Considered from a utilitarian perspective, a strike action may be justifiable if there is evidence of greater long-term benefit to health workers’ welfare, improved health care delivery system, and most of all, an enhanced quality of health care for the public. In fact this has been the justification advanced for many of the strikes by health workers, not just in Kenya. To many well-meaning people a strike action that is focused on improving the quality of health care- improved infrastructure, better staffing, drugs and supplies, etc., and especially if it is likely to stem the steady outflow of qualified health professionals from the public service (and the country as a whole), is justifiable and worth support. They’ll see such an action as bringing common good for the majority of the people.

What ails health care provision in Africa? Japheth Mati

Biases, distortions and patronising attitudes characterise much of the debate on Africa’s poorer performance in international health goals.

 Africa’s scorecard of achievement in most health indicators and in various international health targets is nothing to shout about.  At the same time, it is undeniable that biases, distortions and patronising attitudes have tended to characterise much of the debate on why it’s been this way.

A spread of daunting challenges stand in the way of effective provision of health care in African countries, some of these are linked to environmental factors- quite often facilitated by man, but others may relate to the intrinsic nature of the continent’s physical geography[i]. It has been suggested that Africa’s stride across the equator in a north-south axis may have important impacts on its topography and climate, including accommodation of nearly a third of the world’s desert land[ii]. To a considerable extent, these geographical features help explain the ecology of tropical diseases in Africa.

The sub-Saharan Africa (SSA) bears the highest burden of disease, globally.

Africa is home to several Tropical Diseases that continue to stifle its social and economic development; among these are malaria and the so-called “Neglected Tropical Diseases” (NTDs): African sleeping sickness (Trypanosomiasis), yellow fever, bilharzias (Schistosomiasis), Kala-azar (Leishmaniasis), Lymphatic filariasis, Trachoma, and (though not confined to the tropics), HIV and AIDS and tuberculosis.

The Global Burden of Disease Study 2010[iii] revealed that whereas the biggest contributor to the world’s health burden used to be the high mortality in infants and children under 5 years, now the disease burden is caused mostly by chronic diseases- cardiovascular, metabolic and musculoskeletal (arthritis) disorders, cancer, mental health conditions; and injuries. But while this is increasingly true across most regions of the world, SSA stands out as a notable exception.

In Africa, harsh environmental factors, poverty, famines and hunger, political conflict leading to internal and external displacement of persons, continue to play roles in facilitating spread of infectious diseases, childhood illnesses, and maternal causes of death, accounting for as much as 70% of the burden of disease. In addition, the region is characterised by the gross socio-economic inequalities, wide gaps between the ‘haves’ and the ‘have-nots’. The result is that African countries have to simultaneously cope with the double burden of communicable and non-communicable diseases.

Africa has been plagued by conflicts since the colonial era and continuing long thereafter. The negative effects of war on the health of populations are well documented, especially the destruction of infrastructure, and the interruption, neglect or abandonment of essential public health services. For instance, the ten-year civil war in Sierra Leone (1991 – 2002), left the health infrastructure virtually non-existent, with rates of infant and child mortality counting among the highest in contemporary world[iv]. Effects of conflict may also account for the difficulties experienced in controlling the Ebola virus disease in Sierra Leone and Liberia.

Besides mortality and morbidity, conflict has wide-ranging consequences on the health and well-being of populations, which include: rape, torture, post-traumatic stress, sexually transmitted infections (including HIV/AIDS) and long-term mental health problems.

Rapid population growth rates

Generally, rapid growth of population is associated with challenges that negatively impact on provision of health services, poverty, hunger, and inadequacies of social services and infrastructure being but a few of them. The annual Population growth rate in SSA reduced slightly from 2.8 percent in 1990 to 2.5 percent in 2010, and has sustained this rate since then. According to World Bank data, the region’s total population is projected to double by 2036. This implies diminishing opportunities and resources, particularly for the most vulnerable members of society: women, children, the poorly educated and the unemployed. It further implies more famines, exacerbated by expanding conflicts over shrinking resources.

The health care demands of a rapidly increasing population far outpace available resources, with inevitable deterioration in the quality of care that is provided. A vicious circle manifests when the underperforming health care systems minimise access to family planning services, thereby fuelling further population growth.

At the national level, rapid population growth normally translates into reduced GDP per capita. As a result, in many sub-Saharan African countries including Kenya, healthcare is predominantly funded by households through out-of-pocket spending. A household without a health insurance may be forced to pay huge medical bills for treatment of an ailing family member, exposing it to financial catastrophe and impoverishment. In 2007, about eleven percent of Kenyan households experienced catastrophic health spending, with 4 percent being impoverished. This was particularly so among the poorest households^[v].

From the public health perspective, the high fertility rates that drive rapid growth of populations are also associated with high maternal morbidity and mortality rates. Pregnancies that are too close together do not allow enough time for the mother to recoup nutrients that are expended during pregnancy and breastfeeding, which may precipitate a condition referred to as maternal depletion syndrome.

Haphazard and Unrealistic planning- not addressing greatest need

The fundamental challenge facing African governments in their efforts to fulfil the mandate of providing health care for all citizens, may be traced back to the time of independence when they mostly chose to inherit the colonial, European model, of health care, where curative care was overly emphasised, while primary health care took low priority (apart from immunization to stall epidemics).

A community member explains health education message chart, Magadi, Kenya

Also perpetuated was the inequitable distribution of health facilities and services, which were predominantly sited in urban centres with little consideration for rural areas, which lacked meaningful infrastructure. It is no wonder that the World Health Organization has estimated that up to 80 percent of the populations in some African countries rely, almost entirely, on traditional systems of medicine to meet their primary health care needs^[i]. In such scenario the greater majority of the population benefit little from the national health services.

The above is a clear example of planning which is not based on reality on the ground, one that does not address where the highest burden of ill-health exists. The practice of evidence based planning and priority setting which has increasingly caught up in recent years, aims to address situations such as these. Evidence based planning is particularly important where resources are limited; it is particularly important to invest in public health and health promotion strategies that are effective.

Under-resourced health care systems

Despite the Abuja pledge of 2001 to allocate at least 15% of the annual budgets to health[ii], generally, the health sector in sub-Saharan African countries remains grossly underfunded. More than a decade later, only a couple of countries can claim to have achieved the target, the majority including Kenya, are as yet to achieve the goal.

All the same, the gross amounts allocated to health have been rising in most countries. For example, between 2007 and 2011, the gross allocations to Kenya’s Ministry of Health more than doubled, from KES21.7 billion in 2007/08 to KES45.2 billion in the 2011/12 budget. But of concern is the trend in the prioritisation of health, which has not kept pace with other areas of expenditure as the economy has expanded.  Over the same period, the overall gross Government expenditure rose from 353.8 billion to 815.6 billion^[iii], a more than 230 percent increase. But, the share for health as a proportion of overall government expenditure declined from 6.13 percent to 5.54 percent, way below the 15% pledged in the Abuja Declaration.

Deficient budgetary allocation to health, coupled with inefficient and corrupt systems are the ultimate explanation for the disappointing performance in the public health sector, and what breeds the multitude of the perennial complaints levelled against it. More importantly, it is the root cause of denial and violations of the right to health as enshrined in national constitutions.

Human resource constraints

Efficient delivery of health care services demands availability of a viable workforce composed of well trained health professionals, and in adequate numbers. This is a prerequisite to having an effective health care system. On the other hand, most Sub-Saharan African countries continue to experience serious human resource constraints, not just with regard to doctors but also nurses and midwives, and indeed all health workers in general.

Most of them are operating with an extremely low doctor to population ratio, an average of just 1.3/10,000 compared to countries such as India (6.0/10,000), Brazil (19.2/10,000) and the United States (28.0/10,000)[iv].  In fact, some individual countries on the continent have physician to population ratios as low as 0.1-0.2/10,000. According to the World Health Organization (WHO), in order to achieve coverage of the primary healthcare needs, a country should have a minimum of 23 health workers (doctors, nurses, and midwives) per 10,000 population, a ratio few Sub-Saharan African countries can claim to possess.

For example in East Africa the country with the highest ratio of doctors, Kenya, can only claim 1.8 doctors per 10,000 people (Uganda1.2, Rwanda 0.6, Tanzania 0.1). Uganda has the highest ratio of nurse/midwives with 13.1 per 10,000 people (Kenya 7.9, Rwanda 6.9, and Tanzania 2.4). In terms of ‘health workers’ ratios Uganda leads with 14.3 per 10,000 (Kenya 9.7, Rwanda 7.5, Tanzania 2.5) [v]. Thus, none of these selected East African countries has the human resource that WHO considers prerequisite to achieving national and international health goals.

The shortage of health workers in sub-Saharan Africa is attributable to a variety of reasons, including inadequate investment in training, both pre- and in-service; internal and external migration (‘brain drain’), premature retirement, morbidity and premature mortality. In many countries the current pre-service training activities are insufficient to maintain absolute numbers even at their current levels, and mostly not enough to keep pace with population growth[vi].

Out-migration of doctors and nurses is particularly a serious drain on the economy; loss of returns from investment on their education and training has been estimated at around US$ 518,000 per doctor and US$ 339,000 per nurse^[vii]. A recent survey of medical schools in sub-Saharan Africa has shown that within five years of graduation, as many as 26% of graduates had migrated out of their country – 80% emigrating outside of Africa. Of those doctors remaining at home, they were largely concentrated in urban centres, whether in public or private practice, specialist or general practitioner^[viii].

There are numerous factors that drive the brain drain of health professionals. These include poor wages especially compounded by concurrent high inflation rates; poor working environment which is a common reason for job dissatisfaction; limited opportunities for self professional growth due to lack of functional facilities, equipment and supplies; and generally the lack of appreciation by the employers and the society. In some countries many of the graduating nurses may remain unemployed for years, despite the great demand for their services in public health facilities, an example of distorted prioritisation.

Corruption: the daunting challenge of combating sleaze

In most African countries, corruption has undoubtedly become the bedevilling monster behind underperformance in all development sectors, including health. The vice has been defined as abuse of entrusted power for private gain, in public and private sectors[ix]. Corruption is not just a curse in Africa; it is known to exist all over the world[x], even then, it is in Africa where the woes caused by its pervasiveness are most magnified. Corrupt practices may take varied shapes and shades, ranging from staff absenteeism, nepotism and cronyism, to irregularities in public purchasing and contracting processes, especially over-invoicing. Drugs and other items are ‘leaked’ from public health facilities to be sold privately- sometimes to patients admitted in the very same public hospitals.

The World Bank^[xi] has used the term “Quiet corruption” to describe denial of public services that are due to poor people even though they are paid for. Examples of these are absenteeism among health workers, and the distribution of fake drugs while genuine ones are sold for profit.

Absenteeism occurs for various reasons, some of them legitimate or necessary, as when staff have to travel to headquarters to check why their salaries have not been paid. Staff can be absent because they are involved in personal engagements, including undertaking paid side jobs. Unfair hiring practices such as nepotism and preferential treatment to well connected individuals, promotions of undeserving staff at the recommendations of politicians, and others in positions of authority, are all expressions of corruption.

Clearly, effectively addressing corruption in African countries has become a development imperative.

An unresolved status of traditional systems of medicine

Human societies have since time immemorial, independently evolved and maintained systems of healing; Africans are not an exception. Despite efforts to suppress indigenous African medicine during the colonial era the practice still thrives throughout the continent. Traditional African medicine and African religion are intricately intertwined; illness, disease and misfortunes are understood within the context of African theology. Concepts such as these were obviously viewed as a serious threat to the work of early Christian missionaries, who preached that traditional African practices including medicine were sinful. As such, converts risked excommunication for engaging in the practice, whether as practitioners or patients.

Practitioners of western medicine have over the years, eschewed traditional African medicine dismissing its methods as primitive, superstitious and pagan. They failed to appreciate the philosophical underpinning of traditional African Medicine, in which good health, disease, success or misfortune, are seen as interrelated circumstances, which do not happen by chance but arise from actions of living individuals or ancestral spirits. Thus, traditional African medicine embraces two mutually reinforcing practices: African spirituality (divination) and herbal medicine.

In more recent years, traditional medicine has become more widely accommodated. This, in any case, was bound to happen considering that in most African countries, the penetration of ‘modern’ medicine remains such that large populations lack access to it, due to its relatively high cost and the concentration of health facilities in urban centres. As noted above, WHO’s estimates show that as much as 80% of the population in some African countries may depend on traditional medicine for their primary health care.

In fact, quite frequently, both systems of medicine (traditional and western) are used complementarily, with traditional therapies serving as a first-line treatment before modern drugs are sought. Within certain communities in Kenya, for example, majority of pregnant women will have consulted a traditional healer (mganga) who administered to them herbal preparations and potions to ward off evil spirits before making their first antenatal clinic visit^[xii].

This should be strong reason why governments ought to address the unresolved status of traditional medicine, by setting up regulatory mechanisms for accommodation of the practice within the national health system. Such a measure, besides ending the unholy alliance with traditional medicine, should go a long way towards assuring safety and effectiveness of the practice.

[i] http://www.who.int/mediacentre/factsheets/2003/fs134/en/‎

[ii] The Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases 2001

[iii] Figures based on gross approved expenditure (2007/8 – 2010/11) and gross estimates (2011/12), and indexed to inflation at 2007 CPI.

[iv] http://data.worldbank.org/indicator/SH.MED.PHYS.ZS

[v] (http://kff.org/global-indicator/physicians/, http://kff.org/global-indicator/nurses-and-midwives/)

Yohannes Kinfu, Mario R Dal Poz, et al. The health worker shortage in Africa: are enough physicians and nurses being trained? Bulletin of the World Health Organization 2009;87:225-230. doi: 10.2471/BLT.08.051599

[vii] Kirigia JM, Gbary AR, Muthuri LK, Nyoni J and Seddoh A The cost of health professionals’ brain drain in Kenya. BMC Health Serv Res. 2006; 6: 89. Published online 2006 July 17. doi:  10.1186/1472-6963-6-89 PMCID: PMC1538589 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1538589/ Accessed 28 March, 2013.

A survey of Sub-Saharan African medical schools, Human Resources for Health 2012, 10:4  doi:10.1186/1478-4491-10-4 http://www.human-resources-health.com/content/10/1/4

[ix] (http://www.transparency.org/topic/detail/health).

http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/publications/hen-summaries-of-network-members-reports/how-does-corruption-affect-health-care-systems,-and-how-can-regulation-tackle-it

[xi] http://www.lse.ac.uk/IDEAS/publications/ideasToday/06/worldBank.pdf

[xii]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003.

[i] Jared Mason Diamond, 1999, quoted in James R. Moore, 2014, Shattering Myths about Africa: How Geography, Diseases, and Hunger Hinder Africa’s Economic and Social Development. American International Journal of Social Science Vol. 3 No. 2; March 2014. http://www.aijssnet.com/journals/Vol_3_No_2_March_2014/1.pdf

[ii]Osei, W.Y. (2010). Human-environmental impacts: Forest degradation and desertification. In S.A. Attoh (Ed.), Geography of Sub-Saharan Africa (pp. 63-90). New York: Prentice Hall.

[iii] http://www.who.int/pmnch/media/news/2012/who_burdenofdisease/en/index1.html

[iv] ‘Sierra Leone’s long recovery from the scars of war’, Bulletin of the World Health Organization: Volume 88:2010, http://www.who.int.

[v]Kimani, D. and T. Maina. 2015. Catastrophic Health Expenditures and Impoverishment in Kenya. Washington, DC: Futures Group, Health Policy Project.

Regulation of Traditional Medicine in Kenya: Kenya’s Health Bill, 2015- Japheth Mati

In our post of January 9, 2015 entitled “What prospects for complementary use of African and western systems of medicine?” we called on African governments to establish appropriate regulatory mechanisms for accommodation of traditional medicine within the national health care system. This was in consideration of the fact that WHO’s estimates show that up to80 percent of the population in some places rely on traditional medicine for their primary health care.

Already, evidence exists that shows that in Kenya traditional medicine and modern (western) medicine are frequently used complementarily, with traditional therapies serving as the first-line treatment before modern drugs were sought. As such, there was urgent need for mechanisms to  ensure safety and effectiveness of traditional medicine.

So, we say kudos to Kenya’s National Department of Health for publishing the Health Bill, 2015, which among other measures seeks to establish regulatory mechanisms for the practice of traditional medicine. The relevant sections are:

• Clause 42 (1) and (2): “The national government department of health shall formulate policies to guide the practice of traditional and alternate medicine. The county executive department for health shall ensure implementation of any policies thereto.”
• Clause 42 (1): “There shall be established regulatory body by an Act of Parliament to regulate the practice of traditional and alternative medicine.
• Clause 47: “The national government department of health shall develop policy guidelines for referral mechanisms and a system of referral from practitioners of traditional and alternative medicine to conventional health facilities…….”

Obstetric Fistula afflicts nearly 100,000 women in Kenya – Japheth Mati

The recently released findings of the 2014 Kenya Demographic and Health Survey (KDHS 2014) included, for the first time ever, an estimate of the prevalence of fistula in Kenya. After describing the condition, women were asked if they had ever experienced the symptoms of fistula, to which 1 percent responded in the affirmative. What this means is that 1 percent of women of childbearing age (15-49 years) had actually suffered a fistula, and based on the 2009 population census, this translates to at least 93,120 women.

As I read the KDHS results recently, I could not help recalling a post I made three years back, under the title “Remembering my fistula patients as Kenya observes FGM Day”. I was referring to the 1970s when I was one of two gynaecologists in the Department of Obstetrics and Gynaecology at the Kenyatta National Hospital (KNH), who had special interest in the treatment of urinary incontinence, the commonest cause of this being vesico-vaginal fistula (VVF). I remember that at any given day there would be one or two such cases in my ward.

This condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women received skilled care during labour and delivery. Yet it has persisted as a major problem, decade after decade.

Dr Peter Candler way back in 1954 reported that obstetric VVF was the commonest gynaecological condition encountered at the King George VI Hospital (today’s KNH); and as I indicated above, it still was common in the 1970s. How sad it is that decades after independence, a substantial proportion of Kenyan women remain at risk of this tragedy. Today, the KDHS data tells us there could be well over 93,000 women living with the condition.

On the brighter side we must recognise the commendable efforts in the recent past towards improving access to surgical treatment of fistula. But the magnitude of the problem remains intimidating. How long will it take to clear the backlog, while at the same time new cases are being created?

Let us assume 10 hospitals undertook to operate 10 cases daily, 5 days a week, completing 500 surgeries per week. To do all 93,120 women at that speed would take 187 weeks or 3.5 years. But this assumes that no new cases are added throughout the 3.5 years and that each operation was successful, (which is not always the case!), and more importantly, the survey estimate of 1 percent was correct, (stigma could have affected responses). Finally, it is possible that a crush programme involving surgical camps may accomplish the task sooner, the cost and logistic nightmare notwithstanding.

On the whole, the above underlies the importance of prioritising prevention. Looking to the future, the hope lies in improving access to skilled maternal health care for all pregnant women, antenatal care and delivery services. This is the only way of eliminating the risk of obstetric fistula. In this regard, kudos to our First Lady! Her Initiative, Beyond Zero Campaign, is a practical demonstration of her love for the women and children of Kenya. Indeed, such level of commitment is unprecedented.

The KDHS 2014 has given us some hope- the proportion of women who received skilled care during delivery has increased from 44 percent in 2008/9 to 62 percent in 2014, while those who gave birth in a health facility increased from 42 percent in 2008/9 to 61 percent in 2014. Even though a lot remains to reach the MDG 5 target of 90% by 2015, this data is, nevertheless, extremely encouraging and motivating. Better late than never!

What prospects for complementary use of African and western systems of medicine?

Human societies have, from time immemorial, independently evolved and sustained systems of healing; Africans were not an exception. Despite efforts to suppress indigenous African medicine during and even after the colonial era the practice still thrives throughout the continent. The big question is whether there are prospects for complementary use of western and African medicine?

The World Health Organisation (WHO) defines traditional medicine as the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses. Traditional African medicine and African religion are intricately intertwined; it is through African theology that illness, disease and misfortunes are understood.

Traditional African Medicine is a holistic discipline that embraces the use of herbs, African spirituality (diviner-healers), and traditional midwifery. African spirituality is centred on a belief in a supreme deity above a host of lesser semi-divine figures, including the power and intercession of ancestral spirits.

Normally, every rural African community will have a traditional healer, to whom they go for advice on a variety of issues, including health problems. The traditional healer would be knowledgeable about plant species that have medicinal value, including their ecology and conservation.  

The philosophy underpinning traditional African Medicine differs significantly from that of western medicine. Whilst the latter is based on a system that focuses on identification of a specific disease-causing agent (germ theory), African medicine takes a holistic view. Good health, disease, success or misfortune, are seen as interrelated circumstances, which do not happen by chance but arise from the actions of living individuals or spirits of ancestors. Thus, the practice of traditional African medicine embraces the two mutually reinforcing elements of African spirituality (divination) and the use of herbs (herbal medicine).

Unlike in western medicine where the Hippocratic Oath obliges practitioners to be open with their modalities of treatment, absolute secrecy is what has sustained and protected the knowledge and mystery of traditional African medicine, through the ages. The gathering of medicinal plants is customarily restricted to the healers and their novices only, who normally will not divulge the nature of the plant, its environs and the details of its prescription to clients.

Christian missionaries were the indisputable ushers of western medicine in Africa. European and American missionaries pioneered ‘modern’ medicine in Africa, establishing health facilities deep into the interior way in advance of the colonial medical services.

Dr David Livingstone, the Scottish doctor and traveller, is recognized as the main source of inspiration for the involvement of Christian missions in medical work. His writings between 1851 and 1873 played a significant role in the recognition of medical care as an integral part of missionary activity. As a result, starting in the second half of the nineteenth and during the early twentieth century, mission hospitals, dispensaries and other medical facilities were established in West, East and Southern Africa^[1].

Generally, Christianity was initially introduced at the Coast, before the missionaries penetrated the interior. By 1878, the White Sisters (Catholic Missionaries of Africa) had initiated health activities in the regions of the great lakes in East Africa. Among the earliest health facilities in East Africa were the Church Missionary Society (CMS) Hospital at Mengo, Uganda, established by Dr Albert Cook (1870-1951) in 1897, the Church of Scotland Mission (CSM) Hospital at Kikuyu, Kenya, in 1907, and the Africa Inland Mission (AIM) Hospital at Kijabe, Kenya, in 1915.

IMAGE: Mengo Hospital 1897

The arrival of the Christian missionaries provoked a cultural confrontation, especially when they completely ignored the existence of African spirituality. Influenced by their strong belief in the superiority of European culture, early missionaries viewed their primary mission to be that of exposing Africans to Western standards and practices, in other words, to ‘civilise the native’. In the mistaken belief that a spiritual vacuum existed in the lives of Africans, ready to be occupied by Western religion, they assumed that whatever forms of religion Africans subscribed to, could easily be supplanted by a superior religion, Christianity. They failed to distinguish between the roles, in the lives of Africans, of traditional culture and practices on the one hand, and of Christianity, on the other.

Professor John S. Mbiti, the pre-eminent African theologian and philosopher, has since exhorted that Christianity cannot afford to neglect, despise or even condemn outright, African traditional religions. Nor should the connection between African traditional practices and Christianity be seen as an “uncomfortable form of compromise”. He observes that in traditional African societies, religion and culture were completely integrated into one holistic way of life so that there was no distinction between what was sacred and what was secular. He advocates that Christianity ought to be viewed as the “fulfilment of that, after which African religiosity, in all its richness, has groped”^[2].

Establishment of colonial medical services in East Africa was largely driven by the needs of colonial service officials and the white settlers. This was particularly the case in Kenya where there were numerous, and increasing numbers of Europeans in the so-called ‘white highlands’. Second to be considered were Indian, on whom the colonials looked upon to cater for their needs. Lastly, the meagre services extended to Africans, generally targeted the employees in the colonial administration and labour in white settler farms. As though to absolve themselves of the guilt of not providing for the health needs of African communities, the colonials have been quoted as blaming the preoccupation of the natives with witchcraft: ‘It was almost impossible “to administer to a people so thoroughly riddled with witchcraft that no one could do anything with them because they refused to tell anything”’!

The earliest government hospital to be established in Kenya (in 1901) was the Native Civil Hospital (NCH), Nairobi. This 40 bed facility provided in-patient services for Africans, while outpatient services were availed at the Government Dispensary which was located along Government Road (now Moi Avenue), close to Kingsway Police Station (today’s Central Police Station). The NCH was the precursor to the King George VI (1952), later renamed, in 1964, the Kenyatta National Hospital.

For the large population of Africans, especially those who lived far from the urban centres where colonial medical health facilities never existed, it mostly fell on missionaries (and/or traditional healers) to provide the much needed health services. Even today church-based hospitals and health care programmes continue to account for 25 percent to 50 percent of available services in most African countries, including Kenya.

Enjoy the best of both worlds? Practitioners of western medicine have over the years, eschewed traditional African medicine dismissing its methods as primitive, superstitious and pagan. Besides herbs, some healers may involve in their treatments, charms, incantations, and the casting of spells (demons); others may employ music and dance as in the case of the Akamba kilumi.

Under colonial rule, traditional diviner-healers were outlawed being considered to be practitioners of witchcraft. Similarly, African religious practices and medicine were labeled sinful by white Christian missionaries, and as such use of traditional medicine was forbidden for followers. However, in more recent years, traditional medicine has become more accommodated, and practitioners of “modern” medicine have increasingly acknowledged that there is much to learn from certain aspects of traditional medical practices. Indeed even the World Health Organization (WHO) has a department that promotes traditional medicine.

In any case, this was bound to happen since in most African countries, the penetration of ‘modern’ medicine remains such that large populations lack access to it, due to its relatively high cost and the concentration of health facilities in urban centres. According to the WHO, in some African countries, as much as 80% of the population may depend on traditional medicine for primary health care. This, among other reasons, legitimizes the call for enhanced research into the various practices employed in African traditional medicine. Africa is endowed with many plants that can be used for medicinal purposes. In fact, out of the approximated 6400 plant species used for various applications in tropical Africa, more than 4000 are used as medicinal plants, used in the treatments of many varied diseases and illnesses^[3].

Image Traditional healer

 

Faced with the mammoth challenge of making ‘modern’ health care services accessible to all, African governments have increasingly adopted policies in favour of integration of traditional African medicine into national health care systems. For example, in 2001, the African Union (AU) Summit of Heads of State and Government declared the period 2001–2010 as the Decade of African Traditional Medicine, and in 2003 adopted a plan of action for its implementation. In 2008, the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa reiterated the Alma Ata Declaration by calling on countries “to set up sustainable mechanisms for increasing the availability, affordability and accessibility of essential medicines and the use of community-directed approaches and African traditional medicines”, among others.

In countries, such as Kenya, governments have a constitutional obligation to facilitate the right of the citizen “to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”^[4].

However, it would be unfortunate (perhaps naïve?) to simply define healthcare in the context of ‘western’ medicine only. In fact, while still pursuing the ultimate goal of making healthcare available, accessible, affordable, and of good quality for all citizens, governments should be prudent enough to take the bold step (hard choice) of accepting the reality that a large segment of the population is already relying on traditional medicine.

There is evidence to show that traditional medicine and modern (western) medicine are quite frequently used complementarily, with traditional therapies serving as a first-line treatment before modern drugs are sought. For example, within certain communities in Kenya, majority of pregnant women will have consulted a mganga (traditional healer) who administered to them herbal preparations and potions to ward off evil spirits, before making their first antenatal clinic visit^[5]. These women perceive antenatal care services obtained at health facilities, and those provided by TBAs and herbalists, to be complementary, and generally, they seek both types of care interchangeably.

The above is a strong reason why governments ought to establish appropriate regulatory mechanisms for accommodation of traditional medicine within the national health care system. Such a measure can go a long way towards assuring safety and effectiveness of the practice. A lesson may be learnt from the way traditional systems of medicine have been facilitated to grow in India and China, to the extent that today, leading institutions in the West are teaching and licensing practitioners of Ayurvedic medicine and Traditional Chinese Medicine.

However, a critical challenge for integration is sustaining the holistic concept of traditional African medicine, which traditionally embraced herbal medicine, divination and spiritual healing as mutually reinforcing systems, capable of dealing with physical, emotional and spiritual indispositions.

Whereas a considerable body of knowledge exists on herbal medicine, there is a dearth of scientific data on the other modalities of traditional medical therapy. This ought to be a challenge to African scientists, to engage with traditional medical practitioners, in the hope of establishing what is, and what is not practicable to integrate.

[1] H. J. O’D. Burke-Gaffney The History of Medicine in the African Countries http://www.ncbi.nlm.nih.gov/pmc/articles/…/pdf/medhist00144-0036.pdf‎

[2] Extract from a lecture given to the Christian Churches’ Educational Association of Kenya, 19 September 1969; see also J S Mbiti African Religions and Philosophy (London: Heinemann, 1969)

[3] Network on Medicinal Plants and Traditional Medicine (Eastern Africa). http://www.idrc.ca/EN/Resources/Publications/Pages/ArticleDetails.aspx?PublicationID=713

[4]The Constitution of Kenya, 2010 Article 43. (1)(a)

[5]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

‘What if the HIV epidemic first manifested in poor countries?’

Japheth Mati

This week’s call by Doctors Peter Piot, David Heymann and Jeremy Farrar urging US authorities and WHO to make available for African Ebola patients, the same treatment already given to the two American missionaries, Dr Kent Brantly and Nancy Writebol, reminds me of the above question I raised in a blog I wrote in 2012.

In the article I compared the unprecedented brisk response to the HIV epidemic with the dilatory reaction to the so-called ‘neglected tropical diseases’. The contrast is regrettably dependent on who the patient is: the high profile wealthy and powerful versus the poor and powerless.

I believe it is because of the former that within less than a decade of the first AIDS case in San Fransisco, several drugs had received FDA approval. In other words, authorities were prepared to ‘bend rules’ in order to permit early availability of life-saving treatment.

Now Dr Piot and colleagues tell us that there are in fact several drugs and vaccines under study that could be used to combat the disease.

In a desperate situation such as in the West African countries, it is difficult to imagine what else makes the relevant authorities not ‘bend rules’ as they did previously, to avail experimental treatment where it is needed the most?

We salute the Initiative by Kenya’s First Lady towards improved maternal and child health outcomes in Kenya. Japheth Mati MD

The “Beyond Zero Campaign” launched on 24 January 2014 under the stewardship of Kenya’s First Lady, Margaret Kenyatta, seeks to improve maternal and child health outcomes in Kenya. Her enthusiasm and commitment to the success of the Initiative, including the pledge to raise funds for it through participation in the forthcoming London Marathon, is completely unprecedented in Kenya’s history. We salute this initiative by the First Lady of Kenya.

The Strategic Framework for the engagement of the First Lady in HIV control and promotion of maternal, newborn and child health in Kenya, which was unveiled on World AIDS Day 2013 focuses on the following five key areas: (i) Accelerating HIV programmes, (ii) Influencing investment in high impact activities to promote maternal and child health and HIV control, (iii) Mobilizing men as clients, partners and agents of change, (iv) Involving communities to address barriers to accessing HIV, maternal and child health services and (v) Providing leadership, accountability and recognition to accelerate the attainment of HIV, maternal and child health targets.

In an earlier post under the title “What’s in the way of achieving improved maternal health in Kenya” it was observed that there is sufficient knowledge of the causes of maternal deaths, and how they can be prevented. It is known which interventions work and which do not. What appears to be the main barrier is the lack of commitment to act; to prioritize reduction of maternal mortality, and to reflect this in resource allocations to the health sector, and to maternal health services, in particular.

The health budgets in most African countries, Kenya included, do not demonstrate that health is rated as a high priority among other national needs. This is often the result of failure by governments to recognise the importance of health in development, so that expenditure on health is not perceived as a critical economic investment alongside spending on education, agriculture or industries. Yet, health is a critical resource, without which investment in all other sectors would go to waste. Further, poor health creates critical barriers to economic production.

Within the health sector, lack of equity in planning and distribution of resources for health results in inequitable access to health care services: Physical access (e.g. distance to the nearest health facility); Affordability (when fees charged for services are unaffordable); Acceptability (where people lack confidence in the services provided and decide not to utilise them). People who are denied access through the above barriers often turn to out-of-pocket expenditures on their health care. Ironically, evidence reveals that the poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care.

From available evidence it is obvious that local and international health goals cannot be achieved without emphasis on equitable expansion of access to basic services for all. Policy makers and planners must begin to accept the existence of, and to act on, the vast inter- and intra-regional health disparities in Kenya. It was the expectation that devolution would create opportunities for better prioritization of needs at the grassroots, and, through better knowledge of community needs, formulate more focused interventions. 

Engaging with communities as envisaged in key area (iv) of the proposed Strategic Framework is indeed a critical focus, considering that proximity to health facilities and services, is no guarantee they will be utilised. For example, there are several areas in Kenya, both rural and urban, where communities will prefer traditional medicine as their first line of health care before modern drugs are sought. There is evidence to show that within certain communities in Kenya, majority of pregnant women will have consulted a mganga (traditional healer) who administered to them herbal preparations and potions to ward off evil spirits, before making their first antenatal clinic visit^[1]. These women perceive antenatal care services available at health facilities- dispensaries and health centres, and those provided by TBAs and herbalists, to be complementary, and generally, they seek both types of care interchangeably. This may have negative effects, for example, due to delays in early diagnosis and management of antenatal complications, resulting in poor pregnancy outcomes.

https://africahealth.wordpress.com/2010/10/27/what%E2%80%99s-in-the-way-of-achieving-improved-maternal-health-in-kenya/

Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

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[1]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

“What do women want?”

“What do women want?” This rather vague question, sometimes attributed to the famous psychoanalyst Sigmund Freud (1856-1939), still crops up in today’s male-oriented societies where women occupy a second place in terms of recognition. Yet, within the context of the axiom “your health is in your hand”, this is surely a pertinent question.  It becomes equally appropriate when it is recognised that current status of health is, to a considerable degree, determined by past events, related to behaviour and the social milieu, and that today’s lifestyle has considerable bearing on tomorrow’s health status.

The scope of actions that individual women may take to protect their health will, obviously, vary according to where they live and what resources are available to them. Regrettably, majority of world’s women still live in societies where they not only occupy a second place in terms of recognition, many are condemned to play subservient roles in society, where they labour under the yoke of gender discrimination and denial of their reproductive rights. For these women, the various international instruments touching on reproductive rights, as well as the national constitutional guarantees of equality and non-discrimination, have little meaning in their lives.  They remain governed by a separate set of laws based on religion or custom, as they continue being tormented by several harmful practices, some having serious negative impacts on their health and social well-being.

But, irrespective of their status, women should want empowerment to make sound choices that have a direct and immediate impact on their reproductive health; a source of accurate information that is relevant to their immediate problem. They want basic tools for self direction and growth; knowledge of themselves: soma and psyche, their bodies’ rhythms, their sexual and reproductive health and how to protect it. They need to learn how to avoid and prevent sexually transmitted infections and unplanned pregnancy; they must be encouraged to seek knowledge of their own individual condition, ways to promote their own health, and to embrace positive health seeking behaviours.

Under circumstances such as these women would surely need a resource that provides the much needed information, but which is presented in such a style that it can be understood without a medical background.  A source that addresses some of the relevant concerns of women from age of sexual maturity to old age, seeking to empower them with information and knowledge that can assist them in making decisions regarding their sexual and reproductive health.

Obviously books and other media cannot, and shouldn’t, take the place of direct consultation with the doctor; on the other hand, they can enable a woman to have a better understanding of her medical problem and to ask their doctors more useful questions. It is their right to know all the facts that pertain to personal health care decision making.

A new addition to books that answer to the above concerns can be found at https://www.createspace.com/4183612