Kenya’s new county governments likely to be hard put in fulfilling their health care mandate

Health care provision within the devolved system of government as provided for in the Constitution of Kenya (2010) will come up against several obstacles, key among these being the challenge posed by uneven inter-county levels of development- unequal distribution of resources for health especially the distribution of health facilities, human resources, and poorly developed communication infrastructure. Also unevenly distributed across the country are poverty levels, the effect of which is to make health services largely inaccessible to a large chunk of the population that cannot afford the high out-of-pocket expenditures, which are known to be common in Kenya.

According to the Fourth Schedule of the Constitution, county governments are entrusted with all functions related to health care except for health policy and national referral health facilities which remain the responsibility of the national government. Specifically, County Health Services will be responsible for health facilities and pharmacies at Levels 1 to 4; ambulance services; and promotion of primary health care. However, within the situation highlighted above it is obvious that some of the counties will be hard pressed fulfilling this mandate. Such counties may benefit from experiences derived from elsewhere, where health services have been provided with some measure of success at low cost.

In Kenya, as in most sub-Saharan African countries, nearly three quarters of the population lives in rural areas. According to the World Bank Indicators in 2008, about 79 percent of Kenya’s population lived in rural areas[i], where the infrastructure for communication and health services is poorly developed. Under such circumstances, there is no short-cut to it that, unless the population is extraordinarily motivated, services have to be brought closer to people rather than expecting them to travel long distances for the services. This is true for all promotive health services such as family planning, antenatal and postnatal care and child health services (growth monitoring and immunization). This has recently been confirmed by a study based in western Kenya[ii], which explored the impact of distance to health facility on utilisation of child health services. The study showed that for every 1 km increase in distance of residence from a health clinic, the rate of clinic attendance decreased by 34% from the previous kilometer. This means that creative strategies will be needed to ensure rural populations can have access to health services, which are a reasonable distances from them.

Making health services accessible to all rural communities

Over the years a number of approaches have been utilized in Kenya to provide health services to populations that do not live close to static health facilities. Three such approaches include the use of mobile clinics, community-based distribution (CBD), and social marketing of health commodities. Mobile clinics on periodic basis have been used to take services to remote places, where the distribution of health facilities network is inadequate; they are particularly useful for the provision of services such as immunization, or family planning methods; especially for the latter, mobile services can be used to avail methods such as surgical contraception where there are no resident doctors. However, mobile clinics suffer two serious drawbacks, first, the costs involved in transport to these sites, and secondly, the usual monthly or quarterly visits do not permit continuity of care in case something happened in between visits.

Kenya has had extensive experience in community-based distribution (CBD) of health services, particularly the distribution of family planning commodities. This approach has several advantages over clinic-based services:  it makes services available and accessible at the home setting, and this can increase acceptance and particularly continuation rates of contraception. The involvement of locally known individuals in the service removes the fear of strangers discussing sensitive matters. The CBD workers can also be trained to elicit health problems in the community and to refer them to clinics; this can include identification of malnourished children, as well as provision of de-worming tablets. They can also be trained to convey health education on various health conditions, including STIs, reproductive organ cancers, and to encourage early reporting of symptoms at health facilities.

Social marketing, on the other hand, involves empowering retailers to market commodities off-the-counter, normally the non-prescription types, and usually at subsidised prices. Besides contraceptives (e.g. condoms and pill), social marketing has been utilized to promote use of mosquito nets and oral rehydration therapy, among others. Social marketing is an important approach to making these services more easily available at places which are accessible to the people, i.e. the local duka. However, social marketing approach must be backed up by accessible health facilities where clients can get clinical evaluation and treatment, as necessary.

Bringing the static clinic closer to the people

In the 1980s, University of Nairobi’s Department of Obstetrics and Gynaecology pioneered a community-based health care system[iii] that provided clinical services on an outreach basis, with an assured continuation of care through clinic-based community health workers (CHWs). The system is based on the appreciation that a major constraint to bringing services closer to people is the cost of construction of clinic buildings. Hence, if locally available buildings can be utilized this can permit the expansion of health clinic networks at minimal cost. Such buildings are to be found practically everywhere in rural Kenya, in small market places, which are sited within convenient reach of the population. Quite often a large number of these shop buildings are either not in use or are under-utilized, and they can be rented at very low cost to be used as health care facilities. Facilities such as these can be maintained hygienic and can provide reasonable privacy for the clients. Being in the market place the clinics enable clients to benefit from health services within reach of their business transactions, so that clinic attendance need not clash with income generating activities. Thus, these clinics offload rural communities not only the cost of transport to a distant clinic, but also opportunity cost of prolonged absence from their business.

A wide range of outpatient services can be provided through these affordable clinics, including preventive services- health education, family planning, antenatal and postnatal care, child growth monitoring and immunization; limited screening for cervical cancer, HIV testing and diagnosis and treatment of common sexually transmitted diseases. Through a similar set up the Machakos Project was able to introduce and sustain high levels of modern contraceptive methods in a rural population, which included methods that are generally confined to hospital settings such as surgical contraception and the sub-cutaneous implant, Norplant, as well as high levels of antenatal care and child immunization coverage. This was found to be a particularly useful approach for introduction of cervical cancer screening at the community level.

This approach fits well within the national Community Strategy[iv] in which Levels 2 and 3 provide backup support to level 1, with Community Health Workers (CHWs) being supervised by Community Health Extension Workers (CHEWs), usually stationed at Level 2. In this setting one or two CHWs will be posted at the clinic, although they can also be employed in extension roles outside the clinic. Community Nurses from the nearest dispensary (Level 2) will provide professional services through two or three visits every week to the market-based facility, and since a CHW will be based at each facility, these can operate on a daily basis. The widespread availability of the mobile phone and the boda-boda transport should facilitate an efficient referral system between Levels 1 to 4, permitting nurses, clinical officers and doctors stationed at Levels 2,3 and 4 to communicate and provide advice to Level 1 on the mobile phone.

The CHWs should be given instructions on clinic operations, how to handle clients in the clinic, including history-taking, and provision of information on available services. Additionally, they can be taught how to weigh children and adults, and even the measuring of blood pressures. A spot random check on the CHW’s measurements can provide a quality assurance on their performance. The involvement of CHWs in these processes releases the nurses to concentrate on more professional tasks such as counseling, clinical examination and prescription of appropriate measures.

[ii] Feikin DR, Nguyen LM, Adazu K, Ombok M, et al., The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. [ii] Trop Med Int Health. 2009 Jan; 14(1):54-61. Epub 2008 Nov 14.

[iii] The Machakos Project (1981-1994) was supported by the Special Progranune of Research in Human Reproduction, WHO/HRP, WHO, Geneva, the Population Council, New York, the Rockefeller Foundation and the Ministry of Health, Kenya.

[iv] The objective of Community Strategy is to enhance access to and use of health services at community level The Strategy is described in “A Strategy for the Delivery of Level One Services” (MOH, June 2006).

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