Can Kenya make the “youth bulge” a source of strength, not a threat?

Population momentum: Fertility rates fall, but global population explosion goes on

The reality of falling fertility rates while global ‘population explosion’ goes on is depicted in the Figure above. The relentless growth in population might seem paradoxical given that the world’s average birth-rate has been slowly falling for decades. Humanity’s numbers continue to climb because of what scientists call population momentum. As a result of unchecked fertility in decades past, coupled with reduced child mortality, many people are now in their prime reproductive years, making even modest rates of fertility yield huge population increases. This according to John Bongaarts of Population Council in New York translates to adding more than 70 million people to the planet every year, which has been happening since the 1970s. The African continent is expected to double in population by the middle of this century, adding 1 billion people despite the ravages of AIDS and malnutrition.

What does this augur for Kenya? The 2009 Population & Housing Census suggested that Kenya’s population had increased by close to one million people annually over the period 1999 – 2009, equivalent to at least two children being born in Kenya every minute. Reacting to these findings, the HonMinister of State for Planning, National Development and Vision 2030, stated: “This high rate of population growth has adverse effects on spending in infrastructure, health, education, environment, water and other social and economic sectors. In order for the Government to achieve Vision 2030 goals, there is need to invest in education to meet the demands of the growing school age population and the demand for future manpower. In addition, critical investment will be required in family planning services, health and other social and economic sectors to improve the welfare of Kenyans.”

Kenya’s Total Fertility Rate (TFR) estimated at 8.1 in 1977/78 declined to 4.6 children per woman by 2008/9 (KDHS 2008/9). This drop was largely attributed to increased practice of modern contraceptive methods over the time, and improved educational status of women. The contraceptive prevalence rate (all methods) rose sharply since the early 1980s; rising from 17% in 1984 to 33% in 1993 and to 39% of married women in 1998 and 46 percent in 2008/9.

Kenya’s population growth rate increased steadily from 2.5 percent in 1948, peaking at 3.8 percent in 1979, this being one of the highest growth rates ever recorded. Demographic transition began to manifest in 1989, when population growth rate declined to 3.4 percent and further to 2.5 percent in 1999, but estimated at a higher level of 2.9 per cent in 2009. Owing to the past growth rates Kenya’s population is still youthful with nearly half being aged 18 years or below. This is a clear demonstration of demographic momentum- a phenomenon of continued population increase despite reducing fertility rates, which is brought about by waves of large populations of young persons entering reproductive age in successive years. This may in part explain the addition of one million people annually to Kenya’s population referred to above, contributing to the “youth bulge”.

I have in a previous post asked “Can Kenya make the “youth bulge” a source of strength not a threat?”  Indeed, this can happen, with better planning and viable economic policies that mobilise the potential of every corner of this nation. Current investments on family planning (including the proposed Joint Global Birth Control Push), are not expected to translate into slowing of population growth rate in the short or medium terms, but should be viewed as a long-term goal. On the other hand such investments will empower women and men or couples as the case may be, with the choice when to have children and how many to have. This will lead to healthier families, and more productivity. Strengthening of institutions and equitable investment of resources can unleash a strong and better-educated workforce with fewer children to support and no elderly parents totally dependent on them.

In such a scenario, the “youth bulge”,generated by our recent demographic history and fertility decline through effective fertility regulation measures, could transform to the driving force behind economic prosperity in future decades.

UPDATE 06-10-2012: Recently Kenya’s Minister of State for Planning, National Development and Vision 2030 confirmed Government’s commitment to FP and the belief that no woman should die while giving birth to life. On October 2, 2012 Kenya’s Parliament approved the Sessional Paper No. 3 of 2012 on Population Policy for National Development which has (among others) the objective of lowering the TFR to 2.6.

Barriers to enjoyment of health as a human right in Africa

The full enjoyment of the ‘Right to Health’ in most African countries is constrained by several pervasive barriers that are the subject of the current review, which urges that governments urgently adopt human rights based approaches to all health interventions in order to ensure equitable distribution of health resources throughout all sections of communities.

The Concept of Health as a Human Right: Health is a basic need for human existence and survival and as such, it is a right that must be respected, promoted and protected by government and society. The Universal Declaration of Human Rights states that “Everyone has the right to a standard of living adequate for health and well-being of himself and his family”. The concept of health as human right is stated in the Preamble of the World Health Organization’s Charter (1946), and also in the International Covenant on Economic, Social and Cultural Rights (1966). Art. 12 states of health as a human right: “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The Declaration of Alma Ata (WHO, 1978) stated: “Health, which is the state of complete physical and social well-being, and not merely the absence of infirmity, is a fundamental human right…. the attainment of the highest possible level of health is a most important worldwide social goal.” The right to health is fundamental to the physical and mental well-being of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of an adequate standard of living. Indeed health is fundamental to enjoyment of the right to life, and the right to a healthy life is fundamental to all other constitutional guarantees.

Right to Health is a Constitutional Issue Besides the South African Constitution[i], the Constitution of Kenya (2010), which was promulgated in August 2010, is among the most progressive constitutions in Africa. It provides for the right to health care services. Article 43(1)(a) in the chapter on Bill of Rights states that every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care, and in Article 43(2), that a person shall not be denied emergency medical treatment. Further, Article 27(2) guarantees equality and freedom from discrimination, and the full and equal enjoyment of all rights and fundamental freedoms. The Constitution obligates the government to take legislative, policy and other measures to achieve the progressive realization of the rights as guaranteed in the Constitution, including the right to health. The Right to Equality encompasses within itself the right of a poor patient to quality health care, regardless of their ability to pay.

Right to reproductive health care services: The concept of reproductive rights as a fundamental human right was endorsed at the 1994 International Conference of Population and Development in Cairo, Egypt. The constellation of rights, embracing fundamental human rights established by earlier treaties, was reaffirmed at the 1995 Fourth World Conference on Women in Beijing, China, and in various international and regional agreements since, as well as in many national laws. They include the right to decide the number, timing and spacing of children, the right to voluntarily marry and establish a family, and the right to the highest attainable standard of health, among others.

That reproductive rights are central to meeting international development goals was recognized by the UN World Summit of September 2005, which also endorsed the goal of universal access to reproductive health. Reproductive rights are recognized as valuable ends in themselves, and essential to the enjoyment of other fundamental rights. Attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.

Right to reproductive health care services is explicitly recognised in the Constitution of Kenya (2010), just as it is recognized or implied in several international and regional instruments (see above), including the United Nations Millennium Development Goals (2000); the Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009).

Barriers to enjoyment of Right to Health

1. General issues

Enjoyment of right to health in Africa, besides the inadequate financing of the health sector (see below), is indirectly constrained by several factors that operate at the regional and national levels, and mostly outside the mandate of the health sector. These include poverty, food insecurity and hunger, persistent violent conflicts and displacement of persons, heavy disease burden especially due to HIV and AIDS, and the pervasive gender-based negative traditions such as early marriage, female circumcision and lack of women’s empowerment all of which have profound effects on reproductive health outcomes.

2. Inadequate Funding to Health sector

Many governments in Africa have yet to recognise the importance of health in the overall national development, and expenditure on health is not adequately perceived as a critical economic investment alongside spending on education, agriculture or industries. Health is a critical resource for development, without which investment in all other sectors would go to waste. Poor health impacts negatively on economic productivity, through loss of labour, and under-performance due to illness. Poor health creates critical barriers to any measures intended to uplift the social wellbeing of poor and disadvantaged communities.

The levels of health budgets in most African countries do not demonstrate that health is rated as a high priority among other national needs. Despite the fact that in 2001 African countries pledged in Abuja, to increase health sector budgetary allocation to 15% of government expenditure, and although they repeated this pledge in Kampala in July 2010, in most countries national budgetary allocations for health remain far below this target. A 2007 report of the Regional Network for Equity in Health in East and Southern Africa (EQUINET)[ii] which looked into the progress made in various Southern and East African countries towards achieving the Abuja target, showed that with few exceptions most of the countries were still lagging far behind this target seven years since the declaration.

In Kenya, for the fiscal year 2010-11 just about 5.5 percent of the total Government expenditure was allocated to the ministries of Medical Services and Public Health and Sanitation. This translates to less than $1 per capita expenditure, against the recommended figure of $34 which WHO recommends for effective implementation of health interventions.

Figure 1: Real gross expenditure to the health sector, compared to overall gross Kenya Government expenditure (2007/08 – 2011/12)[iii]

A concern of particular relevance to achieving MDG5 is the disproportionate allocation within the health budget to reproductive health care services. Africa Union’s Maputo Plan of Action for Universal Access to Comprehensive Sexual and Reproductive Health Services in Africa (2007-2010) recommended an increase in per capita expenditures to about 18-24% of the $34 per capita recognized by the WHO. However, in many countries the allocation remains much below these figures.

At the international level, global assistance for reproductive health including family planning, financing has fallen in all recipient countries. Figure 2 shows that whereas there has been a steady increase in overall assistance for health, the amount focused on reproductive health and family planning has remained more or less unchanged since the year 2000.

Figure 2: Total international assistance to health and allocation to reproductive health care programmes (2000-2009)

Source: The Millennium Development Goals Report 2011

 

3. Lack of Equity in Planning for health and distribution of resources resulting in inequitable Access to Health Care services:

Physical access to services (distance to nearest Health Facility): Health care utilization is known to be greatly negatively impacted by distance to health care facilities and access to means of transportation. A study[iv] in western Kenya which explored the impact of distance on utilisation of sick child services in rural health facilities established that for every 1 km increase in distance of residence from a clinic, the rate of clinic visits decreased by 34% from the previous kilometer. According to the Kenya National Bureau of Statistics[v], on average only 6.4 percent of people in Kenya can reach a health facility within one kilometre of their residence; nearly a half (47.7%) of the people have to travel 5km or further to reach the nearest health facility, with marked regional variations (Table 1).

 

Figure 3: Proportion of community that has to travel 5km or more to the nearest health facility in Kenya

(Source: The Kenya Integrated Household Budget Survey (KIHBS) 2005/06).

For example, the proportion of people who live 5km or further from the nearest health facility ranges from 20% and 29% respectively in Nairobi and Central regions to 60%, 64% and 86% respectively in Coast, Eastern and North Eastern regions. The geographical dimension must be taken into consideration when planning health care interventions, especially when targeting socio-economically disadvantaged groups.

Affordability of services: Big disparities exist between the poor and the better off with respect to access to health care services which explains the wide gaps in health outcomes not only between rich and poor countries, but also between the wealthy and the poor in most countries. Generally, the poor lack access to health care in terms of: availability, affordability, and acceptability. Poor people are denied access to health care: (a) where public health facilities lack essential drugs, supplies and commodities; (b) where people have to travel long distances to reach health facilities, especially where public transport is scarce; (c) when fees charged for services (cost-sharing) are unaffordable, and even if there is official exemption (e.g. for pregnant women and children under five) or waiver of fees, people still end up paying on top, for drugs and transport (out-of-pocket expenditure); and (d) where people lack confidence in the services provided at local public health facilities and decide not to utilise them (e.g. poor quality services or negative provider attitudes).

The poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care. In Kenya, data from the National Health Accounts (NHA) for fiscal year 2001/2002 showed that Kenyan households were financing over half of all health expenditures[vi], clearly justifying a conclusion that ill-health contributes to, and perpetuates, poverty because health costs deplete people’s meagre resources. In addition, there is considerable evidence to suggest that by and large public spending on health tends to benefit the better off more than the poor. Quite often it is the better off who get the most from public health services, especially hospital care. In other words, government’s investment in health services, far from promoting equity, works against it[vii].

FY 2001/2002 National Health Accounts (NHA) estimation in Kenya

Inadequate financing of the health sector and inequitable distribution of resources explain the major gaps and disparities in health indicators in most African countries, which have featured repeatedly in successive surveys such as the Demographic and Health Survey (DHS). It is important to realise that because of the size of the poorest population, countries cannot hope to achieve health-related MDGs without urgent implementation of inclusive policies in the planning of health interventions.

Addressing barriers to enjoyment of right to health

Governments must strive to address the pervasive barriers to enjoyment of right to health (including sexual and reproductive health) by all citizens by implementing human rights based approach to all interventions aimed at improving the health of the community. This will empower people to participate in decision making and health policy development, as well as strengthening their capacity to hold the health managers and providers accountable. Ministries of Health should work out clear strategies that seek to make health services inclusively available and accessible, of good quality, affordable and culturally acceptable. It is particularly important to adopt evidence-based planning which should ensure equitable distribution of health resources throughout all sections of communities.

Governments in Africa urgently need to recognise the importance of health in the overall national development, and support it by making appropriate budgetary allocation to the health sector along other critical economic investments. In addition, the international community also needs to examine their funding policies over the last decade or so, which have resulted in stagnation of financing of reproductive health especially family planning programmes.

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[i] www.righttohealthcare.org/Intl/SAfr.htm

[ii] Equinet (2007). Reclaiming the Resources for Health: A regional analysis of equity in health in East and Southern Africa. Fountain Publishers Kampala, Uganda.

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

[iv] Feikin DR, Nguyen LM, Adazu K, et al., The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. Trop Med Int Health. 2009 Jan;14(1):54-61. Epub 2008 Nov 14. http://www.ncbi.nlm.nih.gov/pubmed/19021892

[v] Kenya National Bureau of Statistics (KIHBS) BASIC REPORT – www.knbs.or.ke/pdf/Basic%20Report%20(Revised%20Edition).pdf

[vi] www.who.int/entity/nha/country/Kenya_NHA%202002.pdf; Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

[vii] Davidson R. Gwatkin (2003) Free Government Health Services: Are They the Best Way to Reach the Poor?

Factors contributing to Africa’s failure in achieving MDG5 by Japheth Mati

ABSTRACT[1]

The latest UN Report on MDGs reveals considerable reductions in maternal mortality in most regions of the world except in the sub-Saharan Africa where, despite progress having accelerated since 2000, very high maternal mortality ratios and low rates of access to universal reproductive health services, still persist. This discussion highlights several challenges that operate both at the regional and country levels. The challenges at the regional level include poverty, food insecurity, persistent violent conflicts, inadequate budgetary allocation to health sector, and heavy disease burden. At the country level are the persistent inequalities in access to health care both between countries and within individual countries. A review of the status of MDG 5 indicators particularly focusing on the known drivers of maternal mortality reductions shows that most SSA countries fall far below the targets, to the extent that they are least likely to achieve this goal by 2015. Successive national surveys show disparities which relate to wealth status and area of residence, both reflecting a lack of equitable distribution of health services. Two key challenges stand in the way of addressing these inequalities- improving human resources for health, and strengthening health systems. A critical cross-cutting determinant for both is the proportion of national budgets allocated to reproductive health services. In addition, donor-dictated policies of budgetary ceilings on certain expenditures, including hiring of health professionals, constitute another obstacle. Finally, SSA countries are particularly adversely affected by the drop in international aid towards reproductive health, and especially the financing of family planning programmes.

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[1] Abstract of an invited presentation at the FIGO World Congress October 7 – 12, 2012

 

How the world’s population jumped from 3 to 7 billion in my lifetime

Japheth Mati

When on 31 October 2011 the earth’s population clocked seven billion people, this happened to be only 12 years after we had celebrated the sixth billion. So I started to wonder where I was in the complex arithmetic, realising that while it had taken 123 years to change numbers from the first to the second billion, the increase from the fifth to the seven billion people had taken just 24 years. I started thinking how many billions I had in fact ‘seen’, and who in my foggy past might have existed before the clocking of the first billion. This short history is summarised in the accompanying table, which shows that whereas my predecessors counted in the first and second billion, in my short life I have been counted within six consecutive billions- from the second up to the seventh billion; and God willing, I might also spill to the eighth billion. In my lifetime, I have witnessed the earth’s population almost triple.

Table: Population growth from 1 to 7 billions 1804-2011

(Source: The State of World Population 2011)

Around the beginning of the first millennium the world’s population was about 300 million, and it would take more than 1,600 years for the world population to double to 600 million. The rapid growth of the world population is a recent phenomenon, which started around 1950, as a result of significant reductions in mortality thanks to emerging medical technologies. By the years 2000 the world population had reached an estimated 6.1 billion, which was nearly two-and-a-half times, the population in 1950. The highest global population growth rate (2.0 per cent) was recorded in the period1965-1970, in Kenya, reaching the high of 3.8% in 1979.

As Professor Babatunde Osotimehin, Executive Director, UNFPA states in the Foreword to the SOWP 2011, how we became so many, and how large a number our Earth can sustain may be important questions, “but perhaps not the right ones for our times”. “When we look only at the big number, we risk being overwhelmed and losing sight of new opportunities to make life better for everyone in the future”. Instead, we should be asking what we can do to make our world better, to transform our growing populations into forces for sustainability by empowering and removing barriers to equality between women and men, and in particular, what we can do “to unleash the creativity and potential of the largest youth cohort humanity has ever seen”

I have in a previous post asked Can we make the “youth bulge” a source of strength not a threat? Indeed, this can happen, with better planning and viable economic policies that mobilise the potential of every corner of this nation. Strengthening of institutions and equitable investment of resources can unleash a strong and better-educated workforce with fewer children to support and no elderly parents totally dependent on them. In such a scenario, the “youth bulge”, generated by our recent demographic history and fertility decline through effective fertility regulation measures, could transform to the driving force behind economic prosperity in future decades.

 

Unsafe Abortion on the increase in Africa, a new WHO Report reveals.

Unsafe abortion as a significant contributor to the persistently high maternal mortality rates in Kenya and other sub-Saharan Africa in general, has been highlighted in several earlier posts. Sadly, a WHO report in conjunction with the Guttmacher Institute published today in the Lancet (on 19^th January, 2012), shows that rather than abating, unsafe abortion rates are still rising, this being particularly the case in sub-regions where access to safe abortion is restricted. While worldwide, 49% of all abortions were unsafe in 2008, in Africa, nearly all abortions (97%) were unsafe. The report confirms that restrictive abortion laws do not translate to lower abortion rates, and that unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion. These are crucial steps toward achieving the Millennium Development Goal 5 in countries such as Kenya.

 

Read more on unsafe abortion…

•  The Status of Maternal Health and Unsafe Abortion in Kenya
• Women have the right to safe abortion services within the law
• Focus on providing safe abortion services, not post-abortion care.
• Champions are Urgently Needed for Accelerated Reduction of Maternal Mortality in Africa
• How Kenya’s New Constitution is likely to impact on access to safe abortion services
• A commentary on Unsafe Abortion in Africa

Do HIV infected women in Kenya have the guaranteed right to free choice contraception?

Government’s commitment to voluntary and free-choice family planning practices comes to question as Kenyan HIV infected women continue being coerced to use the IUCD. The Citizen TV on November 22, 2011 ran a story[1] about a widow in Mbita who has benefited from a fish farming venture supported by a grant from an American based non-governmental organisation. The sole qualification she needed to qualify for the grant was to be HIV positive and willing to be fitted with an intrauterine contraceptive device (IUCD). It is probable that this poor widow had no choice but to accept the condition- she needed help to support her family and, to that end, would take considerable risk. The question here is whether she had any choice in embarking on this method of family planning? Is it fair to assume she was in fact coerced to accept an IUCD by the grant of much needed cash?  What is the position of the Kenya Government on the matter?

Cash for contraception? Photo: Edgar Mwakaba/IRIN

According to Prof Peter Anyang’ Nyong’o, Minister for Medical Services, family planning practice should be voluntary[1]. Service providers must educate clients on the range of choices available, and let them choose that which suits them best. “But to flash money and say take this – no, that is not how to do it!” he added. However, it is not clear what the Minister has done to arrest the coercive practices.

Coerced sterilization of HIV-positive women came to light in 2007 when 13 cases were documented in Namibia^[2]. Shortly afterwards there were reports of HIV-positive women in Kenya being paid money to accept long-term contraceptive methods, particularly IUCD^[3]. These activities in Kenya (which include the case in point) are supported by Project Prevention, an American NGO founded in 1997 which also pays female drug users in the U.S. and UK to be sterilized. Whereas HIV-positive women do have a legitimate need for FP services, like every other woman they are entitled to exercise choice free of coercion or manipulation through incentives. Use of incentives and disincentives to pressure poor people to be sterilized was rejected at both the 1994 International Conference on Population and Development (ICPD) in Cairo, and the 1995 Fourth World Conference on Women in Beijing. In particular, the Beijing Platform for Action states clearly that “The human rights of women include their right to ….decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence”.

Coercion for sterilisation through incentives reached its peak in India during the rule of Prime Minister Indira Gandhi, with her government’s policy of sterilising (vasectomy) millions of Indian men who had fathered two or more children, being compensated with a transistor radio! This policy was ruthlessly and often illegally applied to the extent it came to symbolize the dangers of authoritarian rule[4]. It is notable that payment for sterilisation continues in India to this very day; for example, a medical college was recently reported to pay men that opt for non-scalpel vasectomy 1,100 Indian Rupees[5]. In Uttar Pradesh, to obtain a shotgun licence requires two people being sterilised; for a revolver licence, the price would be five. Wealthy farmers have managed to stock their armory through forcible sterilization of their poor farm hands![6]

Proponents of coerced contraception are usually driven by the wish to create an HIV-free tomorrow by preventing birth of children infected by their mothers. It is known that in Africa before the advent of antiretroviral drugs up to 40 percent of children born to HIV infected mothers were also infected. However, in Kenya, there has been an increasing access to services for prevention of mother-to-child HIV transmission (PMTCT), most often offered at antenatal clinics and at delivery. According to the Kenya Service Provision Assessment Survey of 2010, 58% of all health facilities nationwide offered some component of PMTCT services, with 33% of these facilities providing all four components for the minimum PMTCT package (HIV testing with pre- and post-test counseling, ARV prophylaxis for mother and newborn, counseling on infant feeding, and FP counseling or referral). This is increasingly reducing the incidence of perinatal transmission as well as rates of mortality among infected children. Accumulated evidence to date shows that administration of antiretroviral therapy to the mother during pregnancy, labour and delivery, and then to the newborn, as well as delivery by Caesarean section for women with high viral loads, can reduce the rate of perinatal HIV transmission to well below 10 percent[7]. What this means is that despite the many challenges not addressed here, it is possible to dream of an HIV-free generation without having to resort to cruel acts of forced contraception for HIV infected persons. Indeed this was the view expressed by UNAIDS Executive Director Michel Sidibé, during a visit to a Millennium Villages Projects (MVP) in Kenya: “We have seen that it is possible to virtually eliminate infant HIV infections in high-income countries ….Now we must apply the knowledge and tools to create an AIDS-free generation in Africa and the rest of the world.”[8]

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[1]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[2] Mallet J, Kalambi V. HIV AIDS Policy Law Rev. 2008 Dec;13(2-3):77-8. http://www.ncbi.nlm.nih.gov/pubmed/19297769 accessed October 22 2011

[3]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[4] “The World: The Issue that Inflamed India” Lawrence Malkin, TIME New Delhi Bureau Chief, Monday, Apr. 04, 1977

[5] Team to probe forced sterilisation charge Express News Service

http://www.indianexpress.com/news/team-to-probe-forced-sterilisation-

[6] Outrage at guns for sterilisation policy, Indian farmers given firearms licences as an incentive to curb population growth. Randeep Ramesh in Lakhimpur The Guardian, Monday 1 November 2004 23.56 GMT http://www.guardian.co.uk/world/2004/nov/01/india.randeepramesh

[7]http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets/perinatal.htm

[8] http://www.avert.org/pmtct-hiv.htm

Forgetting Them Is Not An Option

Is it possible to achieve the health related MDGs without a special focus on the health status of the poor, the marginalized and the hard-to reach in Kenya?

The Government of Kenya being signatory to the Millennium Declaration is obliged to put in place measures for achievement of the Millennium Development Goals (MDGs). While only three of the eight MDGs relate directly to health, all others have important direct effects on health considering the interrelationship between health and development in general. The core health MDGs are Reducing Child Mortality (MDG4), Improve Maternal Health (MDG5), and Combat HIV/AIDS, Malaria and other Diseases (MDG6).

Achieving the health related Millennium Development Goals (MDGs) will not be possible without a special focus on the health status of the poor, the marginalized and the hard-to reach in Kenya. This post examines the evidence to support this position utilising findings from the 2008-9 Kenya Demographic and Health Survey (KDHS), with regard to the following selected indicators: Under-five mortality rate (MDG4.1); Percent births attended by skilled attendant (MDG5.2); Contraceptive prevalence rate (MDG5.3); and Unmet need for family planning (MDG5.6).

Analysis of the data on the various health indicators shows vast disparities exist based on socio-economic status and the area of residence (see Table 1). These disparities have persisted in results of successive national surveys over the last three decades. Generally, the national average statistic is used in reports regarding achievement of goals (national or international). However, such data is not particularly useful when it comes to designing interventions to improve on the health indicators, since it fails to direct attention to where greatest need for intervention exists.

Under-5 Mortality Rate (MDG4.1): Nationally there has been significant improvement in child survival in the last decade which could be attributed at least in part to childhood immunization coverage and malaria prevention interventions. However, analysis of the data by region shows there are areas in this country where child mortality rates remain very high. Whereas there was a 28 percent reduction in under-five mortality rate in Nyanza from 206 deaths per 1,000 reported in 2003 to 149 deaths per 1,000 in 2008/9, the region remains the place with the highest child mortality rate in Kenya. Almost one in seven children in Nyanza dies before attaining his or her fifth birthday, compared with one in 20 children in Central province (51 deaths per 1,000), which has the lowest rate. The risk of dying before age five is almost three times higher in Nyanza than in Central province.

The other variables shown in Table 1 which influence child survival are mother’s level of education and household wealth status. Under-five mortality is noticeably lower for children whose mothers either completed primary school (68 deaths per 1,000 live births) or attended secondary school (59 deaths per 1,000 live births) than among those whose mothers have no education (86 deaths per 1,000 live births). However, under-five mortality is highest among children whose mothers have incomplete primary education. Similar patterns are observed for infant mortality levels (not shown). Child mortality rates generally decline as the wealth quintile increases, though the pattern is not uniform.

Skilled attendance at delivery (MDG5.2): The policy of the Ministry of Health as stated in the National Reproductive Health Policy (2007) is that all women should have access to skilled attendance throughout the continuum of pregnancy, childbirth and postpartum periods, and that the Traditional Birth Attendant (TBA) is no longer recognised as a skilled attendant. Overall, the data shows that only 44 percent of births in Kenya are delivered under the supervision of a skilled birth attendant, usually a nurse or midwife, and that TBAs continue to play a vital role in providing delivery services. Almost 28 percent of births were assisted by TBAs, the same percentage as were assisted by nurses and midwives. As expected, births in urban areas and births to mothers who have more education or wealth are more likely to be assisted by medical personnel than are those births to mothers who reside in rural areas or who have less education or wealth. Regional differentials in type of assistance at delivery are also pronounced, with Western province recording the lowest proportion (26 percent) of births assisted by medical professionals, followed by North Eastern province (32 percent). Nairobi has the highest proportion of births assisted by medical personnel (89 percent).

Contraceptive Prevalence Rate (MDG5.3): Married women in urban areas are more likely to use a contraceptive (53 percent) than their rural counterparts (43 percent). Contraceptive use increases dramatically with increasing level of education. Use of any contraceptive methods rises from 20 percent among married women in the lowest wealth quintile to 57 percent among those in the fourth wealth quintile, and then drops off slightly for those in the highest wealth quintile. The North Eastern Province had the lowest CPR of 4 percent.

Unmet need for FP (MDG5.6): Levels of unmet need for family planning remain high among Kenyan women, with nearly a quarter (26%) of currently married women indicating that they have unmet need for family planning. Unmet need for family planning is higher in rural areas (27 percent) than in urban areas (20 percent). Nyanza province has the highest percentage of married women with an unmet need for family planning (32 percent), followed by Rift Valley province (31 percent), while Nairobi, North Eastern, and Central provinces have the lowest unmet need at 15-16 percent. Married women with incomplete primary education have the highest unmet need for family planning (33 percent) compared with those with completed primary education (27 percent), no education (26 percent), and secondary and higher education (17 percent). Unmet need declines steadily as wealth increases, from 38 percent of married women in the lowest quintile to 19 percent of those in the highest quintile.

What we learn from these findings in KDHS is that vast disparities persist according to spatial distribution and socio-economic strata of the populations; this implies that we cannot achieve health related MDGs without bringing on board all including the poor and marginalized groups. Forgetting them is not an option! The GOK needs to openly recognise that achievement of MDGs will remain an illusion so long as current disparities in access to health care persist. There needs to be concordance between policy statements of equity and practice; commensurate allocation according to need. Hopefully the devolved county governments will make use of disaggregated data in their planning and budgetary processes, and ensure equitable access to health care for all.

My considered view on the new Africa based study published in the Lancet linking hormonal contraception for women to increased HIV infection risk

A research report published in the Lancet on 4^th October 2011 has provoked widespread fear throughout the world. This multicentre study involving in seven African countries: Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zimbabwe, has shown increased risk of HIV infection to women who used hormonal contraceptives– particularly injectable methods like Depo Provera, as well as to male partners among discordant couples. The global concern is due to the fact that there are more than 140 million women worldwide using hormonal contraceptive methods. In most African countries, Kenya included, the injectable contraceptive is the most widely preferred method. The Kenya Demographic and Health Survey (2008-9) showed that more than a half (22%) of the 39% of Kenyan married women using a modern contraceptive method relied on Depo provera.

Three points are worth emphasizing. First, generally, hormonal contraceptives are safe and effective family planning methods that are central to initiatives to reduce unintended pregnancies, empower women, promote economic development, and improve maternal and child health.  Family planning has a key role to play in the attainment of Millennium Development Goals.

Second, there is no such thing as a contraceptive that is 100% safe and, in fact, contraceptive practice is associated with a variety of risks, depending on the method used. This is why family planning service providers have a responsibility to assess the risk to clients of developing method-associated complications (side effects), depending on the health history and the nature of the method chosen. It is important that all clients seeking family planning services should be assessed with regard to their risk of STIs including HIV/AIDS, remembering that all persons at risk of getting infected with an STI are also at risk of getting infected with HIV. It must be realized that HIV/ AIDS is largely a sexually transmitted disease.

The third point to emphasize is that whereas hormonal contraceptive methods are extremely effective in preventing pregnancy they do not prevent infection with STIs including HIV. On the other hand, proper and consistent use of condoms (male and female) is an effective way of preventing most STIs, including HIV. This is why family planning service providers should promote dual protection- the use of condoms for clients who are at risk of acquiring STIs even when they are using other methods of family planning methods.

In Kenya, the above points are emphasized in the Fourth (2009) Revised Edition of Family Planning Guidelines for Service Providers published by the Division of Reproductive Health, Ministry of Health, which is updated from time to time to incorporate evolving research evidence. It is guided by a WHO Scientific Working Group which periodically reviews the latest scientific information on safety of contraceptive methods, and makes recommendations on criteria for their use in different situations (WHO Medical Eligibility Criteria).

Hormonal contraception and HIV risk

A new study published in the Lancet suggests that use of hormonal contraception doubles HIV risk to the woman as well as to her discordant male partner. Read more 

The Status of Maternal Health and Unsafe Abortion in Kenya

Unsafe abortion is a public health concern;

• In order to achieve MDG 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed.
• Unsafe abortion is an important contributor to the high maternal mortality rates in Kenya
• Granted unsafe abortion is simply one of several contributors to MMR, BUT it is one we know how to prevent- an important public health principle
• Incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in any particular community.
• Unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

Read more on the  Status of Maternal Health and Unsafe Abortion in Kenya