Category Archives: Health financing

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.


[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?

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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.


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

 

Lack of concurrence between policy and practice is a serious blow to achievement of MDG5 in Kenya

What holds Kenya back in its efforts to achieve MDG 5 is staring us in the face. We just need to look and see the many areas of non-concurrence between policy and practice, for example, while on the one hand the policy is that of equitable access to RH services, in practice on the other hand, many Kenyans, especially those living in marginalized far-flung areas, have nothing close to equitable access to such RH services. This also applies to the poor irrespective of where they reside.

Among the earlier posts by Africa Health Dialogue there was one entitled “What’s in the way of achieving improved maternal health in Kenya?” in which three key barriers to attainment of improved maternal health in Kenya were discussed: the lack of equity in health planning and implementation; inadequacy of funding to the health sector; and inequitable distribution of resources for health especially financial and human resources.

Since the publication of that post, a lot has changed: first, the urgency of the matter in consideration is much greater now- there is much less time left to 2015; secondly, Kenya now has a Constitution that is specific in its provision of health as a basic right. Article 43 (1) (a) states:  “Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”. The constitution is not saying that only the urban rich and those living in the more accessible counties have the right to the “highest attainable standard of health”. No, it is all Kenyans, wherever they may be!

In addition, we also have a National Reproductive Health Policy (2007) with its stated goal of enhancing the RH status of all Kenyans by (among others) increasing equitable access to RH services and improving responsiveness to client needs. According to the Policy all pregnant women should have access to skilled care throughout the continuum of pregnancy, childbirth and postnatal periods. Skilled attendance implies access to appropriately trained health providers whether in a health facility or through domiciliary care. It also implies access to a rapid means of referral to a higher level of care in case of an emergency. In consideration of the above, at least three questions immediately arise: (a) to what extent are maternal health services equitable; (b) are the current health interventions responsive to client needs and (c) how accessible is skilled attendance by all pregnant women in Kenya?

Review of maternal health indicators as published in successive national surveys, such as the Kenya Demographic and Health Survey (KDHS) and the Kenya Service Provision Assessment Survey (KSPA), shows that health services are far from being equitably distributed in Kenya. Women from the more marginal areas which are lacking in communication infrastructure, especially roads, and those who are in the lower socio-economic strata, are all grossly disadvantaged. In fact, these are the women who register the worst maternal health indicators (whether it be maternal mortality ratio, contraceptive prevalence rate, total fertility rate, attendance by a skilled health professional; or availability and quality of antenatal and delivery services in local health facilities, etc. etc. Unfortunately, forgetting them is not an option; Kenya will never achieve MDG5 without their contribution! That’s the way it is.

In many parts of Kenya it’s nightmarish ferrying a woman in labour to a health facility.

CASE STUDY: The following narrative is based on a true event which took place in eastern part of Mwingi in the Kitui County:

Kavata was a married mother of three, all normal deliveries at home assisted by a TBA from the neighbourhood. During her fourth pregnancy she had attended an antenatal clinic at a dispensary, beginning from the sixth month. She made a total of three antenatal clinic visits before she went into labour. At the clinic she had been advised that even though her pregnancy was progressing satisfactorily, she needed to ensure that this time round she delivered at a health centre because of her history of heavy bleeding during her last delivery. The health centre, located about 15km from her home, had only one qualified midwife, who also had other duties apart from midwifery.

Kavata went in labour at night but could not get to the health centre at that hour; the only matatu in the area made the trip twice a day, early in the morning and early in the afternoon. Walking at that time was out of the question for fear of marauding wild animals and muggers in the area. So, at 6am next day she was in the matatus heading for the health centre where she arrived at 9am. However, she could not be admitted immediately to the maternity ward because the midwife had not reported to work until 10am.

By 2pm the midwife observing that labour was not progressing normally radioed the District Hospital located about 80km away, requesting for an ambulance to transfer the patient for more specialized care. This was not possible – the only functional land rover at the hospital had travelled to Nairobi to fetch supplies. Now the only transport option available at that time for Kavata was a ride at the back of a lorry, perched on top of cowpea bags. The lorry made several stops collecting more bags on the way. By the time Kavata arrived at the District Hospital her uterus had already ruptured and she had bled profusely. Her baby had already died; she too died before anything could be done to save her life.

The big question is “Was Kavata and the many other women who are continually going her way, also expected to enjoy the “right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”? Is there concurrence between policy and practice: on the one hand the policy is that of equitable access to RH services, but on the other hand, in practice people like the late Kavata and many others have nothing close to equitable access to such services?

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.

Kenya Parliament passes motion calling for free cancer treatment but fails to point out simultaneously the deficient budgetary allocation to the public health sector.

Parliament recently passed a motion compelling the Government to make cancer treatment free for all Kenyans. This must come as a relief to thousands of Kenyans who are suffering now or in the future, from cancer but are unable to access treatment due to prohibitive costs. The cost of treatment for cancer in the public sector is beyond reach of majority of Kenyans.

A closer look at the contents of the motion presented by Member for Kandara, Hon James Maina Kamau, to the National Assembly on 1st September, 2011, brings out clearly the pathetic status regarding cancer in Kenya:

  •  82,000 new cancer cases are reported every year; [this being only tip of the iceberg];
  • An estimated 18,000 Kenyans die annually due to various cancers;
  • Most cancers are treatable when diagnosed early;
  • Availability and use of advanced technology is essential to early diagnosis and treatment of cancer;
  • Kenya lacks a national policy on cancer, cancer control law and national cancer strategy;
  • Diagnosis of cancer for majority of Kenyans is equivalent to receiving a death sentence owing to lack of access to facilities for proper treatment;
  • High and forbidding cost of cancer treatment is the ultimate barrier to accessing cancer treatment in Kenya.

However, what is clearly missing from the praiseworthy motion is an acknowledgement of the inadequacy of public investment towards minimizing cancer related suffering and deaths among Kenyans, despite the fact that Medical Services Minister Anyang’ Nyong’o admitted that under-funding constrained provision of services . In endorsing free cancer treatment MPs ought to have simultaneously demanded the immediate increase in budgetary allocation to the health sector, which can provide for meaningful free services as called for in the motion.

The world needs 350 000 additional midwives; what of Kenya?

The State of World’s Midwifery 2011, launched in June 2011 by the United Nations Population Fund (UNFPA), reminds us that the greatest “crisis in human resources for health” exists where the need is greatest, in countries which not only accounted for 58 percent of world’s total births (81 million) in 2009, but also accounted for 91 percent of all maternal mortality, and 80-82 percent of global stillbirths and newborn mortality. More importantly, this report confirms that some 350,000 additional skilled midwives are needed to fully meet the needs of women around the world. Increasing women’s access to quality midwifery services is crucial to the realization of the right of every woman to the best possible health care during pregnancy and childbirth. It should be seen as a key investment that is fundamental to reducing maternal and newborn mortality and morbidity, and attainment of MDG 5.

How does this apply to the situation in Kenya? Commenting on the state of midwifery in Kenya the Report observes, among other concerns, the shortages of staff that exist despite the difficulties of newly graduated midwives to find jobs. The Report concludes that for Kenya to make meaningful progress towards achieving MDG 5 appropriate employment and deployment of skilled midwives is essential. The density of the health care workforce is a known determinant of mortality rates for mothers, infants and children under five[i]. Earlier, in 2006 the World Health Organization had listed Kenya among 36 sub-Saharan African countries that were facing a critical shortage of heath care workers[ii].

 Whereas for many sub-Saharan African countries the shortage of health care workers is largely due to inadequate production, the problem in Kenya is of a different nature. The Nursing Council of Kenya (NCK) has accredited nearly 70 institutions for training of nurses and midwives at different professional levels, which collectively put out about 2,250 nurses annually. Kenya surely does have the capacity to meet its nurse workforce needs.

Clearly, by far the lead contributor to Kenya’s nurse workforce shortage is the lack of resources to hire nurses who have been trained at high cost. Factors such as out-migration (brain drain) are relatively less significant and largely fueled by poor deployment which interferes with effectiveness and job satisfaction among trained staff.

Unemployment for nurses in Kenya was something unknown before 1998 when hiring of new nurses was stopped under World Bank and IMF initiated policies. Up to 1996 all nurses were recruited into public service immediately on completing training. In recent past, recruitment supported by development partners under contractual arrangement has helped increase the staff complement, but most of these have been deployed in specific programmes mainly related to HIV and AIDS.

[i] Anand, S. and T. Barnighausen. 2004. “Human resources and health outcomes: cross-country econometric study.” Lancet364(9445): 1603-9. 

UPDATE November 25, 2011:

Speaking at the 54th Conference of the East, Central and Southern Africa Health Ministers which took place in Mombasa, Kenya, 21-25 November 2011, Vice President Stephen Kalonzo Musyoka announced that the Kenya Government is set to hire about 4,000 nurses and health technicians, including an additional 2,100 community health workers, all at a cost of Sh1 billion[1]. They will be distributed equitably throughout the country’s constituencies, and the money for the recruitment has been provided for in the current financial year.

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. http://www.ncbi.nlm.nih.gov/pubmed/19021892

[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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Addressing the barriers that impede timely achievement of MDG5 targets is urgently needed in Kenya

In order to accelerate progress towards the timely achievement of MDG5 governments must take urgent action to address key obstacles to the attainment of improved maternal health, especially among populations with the most unmet need.

Women have constitutional right to life and health, and therefore their right to quality reproductive health services, which ensure that every pregnancy is wanted; all pregnant women and their infants have access to skilled care; and that every woman is able to reach a functioning health facility to obtain appropriate care in the event of complications. Up to 75 percent of all maternal deaths can be averted if women received timely and appropriate medical care. We know the causes of these deaths and how they can be prevented.

Kenya has already put considerable effort to policy development and strategic planning with the aim of accelerating the attainment of health related MDGs, however, these are yet to translate to actual reduction in maternal deaths. Despite the recent observation of an upward trend in contraceptive prevalence rate (CPR), which raises hope that if it can be sustained, there may be possibility of attaining Target 5B of MDG5 by 2015, the country has neither registered any downward trend in maternal mortality ratio (MMR), neither is there any convincing evidence of an increase in the proportion of births attended by skilled health personnel (Target 5A).

However, successive surveys and other evidence show several serious obstacles remain which interfere with effectiveness of reproductive health interventions, and which must be addressed as a matter of urgency. These include the serious disparities which persist in reproductive health outcomes, especially in relation to area of residence and socio-economic status. Reproductive health indicators deteriorate as the socio-economic status declines and vice versa; so is the case as the distance from the main urban centres increases. Generally, the poor lack access to health care in terms of availability and affordability.

A key barrier is the weakness in health system[i]: health infrastructure, trained human resources, and efficient operating systems. Provision of reproductive health services cannot be considered in isolation, and generally, these services are strong where the health sector is strong, and vice versa. The leading cause of the weak health system is inadequate funding of the health sector. Effective service provision requires an adequate infrastructure, and human and material resources, and ultimately, adequate financial allocation. This is why it is disconcerting that Kenya Government’s allocation to the health sector continues to lag way below what was promised at Abuja in 2001 and in Kampala in 2010. For the fiscal year 2010-11 Kenya allocated just about 5.5 percent of the total Government expenditure to the ministries of Medical Services and Public Health and Sanitation, a level of investment that does not demonstrate high prioritization of maternal death prevention and reduction among the national priorities.

The MDGs are inter-related, so that achievement of MDG5 is closely tied to the progress made in several other goals, especially eradication of extreme poverty and hunger (Goal 1), universal primary education (Goal 2), promotion of gender equality and women empowerment (Goal 3), and combating HIV/AIDS, malaria and other diseases (Goal 6). Clearly, if the MDGs are to be achieved by 2015, not only must the level of financial investment be increased, there is need for a rapid scale up of more innovative programmes and policies which aim at overall development and economic and social transformation, nationwide.

It is thus imperative to implement a deliberate effort to target populations with the most need; these in most cases include urban and rural poor, the “hard to reach” groups and people with disabilities. In Kenya, most reproductive health indicators clearly portray big disparities between the poor and the ‘hard to reach’ on the one hand, and on the other, the urban better offs. Health planners must ensure that health needs peculiar to the ‘marginalised’ are factored in, and adequately addressed, in the planning of health services.

Finally, the Constitution of Kenya (2010) provides opportunities for enhancing health in general, including reproductive health and rights of Kenyan women. Article 43 (1)(a) states: Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care. In addition, Article 27 guarantees the right to equality and freedom from discrimination, which encompasses within itself the right of the poor and marginalised persons to adequate and quality health care.


[i] According to the World Health Organisation a health system comprises all structures, institutions and resources that are devoted to producing actions whose primary intent is to improve health.

It Makes Good Sense To Prioritise Health In Development

Many governments in Africa have not yet recognised the importance of health in the overall national development; consequently, they have not allocated commensurate resources to the health sector. The levels of health budgets in many of these 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 at 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 of these countries national budgetary allocations for health remain far below this target. For example, for the fiscal year 2010-11 Kenya allocated just about 5.5 percent of the total Government expenditure to the ministries of Medical Services and Public Health and Sanitation. As a result, out-of-pocket health expenditures in sub-Saharan African countries are generally high ranging from 6% in Namibia to 62% in Chad, and nearly 45% in Kenya. The implication of this is that ill health contributes significantly to, and perpetuates, poverty because health related costs result in the depletion of people’s meagre resources. Irrespective of where sick people seek treatment, be it in public or private health facilities, or private pharmacies and dukas, or even the herbalist, this is to a large extent dependent on their access to cash or household assets that can be sold in order to pay for the out-of-pocket health expenses.

Expenditure on health is not adequately perceived as a critical economic investment in the same way as is spending on education, agriculture or industries. In Africa, the biggest chunk of government expenditure is believed to go to security related expenses (military and civil defence), even in those countries that have not fought a serious war since independence. Despite the lack of absolute and valid correlation (whether positive or negative), between levels of defence spending and socio-economic indices, savings in defence expenditure can be one way of boosting the very low health budgets existing in sub-Saharan Africa. Even though generally, military spending is not recorded in the Public Expenditure Reviews, it has been estimated that in 2011 Kenya spent 2.8% of the GDP on military expenditure alone. Yet it should be common perception that health is a critical resource for development, without which investment in all the other sectors would go to waste. Poor health impacts negatively on economic productivity, through loss of labour, and under-performance due to illness.

Since the advent of the HIV epidemic there has been greater appreciation of the role of health on development. In the highly affected regions of the world the epidemic has negatively impacted on agricultural and industrial output, thereby perpetuating the cycle of poverty. Other diseases that have significantly influenced productivity are malaria and tuberculosis, as well as the so called neglected tropical diseases (NTDs), which even though they kill fewer people compared with HIV and AIDS, TB and malaria, they nevertheless are responsible for the crippling health and socioeconomic burden on the world’s poorest people in Africa, Asia, and the Americas.

The implications from the above are that African governments must recognise the pivotal role that the health sector should play in national social and economic development, and to urgently ensure commensurate allocations of resources. In addition, governments should recognise the critical barriers that poor health poses to any measures intended to uplift the social-economic status of poor and disadvantaged communities.

What are the prospects of achieving ‘skilled attendance’ for all births in Africa?

Ensuring that every birth is attended by skilled health personnel by 2015 is what is expected of all countries if they are to achieve Millennium Development Goal (MDG) 5. But how feasible is this for most African countries? According to WHO, skilled attendance at birth remains drastically low in sub-Saharan Africa; only about 42% of the childbirths are assisted by a skilled attendant in the Africa region, some countries registering as low as 5%[i]. This is against the target of 80% of births being assisted by a skilled attendant by 2015 if the goal of reducing maternal mortality rate by three quarters (between 1990 and 2015), is to be achieved.

Skilled attendance at the time of delivery is an important variable that influences the birth outcome and the health of the mother and her infant. Skilled attendance can be accessed at health facilities or through domiciliary or community midwifery. At both levels appropriate medical attention can reduce the risks of obstetric complications that increase the risk of morbidity and mortality for the mother and her baby.

Figure 1: Maternal mortality ratio by country, 2008

Source: UNICEF, Progress for Children: A Report Card on Maternal Mortality, 2008

Who is a skilled attendant?

A skilled attendant is defined as ‘an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns’[ii] This definition implies that the term ‘skilled attendant’ should refer exclusively to people with midwifery skills; people who are capable of managing normal deliveries and to diagnose, manage or refer complications. Midwifery skills are a defined set of cognitive and practical skills that enable the individual to provide basic health care services throughout the continuum of pregnancy, childbirth and postnatal period and also to provide first aid for obstetric complications and emergencies, including life-saving measures when needed. In 2006, a consensus was reached on what are essential competencies of the skilled attendant in the Africa Region of WHO[iii]. It should be noted that the definition of skilled attendant does not include Traditional Birth Attendants (TBA), trained or untrained.

Until the mid-1990s, the term “trained attendant” was commonly used in national statistics, which tended to lump both professionals and non-professionals (e.g. trained TBAs) together, as long as they had received some “training”. However, training does not necessarily guarantee the acquisition of the needed skills. From 1996 onwards, the word “skilled” has been employed to recognise competent use of knowledge[iv].

Effectiveness of ‘skilled attendants’ depends not just on their knowledge and competency, but also on the environment in which they function. Skilled attendance should therefore not be considered purely in terms of skills of the service providers but also the environment in which they work- physical space, equipment, supplies, drugs and transport for referral of obstetric emergencies. The political, policy and socio-cultural environment can also enable or prevent effectiveness of ‘skilled attendance’[v].

Does skilled attendance at birth lower maternal deaths?

There is no direct scientific evidence to show that skilled attendance lowers maternal mortality; however, comprehensive analyses of the factors behind the successful reduction of maternal deaths in countries such as Malaysia, Sri Lanka, Thailand and Honduras clearly indicate that a central feature in all of them was the presence of a skilled attendant at delivery. The experience from those countries is what is currently guiding maternal and neonatal health policy and programming; especially what was done to ensure high availability of skilled birth attendants, as well as the kind of environment that ensured their effectiveness[vi].

Two important lessons from these experiences are (a) achieving skilled attendance for all requires attention to the political, social and legal actions that address women’s human rights and equity, this being especially important if skilled attendance is to impact on the health outcomes of poor people; and (b) development of skilled attendants must go side by side with the creation of an enabling environment, including putting in place resources that are needed for emergency obstetric care and responsive referral systems.

Will skilled attendance result in reduced maternal deaths in Africa?

According to WHO ensuring skilled care at every birth can reduce the global burden of 536 000 maternal deaths, 3 million stillbirths and 3.7 million newborn deaths each year[vii]. Half of the 75 countries in which 97% of all maternal deaths worldwide occur are located in the sub-Saharan Africa. Within Africa, the eastern region has the lowest proportions of skilled attendance at birth (about 34%). In addition, enormous disparities exist within countries: poor women in rural and urban areas are far less likely than their wealthier counterparts to receive skilled care during childbirth. For example, the 2008-9 Kenya Demographic and Health Survey showed that women in the highest wealth quintile were nearly four times more likely to have been attended by a doctor or nurse/midwife, at their last delivery[viii].

The countries of sub-Saharan Africa are faced by numerous challenges in their effort to ensure skilled attendance at birth. These can be coalesced into the following two: developing the needed human resources for health, and creating an enabling environment for effective skilled attendance.

  • · Development of human resources for health- skilled attendants

Human resource for health is a key component of the health care system, which requires efficient mechanisms for recruitment, deployment, retention and supervision of the workforce, as well as ensuring accountability of service providers.

Five years ago, WHO estimated that to extend coverage of maternal and newborn care in the following 10 years (to 2015), 75 countries[ix] needed at least 334,000 additional midwives (or equivalent skilled attendants), as well as additional training for 140,000 existing professionals providing first-level care and of 27,000 doctors who are not currently qualified to provide back-up care[x]. According to these estimates the current health workforce in some of the most affected countries in sub-Saharan Africa would need to be scaled up by as much as 140% for the country to attain the Millennium Development Goals.

Health worker shortage in sub-Saharan Africa derives from many causes, including inadequate planning and investment for pre-service training, inadequate deployment, loss of trained personnel due to poor work conditions, internal and external movement, career changes among health workers, premature retirement, morbidity and premature mortality.  In some countries trained health workers remain unemployed for long periods because of inadequate budgetary allocations to ministries of health.

A recent study[xi] focused on 12 African countries[xii] has found alarming workforce shortages in all the countries, with the current rate of increase in health workforce density being much slower than what WHO considers necessary for achievement of desired levels of coverage of key health interventions[xiii] (a minimum density of 2.28 health workers per 1000 population). The study has suggested a variety of complementary, shorter-term responses if countries were to aspire to achieving international goals, among them, adoption of aggressive retention policies, e.g. improving the remuneration and working conditions of health workers; addressing current unemployment of trained professionals; and adoption of task-shifting[xiv] practices where necessary. However, all these should be viewed as stop-gap measures while countries further developed/expanded local pre-service training opportunities.

  • · Creating an enabling environment for skilled attendance

An enabling environment can be viewed more broadly to include the political, policy and socio-cultural context in which skilled attendance must operate (structure), as well as the more proximate factors such as pre- and in-service training, supervision and deployment, and health systems financing (inputs). Within the political and policy environment are considerations such as legislation/regulations which govern scope of professional activities, but more important is the level of government commitment and stability which are crucial to smooth functioning of health services. The social/cultural environment will include cultural factors which may influence acceptability and effectiveness of service providers and the services they provide; for example, Muslim societies may object to male skilled attendants (male doctors and nurses), examining women. Socio-economic status, gender and women empowerment are other important factors with strong bearing on the performance and effectiveness of skilled attendants. Finally, effectiveness of the service providers is enhanced by responsible management systems, functional infrastructure, equipment/ supplies, management and health information systems, communication and transport mechanisms. Above all, availability of the above depends on sound planning and financing of the health sector.

Conclusion

The countries of sub-Saharan Africa are faced by numerous challenges in their effort to ensure skilled attendance at birth, particularly the serious human resource shortages and weak health systems. Recent assessments of progress towards MDG 5 suggest that most sub-Saharan African countries have made only modest progress, with at least 8 countries[xv] demonstrating negative change[xvi]. These findings cast a lot of doubt as to whether many sub-Saharan African countries will achieve skilled attendance for all births in the remaining period to 2015. Factors such as limited funding for health services, and inequities in reaching all pregnant women irrespective of wealth status, are some of the major reasons for inadequate progress.

There is data to show that the current number of health workers in most countries is insufficient to meet population health needs[xvii]. Addressing this challenge will require expansion of pre-service training of nurses, midwives and doctors, with a view to increase health worker densities in order to meet the target level of 2.28 physicians, nurses and midwives per 1000 population. Considering that pre-service training is clearly a longer-term solution, a variety of complementary, shorter-term responses, (as discussed above), will need to be considered.

As a way forward African governments need to create health policies and necessary legislation in support of delivery of essential maternal health interventions. Such policies are important building blocks of a well functioning health system- including financing of health services, and ensuring equitable access to skilled attendants for all pregnant women. Despite the fact that total official development assistance (ODA) to maternal, newborn and child health programmes increased by 64%, from US$2.1 billion in 2003 to almost US$3.5 billion in 2006[xviii], expenditures on health in most African countries remain far less than the threshold below which it is difficult to ensure access to basic services (US$45 per person). As a result, out-of-pocket health expenditures in sub-Saharan African countries range from 6% in Namibia to 62% in Chad[xix]. Faced with heavy out-of-pocket expenses, many families either avoid seeking care altogether, or risk impoverishment when they do so. Under such scenario ill-health contributes to, and perpetuates, poverty in sub-Saharan Africa[xx].

Related links:


[i] WHO/AFRO. Consensus on Essential Competencies of Skilled attendant in the African Region Report of regional consultation, Brazzaville, 27th February-1st March 2006 WHO Africa Regional Office, 2006

[ii] WHO/UNFPA/UNICEF/World Bank Statement (1999). Reduction of maternal mortality: a joint statement. Geneva: WHO.

[iii] WHO/AFRO. Consensus on Essential Competencies of Skilled attendant in the African Region Report of regional consultation, Brazzaville, 27th February-1st March 2006 WHO Africa Regional Office, 2006

[iv] Starrs A (1997). The Safe Motherhood Action Agenda: Priorities for the Next Decade. New

York: Inter-Agency Group for Safe Motherhood and Family Care International.

[v] Wendy J Graham, Jacqueline S Bell and Colin HW Bullough Can skilled attendance at delivery reduce maternal mortality in developing countries ? Studies in Health Services Organisation & Policy, 17, 2001 pp97-129

[vi] Wim Van Lerberghe and Vincent De Brouwere Reducing maternal mortality in a context of poverty Studies in Health Services Organisation and Policy, 17, 2001

[viii] Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health

Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro.

[ix] Half of these countries are in sub-Saharan Africa.

[x] WHO. 2005. World Health Report 2005. Geneva: WHO.

[xii] Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Kenya, Liberia, Madagascar, Rwanda, Sierra Leone, Uganda, the United Republic of Tanzania and Zambia

[xiii] World Health Organization, The world health report 2006.

[xiv] The shifting of certain tasks from professional that require longer-term training to those requiring less intensive training which may be more affordable, for example permitting midwives to administer perenteral drugs, to manually remove the placenta, to remove retained products of conception, and to resuscitate newborns.

[xv] Chad, Cote d’Ivoire, Kenya, Lesotho, Malawi, Nigeria, Senegal.

[xvi] Countdown to 2015, 2008 Report Tracking Progress in Maternal, Newborn & Child Survival New York, United Nations Children’s Fund, 2008.

[xviii] Note: The total amount of aid for maternal, newborn and child health-related activities represents just 3% of total ODA

[xix] 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

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