Tag Archives: health care

What will define Kenya’s Health Care System in Devolved County Governments?

 

 

President Kibaki in a past event. He presided over the handing of ambulances to District Hospitals

With the impending devolution of healthcare management functions to the counties anxiety looms over the levels of preparedness for such an undertaking in all the counties. In an earlier post a number of challenges were identified, including 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 prevail in Kenya. This post reviews the extent to which the decentralisation policy of the Ministry of Health (MOH) has been implemented and how this may impact on assumption of fully devolved management of health services by county governments.

The term “decentralisation” has been used to signify a variety of reforms characterized by the transfer of fiscal, administrative, and/or political authority for planning, management, or service delivery from the central MOH to alternate institutions. “Devolution” is a category of decentralisation; it implies the ceding of sectoral functions and resources to autonomous local governments, which in some measure take responsibility for service delivery, administration, and finance.

Despite decades of intention to decentralise, Kenya’s health care system has remained largely centralised with decisions taken at MOH headquarters from where they are conveyed top-down through the provincial medical officers to the district level. Centralised functions at the headquarters include policy formulation, coordinating activities of all health players (government and non-governmental organizations), initiating and managing implementation of policy changes on various issues including charging of user fees, and undertaking monitoring and evaluation of impact of policy changes at the district level.

Centralised decision making may have contributed to, among others, regional disparities in the distribution of health services, inequities in resource allocations, and unequal access to quality health services, resulting in the wide regional differentials in health indicators which successive demographic and health surveys (KDHS) have highlighted[i].

On paper, the MOH through the various health sector strategic plans has expressed commitment to decentralisation intended to provide increased authority for decision making, resource allocation, and management of health care to the district and facility levels. For example, in 1992 the MOH established the District Health Management Teams (DHMTs) and the District Health Management Boards (DHMBs), which were charged with managing public health services at the district level. Together, the DHMT and DHMB are supposed to provide management and supervisory support to lower level health facilities (sub-district hospitals, health centres, and dispensaries).However, despite the fact that these bodies coordinate health activities in the district and may develop plans for spending cost sharing funds, the final decisions on budgets and resource allocation is retained at the central level. Lack of funds and transport are the most commonly cited reasons for failure by DHMTs to meet their supervision targets despite the near universal existence of documented supervision plans[ii]. Budgetary remittances to the districts have neither been regular nor timely.

Health care under devolved system of governance:

The Constitution of Kenya (2010) has assigned the larger portion of delivery of health services to Counties, the exception being the National Referral Services. This implies that Counties should bear overall responsibilities for planning, financing, coordinating delivery and monitoring of health services toward the fulfilment of right to ‘the highest attainable standard of health’.

For many Kenyans, devolution is looked upon as the answer to the persistent regional disparities in the distribution of health services and inequities in resource allocations. However, much as that is an ideal goal; its realisation may not be immediate, especially because of the current varied levels of preparedness within the counties. Some counties starting at a relative disadvantage will take time to build up their capacity and ability to use devolved resources well, which may lead to even wider disparities. Such counties will require particular assistance to catch-up. In the long run, success of devolution will depend on availability of resources (both financial and human) for counties to carry out their assigned functions, and their empowerment to use resources effectively.

The draft Kenya Health Sector Strategic & Investment Plan[iii](KHSSP)July 2012 – June 2018 proposes a three-pronged framework for overall health sector leadership, i.e: Partnership, Governance and Stewardship– which taken together should address the health agenda towards the fulfillment of the right to health.

The strategic plan proposes that within the counties, the stewardship responsibilities for health services will be exercised at three levels: the National Directorates for Health, the County health management teams, and County Health facility management teams. However, scrutiny of the prescribed responsibilities, functions and roles[iv] of these bodies portrays a continuation of dominance by MOH headquarters in matters to do with policy formulation, planning and priority setting, which leaves the county management teams to be purely concerned with programme implementation (under close supervision from above). This is unfortunate since it perpetuates central planning which has not always taken into consideration the peculiarities of our country’s diversity, with consequent wide disparities in health status.

Planning at the county level should enable better definition of local priorities and design of innovative models of service delivery that adapt to local conditions, e.g. serving pastoralist communities in arid and semi-arid areas. It also can improve quality and legitimacy owing to user participation in decision making; and greater equity through distribution of resources toward traditionally marginal regions and groups. Local hiring of service providers can improve staffing levels and appropriate deployment, especially in rural health facilities.

One major challenge facing proposed county health services is the serious shortage of resources, human and material, especially due to financial limitations. Currently the public health sector is seriously under-funded and is generally operating on shoe-string budgets, inadequate infrastructure and lack of essential supplies. Although better distribution and deployment of health personnel may somewhat alleviate current acute shortages in some counties, still more will be needed. Many counties will especially require strengthening in health planning and monitoring.

[i] Ministry of Health (MOH) 2006 Reversing the trends, The Second National Health Sector Strategic Plan of Kenya: Annual Operational Plan 2 2006/07. Nairobi, Kenya.

[ii] Ndavi, P.M., S. Ogola, P.M. Kizito, and K. Johnson. 2009. Decentralizing Kenya’s Health Management System: An Evaluation. Kenya Working Papers No. 1. Calverton, Maryland, USA: Macro International Inc.

[iii] Ministry of Medical Services and Ministry of Public Health & Sanitation KENYA HEALTH SECTOR STRATEGIC & INVESTMENT PLAN (KHSSP) July 2012 – June 2018: Transforming Health: Accelerating attainment of Health Goals

[iv] National Directorates for Health: provide overall direction- policy formulation, national strategic planning, priority setting, budgeting and resource mobilization, regulating, setting standards, formulating guidelines, monitoring and evaluation, and provision of technical backup to the county level. County Health Management Teams: Provide Strategic and operational leadership and stewardship for overall health management in the County, including resource mobilization, creation of linkages with national level referral health services, monitoring and evaluation, coordination and collaboration with State and Non state Stakeholders at the County level health services. County Health Facility Management Teams: Develop and implement facility health plans for levels 1–3 health care services; coordinate and collaborate with stakeholders through County Health Stakeholder Forums; undertake in-service training and capacity building; and supervision, monitoring and evaluation.

 

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

 

Access to legalised abortion is a key ingredient to improvement of maternal health in Africa

It is worrying to note that while most advocates of improved maternal health are greatly disturbed by the WHO report that rates of induced abortion worldwide remain high worldwide, and especially the finding that in the Africa region almost all (97%) abortions are unsafe, there are others who belittle the significance of these findings, stating: “Ireland, where abortion is banned, has one of the world’s best maternal health records. Legalised abortion does nothing to improve medical care.”

Whilst it may be possible that Ireland has one of the world’s best maternal health records, it is unrealistic to make that the yardstick, and to conclude that African countries, for example, should stick to their strict anti-abortion laws, and by some grace the high rates of unsafe abortion and maternal deaths will reduce. There is a world of difference between the circumstances under which an average Irish woman lives and that of the average African woman. The Irish woman is today enjoying a living standard above the average woman in the British Isles, and can with ease slip across the channel to obtain safe abortion if need be. All these benefits are beyond the reach of the African woman. The truth of the matter is that the high mortality is concentrated among the poor and marginalised. The wealthy women in Africa have easy access to very safe abortion in their countries or abroad, as necessary. To the rich African woman as it is for the Irish, perhaps “legalised abortion does nothing to improve medical care”; to the average woman in Africa, it can be a matter of life and death. Restrictive abortion laws do not translate to lower abortion rates, but 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.

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?

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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