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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

IMAGE: Mengo Hospital 1897

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

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

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

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

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

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

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

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

Image Traditional healer

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What 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.

 

Thirty first of every August is ‘African Traditional Medicine Day’ but how many know about it?

Over a span of about 150 years three members of my family have practiced medicine. My grandfather, my brother and I have all at one time or another provided medical care to the needy, all of us receiving acknowledgements from our patients and society. However, that is about where the similarities cease, for with the coming of the colonial power to our lands my grandfather’s practice became severely restricted and despised. Generally, he practiced in secrecy from then on. On the other hand, in the case of my brother and I who were trained in ‘scientific medicine’ by the colonials, our practices were legitimised by stints in the ‘motherland’ as well as being registered by professional regulatory authorities.

 African traditional medicine

In all countries of the world there exists traditional knowledge related to the health of humans and animals. The World Health Organization (WHO) defines traditional medicine as “the sum total of all the knowledge, skills and practice, based on the theories, beliefs, and experiences indigenous to different cultures,whether explicable or not, used in the maintenance of health as well as in the diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing”[i].

This definition applies to all traditional systems of medicine whether in Europe, India, China or Africa. Yet whereas European missionaries and colonial administrators left alone, sometimes even encouraged, traditional medicine in India and China, they almost violently discouraged African traditional medicine. In particular, the intricate relationship between African medicine and African religion[ii] made traditional medical practices key targets of attack by early European Christian missionaries, who considered many African traditional religious rites and rituals to be against Christian teachings and morals. Traditional healers were regarded as heathens because of their participation in African Traditional Religion.

The medicine my brother and I practice derives from the germ theory of disease (see below) while my grandfather’s traditional African medicine is based on concepts that are much broader and holistic. In traditional African societies it is believed that good health, disease, success or misfortune are not chance occurrences but arise from the actions of individuals and ancestral spirits according to the balance or imbalance between the individual and the social environment. African traditional understanding was that sickness was a kind of punishment by the spirits of the ancestors to those who do not observe the rules of good social behaviour, from whom the ancestors withdraw their protection leaving them exposed to the whims of evil spirits who cause physical and mental dysfunctions. Traditional healers use plants in a variety of ways, depending on the illness to be cured. Parts of plants can be applied directly to wounds and cuts or, if necessary, prepared as powders, infusions, or even used in the form of smoke or fumes. African herbal medicine is often associated with magic[iii], for example the prescription of amulets and charms as prevention or treatment of diseases.

Today, many Africans including some self proclaimed Christians, and especially politicians, consult a traditional healers for advice on various issues, including health-problems. The African traditional ‘doctors’ have skills in both herbal remedies as well as in spiritual healing, the latter involving various traditional religious rites and rituals. In this regard, African medical practice is holistic- it takes into account all of patient’s physical, mental, and social conditions in the treatment of illness.

The Germ Theory of disease

The Germ Theory of disease is the foundation of modern (western) medicine and was an important basis for innovations such as antibiotics and hygienic practices. Germ theory was validated in the late 19th century, thanks to the works of Louis Pasteur (1822-1895) and Robert Koch (1843-1910). It proposes that microorganisms are the cause of many diseases. Hence management of the disease is focused on establishing which microorganisms are responsible and applying specific drugs (antibiotic) for their elimination. Modern medicine is also referred to as Allopathy, which is defined as the treatment of a disease by using remedies whose effects differ from those produced by that disease. This is the principle of mainstream medical practice, as opposed to that of homeopathy– a complementary disease-treatment system in which a patient is given minute doses of natural substances that in larger doses would produce symptoms of the disease itself.

There is no doubt that introduction of antibiotics (e.g. Penicillin), revolutionised medicine and remains one of the most important milestones in the history of medicine. However, as observed by some critics, the concentration in modern medicine on fighting germs using antibiotics has tended to ignore the “soil upon which the bacteria flourish[iv]” In other words modern medicine tends to focus on the disease not the whole person, as is the case in traditional systems of medicine. “Modern medicine seems too grounded in the study of disease [pathology] and in its eradication and not enough in studying health and how to create and sustain it”. This in fact, is where the great divide exists between modern medicine and African traditional medicine.

 

Preparing and drying out freshly picked mutis

Bridging the divide- Integration of traditional medicine in national health systems

The World Health Organization estimates that 80% of the populations of Asia, Africa and Latin America use traditional medicine to meet their primary health care needs. For many people in these countries, particularly those living in rural areas, this is the only available, accessible and affordable source of health care. In scenarios such as these African governments should have no option but to ensure there is collaboration between conventional and traditional health practitioners. To this end, Ministries of Health need to set up mechanisms for the regulation and integration of traditional medical practice in national health systems.

The 50th Session of the WHO Regional Committee for Africa which took place in Ouagadougou, Burkina Faso, 28 August to 2 September 2000 recognized the importance and potential of traditional medicine for the achievement of health for all, and set 31st August of every year as African Traditional Medicine Day[i]^{, [ii]}. The Regional Committee adopted a regional strategy for the promotion of the role of Traditional Medicine in national health systems, including establishing structures, programmes and offices in Ministries of Health to institutionalize traditional medicine. Currently 39 countries (including Kenya) have set up such offices, and a few training institutions have established departments of Herbal Medicine[iii]. Other examples of collaboration between traditional medical practitioners and modern medical practitioners are to be found in Uganda and South Africa. In Uganda the Traditional and Modern Health Practitioners against HIV /AIDS (THETA[iv] ) have demonstrated the positive impact traditional medical practitioners can make on health care delivery. In South Africa research conducted by AMREF shows that traditional practitioners can play important roles in integrated HIV/AIDS/STI/tuberculosis programs[v].

Conclusion:

As we look forward to this year’s African Traditional Medicine Day it cannot be lost on us that the ongoing WHO-led collaboration appears to focus solely on herbal medicine, yet traditional African medicine is a broader concept than that, incorporating (beside use of herbs) divination and healing of physical, emotional and spiritual illnesses. In any case, a large proportion of herbalists also engage in divining causes of illness and providing various solutions to spiritually or socially-centered complaints, in addition to use of plant and animal products. To this extent herbal medicine and spiritual healing act as mutually reinforcing systems of African traditional medicine. Accommodating the holistic approach in the proposed integrated health systems remains a critical challenge for all involved including WHO.

[i] http://www.afro.who.int/en/fiftieth-session.html

[ii] African Traditional Medicine Day, 31 August, Special issue, African Health Monitor, World Health Organization Regional Office for Africa).2010

[iii] The Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, established a Bachelor of Science Degree in Herbal Medicine in 2001 to train Medical Herbalists.

[iv] Initiated in 1992 through a partnership between The AID S Support

Organization (TA SO) Uganda Ltd and Medicines Sans Frontières (Doctors without Borders), an international humanitarian organization.

[v] Melusi Ndhlalambi:Strengthening the Capacity of Traditional Health Practitioners to Respond to HIV/AIDS and TB in Kwa Zulu Natal, South Africa AMREF Case Studies 2009.

 

Medical practice changed for ever the moment AIDS arrived

Treatment Action Campaign activists in Cape Town South Africa, June 2012

 

The AIDS epidemic has changed practically every aspect of medical practice; from the way we view the disease, the accelerated global research to discover diagnostic tools, to unprecedented drug approval processes and speedy distribution and utilisation of new drugs. To date, manifestations of the AIDS virus are dealt with in practically all branches of medicine; unlike in the early years of the epidemic when cases were largely found in medical (internal medicine) wards, and even there they were isolated from the general patient population.

For example, the first AIDS cases admitted at the Kenyatta National Hospital were isolated in small dark cubicles in selected medical wards, often much against the wishes of the consultants in charge of the wards. No one physically touched the patients and medicines were placed on a stool and pushed inside the room by a nurse who stood clear of the door. Supposedly, the patient would reach the stool from his bed and collect not only the medicines, but also something to eat. When they died the corpse was placed in a black body-bag into which copious amounts of formalin would be poured. Relatives were not permitted to take the bodies for burial lest they spread the disease; the bodies had to be incinerated.

The AIDS virus has received the greatest attention of all time in medical history, more than any other pathogen; it has been as challenging to medical doctors, biomedical and social scientists, economists, theologians and philosophers alike, the pharmaceutical industry and drug regulatory authorities. Indeed, it is the combined effort of all these disparate groups and their quest to understand the disease that finally has shed some light at the end of the tunnel. As a result, today AIDS is not as perplexing as it once used to be. Within a span of under three decades HIV infection has changed from a death sentence to a chronic disease (at least where antiretroviral drugs-ARVs are readily available). This is unprecedented in medical history. For example, it took more than 400 years from the first recorded outbreak of syphilis in Europe (1494/1495) to identification of the causative organism, Treponema pallidum, in 1905 and discovery of the first effective treatment (Salvarsan) in 1910, before the wider availability of Penicillin in 1946. In contrast, the virus that is associated with AIDS was first identified by Montagnier et al. in France in 1983 and by Gallo et al. in the US in 1984, and within less than a decade, several drugs had already received FDA approval.

AIDS hit the world in 1981, first in California and New York in the United States. In 1982 the Centers for Disease Control (CDC) coined the term ‘acquired immunodeficiency syndrome’ (AIDS) and identified four “risk factors”: male homosexuality, intravenous drug use, Haitian origin, and hemophilia A. In 1983 a major outbreak of AIDS was reported among both men and women in central Africa, prompting the CDC to add female sexual partners of men with AIDS to its list of “risk groups”. Shortly afterwards, a history of blood transfusion and  female sex workers were added to the list, and before long the disease became a threat to all segments of society—though it still remains largely concentrated within the poorer and marginalised groups.

Kenyan Aids activists in Nairobi take their campaign in support of the Global Fund to the streets. Photograph: Sidi Sarrow

Amongst the significant impacts of AIDS on the practice of medicine, three can be pointed out, namely, increased precautionary actions by health care workers, safer blood supply (for blood transfusion), and disease activism. Specifically, the AIDS epidemic has impacted on medical practice in the following ways:

Safer infection prevention practices: Today health care workers have to treat all cases as being potentially infectious, and have to observe standard guidelines on infection prevention- to guard against cross-infection between cases, as well as protecting themselves from being infected by their patients. Hospital hygiene and safe injection practices, previously neglected in much of the developing world, have become topics of global concern. There are written instructions on how to handle blood and other bodily fluids, including the use of sterile gloves when handling blood and other body fluids, double gloving during surgery and wearing of visors to protect eyes from splashed blood. Health care workers are trained on safe handling of used needles and surgical blades (sharps), and there is a total ban on re use of syringes and needles. Hospitals would normally maintain registers of needle prick (stick) occurrences and administration of post-exposure ARV prophylaxis (PEP), etc. is administered to the staff involved.

In most countries today blood for transfusion is safer than previously. There has been more careful screening of blood for transfusion- to include besides HIV and syphilis- hepatitis B, A and C, malaria and other pathogens depending on the technological capability of the lab. This has been facilitated by creation of regionalised blood transfusion centres with capability for safe storage of larger volumes, and in contact with hospitals in the catchments areas.

The major challenge in countries like Kenya is ensuring sustained flow of resources to enable supply of the essential items needed for the above. Among the complaints raised by nurses and doctors in recent months are the lack of basic supplies such as protective gear- gloves, gowns and disinfectants. We must guard against slipping back to the days when gloves, syringes and needles were reused- as late as in the early 1990s! Fear of contracting HIV infection may influence choice of career. There have been anecdotal reports that today medicine is no longer the first choice for ‘A’ students in Kenya. A 1988 survey of house officers in the US, 25 percent of all respondents reported that they would not continue to care for AIDS patients if given a choice, while another study in 1991 reported that half of all primary care providers would not treat AIDS patients if they could avoid it[i]. A more recent study shows there is reluctance on the part of some nursing students in some regions of the world to provide care for people with HIV/AIDS, and recommends that educational programmes based on research evidence must play a leading role in developing strategies to help nursing students understand and overcome such attitudes[ii]. However, many would believe things have changed a lot for the better since then.

Disease activism:  In no other disease has there been as much advocacy as in the case of AIDS. For example, the response to the continuing presence of the so-called neglected tropical diseases (NTDs) stands in sharp contrast to the unparalleled achievement in addressing the HIV epidemic. Yet these diseases continue to cause massive but hidden and silent suffering, and frequently kill, largely because the people affected or at risk have little political voice. On the other hand, as mentioned above, the first cases of AIDS reported in the US involved highly educated men, many from the upper echelons of the American society. They soon realized their plight and, through a strong well organized lobby movement, fought hard for public attention and support of the search for ‘cure’. Within less than a decade their advocacy started bearing fruit. Patients also became more active participants in the research and drug development, sometimes not just being study subjects but actively helping in design of clinical trials.

Disease activism has played a major role in quickened drug approval processes, which was almost unheard of before AIDS patients spoke up, and is now becoming common among a whole range of other illnesses, including breast cancer. Although the strongest AIDS activism in Africa has largely been concentrated in South Africa, organised groups of PLWHA in other countries are increasingly becoming vocal in demanding increased access to ARVs as well as to TB and Malaria treatment. One area of success for global disease activism is increased availability of low priced generic drugs

Spill-over effects of research: Funding for AIDS research has surpassed expenditures for any other disease. According to UNAIDS in 2008, an estimated US$15.6 billion was spent on HIV and AIDS compared to US$300 million in 1996. However, a 2010 UNAIDS report warned that flattening of global funding for HIV research may limit ability of researchers to move promising approaches forward, especially in search for a vaccine.

The extensive research connected with AIDS has spilled over into a greater understanding of other chronic diseases especially cancer. Sexually transmitted diseases research, prevention and treatment is another area that has received renewed attention since AIDS, as sexual and reproductive health gained renewed prominence. The frequency with which Tuberculosis occurs in HIV-infected persons has led [1]to a resurgence of interest in the diagnosis and treatment of this ancient disease, while advances in the treatment of HIV-associated Opportunistic Infections have benefited other immune-suppressed persons.

Scientific advances have resulted in the development of lifesaving, albeit not curative, treatment for HIV. By the end of 2009, more than 5 million persons in low- and middle-income countries were accessing Antiretroviral Therapy (ART), unimaginable just a few years before and made possible through the use of generic drugs, price reductions for brand-name drugs, and efforts of international donors through initiatives such as the US PEPFAR and the Global Fund. The increasing availability of highly effective ARVs have transformed the way doctors look at HIV infection, and so too has terminal care changed. What had previously been an emphasis on simply maintaining life is increasingly shifting to give greater weight on quality of life, comfort and individual productivity.

Research on the prevention of mother-to-child transmission of HIV has led to interventions with the potential to virtually eliminate HIV disease in children (i.e. HIV-free generation). This should have a bearing on doctors’ attitudes towards childbearing for those infected with HIV, including investigating them for infertility. Research has identified viable options for HIV prevention in intravenous drug users, such as opioid substitution therapy and needle/syringe exchange.

Diminishing stigma: There was a time when doctors that treated AIDS cases were stigmatized and shun by other colleagues and patients. Even Hospital administrations quietly tried to discourage doctors from taking too many AIDS patients because it affected their facilities’ bottom lines. Today this is generally the least of their concerns. Even Insurance companies have opened up to people living with HIV albeit at much higher premium.

Typically, it has taken AIDS to bring the existence of marginalized groups such as sexual minorities to attention in low- and middle-income countries and to highlight their vulnerability and needs. They belong to what have been referred to as the ‘most at risk populations’ (MARPs), that include sex workers and their clients, men who have sex with men (MSM), and people who inject drugs (IDUs). It is recognised that failure to address these groups will compromise efforts towards reduction of new infections. As such it is unrealistic to operate as though they do not exist!

On the future: There is no better way of summarising the future of AIDS than to quote Dr Kevin M. De Cock, Director of the Center for Global Health at CDC in Atlanta: “Inevitably, the story of HIV/AIDS ‘could not be one of final victory. It could be only the record of what had to be done, and what assuredly would have to be done again in the never-ending fight against terror and its relentless onslaughts.’ An enduring frustration is that we will not know how the story of AIDS will finally end because the epidemic will outlast us. Yet the tide can be turned with principled pragmatism, adequate resources, trust in communities, and science as our guide”

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[i] Infectious Disease News, June 2011, Infectious disease and the evolution of AIDS Thirty years since “patient zero,” how the world’s worst epidemic forever changed the specialty. http://www.healio.com/infectious-disease/hiv-aids/news/print/infectious-disease-news/%7BC1A89E60-E999-4FAB-A0FE-9DC54FD9AEED%7D/Infectious-disease-and-the-evolution-of-AIDS

[ii] Pickles D., King L. & Belani I. ( 2 0 0 9 ) Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review. Journal of Advanced Nursing 65(11), 2262–2273. doi: 10.1111/j.1365-2648.2009.05128.x

 

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

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

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

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

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

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

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

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

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

Medical negligence and malpractice is rife in Kenya’s health facilities, a Public Inquiry reports

The recently launched report[i] of a public inquiry into violations of sexual and reproductive health rights in Kenya has highlighted the existence of widespread medical negligence and malpractice in health institutions. Indeed many of the complaints of mistreatment in health facilities, especially those raised by former obstetric patients, frequently bordered on medical negligence and malpractice. Medical negligence and malpractice interfere with the quality of care received by patients, and deny them enjoyment of the right to the highest standard of health care which is their constitutional right.

(Women are being counselled at a RH clinic. Picture source: J Mati)

Medical negligence can be defined as the commission of an act that a prudent person would not have done or the omission of a duty that a prudent person would have fulfilled, resulting in injury or harm to another person (patient)[ii]. Medical malpractice means bad, wrong, or injudicious treatment of a patient professionally, which results in injury, unnecessary suffering, or death. Malpractice and negligence may occur through omission of a necessary act as well as commission of an unwise or negligent act[iii]. This may be in the form of misdiagnosis, wrong decisions and treatment, prescription errors, and medical or surgical complications, all of which may result in suffering, permanent injury or death.

In Kenya, medical, nursing and midwifery practices are regulated by statutory authorities, including the Medical Practitioners and Dentists Board[iv] (established under Cap 253 Laws of Kenya), the Nursing Council of Kenya[v] (established under the Nurses Act Cap 257 Laws of Kenya) and the Clinical Officers Council (established under the Clinical Officers [Training, Registration and Licensing] Act Cap 260 Laws of Kenya)[vi]. These bodies are obliged to protect members of the public by ensuring that the medical practitioners (including dentists), nurses and midwives, and clinical officers are properly qualified, that they perform their services to patients with skill and diligence, and that they observe at all times high moral and ethical standards

Evidence regarding alleged mistreatment in health institutions was received at all sittings of the Inquiry, and among the witnesses raising complaints of medical negligence and malpractice the majority were obstetric cases that suffered various types of injury and suffering to themselves and their babies. Complaints of long waiting periods and delays in getting attended to in health facilities were common. Sometimes this was occasioned by doctors or midwives on call refusing to come when summoned, or due to shortage of staff. Associated with the above were complaints of negligent management of labour resulting in stillbirth, mentally handicapped child and maternal death. There were other complaints of persons who had been subjected to various surgical procedures such hysterectomy without their consent (See below). In spite of this, hardly any of the complaints had been reported to the regulatory authorities.

Selected examples of specific complaints of medical negligence and malpractice:

· Denial of information- failure to explain the nature of illness or injury and the modality of treatment and its consequences. In particular, there was inadequate information given to the patients before and after surgery.

 Sterilisation without consent:

A mother of three was admitted with abruptio placenta at a Mission Hospital, where she was later taken to theatre for C Section and, unknown to her, bilateral tubal ligation was carried out. She was not informed of the latter and since she did not wish to conceive shortly after the operation she commenced on a family planning method. She had taken two doses of Depo Provera when a doctor (elsewhere) happened to read her discharge card which showed she had actually been sterilised!

· Case of malpractice-  Doctor who was drunk;

A case of ruptured uterus and fetal death:

A woman was admitted at a public District Hospital in early labour. She had previously delivered by C Section and so was asked to sign consent for repeat CS which she did. However, a doctor who was drunk saw her in the Labour Ward and asked her to begin pushing the baby, without any success. He then tried unsuccessfully to apply forceps. By the time she eventually was taken to the operating theatre her uterus had already ruptured, the baby had died, and she subsequently developed difficulty in controlling urine (?Vesico Vaginal Fistula). She has not conceived since then and she could as well have had a hysterectomy done.

· Case of medical negligence- denial of services

Forgotten foreign bodies after surgery:

A relative told of the case of a woman who had a C section performed by a doctor during which an abdominal pack was (accidentally) forgotten in the abdomen. When she returned 2 weeks later complaining of abdominal pain and swelling she was told she needed another operation to remove a foreign body which required further payment. This could not be done because she did not have any more money. The patient died of complications most probably associated with the foreign body.

 Another case was that of a single mother of two who delivered normally at a Health Centre (Level 3). An episiotomy had been performed and a swab left in the vagina which should have been removed after a few hours. However, the patient was not informed about it, and the swab was left in for 2 weeks. By that time infection had set in and she had also developed faecal incontinence (?RVF). She is now ashamed of her condition and has not mentioned it to anyone except her mother. [It is a possibility that she suffered rectal injury when the episiotomy incision was made].

 · Negligent management- failure to apply standard procedures:

Management of labour in a HIV+ woman did not conform to guidelines for prevention of mother to child transmission of HIV infection: An HIV+ woman was admitted at a public District Hospital with ruptured membranes. Her husband, also HIV positive, told the staff that they had been advised by another doctor that the delivery should be by CS, but this was declined, besides, she was not given ARV therapy as instructed in the PMTCT guidelines. Instead, she was allowed to have a prolonged labour, delivering a fresh stillborn child.

Failure to give an essential prophylaxis:

A primigravida at term was admitted in a private hospital where she had made several antenatal visits. Her labour was uneventful, delivering a healthy male child. However, although she had been informed at the same hospital that she was Rhesus Negative she was not offered a standard vaccine, anti-D gamma globulin to protect against Rhesus iso-immunisation. In addition, she was not advised what to do in case of a subsequent pregnancy.

· Negligent management of labour, doctor refused to come to the hospital when summoned:

A mother of three was admitted to a public District Hospital in labour where she remained for 48 hours without delivery mainly because the only doctor who could do a C Section refused to come. When eventually the doctor came she was taken to theatre, delivered of a very depressed child who breathed after prolonged resuscitation, but the mother died on the table. The child is now intellectually handicapped.

· Negligent management- Hysterectomy performed without consent

Hysterectomy performed without consent on a disabled person:

A woman with dwarfism (possibly achondroplasia) was diagnosed with uterine fibroids at a provincial Hospital and advised she needed an operation to remove the fibroids. She was taken to theatre but afterwards was not explained what had been done. When three weeks later she realised that a hysterectomy had been performed she sought explanation from the doctor. She was taken aback when the doctor wondered aloud if in her condition she really expected to get a baby!

Hysterectomy performed in a woman diagnosed with an ovarian cyst:

A married woman, a mother of four girls had hope that a boy would come someday. She was seen at a Provincial Hospital complaining of abdominal pain, where an ovarian cyst was diagnosed and confirmed by an ultrasound scan. She was advised to undergo an operation in order to remove the cyst; at no time was possibility of a hysterectomy mentioned. “Later when I read the discharge summary it stated that the uterus had a fibroid and a hysterectomy was performed. That shattered our hope for another child, perhaps a son”. She has contemplated suing the doctor but does not have the resources to do so.

Hysterectomy performed possibly because of intractable post-partum haemorrhage:

A woman in her first pregnancy was under care of a private obstetrician who saw her several times during pregnancy. When she went two weeks past the due date he admitted her at a private hospital for induction of labour, but for three days labour did not set in. However, when labour started on the fourth day her doctor was nowhere to be found; it was not until the next day that he appeared in the middle of the night and attempted to deliver her by vacuum extraction, but this was abandoned because there was a lot of bleeding. She was then taken to theatre and a CS was performed- a baby boy weighing 4kg. When she was returned to the ward the bleeding continued and had to be returned to theatre again, but was not told what was done there. “What annoyed me the most was that the details of my operations were only made known to my husband when he went to clear the bills, and then it was not until three months later that my husband actually informed me of the loss of my uterus. After some years, my husband left me for another woman and to have more children. I contemplated suing the obstetrician, but another doctor dissuaded me saying whatever was done was to save my life”.

Conclusions

The Public Inquiry report makes specific recommendations addressing the various aspects of maltreatment, medical negligence and malpractice in health institutions. It specifically calls on the Government to implement the provisions of Article 43 (1a) in the Constitution of Kenya (2010) and to ensure that health facilities at all levels are adequately staffed and equipped to provide quality health services.

The Ministry of Health and health professional regulatory bodies should ensure adherence to internationally accepted ethical standards and guidelines that govern medical practice with a view to eliminating the rampant cases of mistreatment, medical negligence and malpractice, in health facilities. The codes of practice must incorporate the obligations of health care providers to their patients, and should outline the rights of the patient with clear penalties spelt out in cases where the provisions are not adhered to. The government must make it mandatory that all health facilities establish complaint mechanisms aimed to enable clients forward their complaints to the relevant authorities for action in cases where they feel violated.

Finally, there is urgent need to increase the number of health care providers, across the country. Health training institutions have a duty to inculcate among their trainees high moral standards and respect for patients’ rights, including the right to information and informed consent. The government should recruit, train, employ and deploy more health personnel, and strengthen supervision, with a view to address the current shortage that is being experienced throughout the country.

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[i]Kenya National Commission on Human Rights: A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya, April 2012.

[ii]Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier.

 [iii] Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 Saunders, an imprint of Elsevier.

 [iv] http://www.medicalboard.co.ke

[v]http://www.nckenya.com

[vi] http://www.clinicalofficerscouncil.com

 

Selected case studies of women who were denied enjoyment of ‘right to health’ in Kenya

 

A review of ‘Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?’ and ‘Barriers to enjoyment of health as a human right in Africa’ provides a useful background to the case studies.

The recently launched report by the Kenya National Commission on Human Rights[i] highlights several incidents and situations where women were denied their right to health care services both because of non-availability of resources and non-affordability of services, as well as misdeeds on the part of health care providers. People living with disabilities (PWDs), in particular, complained of mistreatment, especially delays in getting attended to in health facilities. Most health institutions were not disabled-friendly in terms of infrastructure and means of communication, for example, facilities for sign language or Braille.

A Level 2 Health Facility at Mtwapa, Mombasa County (Picture: J Mati)

Witnesses raised several complaints related to the inefficient referral systems in several health facilities that caused considerable delays in obtaining higher level care, not infrequently resulting in fatal consequences for the women and their babies. This was particularly a serious problem when it came to referral of patients from levels 1 and 2 to appropriate higher level facilities.

In some cases, women in rural areas had to be transported on wheel barrows by family members or on donkey carts. Where hospitals had ambulances, the patients or the relatives were required to pay amounts ranging from KSHs. 500 to KSHs. 3,000 supposedly to fuel the vehicles. In situations where people were unable to pay, patients were denied treatment. In other instances, blood was not readily available in hospital blood banks, or the facilities lacked adequate infrastructure to obtain blood for emergency transfusions.

In Tana River, for example, a woman who developed complications after delivering at a dispensary (level 2) died while waiting to raise funds, through harambee, to fuel a government ambulance to take her to Hola District Hospital. A similar report is given in connection with a maternal death due to lack of transport between Magarini Dispensary and Malindi District Hospital, both in Kilifi County.

In Lamu County, patients who needed to be referred to Coast Provincial Hospital in Mombasa were reportedly required to pay between KSHs. 8,000 and KSHs. 10,000 to fuel the hospital’s ambulance. Where there are no ambulances, as in Wajir and Marsabit District Hospitals families had either to hire expensive taxis or resort to donkeys and camels to transport their sick members.

Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled attendance at delivery. A witness during the inquiry stated thus: ‘Many women deliver at home because they do not have enough money to go to the hospital’.

 Corruption, especially among hospital management staff, was also cited as a barrier to accessing maternal health services. According to witness accounts from Kitale, corruption in health facilities meant that patients ended up paying for drugs and other items that ought to be provided for free. Similarly, bribes were solicited to facilitate earlier scheduling of surgical treatment, as stated by a witness at the Coast: “For one to get an operation done quickly at Coast General Hospital one has to pay bribes or know someone because there are long queues, so I left”.

Mistreatment in health facilities by unkind, cruel, sometimes inebriated hospital staff, who scolded, abused and even beat patients also features prominently in the report. So are delays in getting attended to in health institutions, particularly in the labour ward, where witnesses complained of being neglected during labour, in some cases ending in delivering unattended within the hospital. An example is the case of a woman who waited at the out-patients from 5am to 4pm before being admitted to the labour ward, ending up with a stillborn child. Women complained of being admitted in overcrowded wards and sharing of beds; up to three women with their babies sharing one bed, even when some of them were still bleeding, which exposed them to potential risk of infection, including HIV and Hepatitis B. Detaining of women for non-payment of hospital charges obviously contributes to congestion in hospital wards.

There were complaints of frequent lack of essential medicines, equipment, commodities and supplies in public health facilities resulting in denial of services to the needy. It was common in most public facilities for patients to be asked to purchase medicines, gloves and dressings, besides being referred to private institutions for specialised radiological and ultrasound diagnostic examinations. Essential resources for effective provision of sexual and reproductive health services were lacking in many health facilities. For example, many lacked the drugs needed for post-exposure prophylaxis (PEP) following sexual abuse including rape. The Inquiry established that non-availability of family planning commodities was a fundamental barrier to accessing comprehensive family planning in Kenya, this being illustrated by the frequent stock outs of commodities. There were complaints of frequent shortages of various contraceptives which denied clients a wide choice of family planning methods.

Several witnesses complained of negligent actions by doctors and midwives, for example, forgetting items such as surgical instruments or swabs in a patient’s abdomen; performing procedures such as hysterectomy without prior informed consent; poorly managed labour leading to ruptured uterus, maternal morbidities such as VVF and RVF, intra-uterine foetal death or a mentally handicapped child,. Other examples of negligent actions or omissions were performing episiotomy and failing to repair it, and failure to recognise accidental injury during surgery and failing to repair it immediately. There were women who complained that not enough information was given to them about the various diagnostic and treatment modalities they had been subjected to by health providers. In particular, there was inadequate information given to the patients before and after surgical procedures.

 The Report cites an article published in The Daily Nation Newspaper of 18th January 2011 on a case of maternal death associated with abortion:

“A woman aged 40 years who was held at Murang’a police station for allegedly procuring an abortion died after she developed complications while in the police cells. The Police said the woman was reported to have terminated the pregnancy by swallowing some chemical, and locked her up in a cell at the police station. They said she later developed complications and was being rushed to hospital when she died en route.”

 It can be argued that had the police taken the woman to a health care professional, instead of holding her in remand at the police station, she most likely would have survived. In other words this was a case of preventable death associated with denial of enjoyment of right to health. Yet this was after the promulgation of the Constitution of Kenya 2010 which has relaxed the rigidity on termination of pregnancy that existed previously. Article 26 (4) permits safe abortion if in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law.

What can be learned from the above case studies?

Clearly, they demonstrate that Kenya has yet to address the well known factors and barriers that have over the years sustained the prevailing high rates of maternal and newborn mortality and morbidity. Maternal health services that are inaccessible, non-affordable and of poor quality, have been perpetuated by several serious weaknesses in the health systems- inadequate capacity in terms of human resources and health infrastructure, negligence and malpractices especially among over-worked de-motivated health service providers, and various socio-cultural barriers, among others. Addressing these barriers is a prerequisite to meeting local and international goals and targets including the Vision 2030 and Millennium Development Goals.

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[i] A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya

Barriers to enjoyment of health as a human right in Africa

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

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

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

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

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

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

Barriers to enjoyment of Right to Health

1. General issues

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

2. Inadequate Funding to Health sector

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

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

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

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

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

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

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

Source: The Millennium Development Goals Report 2011

 

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

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

 

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

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

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

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

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

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

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

Addressing barriers to enjoyment of right to health

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

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

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

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

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

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

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

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

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