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

Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?

The findings of a recent Public Inquiry into violations of sexual and reproductive health (SRH) rights in Kenya highlight several factors which underlie the high and increasing rates of maternal mortality in Kenya. This inquiry undertaken by the Kenya National Commission on Human Rights (KNCHR) during 2011 had the overall aim to establish the extent and nature of violation of sexual and reproductive health (including maternal health) rights and to recommend appropriate redress measures.

‘The Public Inquiry Panel receiving evidence from a witness in Kitale’ 12-13 July 2011’

Source: knhcr.org

‘Maternal health’ refers to the health of women during pregnancy, childbirth and the postpartum period (usually up to 42 days). As such, the right to maternal health should encompass access to antenatal care services; delivery services, including delivery by caesarean section where necessary; essential newborn care services and postpartum care services especially during the first 48 hours of delivery. Provision of these services requires availability of trained service providers (midwives, nurses, doctors and clinical officers) at all times and the capacity of facilities to respond to emergency cases, adequate physical facilities, and adequate equipment and supplies including essential medicines and vaccines.

Improving maternal health is the fifth Millennium Development Goal (MDG5). It has two targets: 5.A: Reduce by three quarters between 1990 and 2015, the maternal mortality rate; and 5.B: Achieve, by 2015, universal access to reproductive health. The indicators to show attainment of these targets are as follows: 5A- Maternal Mortality Ratio (MMR) and Proportion of births attended by skilled health personnel; and 5B- Contraceptive prevalence rate (CPR); Adolescent birth rate; Antenatal care coverage; and Unmet need for family planning. Analysis of the latest available data on Target 5A shows that MMR in Kenya remains high and has not started showing any downward trend, nor has there been an increase in the proportion of births attended by skilled health personnel. In the case of Target 5B, on the other hand, it is encouraging to note the recent rising trend in CPR which, if sustained, may get close to the figure projected for 2015.

The factors behind the high and increasing levels of maternal mortality in Kenya fall in the following broad categories: widespread poverty; limited access to health care services; limited availability of skilled attendance at childbirth including inadequate referral systems; and high prevalence of negative socio-cultural practices such as early marriage and FGM. A key cross-cutting factor is inadequacy of funding to the health sector, and disproportionate allocation for reproductive health services within the health budget.

The right to maternal health care services is recognized or implied in several international, regional and national instruments, which many African governments including the Government of Kenya have ratified. Among these are: The Covenant on Economic, Social and Cultural Rights (1966); The International Conference on Population Development Programme of Action (1994); The United Nations Millennium Development Goals (2000); The Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009); The Constitution of Kenya, 2010 (Article 43 (a); The National Reproductive Health Policy 2007; and The Prohibition of Female Genital Mutilation Act 2011.

In these, the State is obliged to fulfill SRH Rights ‘progressively’, depending on the resources available to them. The state is obliged to show that it is making ‘measurable progresses’ towards the full realization of the SRH Rights and to restrain from adopting ‘regressive measures’. At the same time, there are those rights for which the state is under obligation to effect immediately, for instance, the obligation to respect an individual’s freedom to decide freely if, when and how often to reproduce and the obligation to ensure freedom from discrimination and from degrading treatment.

The core obligations that are relevant to SRH Rights, which states are under obligation to fulfill immediately, include ensuring:

• Access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;
• Access to essential drugs, as defined under the WHO Action Programme on Essential Drugs
• Equitable distribution of health facilities, goods and services including trained health personnel;
• Availability of reproductive health services including maternal and child healthcare;

A human rights-based approach to reproductive health care recognizes that all human rights are universal, interrelated, indivisible, and interdependent and are inherent in all human beings. It acknowledges that sexual and reproductive rights cannot be realized without the realization of other broader human rights, for example, the right to information, privacy and confidentiality and education.

The status of maternal health rights is determined by the effectiveness maternal health care services at all levels, namely in terms of: accessibility, availability, quality, affordability and acceptability. From the Public Inquiry findings the following conclusions can be made:

• The physical accessibility of delivery services is an important issue of concern especially in the arid and semi-arid zones where significant percentages of the population must travel long distances to access health facilities.
• Many facilities lack transportation support for maternity emergencies. There was evidence that most facilities in rural areas were ill equipped to handle emergency deliveries and women who needed C-sections in small facilities often died or lost their babies because they could not be transferred to a higher level in good time.
• Lack of safe abortion services in Kenya has resulted in those seeking termination of pregnancy to resort to crude and unsafe methods, often with fatal consequences. There is a lack of awareness regarding provisions in the Constitution of Kenya 2010 (Article 26(4)) among healthcare providers and the general public.
• The quality of maternal health services countrywide remains an issue of serious concern. Some of the key quality issues that have been highlighted are: lack of basic supplies such as cotton wool, pads, gloves, syringes, surgical blades, linen to wrap babies, anaesthesia, disinfectants, medicines, bed sheets, and blankets; dirty and unhygienic conditions; women forced to share beds or sleep on the floor; and the lack of food and hot water for bathing, etc. Overall, the factors that undermine the quality of maternal health services in Kenya were summarized as: (a) Lack of supplies and equipment; (b) Understaffing and lack of training and supervision; (c) Negligence and unethical practices by health providers; and (d) Weak Referral System.
• Non-affordability of services is a serious impediment to accessing maternal health care throughout the country. 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 maternal health services.
• Acceptability of maternal health services- evidence from the Inquiry indicated that some communities did not utilize skilled delivery services because of cultural restrictions, mainly taboos regarding attendance by male nurses, which was prevalent among the Muslims in upper Eastern and North Eastern Kenya, as well as among the Sabaot of Western Kenya. These cultural preferences, together with the chronic shortage of skilled professionals in these areas, and the non-affordability of fees for services, come out as the main factors that perpetuate the demand for the Traditional Birth Attendants (TBAs).

Based on its findings the Public Inquiry concluded that women in Kenya continue to die or suffer disability due to preventable causes. The Inquiry notes that the causes of these deaths prevail against the backdrop of the myriad international and regional human rights frameworks and commitments that Kenya is a party to and the national legal, policy and institutional frameworks that are aimed at enhancing maternal health. From the foregoing therefore, the Public Inquiry concluded that Kenya is still far from realizing the maternal health rights and has made a number of recommendations to government and other stakeholders that are essential in working towards the realization of maternal health rights in Kenya, and the achievement of MDG5 and Vision 2030 goal.

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

ABSTRACT[1]

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

Is it time for a comprehensive Reproductive Health Act for Kenya?

A Presentation made at the Kenya Medical Association State of Maternal Mortality in Kenya Conference held at the Kenyatta International Conference Centre, Thursday 15th September, 2011

Read or download A Comprehensive Reproductive Health Act for Kenya >>>>

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

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

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

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

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

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

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

UPDATE November 25, 2011:

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

[1] Daily Nation November 25  2011, http://www.nation.co.ke/News/4000+jobs+lined+up+for+nurses+/-/1056/1278796/-/tc1c29/-/index.html

 

Women have the right to safe abortion services within the law

Kenya’s constitution confers to all citizens the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care (Article 43 (1a)). Further, Article 26(4) specifies grounds upon which abortion may be legally provided; specifically, “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”. Safe abortion services, as provided by law, therefore need to be available, provided by well-trained health personnel supported by policies, regulations and a health systems infrastructure, including equipment and supplies, so that women can have rapid access to these services (WHO).

It is more efficient to provide legal safe abortion services within the context of Comprehensive Abortion Care (CAC) system that aims to reduce the risk of unwanted (unplanned) pregnancy. Morbidity and mortality related to abortion can be prevented at the following three levels: (a) Primary level- Prevent unwanted pregnancy by providing contraceptive information and counselling, and increasing access to contraceptive services. (b) Secondary level- Prevent unsafe abortion through provision of counselling in early pregnancy, respecting women’s informed choice, and ensuring access to safe medical termination of pregnancy for those who so choose. (c) Tertiary level- Provide post-abortion care (PAC) services: clinical management of complications of unsafe abortion, and prevention of future unsafe abortion through contraceptive counselling and services.