Tag Archives: Millennium Development Goals

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.

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


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

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

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

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

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

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

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

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

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

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

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

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

Forgetting Them Is Not An Option

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Figure 1: Maternal mortality ratio by country, 2008

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

Who is a skilled attendant?

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

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

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

Does skilled attendance at birth lower maternal deaths?

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

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

Will skilled attendance result in reduced maternal deaths in Africa?

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

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

  • · Development of human resources for health- skilled attendants

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

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

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

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

  • · Creating an enabling environment for skilled attendance

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


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

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

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

Related links:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[xix] Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

What if the HIV epidemic first manifested in poor countries?

By Japheth Mati

The first WHO report on neglected tropical diseases[i] highlights the importance of a class of diseases which though medically diverse, are grouped together because all are strongly associated with poverty, all flourish in impoverished environments and all thrive best in tropical areas, where they tend to coexist. Most are ancient diseases that have plagued humanity for centuries. These diseases remain largely silent, as the people affected or at risk have little political voice. As a result, they have traditionally ranked low on national and international health agendas, allowing them to continue causing massive but hidden and silent suffering, and frequently kill, though not to the same extent as in the case of HIV and AIDS, tuberculosis or malaria.

The response to the continuing presence of the neglected tropical diseases (NTDs) in most countries in the Tropics stands in sharp contrast to the unparalleled achievement in addressing the HIV epidemic. The first case of AIDS was diagnosed in 1981. Two years later, in 1983 the HIV virus was identified, and in 1985 the FDA approved the first HIV antibody test, making it possible to diagnose the disease more precisely and to screen individuals (and blood) for the infection. In 1987 the FDA approved the first antiretroviral drug AZT (ziduvidine). Thus, despite remaining a serious global challenge, HIV had changed within a period of less than a decade from being essentially a fatal condition to become a chronic illness, thanks to the unprecedented global cooperation and commitment of massive resources for HIV research and development (R&D) activities.

Source:Working to overcome the global impact of neglected tropical diseases, First WHO report on neglected tropical diseases, 2010

Funding for Research & Development (R&D): HIV and AIDS versus NTDs

From the 1990s until 2009, funding for the HIV epidemic increased substantially[ii]. In 2008, an estimated $15.6 billion was spent on HIV and AIDS compared to $300 million in 1996. These funds mainly derived from donations from national governments, multilateral funding organisations, and private funding. In 2009 the United States of America was the largest donor in the world, accounting for more than half of disbursements to HIV R&D by governments. DFID is the world’s second biggest bilateral donor for HIV/AIDS.

On the other hand, R&D of drugs for NTDs has been very significantly under-funded. The first comprehensive survey of global spending on R&D for neglected diseases[iii], showed that in 2007, nearly 80% of the global investment into R&D of new medical products[iv] was consumed by three diseases- HIV/AIDS, TB, and malaria. Many NTDs, responsible for killing millions of people in developing countries, shared the remaining 20%; each received less than 5% of global funding. These diseases include Filariasis, Schistosomiasis, Onchocerciasis, Sleeping sickness, Leishmaniasis (kalar-azar), Chagas disease, Guinea-worm, Dengue, diarrhoeal illnesses, worm infestations, Pneumonia, Meningitis, Leprosy, Buruli ulcer, Trachoma, Rheumatic fever, Typhoid and Paratyphoid fever, and Rabies.

What is peculiar about the HIV epidemic?

AIDS as a disease entity was first reported in 1981 among homosexual men in the United States, and for some time the disease was considered peculiar to homosexuals, being variously labeled “the gay cancer”, “the gay plague” and “the gay-related immunodeficiency disease [GRID]”). These first cases 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’. No wonder, within less than a decade, several drugs had already received FDA approval. Since then, HIV disease has engulfed the world, and the majority of the cases now live in developing countries. Nevertheless, it is possible that the conscience and momentum built up in those early years continue to play a significant role in sustaining international support for HIV activities.

What is peculiar about the neglected tropical diseases?

The nature of NTDs differs in several respects from HIV[v]. Generally, although these diseases affect the poor and marginalized populations living in rural and urban areas, they are almost exclusively limited to the tropics. These are people that cannot readily influence government decisions that affect their health, and often seem to have no constituency that speaks on their behalf. Also, unlike HIV, most NTDs generally do not spread widely, since their distribution is restricted by climate and its effect on the distribution of vectors and reservoir hosts; in most cases, there appears to be a low risk of transmission beyond the tropics. Consequently, not much is spoken about the impacts of the NTDs, nationally or internationally.

The neglected tropical diseases, also dubbed the ‘ancient companions of poverty’, have an enormous impact on individuals, families and communities in developing countries in terms of disease burden, quality of life, and loss of productivity aggravating poverty, as well as the high cost of long-term care. They constitute a serious obstacle to socioeconomic development and quality of life at all levels. WHO estimates that these diseases blight the lives of 1 billion people worldwide and threaten the health of millions more[vi]; they are a serious obstacle to the achievement of health-related Millennium Development Goals.

These diseases can, at relatively low cost, be controlled, prevented and possibly eliminated using effective and feasible solutions, such as the five strategic interventions recommended by WHO[vii].

What if the HIV epidemic first manifested in poor countries?

The answer to this philosophical question may never be known. However, going by the example of the dilatory international response to NTDs to date, it is worrying to imagine what the status of the HIV epidemic would be if it first manifested in poor countries.

[i] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva 

[iv] Total investment was about $US 2.5 billion.

[v] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vi] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vii] These are: preventive chemotherapy; intensified case management; vector control; the provision of safe water, sanitation and hygiene; and veterinary public health.

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