The arid and semi-arid lands (ASAL) of Kenya are exposed to recurrent climate shocks, especially drought and floods, which interact with local conditions to cause food, nutrition, and water insecurity, and consequently malnutrition, morbidity, and death. Health and nutrition impacts of climate shocks are distributed unevenly in populations according to patterns of vulnerability defined by geography and social differences, such as gender, socioeconomic status, disability, ethnicity, and age. The formal health system must contend with surges in demand for health and nutrition services associated with climate shocks, which are likely to intensify because of climate change, whilst meeting the different needs of these populations. Since provision of health and nutrition services in Kenya was devolved to county governments in 2013, there is an urgent need to understand how the Kenyan health system at the county level can be made more shock responsive so that services can be scaled up to meet climate-related demand surges. Shock responsiveness is determined by the use of resilience capacities to absorb variable caseloads, and to adapt and transform the health system to improve responsiveness during and across shock events.
This first working paper produced by Maintains Kenya presents exploratory research on how county-level actors prepare for and respond to climate shocks. It seeks to provide practical insights on what is working and not working for health system shock responsiveness.
Specifically, it analyses experiences and perspectives in relation to recent drought and flood events in 2019 in the northern Kenyan counties of Marsabit, Turkana, and Wajir. Shock responsiveness is investigated within and across the formal health system building blocks of governance, finance, information systems, medical/nutrition products and infrastructure, and the workforce.
The key emerging messages from this analysis are the following:
New disaster policies and laws have created county-level institutional frameworks for preparing for and responding to climate shocks in the ASAL of Kenya.
National Drought Management Authority (NDMA) early warning bulletins are used by county government and non-governmental actors to raise awareness of and plan for climate shocks, across sectors.
With the exception of nutrition services, national and local government does not prioritise the planning and resourcing of capacities to respond to health-related climate impacts.
Health facilities and services remain under-funded, especially during emergencies, and thus struggle to absorb additional caseloads associated with drought. This means that frontline health staff experience increased workloads, which result in them deploying coping strategies that adversely affect their productivity and wellbeing.
Because frontline workers are mainly women, coping strategies of working longer hours and reducing leave create additional burdens for women, on top of increased domestic workloads during drought, and reduce the time they have available to fulfil their gendered roles as caregivers, especially as many work at health facilities that are distant from their home.
There are multiple institutions, procedures, and tools in place for shock responsiveness, but they are not being effectively put to work for health and nutrition. County policies, contingency plans, and disaster financing prioritise other sectors over health, and early Climate shock responsiveness of the Kenya health system warning information does not provide specific guidance for health system decisionmaking and early action.
Responses are predominantly arranged after the onset of drought and floods, frustrating early action. Bureaucratic processes and politics delay financing and action, and coordination meetings and response planning are mainly reactive rather than anticipatory.
The health system is unable to adequately flex to accommodate surges in demand because of restricted budgets and cumbersome procedures for reallocating funds and temporarily posting staff to hotspots.
The Integrated Management of Acute Malnutrition (IMAM) Surge approach is increasing health information system capacities, enabling health facilities and county teams to communicate and analyse malnutrition admissions data against capacity thresholds in real time, to effectively detect drought-induced spikes in caseloads early, manage resources within and between health facilities, and alert decision makers to the deteriorating nutrition situation.
Connections between the formal health system and the informal community health system could be strengthened so that communities better participate in decision-making and share their knowledge to build trust in formal services and ensure the heath system is adapted to the specific contextual needs of communities of the ASAL.
The working paper concludes that the transition from donor-/non-governmental organisation-(NGO-) dependent emergency response to a climate shock-resilient health system is incomplete in Kenya. The ASAL face multiple shocks, overlapping in space and time, that make linear preparation, response, and recovery approaches inappropriate, yet the dominant mode of working is responding once a specific climate shock becomes an emergency, despite enhanced early warning and surveillance capacities. This is apparent in reactive rather than proactive decision-making, and financial and human resource management mechanisms. The challenge moving forward is to adapt and strengthen county mechanisms and decision-making to better include health and nutrition in shock-response arrangements, building on promising innovations such as IMAM Surge. At the same time, deeper transformative change towards a health system resilience paradigm is required, whereby the building blocks support capacities for continuous proactive absorption of and adaptation to surges and contractions in caseloads associated with the multi-shock context and highly variable climate of the ASAL, minimising the occasions when externally led emergency responses are required.