The current national emergency in Kenya is the result of the unfortunate convergence of several events linked to the rainfall patterns that characterise the country. Drought-like conditions typify the arid and semi-arid areas in Kenya while erratic rainfall patterns have simultaneously caused crop failure on a massive scale in the agricultural food basket. Compounding the poor harvests has been the blight on stored grain in national grain reserves caused by Aflatoxin, a toxin created by a grain mould. Food shortages and the fear of famine are resulting in abnormal grain price increases which, in turn, are having a negative impact on terms of trade for vulnerable populations and food security in general.
Several years of inadequate rains in Kenya have led to a poor cropping season, prompting President Mwai Kibaki to declare the famine facing the country a "national disaster". This year, in five out of the country's seven provinces (and over 26 districts in all), food production will be about 40 per cent of what is needed.
Currently, up to 2.3 million people are in dire need of food and require emergency relief assistance urgently. This number includes 1.8 million persons requiring general food distribution and 0.5 million school-going children for whom assistance under the school-feeding programme is necessary. Close to one million children are currently benefiting from school feeding initiatives. Failure of the short rains in October could conceivably increase the number of people having need for emergency relief food assistance by a further one million. The total food requirement for the next six months is estimated to be 166,000 MT.
Main Public Health Issues and Concerns
Reproductive and child health
Significant gains in reproductive health manifested in the decline in fertility rate-from a high Total Fertility Rate of 8.1 births per woman in 1977-78 to 4.7 in 1998 and increase in contraceptive prevalence rate from a low level of 7% achieved in 1978 to a higher level of 39% attained in 19981-have been achieved over the past two decades. However, the latter has now stagnated at 39%, according to the Kenya Demographic and Health Systems (KDHS) 2003 preliminary report , leading to an upward trend in Total Fertility Rate (TFR). Maternal mortality, which is the leading cause of death among women of reproductive age, is essentially due to hemorrhage, sepsis, eclampsia, obstructed labour, unsafe abortion and anaemia. STI/HIV/AIDS is also a major contributor. Nonetheless, the capability of nearly all district hospitals to perform caesarean deliveries in case of emergency has greatly reduced deaths due to obstructed labour at the district level.
Although significant gains in child health were recorded earlier, these have not been sustained as the major indicators; Infant Mortality Rate (IMR) and Under Five Mortality Rate have been on an upward trend. IMR recorded increases from 62 per 1,000 live births achieved in 1993 to 78 per live births in 2003 while the Under Five Mortality Rate witnessed an augmentation of 96 per 1,000 births achieved in 1993 and 114 per 1,000 live births in 2003 respectively2. Poor access to health care services, especially vaccines and other essential services, as well as a weak referral system are some of the contributing factors to the decline in IMR and Under-five mortality.
Significant progress has been made in the eradication of poliomyelitis, elimination of neonatal tetanus and control of measles. The targets for eradication of the guinea worm disease and elimination of lymphatic filariasis and leprosy have been attained. Other parasitic diseases of epidemiological concern such as schistosomiasis, helminthiasis and leishmaniasis will need to be addressed. However, new emerging and re-emerging diseases continue to pose a threat to the health of Kenyans.
Malaria has remained the leading cause of morbidity and mortality in Kenya. In most parts of Kenya, malaria accounts for over 30% of all new attendances at outpatient departments, and complications of malaria are frequently posing a major burden on the health system. Malaria fatalities in hospitals range from 3.5% to 8.5%. An estimated 34,000 children below the age of five years will die as a direct consequence of malaria infection in Kenya during the year 2002, that adds up to 93 children per day. Recurrent outbreaks of highland malaria and the widespread emergence of drug resistance strains have aggravated the problem of malaria. Fevers and upper respiratory tract diseases are the other commonest causes of ill health, accounting for about 50 percent of all outpatient morbidity and 20-25 percent of all reported deaths. Other causes of morbidity beside malaria and upper respiratory diseases include skin diseases, diarrhea, intestinal diseases, and malnutrition/anaemia.
Tuberculosis is one of the diseases of poverty that has assumed epidemic proportions; 95,310 new cases were registered in 2003 compared to 12,000 cases in the early 1990s. The directly observed treatment short-course (DOTS) has been adopted as a national strategy in Kenya, and the treatment success rate has improved to about 80% in 2003. New initiatives addressing the TB burden have been put in place such as TB/HIV collaborative activities, community involvement in TB care, Private sector involvement, and pilot projects for TB control in the congregate settings. Case detection rates have remained low at 49%. The National TB programme has continued to attract more funding from areas for instance the Global Fund 2nd round.
By 2003, over 1.25 million people in Kenya had been infected with HIV with a national sero-prevalence rate of 6.7%. This trend is encouraging, and the recent data indicates possible stabilization and decline in national sero-prevalence. Prevention activities have been continued with new treatment concepts coming on board. The global launching of the "3 by 5 initiatives" took place in Nairobi on 1 December 2003. This initiation prompted Kenya to reflect actions within the line of ART. Support of US$ 200,000 was extended to the country to kick-start the "3 by 5 initiatives". The country's target for these is to enable 95,000 AIDS patients to access the Antiretorvials (ARV's) through the efforts of WHO and partners in Kenya by the end of the year 2005. Considering the end of 2003, only 11,000 patients were accessing ARV's and most of them in the private sector.
Emerging diseases and epidemics
In the current drought emergency situation in the country, there are major health challenges that are anticipated as lessons learned from previous drought situations. Key challenges include protein -energy malnutrition, micronutrient deficiency, and disease outbreaks especially increase in diarrhoeal diseases which is associated with the lack of safe drinking water. Population movement in search for water and food sources exposes this population to additional health risk, especially to communicable diseases like measles and cholera. The country has experienced emerging disease outbreaks in the recent past mainly as a result of food insecurity and drought, including AFLATOXIN food poisoning which affected five districts in the concerned areas. In addition, leptospirosis in western Kenya and Cholera outbreaks in Kwale occurred as a result of poor water quality.
Malnutrition is common among the under-fives, with mild stunting being 37%, severe stunting 18%, mild wasting 6% and severe wasting 1.3%. It was estimated that 23,000 deaths among under-fives were associated with malnutrition in 2000. Micronutrient deficiency is also a major problem. Up to 76% of children under five are anaemic or are deficient in vitamin A and zinc; 50% of women of childbearing age are also anaemic and 40% are deficient in both vitamin A and zinc. Other conditions contributing to the growing burden of these diseases include cardiovascular disorders, hypertension, diabetes, chronic respiratory infection, mental illness as well as health conditions related to tobacco use, drug abuse and injuries. Changing life styles are a major contributor with less physical activities. The country is in the process of domesticating the Tobacco Control Bill after signing and ratifying the WHO Framework Convention on Tobacco Control. Needs assessment and risk factor surveillance for the common NCDs is to take place soon. Advocacy for mental health, to be integrated into the general health care system at the district level, is on-going. The country has also passed and launched the road traffic policy putting in place road safety measures to curb road damage which had been a big problem in the country.
Environmental Health Profile
The rapid urbanization and population growth has not been matched with infrastructure development and economic growth which therefore poses challenges to the improvement of environmental health in Kenya. Moreover, the management of solid wastes, liquid wastes, human wastes, occupational health, food safety and chemical safety continues to present defiance.
The constraints in the sanitation sector include the low investment/resource mobilization and the low capacity of households being able to provide adequate sanitation. Difficult soil conditions pose challenges in the selection of appropriate technologies. Issues of customs, taboos and low community participation affect negatively the rapid provision of sanitation. The free primary education policy has increased the number of pupils in primary schools but without a corresponding augmentation in the number of sanitation facilities.
The resultant effect has been the decline in sanitation coverage (46% in 1992, and 42% in 1996). Epidemics of environmental related diseases reported during the last two years included cholera, typhoid and other diarrhoeal diseases. Other ailments of importance were Aflatoxicosis and Leptospirosis.
In response to the low status of sanitation and the outbreak of diseases, the government has put into place strategies that include the Participatory Hygiene and Sanitation Transformation (PHAST), Healthy Cities initiative, Hazard Analysis Critical Control Points (HACCP), water quality surveillance and occupational health strategies. In schools, Participatory Hygiene and Sanitation Education (PHASE) has been piloted and is ready for scaling up. A sanitation policy has been developed and will give guidance in the delivery of services in sanitation.
The approval of the sanitation policy by parliament will be crucial in the improvement of sanitation in Kenya. In addition, it will be necessary to develop a sanitation strategic plan for the implementation of the sanitation policy.
Health policies and systems
The Kenya Health Policy Framework (1994) sets out the policy agenda for the health sector up to the year 2010. This includes strengthening of the central public policy role of the Ministry of Health, adoption of an explicit strategy to reduce the burden of disease, and definition of an essential cost effective health care package. To operationalize this Health Policy Framework Paper, the National Health Sector Strategic Plan (NHSSP, 1999-2004) was developed in 1994. The strategic plan emphasized the decentralization of health care delivery through redistribution of health services to rural areas. The plan is currently being revised to reflect the Poverty Reduction Strategy Paper (2001-2004) agenda. The new plan focuses on the essential key priority packages based on the burden of disease and the required support systems to deliver these services to the Kenyans.
Major players in the health sector include the government represented by the Ministry of Health (MoH) and the Local Government, private sector and non-governmental organization (NGOs). The organization of Kenya's health care delivery system revolves around three levels, namely the MoH headquarters, the provinces and the districts. The headquarter sets policies, coordinates the activities of NGOs and manages, monitors and evaluates policy formulation and implementation. The provincial tier acts as an intermediary between the central ministry and the districts. It oversees the implementation of health policy at the district level, maintains quality standards and coordinates and controls all district health activities. In addition, it monitors and supervises district health management boards (DHMBS), which supervises the operations of health activities at the district level.
The district level concentrates on the delivery of health care services and generates their own expenditure plans and budget requirements based on the guidelines from the headquarters through the provinces.
Government allocation to the MoH has been on the increase in the last three years. Total approved and actual expenditures (development and recurrent) augmented for the fiscal years of 1999/2000 to 2002/2003: the expenditures added up from about Kshs.10 billion in 1999/2000 to about Kshs.15 billion in 2002/03, with the actual expenditures remaining at about the same level as the approved budget in all fiscal years.
The recurrent allocation has increased in absolute terms and as a percentage of GDP where recurrent stands at about 1.3% of GDP while development is below one per cent of GDP4. This signifies that the recurrent allocations have consistently been higher than the development allocation. This scenario can be explained by the fact that the wage component of the recurrent budget constitutes over 55% of the recurrent allocation and the three year increment to the total budget (both recurrent and development) only affects recurrent and more so the wage component.
Health expenditure as percentage of total Government spending has been around 8% for the last three fiscal years. Both Recurrent and Development expenditures represent only 1.5% of the GDP while per capita total health spending currently accounts for around Kenya shillings 500 (or US$6.2), showing that in the last three years Kenya's health spending remains low.
Considering what Kenya is spending as percentage of GDP (8%) and in per capita terms (US $ 6.2), it is evident that Kenya will have to double its expenditure to even attain the recommended WHO spending of 15% (US $11) set up in the Abuja declaration. To meet the two commitments, Kenya will need to double its allocation to the health sector.
Low income countries like Kenya, spend as little as 11 US $ per person per year of which 6 US$ comes from budgetary resources that also includes donor contributions. The balance of about 5 US $ mainly comes from out-of-pocket expenditures. This falls far below the WHO's recommended US$34 per capita, and even below the Government's commitment to spend 15% of total spending following the Abuja Declaration5. Cost sharing mechanisms introduced in the mid-1990s to augment the government allocation to the health sector constitute around 8% of the non-wage recurrent budget of the MoH and about 21% of the non-wage recurrent budget of the MoHh (excluding Kenyatta National Hospital). However, waivers and Exemption that was introduced to cushion the poor as a way of ensuring that government's equity principle that all Kenyans have access to basic health care services has not functioned satisfactorily, posing serious challenges to accessibility to health care by the poor in an environment of growing poverty.
Health services: access and quality
The health system in Kenya is organized and implemented through a network of facilities organized in a pyramidal pattern. The network starts from dispensaries and health clinics/posts at the bottom, up to the health centers, sub-district hospitals, district hospitals, provincial general hospitals and at the apex there is the Kenyatta National Hospital. Facilities become more and more sophisticated in diagnostic, therapeutic, and rehabilitative services at the upper levels.
The MoH is the major financier and provider of health care services in Kenya. Out of the over 4,500 health facilities in the country, the MoH controls and runs about 52% while the private sector, the mission organizations and the Ministry of the Local government run the remaining 48%. The public sector controls about 79% of the health centers, 92% of the sub-health centers, and 60% of the dispensaries. The NGO sector is dominant in health clinics, maternity and nursing homes (94%) and medical centers (86%). Both the public and the NGO sector have an almost equal representation of hospitals.
The health sector is faced with inequalities. Only 30% of the rural population has access to health facilities within 4 km, while such access is available to 70% of urban dwellers. The arid and semi-arid north and north eastern areas of Kenya are underserved due to limited number of health facilities.
The quality of health services is reputedly low due to inadequate supplies and equipment as well as lack of personnel. Moreover, regulatory systems and standards are not well developed. There are deliberate efforts by the government to shift towards decentralization of health care provision. The MoH has embarked on developing the legal and regulatory framework and capacity building to devolve the entire authority for planning and financial management to districts.
1 KDHS 2003, preliminary report
2 KDHS 1993, 1998 and 2003
3 Country Cooperation Strategy 2002-05
4 PER 2003, 2004
5 Macroeconomic and Health: Investing in Health for Economic development (2001)
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