Women as caregivers: the consequences of changes in health provisioning on food and nutrition security among women in poor urban settings in Kenya

Case study

December 2007

Contents Page

Abbreviations..................................................................................iv1.0 Background.....................................................................11.1 Introduction...............................................................................12.0 Literature review and policy analysis...............................32.1 Globalization..............................................................................32.2 Poverty......................................................................................52.3 Education..................................................................................52.4 Health.......................................................................................62.4.1 Expenditure on health.............................................................72.4.2 Overview of the National Health Accounts (NHA)...................112.4.3 HIV and AIDS.........................................................................122.5 Brief overview of Kenya’s health care system............................132.6 Kenya health policy overview.....................................................142.6.1 Health policy evolution and framework...................................142.6.2 Organization of the health sector............................................152.6.3 Access and quality of health services......................................162.6.4 HIV/AIDS policy and regulatory framework............................162.7 Framework for reviewing health inequalities.............................173.0 Nakuru district profile.....................................................213.1 Location, size and population.......................................................213.2 Topography, geology and climate.................................................223.3 Breakdown of health facilities....................................................233.4 Administration/organization of the district health sector............243.5 Health information system (HIS)................................................253.6 Top ten causes of out-patient morbidity – 2003..........................253.7 Health organization in the district..............................................273.8 Food security and nutrition........................................................274.0 Kaptembwo informal settlement......................................314.1 The choice of Kaptembwo..........................................................314.2 About Kaptembwo.....................................................................314.3 Mapping of health provision points in Kaptembwo.....................325.0 Discussion and conclusion...............................................406.0 References.......................................................................44 List of Tables

Table 1: WHO health statistics of 2003...............................................6Table 2: Kenya health development index (HDI) rank – 152.............9Table 3: Health expenditure ratios ..................................................10Table 4: Administrative units and area of district by division...........21Table 5: Health parameters in Nakuru district – 2003......................23Table 6: Type of health facilities in Nakuru district by 2003.............23

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Table 7: Divisional distribution of health facilities............................24Table 8: Records personnel distribution in the district – 2003..............25Table 9: Disease morbidity pattern.....................................................26

List of Figures

Figure 1: Number of people in Nakuru district by age group...........22Figure 2: Morbidity trends and burden of disease in the district......25Figure 3: Monthly out-patient return of morbidity (2007)................35

Annex 1: Observational checklist for health facilities......................49

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Abbreviations

ACU - Aids Control UnitAFP - Acute Flaccid ParalysisAIDS - Acquired Immuno Deficiency SyndromeAIHD - African Institute for Health and DevelopmentAKIN - AIDS Kids of NakuruAMREF - African Medical and Research FoundationARI - Acute Respiratory InfectionARV - Anti-RetroviralASAL - Arid and Semi-Arid LandASK - Agricultural Society of KenyaCACC - Constituency Aids Control CommitteeCBO - Community-Based OrganizationCBS - Central Bureau of StatisticsCDN - Catholic Diocese of Nakuru CHAK - Christian Health Association of KenyaCHANIS - Child Health and Nutrition Information SystemDACC - District Aids Control CommitteeDARE - Development and Recurrent Expenditure DFID - Department for International DevelopmentDH - District HospitalDHAO - District Health Administration OfficerDHMB - District Health Management BoardDHMT - District Health Management TeamDMOH - District Medical Officer of HealthDOMU - District Outbreak Management Unit EGC - Evangelical Gospel Church EQUINET - Regional Network on Equity in Health in East and Southern AfricaERS - Economic and Recovery StrategyFBO - Faith Based OrganizationFGD - Focus Group DiscussionFHI - Family Health InternationalFP - Family PlanningFPE - Free Primary EducationFPAK - Family Planning Association of KenyaFY - Financial YearGATS - General Agreement on Trade in ServicesGAVI - Global Alliance for Vaccines and ImmunizationGDP - Gross Domestic ProductGER - Gross Enrollment RateGFATM - Global Fund against AIDS, Tuberculosis and MalariaGNP - Gross National Product

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GoK - Government of KenyaHBC - Home-based CareHCFD - Health Care Financing DivisionHDI - Human Development IndexHIS - Health Information SystemHIV - Human Immune VirusHMIS - Health Management Information SystemsHPI - Human Poverty IndexHSR - Health Sector ReformsHRD - Human Resources and DevelopmentHSRS - Health Sector Reform SecretariatICRC - International Committee of the Red Cross IEC - Information Education and CommunicationIMF - International Monetary FundIPAR - Institute of Policy Analysis and ResearchIRIN - Integrated Regional Information NetworksJPPI - Joint Public – Private InitiativeKANCO - Kenya NGO AIDS ConsortiumKDHS - Kenya Demographic Health SurveyKEPI - Kenya Expanded Programme on Immunization KHPF - Kenya Health Policy FrameworkKHPFIAP - Kenya Health Policy Framework Implementation Action Plan KMTC - Kenya Medical Training CollegeKSPA - Kenya Service Provision AssessmentLA - Local AuthoritiesMCH - Maternal and Child HealthMDG - Millennium Development GoalMOF - Ministry of FinanceMOH - Ministry of HealthMRC - Ministerial Reform CommitteeMTEF - Medium Term Expenditure Framework NACC - National Aids Control Council NARC - National Rainbow CoalitionNASCOP - National AIDS and STI Control ProgrammeNCAPD - National Coordinating Agency for Population and DevelopmentNGO - Non-Governmental OrganizationNHA - National Health AccountsNHIF - National Health Insurance FundNHSSP - National Health Sector Strategic PlanNSHIF - National Social Health Insurance FundOOP - Out-of-PocketPACC - Provincial Aids Control CommitteePGH - Provincial General Hospital

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PMTCT - Prevention of Mother to Child TransmissionPRSP - Poverty Reduction Strategy PaperRHDC - Rural Health Demonstration Centre RTI - Respiratory Tract InfectionSAP - Structural adjustment programmeSID - Society for International DevelopmentSSA - Sub-Saharan AfricaSTI - Sexually Transmitted InfectionSWAK - Society for Women and AIDS in KenyaTAPWAN - The Association of People living with AIDS in NakuruTB - TuberculosisTRIPS - Trade-related Intellectual Property RightsUN - United NationsUNAIDS - The Joint United Nations Programme on HIV/AIDSUNDP - United Nations Development ProgrammeUNESCO - United Nations Educational, Scientific & Cultural Organization UNICEF - United Nations Children’s FundUPE - Universal Primary EducationURTI - Upper Respiratory Tract InfectionUTI - Urinary Tract InfectionVCT - Voluntary Counselling and TestingWHO - World Health OrganizationWMS - Welfare Monitoring StudyWTO - World Trade Organization

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1.0 Background

1.1 Introduction

Statistics from Kenya’s Ministry of Health (MOH) show an increasing share of health expenditure which is taking place outside of the public sector in the form of out-of-pocket payments, especially among poor people (MOH, 2002). This report is part of the study that looks at the impact of health reforms on health provisioning in Kenya. The report endeavours to bring out the link between health provision and food and nutrition security among poor women in informal settlements in Kenya. The current health care patterns in Kenya are also linked to the past and the progress the MOH has made. The general objective, hypothesis and the research questions of the study are as outlined below:

General objective: To explore the consequences of globalisation led reforms in health care provisioning on women’s caring and health promoting roles, burdens and capabilities, and the consequences for household health and food security in poor urban Kenya.

Hypothesis to be tested: Globalisation led reforms in health provisioning have increased women’s roles and workloads of care with inadequate returns for their own health and nutrition and for that of their children under five years.

Research questions1. What changes related to health reforms have occurred in the provisioning of

health services over the last 10 years?a. What is the range of public and private health care services (Non-

governmental organization [NGO] and individual owned facilities) available to women in urban informal settlements of Nakuru?

b. What specific changes have occurred in public and private health care services as a result of commercialization of services in these areas focusing on cost and time?

c. What range and quality of services do each of the different providers offer? What gaps are there in health care provisioning among different providers and across major providers generally and specifically in relation to the major public health problems affecting women and children (focusing on malaria and diarrhoea among the under-fives and preventive services for maternal and child health - MCH)?

d. What cadre of providers are available in the different facilities (including outreach/mobile services)?

2. How does the nature of health provisioning affect women’s access to and use of health care services focusing on acute conditions among under-five

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children (malaria and diarrhoea) and preventive health services in terms of full coverage of vaccinations and ante-natal care?

a. What are the barriers and facilitators to access and use of the curative and preventive services?

b. How do the women access information about health services?c. What trade-offs do women make in using or not using the available

health care services?3. How do user charges in public health facilities and cost of private health

care affect women’s caring workloads?a. What do women do when faced with acute illnesses (diarrhoea and

malaria) for their under-five children?b. What do women do to meet their health promotion needs around

pregnancy and child immunization and nutrition?c. What roles, workloads and resources are associated with the actions

the women take (time and money spent on health care)?d. What role does consideration of cost play in the options for health

care available to women during their children’s illnesses and for preventive actions?

e. How do these health care roles, workloads and resources affect their personal and household dietary patterns?

The report is two-pronged. The first part entails a background literature review and policy analysis, while the second part provides details on the mapping of health provision points in Kaptembwo informal settlement. The review included some key informant interviews at the national and district levels focusing on health reforms and the situation in informal settlements. The review also assessed the nature of health care changes and provisioning at the global, national and district levels. The second part involved the research team’s visit to Kaptembwo in Nakuru district to map the health provision points. The process utilized observation and checklists (capturing the conditions of the various facilities). At the health provision points, the focus was on the type of services provided, the interaction between the health seekers and the providers, duration it takes to serve a client, and the status of the health facilities (equipment, materials and cleanliness).

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2.0 Literature Review and Policy Analysis

The process proposed for data collection for the Kaptembwo study is one that envisages building on information and refining the tools and questions as the study progresses. The first step as documented in the proposal entails background literature review and policy analysis. This section therefore details globalization; poverty, education and health situations in Kenya including the impact of HIV and AIDS; a brief overview of Kenya’s health care system and health policy; the framework for reviewing health inequalities; and a brief discussion on the entire section.

2.1 Globalization

Globalization, defined at its simplest, describes a constellation of processes by which nations, businesses and people are becoming more connected and interdependent across the globe through increased economic integration and communication exchange, cultural diffusion (especially of Western culture) and travel. It is an inescapable and primarily benign process of global economic integration, in which countries increasingly drop border restrictions on the flow of capital, goods and services. It is taken to be the process whereby national and international policy-makers promote domestic deregulation and external liberalization. The shift towards such a policy paradigm began in the 1980s with the adoption of domestic deregulation, trade liberalization, and privatization, the last often taking the form of cross-border acquisitions by multinational firms. The process intensified in the 1990s with the removal of barriers to international trade, foreign direct investments, and short-term financial flows. Globalization has a complex influence on health. Its effects are mediated by income growth and distribution, economic instability, the availability of health and other social services, stress and other factors. Health status is also affected by the initial conditions of each reforming country, i.e. the size and international specialization of its economy, the availability and distribution of assets, its human capital and infrastructure, and the quality of its domestic policies. Global market forces work efficiently in settings where access to public health services is widespread and social safety nets are in place. Countries like Mexico, Uruguay, Zimbabwe, Kenya, India and the Philippines, for example, all witnessed serious declines in income, and corresponding increases in poverty and poor health, among their rural populations following liberalization (reference?). Globalization may improve human health and development in some circumstances but damage it in others, especially when liberalization has been rapid and without government support to affected sectors and populations (Cornia & Paniccia, 2000).

Globally, the major vehicles or processes through which contemporary globalization operates are imposed macroeconomic policies. One category consists of the Structural adjustment programmes (SAPS) of the World Bank

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and IMF, which were the precursors to and a key component of today’s ‘free trade’ agenda, and the more recent Poverty Reduction Strategy Papers (PRSP) program of the World Bank and IMF, required for debt relief and, increasingly, for development assistance. A second category consists of enforceable trade agreements (notably those administered by the World Trade Organization - WTO) and associated trans-border flows in goods, capital and services. Third, official development assistance represents a form of wealth transfer for public infrastructure development in poorer nations. Fourth, there are ‘intermediary global public goods’ – the numerous yet largely unenforceable multilateral agreements we have on human rights, environmental protection, women’s rights, and children’s rights. These vehicles, in turn, have both positive and negative health effects on domestic policy space, by increasing or decreasing public sector capacity or resources and regulatory authority. Key domestic policies that condition health outcomes include universal access to education and health care, legislated human and labour rights, restrictions on health-damaging products, such as tobacco, or exposure to hazardous waste and environmental protection (Breman & Shelton, 2001).

Liberalization, whether through trade agreements or SAPs, lowers tariffs on imported goods. This has been particularly hard on developing countries, which derive much of their national tax revenue from tariffs and which lack the capacity to institute alternative revenue-generating sources. This affects their abilities to provide the public health, education and water/sanitation services essential both to health and to economic development. Global and regional trade agreements, in turn, are increasingly circumscribing the social and environmental regulatory options of national governments. National policies and resource transfers affect the abilities of regional or local governments to regulate their immediate environments, provide equitable access to health-promoting services, enhance generic community capacities (community empowerment) or cope with increased and usually increasingly rapid urbanization. At the household level, all of the above determine in large measure family income and distribution (under conditions of poverty, for example, when women control household income, children’s health tends to be better), health behaviors and household expenditures (both in time and in money) for health, education and social programs (Breman & Shelton, 2001).

In Africa, SAPs have had the effect of integrating countries into the global economy through the imposition of stringent debt repayments and liberalization of trade. SAPs have also resulted in significant macro-economic policy changes and public sector restructuring and reduced social provisioning, with negative effects on education, health and social services for the poor. A recent review of available studies on structural adjustment and health for a WHO commission states: “The majority of studies in Africa, whether theoretical or empirical, are negative towards structural adjustment and its effects on health outcomes”. Other instruments of globalization have further undermined the ability of developing country governments to provide health care for their

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populations. For example, the development of agreements under the WTO, notably Trade-related Intellectual Property Rights (TRIPS) and its interpretation by powerful corporate interests and governments, have already threatened to circumscribe countries’ health policy options. The best known case relates to the recent legal battle around the attempt by South Africa to secure pharmaceuticals, especially for HIV/AIDS, at a reduced cost. In 1997 Nelson Mandela signed into legislation a law aimed at lowering drug prices through “parallel importing” - that is importing drugs from countries where they are sold at lower prices - and “compulsory licensing”, which would allow local companies to manufacture certain drugs, in exchange for royalties. Both provisions are legal under the TRIPS agreement as all sides agreed that HIV/AIDS is an emergency. This was confirmed during the WTO meeting in Doha in 2001. The USA administration did not bring its case to the WTO but instead, acting in concert with the multinational pharmaceutical corporations, brought a number of pressures (e.g. threats of trade sanctions and legal action) to bear on the South African Government to rescind the legislation. This followed similar successful threats against Thailand and Bangladesh. However, an uncompromising South African Government, together with a vigorous campaign mounted by local and international AIDS activists and progressive health NGOs, forced a climb-down by both the US Government and the multinational pharmaceutical companies. Notwithstanding this important victory, the provisions of the WTO, particularly TRIPS and the General Agreement on Trade in Services (GATS) hold many threats for the health and health services of developing countries (Breman & Shelton, 2001).

Accompanying neoliberal reforms of the macro-economy have been health sector reforms (HSR). Key components of HSR include decentralization of management responsibility and/or provision of health care to local level, improvement of national ministry of health's functioning, broadening health financing options through, for example, user fees, insurance schemes and introduction of managed competition; and rationing of health care through the identification of public health and clinical “packages”, comprising a set of interventions. The combined effect of the above interventions together with the impact of HIV/ AIDS on the health workforce has resulted in a significant reduction in public provision of social (including health) services in SSA, and there is mounting evidence of a general decline in access to health services, affecting particularly the poor. This is starkly illustrated by immunization coverage, a sensitive marker of health service coverage, which has fallen during the 1990s. In recognition of the growing global health divide between North and South, the crisis imposed by HIV/AIDS and the resurgence of TB and malaria, as well as the inability of both governments and increasingly cash-strapped multilateral (UN) agencies to invest in health services, a number of Joint Public - Private Initiatives (JPPIs) have been recently launched. The best-known of these in health are GAVI (Global Alliance for Vaccines and Immunization) and the GFATM (Global Fund against Aids, Tuberculosis and Malaria) - (Hong, 2000).

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2.2 Poverty

Despite recent indications of economic resurgence in some sectors of the economy, the cumulative impact of 15 years of stagnating per capita income growth has meant that little progress has been made in reducing overall poverty, and it is likely that the conditions of some of the most vulnerable groups may have worsened. The rural poverty lines are Kshs. 1,667 and Kshs. 2,228 (food and food together with basic goods respectively) and the urban equivalents are Kshs. 2,255 and Kshs. 4,761 respectively. Poor economic growth, together with increasing inequality in the distribution of income and increasing rates of unemployment, has led to a rise in poverty levels such that the population in absolute poverty1 is currently at 17 million (46%) of the 36.9 million Kenyan population (GoK 2007a; 2007b). Poverty therefore remains a major impediment to fulfillment of basic needs of Kenyans especially women and children. On the one hand, the high incidence of poverty has greatly undermined the government’s ability to address the pressing needs in such critical sectors as primary health care, nutrition, and basic education. On the other hand, poor health and malnutrition serve to entrench poverty due to low productivity. Hence, only a rapid economic growth can lift the country out of this vicious circle of poverty. Governance, corruption, and inefficient use of public resources still remain critical barriers to the achievement of the national targets of poverty reduction (Ole Leliah, 2005).

The Human Poverty Index (HPI – 1) Value (%) for developing countries measures deprivations in three aspects of human development as the Human Development Index (HDI) (longevity, life expectancy, and a decent standard of living). Deprivations in longevity are measured by the percentage of newborns not expected to survive to age 40. Deprivations in knowledge are measured by the percentage of adults who are illiterate. Deprivations in a decent standard of living are measured by two variables: the percentage of people not using improved water sources and the percentage of children below the age of five who are underweight. A higher HPI value means a greater level of poverty. The HPI-1 value for Kenya, 35.5, ranks 60th among 102 developing countries for which the index was calculated (Kenya Human Development Report of 2007-2008).

2.3 Education

Within the Human Resources and Development (HRD) component, the education objectives of the Economic and Recovery Strategy (ERS) focus on the provision of Universal Primary Education (UPE), the enhancement of

1 According to the Central Bureau of Statistics (2005), the worst poverty hotspots are in Nyamira, Central Kisii and Gucha Districts of Nyanza Province; Vihiga, Butere-Mumias and Kakamega Districts in Western Province; Embu, Meru South and Machakos Districts in Eastern Province; and a few small areas near Mombasa in Coast Province.

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secondary transition and the improvement of public resource utilization. The education targets set out in the PER 2004 are: achieve 100 percent net primary enrolment; increase net enrolments for boys and girls; reduce the rate of primary drop out for boys and girls; reduce incidence of primary repetition; and increase transition rate to secondary schools from 47.3 percent in 2002 to 70 percent by 2008. According to the Paper read by the Permanent Secretary of the Ministry of Education at a conference on, “Strengthening Quality and Innovation in Education” in Brussels-Belgium (20 – 24 November, 2007), after FPE was introduced in 2003, enrolment increased from 5.9 to 7.5 million children. The Gross Enrolment Rate (GER) rose from 88.2 percent to 107 percent in 2006, and the Net Enrolment Rate (NER) increased from 77 percent in 2002 to nearly 84 percent in 2007. GER in secondary education is 29.8 percent while drop out rate is at 7.1 percent. As a result of the FPE, secondary education experiences regional and gender disparities due to the imbalance between primary and secondary schools that has grown more acute particularly in urban areas. Enrolment is particularly low in Arid and Semi-Arid Lands (ASALs) for girls, and concerns have arisen regarding the quality of teaching and learning (UNICEF Report, 2004 – 2008).

2.4 Health

Kenya’s health and development indicators have been on the decline in the last two decades. Child health indicators have deteriorated over the years to the extent that presently 20 percent of under-fives are underweight, almost one in three (30 percent) are stunted and 6 percent are wasted. In Kenya, the prevalence of stunting, wasting and underweight, according to the 1998 Kenya Demographic Health Survey (KDHS), was 33 percent, 6 percent and 22 percent respectively. The situation has since slightly improved by dropping to a prevalence of 30 percent and 20 percent in stunting and underweight, respectively, as shown by the 2003 KDHS (Kirogo, Wambui, & Muroki 2007). The World Health Organization (WHO) presents the 2003 child health statistics as follows:

Table 1: WHO Health Statistics of 2003Indicator Value (year 2003)Children under five years of age stunted for age (%)

35.8

Children under five years of age underweight for age (%)

16.5

Children under five years of age overweight for age (%)

5.8

Source: WHO Health Statistics Report, 2007

According to UNICEF, infant mortality stood at 78 deaths per 1,000 live births in 2001 and under-five mortality at 122 deaths per 1,000 live births (UNICEF, 2003). Infant mortality rose from 63 per 1,000 live births in 1990 to 78.5 in

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2004, while under-five mortality stood at 115 deaths per 1,000 live births. Life expectancy declined from 57 to 48 years during the same period, in part due to the HIV/AIDS pandemic. Depending on the type of facility, immunization services are expected to be available five days a week for any child less than five years of age (GoK, 1999). However, only 57 percent of Kenyan children are fully immunized. Measles vaccination coverage reduced from 84 percent in the 1990s to 76 percent in 2000 and to 74 percent in 2003. According to the 2003 KDHS the percentage of infants reaching their first birthday that have been fully immunized against measles stands at 73 percent. Measles vaccination is particularly low in Western and Nyanza provinces – 58 percent and 68 percent in 2000, respectively (CBS et al. 2004; GoK & UNDP, 2003).

The major childhood diseases responsible for high childhood mortality are malaria, acute lower respiratory infections, diarrhoea, dehydration, measles and also HIV/AIDS. Other contributing factors include poor hygienic conditions, lack of access to safe drinking water, inadequate exclusive breastfeeding, inadequate cleaning of bottle teats and over-diluted-milk. As of 1999, 40 percent of Kenyan children below five years of age were iron deficient and about 73 percent suffered from anaemia. The time spent by mothers away from their babies due to wage or self-employment, collecting water and looking for food, limits the time they spend caring for their children hence increasing children’s vulnerability to diseases and malnutrition (CBS et al. 2004). In addition, there is evidence that parents and other caregivers are not stimulating and caring for their young children as they used to do in the traditional societies. Therefore, the decline in the quality of parental care may be one of the factors contributing to increased under-five mortality rates (Koech & Njenga, 2006).

According to a study conducted by Amuyunzu-Nyamongo and Nyamongo (2006) in Nairobi informal settlements, prompt and appropriate health seeking is critical in the management of childhood illnesses. The study shows that mothers classify childhood illnesses into four main categories: (1) not serious - coughs, colds, diarrhoea; (2) serious but not life-threatening - malaria; (3) sudden and serious - pneumonia; and (4) chronic and therefore not requiring immediate action - malnutrition, tuberculosis, chronic coughs. This classification is reflected in the actions taken and time it takes to act. Shops are used as the first source of health care, and when the care moves out of the home, private health facilities are used more compared to public health facilities, while even fewer mothers consult traditional healers. Consequently, they concluded that there is a need to train mothers to recognize potentially life-threatening conditions and to seek appropriate treatment promptly. Drug vendors should be involved in intervention programs because they reach many mothers at the critical time of health seeking.

2.4.1 Expenditure on health

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Total health care financing in Kenya in 1994 is estimated to have been about Kshs. 31 billion or US$ 560 million. This was equivalent to about 8.4 percent of Gross National Product (GNP), or Kshs. 1,170 per capita (US$ 21). This estimate of total financing includes a number of important gaps and data adjustments. Household out-of-pocket spending estimated from the 1994 Welfare Monitoring Study-2 (WMS-2) was adjusted downward by 25 percent to reflect suspected overestimation due to recall bias common to such surveys. The 1994 estimate of health financing as a share of GNP is very high for several reasons. First, health spending relative to income in Kenya is particularly high for a low income country. Second, GNP in 1994 was unusually low by Kenyan standards. If the average per capita GNP from 1991 to 1997 is used for 1994, the estimated health financing level would have been 7 percent of GNP. However, these caveats do not affect the estimated absolute level of spending or the shares of different sectors, providers, or functions. The Kshs. 31 billion mobilized in the health sector did not just pass directly from the sources to the providers. Approximately one-third of funding first passed through financial intermediaries before being transferred to the final users. For most sources, funds were transferred to more than one financing intermediary. The major intermediaries in the flow of funds were the MOH, local councils, private insurance agencies, NGOs, and the social insurance scheme, which is managed by the National Health Insurance Fund (NHIF2). However, some employer spending and most household spending passed directly to the ultimate providers of care.

The estimated population in 1994 was 26,762,000 (GOK/CBS, 1996). The average per capita GNP for the years 1991-1997 was about US$ 300 (World Bank World Development Reports, 1993-1998). The five major pathways of financing were as follows:1. From the GOK to MOH facilities through the MOH Appropriations Budget (18% of financing);2. From donors to the MOH and NGOs (7% of financing);3. From employers to on-site care and company self-insurance schemes (17% of financing);4. From households to hospital facilities through the social insurance scheme (4% of financing); and,5. From households through out-of-pocket spending directly to retail providers of pharmaceuticals, private hospitals and outpatient centers (49% of financing).

The first pathway consisted of GOK financing, in which funds were transferred to the MOH Appropriations Budget via the Ministry of Finance (MOF), and on to MOH facilities. Few GOK funds were transferred to private sector intermediaries. The second major pathway consisted of donor funding, of which

2 The NHIF is a mandated hospital insurance programme, which, in 1994, was financed through a two percent payroll tax on those earning taxable wages of Kshs. 1,000 or more per month.

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61 percent went to the MOH and 18 percent went to NGOs. Together, these two channels accounted for about one quarter of total health sector financing. The third major pathway consisted of contributions made by parastatal and private employers to cover the costs of on-site outpatient care for employees and their dependents as well as to fund company-managed health insurance schemes. The fourth major pathway consisted of social insurance funding. Approximately seven percent of household funding went to the NHIF, which reimburses hospitals, both public and private, for services provided to members. The NHIF invests the contributions it receives from its members and, in 1994 the fund returned Kshs. 101 million on these investments. Out of the total NHIF revenues of Kshs. 1.3 billion, 85 percent were used to reimburse for hospital services, 10 percent were spent on administrative functions, and 5 percent remained in the fund.

The NHIF is intended to cover inpatient care only (Berman et al., 1995, p. 60). As these payments are not voluntary, and contributors have no control over the allocation of the money collected, contributions to the NHIF can be regarded as a form of hypothecated tax for health services. This form of taxation differs from general revenue funding of health services in that eligibility for use of the fund is restricted to contributors. Most, if not all, social health insurance schemes in middle to high income countries receive governmental subsidies to supplement contributions. In those countries with universal coverage, such transfers generally are used to subsidize health insurance for members of the population outside of the formal employment sector (Rannan-Eliya et al., 1997). However in Kenya, the government does not provide these subsidies to the NHIF. The most important pathway consisted of direct household funding of provider services. Virtually all providers in Kenya’s health care system earned revenues from out-of-pocket spending by households, but most of these transfers (93%) went to private providers including non-profit/volunteer facilities, private-for-profit facilities, traditional healers, and retail providers of pharmaceuticals and other medical goods. User fees to government facilities accounted for only a small share of total household out-of-pocket spending. Presently, employee contributions to the NHIF are based on a somewhat progressive tax system. A large amount of NHIF payouts were made to small private hospitals, where it is uncertain that the funds were only used to cover inpatient services. Thus, inpatient spending may be over-estimated. A contributor’s eligibility to receive benefits is conditional upon the event of becoming sick and needing to obtain diagnosis and treatment, the payment for which the fund makes at least partial reimbursement. Retail providers of pharmaceuticals and other medical goods include private pharmacies, dispensaries and shops (Annual Health Pamphlet/Brochure, 2005).

Within the health component the primary focus is on the provision of basic health services, which is to be achieved by revisiting health sector financing to reduce out-of-pocket (OOP) expenditure by the poor and vulnerable, which escalated following the adoption of cost recovery within the health sector,

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through the adoption of a major new Social Health Insurance Scheme. The emphasis is on investments to benefit the poor and vulnerable, and to improve health indicators by re-allocation of resources to promotive, preventive and basic health services, and to increase efficiency and effectiveness by combining government and partners’ investments, a strategy articulated in the second National Health Sector Strategic Plan (NHSSP II). The goal is to increase total government spending to 12 percent of total public expenditure, the figure estimated to address MDGs and respond to inadequate previous levels of expenditure and at the same time to carry out a re-allocation of resources within the sector to primary health.

In 2001, the total per capita expenditure on health care was $114 (7.8% of GDP). According to the WHO Health report of 2004, the overall health system performance score placed Kenya 140/191 countries. This composite measure of overall health system attainment is based on a country’s goals relating to health, responsiveness, and fairness in financing. The measure varies widely across countries and is highly correlated with general levels of human development as captured in the human development index (WHO World Health Report, 2004). In 2004/2005 the WHO Health Statistics Report estimated the total population of Kenya as being 34,256,000; the Gross national income per capita (PPP international $) as 1,170; probability of dying under five (per 1,000 live births) as120; total expenditure on health per capita (International $, 2004) as 86 and total expenditure on health as % of GDP (2004) as 4.1 (WHO Health Statistics Report, 2007). Aggregate funding in this sector is very low, with public per capita expenditure on health totaling only US$6.2, compared to the US$34 recommended by WHO. Public health spending accounts for 8 percent of total health spending, below the Abuja target of 15 percent of total spending allocated to health (MOH Draft PER 2005, cited in NHSSP II).

The 2005/2006 allocation to the health sector was Kshs. 30 billion, of which Kshs. 20.2 billion was recurrent. Although recurrent allocations increased from Kshs. 9.3 billion to Kshs. 16 billion between 1999/2000 and 2003/2004, this increase was not significant in real terms given high demand and commitment to pro-poor services. As a percentage of GDP, the health sector’s budget, has remained essentially flat, rising from 1.44 to 1.91 percent between 2000/2001 and 2004/2005, with the increase in spending being accounted for by an increase in development allocations from 0.12 to 0.62 percent, while recurrent expenditure remained stable at 1.3 percent over the period (UNICEF Report, 2004 – 2008). The Kenyan government vowed to raise its spending on health services by 30 percent during the 2005/2006 financial year in a bid to improve medical care and make it readily available to the poor. The following table represents the Human Development Index as indicated in the WHO Health Report of 2007/2008.

Table 2: Kenya Human Development Index (HDI) Rank -

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152Human development index (HDI) value, 2004 0.491Life expectancy at birth (years) (HDI), 2004 47.5Adult literacy rate (% ages 15 and older) (HDI), 2004

73.6

Combined gross enrolment ratio for primary, secondary and tertiary schools (%), 2004

601

GDP per capita (PPP US$) (HDI), 2004 1,140Life expectancy index 0.37Education index 0.69GDP index 0.41GDP per capita (PPP US$) rank minus HDI rank 7

Source: WHO Health Report, 2007/2008

However, the Human Development Index Report of 2007/2008 ranks Kenya 148 out of 177 countries in the achievement of medium human development. HDI measures achievements in terms of life expectancy, educational attainment and adjusted real income. The following table shows the expenditure rations from 1996 to 2005 as presented in the World Health Organization – National Health Accounts Series Report of 2006.

Table 3: Health Expenditure RatiosYear

Total expenditure on health as % of GDP

Total exp. on health (THE)

General gov. exp. on health (GGHE)

General gov. exp. on health (GGHE) as % of GDP

Private sector exp. on health as % of THE

General gov. exp. (GGE)

General gov. exp. on health as % of GGE

Social security funds as % of GGHE

Private exp. on health (PvtHE)

Private households' out-of-pocket payment as % of PvtHE

External resources on health as % of THE

1996

4.4 30 512 11 596

38.0 62.0 150 576

7.7 7.4 18 917 83.0 8.2

1997

4.4 34 056 12 480

36.6 63.4 169 772

7.4 8.8 21 576 82.7 10.8

1998

4.1 34 848 16 008

45.9 54.1 195 000

8.2 6.0 18 840 79.6 10.8

1999

3.8 34 588 14 408

41.7 58.3 345 040

4.2 16.4 20 180 79.3 13.7

2000

4.4 42 344 19 884

47.0 53.0 175 120

11.4 11.5 22 460 80.1 8.5

2001

4.3 43 722 18 872

43.2 56.8 232 920

8.1 14.6 24 850 80.5 15.7

2002

4.6 46 989 20 694

44.0 56.0 225 760

9.2 9.2 26 295 80.0 16.4

2003

4.4 49 503 19 218

38.8 61.2 264 140

7.3 9.9 30 285 82.5 15.6

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2004

4.1 53 215 22 700

42.7 57.3 275 440

8.2 8.4 30 515 81.9 18.3

2005

4.0 56 700 23 500

41.4 58.6 296 350

7.9 7.9 33 200 82.8 20.5

Source: World Health Organization – National Health Accounts Series (2006)

The share of the budget spent by the GOK no longer comprises the dominant share of total health spending from all sources. The private sector is becoming an increasingly more important component of total spending. The World Bank estimated that over two-thirds of curative services were provided by non-governmental entities, including hospitals, clinics and individual practitioners. This represented an increase from 60 percent estimated in 1993. Thus, it is likely that more than half of all registered health care workers in Kenya work in the private sector. However, despite the growth of the private sector, more than half of Kenyans do not have access to affordable health care. Moreover, little is known about the quality of services provided in the private sector as many essential standards either have yet to be legislated or are not enforced sufficiently (Deolalikar, 1997).

Although Kenya’s health infrastructure expanded massively following independence, the increase in population and demand for health care have outstripped the ability of the government to provide effective health services. Concerns requiring attention include inadequate health personnel, financing, drugs, health infrastructure, inefficiency in health delivery, and inequality in delivery of health care to an overwhelming majority of the poor. About 70 percent of the population in rural areas and 81 percent in urban areas cannot afford private health care; and 20 percent of the urban poor and 8 percent of the rural poor find even public health charges unaffordable. The introduction of macro-economic reform measures including user fees for health care in the late 1980s adversely affected health care access and affordability of government health services by the poor (Kimalu et al. 2004). The Government of Kenya (GoK) therefore, faces the dilemma of combating a growing burden of disease, regulating quality, and improving equity in health care distribution within the context of declining public financing that is forcing rationalization of health service delivery. To help resolve this dilemma, it is postulated that Kenyan policymakers need a comprehensive understanding of the organization and financing of the country’s health care system, including the expenditures on health care made by donors, public sector entities, and the private sector, particularly households (MOH, 2005).

2.4.2 Overview of the National Health Accounts (NHA)The National Health Accounts (NHA) is a tool that the government is using to understand health care expenditures. It is an internationally accepted framework for tracking the expenditures from their sources to their end uses. Kenya conducted its first NHA estimation in 1998, using 1994 data. Prior to

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this, key policymakers assumed that the GoK was the major financier of health care services. However, the 1998 NHA revealed that more than 53 percent of health care spending actually came from households, with the Kenyan government financing only 19 percent. The high household expenditure finding was particularly alarming and spurred Kenyan policymakers to further investigate health care equity issues. Consequently, the government commissioned a series of in-depth studies on the burden of health financing in the country. The GoK also undertook a second NHA exercise, using expenditures from fiscal year (FY) 2002. This NHA round was more ambitious than that done in 1998; it included detailed data on householdspending gleaned from a household health care utilization and expenditure survey and extended the NHA framework to estimate expenditures on HIV/AIDS health care, a pressing national policy issue. Its findings should be of use to all health care stakeholders – public, private, and donor – who seek to efficiently and equitably distribute their health care resources (MOH, 2005).

The findings from Kenya’s NHA 2002 report show that in terms of the overall health resource envelope, Kenya spent 5.1 percent of its gross domestic product (GDP) on health. This is comparable to other countries in sub-Saharan Africa, which average 5.7 percent, but well below the high-income OECD countries’ average of 9.8 percent. Per capita spending is Kshs. 1,506 (US$19), which translates to a 10 percent decline from spending level in 1998 (Kshs. 1,170; US$21). The NHA household health care utilization and expenditure survey found that households in the poorer income quintiles use less health care than do households in the richest quintile – more than a third of the poor who were ill did not seek care compared to only 15 percent of the rich. This suggests that inability to pay is contributing to lower utilization rates by the poor. The FY 2002 NHA exercise found that more than half of health care financing (51 percent) comes from households. This is significant considering that 56 percent of the population (estimates of 2006) is poor, and, like the survey findings, it raises concerns about financial accessibility to health care by that segment of the population (MOH, 2005).

Although public facilities receive 60 percent of all spending on health care, public sources of funds account for only 30 percent of total health expenditures, or approximately 8 percent of all spending by the government. This share of public spending on health care falls appreciably short of the 15 percent goal outlined in the Abuja Declaration. The other major financiers of health care in Kenya were the donor community, which contribute 16 percent of total health expenditures, and employers, who contribute 3 percent. With these findings, NHA identified the magnitude of issues facing policymakers. NHA estimations now are being used to explore alternative and sustainable financing mechanisms to encourage equity in financial access to care. Currently, the government is using NHA findings to inform allocative formulas for health care resources in its design of a social health insurance scheme and community-based health insurance programs. With over half the population

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considered poor, it is alarming that 51 percent of all health care expenditures in Kenya are borne by households. HIV-infected persons pay nearly half of HIV/AIDS treatment costs, and donors fund more than half of Kenya’s HIV/AIDS expenditures overall. Such National Health Accounts findings reveal a need to address sustainability and equity of health care resource allocation (MOH, 2005).2.4.3 HIV and AIDSHIV/AIDS remains one of the most serious public health challenges facing Kenya today and it has an impact on health policy. The pandemic poses a serious threat to Africa’s existence. Approximately 95 percent of people with HIV/AIDS live in developing nations, with Sub-Saharan Africa remaining the worst affected region in the global Aids epidemic. In Kenya, the first AIDS case was reported in 1984. HIV/AIDS has remained a national crisis in Kenya with many challenges to all the sectors of the society. Trends indicate that the annual number of AIDS related deaths is still rising steeply and has doubled over the past six years to about 150 000 deaths per year because of the high number of people who were infected in the 1990s. New infections, however, which had peaked to over 200,000 per year, have now dropped to well below 100,000 per year. According to the report of “AIDS in Kenya” 7th Edition published by National AIDS and STI Control Programme (NASCOP) of the Ministry of Health in 2005, the total number of people living with HIV in Kenya includes 1.1 million adults aged 15-20 years, another 60,000 aged over 50 years and approximately 100,000 children. The majority of new infections occur among the youth; especially young women aged 15 - 24 and young men under the age of 30. HIV infection among adults in urban areas stands at 10 percent and is almost twice as high as in rural areas where the average rate averages 6 percent. It is estimated that 7.5 percent of married couples are discordant for HIV. The total number of HIV/AIDS orphans is estimated at 1.6 million (Christian Health Association of Kenya [CHAK] Report, 2006).

However, as the world marked World Aids Day on 1st Dec. 2007, the 2007 UNAIDS estimates stand at 33.2 million people living with HIV worldwide, including 2.5 million children. This is fewer than original estimates of close to 40 million infected people globally. During 2007 some 2.5 million people became infected with the virus. Around half of all the people who become infected with HIV do so before they are 25 years and die before they are 35 years of age. The country has been able to demonstrate a clear trend of decreasing HIV prevalence over the past several years. Although HIV prevalence rate has dropped from 13.4 percent in 2001 to 7 percent in adults aged 15-49 years in 2003 according to the report of the 2003 KDHS, the social economic status and disease burden are enormous. The prevalence ranges from 1 percent in North Eastern Province to 15 percent in Nyanza Province (CBS et al. 2004). HIV prevalence in Kenya has declined to 5.1 percent in 2007 from 5.9 percent in 2006 and 6.1 percent in 2005, and HIV prevalence among women in the country is 7.7 percent, compared with 4 percent among men (National Aids Control Council (NACC) Report; Mwai, East African

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Standard/AllAfrica.com, 10/12, 2007). During the past three years, critical HIV services have been scaled up and as a result, general awareness and knowledge of HIV transmission are nearly nationwide. In 2006, 760,000 adult Kenyans underwent HIV testing, and 110,000 (35%) of those in need of treatment had access to it, including about 6,000 children. Up to 40 percent of pregnant women who attended antenatal care clinics in 2004 benefited from prevention of mother-to-child transmission services. Increased resources have been allocated to impact mitigation nationwide; specifically to programmes supporting orphans and other children made vulnerable by HIV (UNAIDS Report, 2007). Thus, the decrease in HIV prevalence was attributed to several initiatives, including voluntary HIV testing and counseling and programs to prevent mother-to-child HIV transmission (Xhinua/People's Daily, 10/13, 2007). It was also noted that 1.4 million pregnant women need HIV counseling and testing annually so they can know their status:

There is an increase in the number of children being born infected with HIV, meaning that there is still a large number of women who have not fully understood the message (Alloys Orago, NACC Acting Director).

The latest NACC statistics also show a 9.6 percent HIV prevalence in urban areas, compared with 4.6 percent HIV prevalence in rural areas (Nation/AllAfrica.com, 10/12, 2007). But in terms of absolute total number of people infected, the effect is greatest on rural areas where over 79 percent of Kenya’s population lives, and, more importantly, to 85 percent of the poor (GoK, 2007a). Orago said the statistics show that the HIV prevalence of 4.5 percent among girls and women aged 15 - 24 is particularly high, compared with a HIV prevalence of 0.8 percent among boys in the same age group. This implies that young women are particularly more vulnerable to HIV infection than young men. The peak prevalence among women is at age 25-29 years (13%), while among men the prevalence rises gradually with age, to peak at age 40-44 (9%). Only in the 45-49 year age group does HIV prevalence become higher among men (5%) than for women - 4% (Institute of Policy Analysis and Research -IPAR- Policy Brief, 2004). The critical thing to note is that the most vulnerable women are those who have children aged five years and under.

The burden of care for the infected and affected on the family and health care providers has increased tremendously. There have been a number of comprehensive reviews of the impacts of the HIV and AIDS epidemic on food security. The evidence from these reviews indicates that: the disproportionately severe effects of AIDS on relatively poor households increases rural inequality. A reduction in household assets and wealth due to AIDS leads to less capital-intensive cropping systems for severely affected communities and households. The epidemic further undermines nutritional status and health as diets worsen because of decreased food security, and also because of a shift to less nutritious but more easily cultivated crops such as cassava (UNAIDS Report, 2003).

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2.5 Brief overview of Kenya’s health care system

Since independence in Kenya (1963), continuous attempts have been made to create an equitable health care system. It was clear that access to formal health services was a major problem to the bulk of the population, 95 percent of who were listed as rural in the 1962 census (Mburu, 1980 ) . Despite declining economic growth, high population growth rates and an increasingly overwhelmed and under-resourced health system, Kenya was able to realize precipitous and sustained declines in infant and child mortality between 1960 and the early 1990s (Mburu, 1980; Owino, 1997 ) . In 1994, the Government of Kenya launched its proposal for health sector reform placing greater emphasis upon decentralized priority setting and equitable allocation of resources. The health sector reform required a combined epidemiological and micro-economic framework to develop standard geographic criteria for resource allocation (MOH, 1994 ).

Kenya recognizes that good health is a pre-requisite to the socio-economic development of the country. According to the current National Development Plan (2002-2008), health policy in Kenya revolves around two critical issues namely, how to deliver a basic package of quality health services to a growing work force and their dependants; and how to finance and manage these services in a way that guarantees their availability, accessibility and affordability to those most in need of them. Therefore, health policies and strategies are aimed at reducing the incidence of disease and improving the health status of Kenyans as indicated by increases in life expectancy, reduction in mortality rates and improvement in the nutritional wellbeing of the general population and children in particular between 1992 and 1993. The overall goal of the government is therefore to promote and improve the health status of all Kenyans by making all health services more effective, accessible and affordable (Kimalu, 2001).

While high-income countries are able to fund and integrate new information tools to guide national health policy, low-income countries, who bear the majority of the global burden of disease, have inadequate and poorly performing Health Management Information Systems (HMIS). Many countries in sub-Saharan Africa (SSA) have embraced the need to develop broad health sector reforms linked to poverty reduction strategies (Owino, 1997; Bossert, 1998; Agyepong, 1999 ) . Targets are established by national governments to reach specific goals of mortality reduction through equitable access to services. The strategies adopted to achieve these goals should be based upon knowledge of existing services, disease burden and equity. In practice, the extent to which the evidence base for these decisions can be developed is often limited (Murray, 1995; Owino & Munga, 1997; WHO, 2000; Niessen et al., 2000).

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2.6 Kenya health policy overview Since independence the government has given high priority to the improvement of the health status of Kenyans. In a number of government policy documents and in successive National Development Plans, it has set forth that the provision of health services should meet the basic needs of the population, be geared to providing health services within easy reach of Kenyans and place emphasis upon sustainable and quality preventive, promotive, rehabilitative and curative services.

2.6.1 Health policy evolution and frameworkIn 1965 fee collection in health facilities was abolished. In 1970 the MOH took over the health centers and dispensaries run by local authorities without a corresponding transfer of budget from local authorities to the MOH. The MOH has the responsibility of ensuring the provision, improvement and promotion of health for all Kenyans. Different policy initiatives have had mixed success. One initiative was cost-sharing which was introduced in 1989. It introduced consultation fees in government health facilities and it was later modified in 1992 to convert user charges from consultation fee to treatment fee. The aim of the program was to increase the level of resources available at the local level for improving the functions of the health system. Three quarters of the revenue are used at the collecting facility, and one quarter is set aside for district level expenditure on primary health care. However, with the poverty level in the country, many people are unable to access the health facilities as they cannot afford (Owino, 1998). In 1992, District Health Management Boards (DHMBs) were created by legal notice to provide local insight of the cost-sharing program. In 1993 the MOH adopted the civil service health manpower reform which sought to trim the size of the civil service on a voluntary basis for those in lower job groups. The decline in resource availability and to some extent the mismanagement of resources limited the implementation of policy and expected benefits were therefore not fully realized. The government is no longer able to provide unlimited free care as budgetary allocations are insufficient to meet rising costs (Ngigi & Macharia, 2006).

Despite the expansion in health care delivery systems since independence, it is widely recognized that increasing population and demand for health care outstrip the government’s ability to provide effective services. In 1994, the government approved the Kenya Health Policy Framework (KHPF) as a blueprint for developing and managing health services. This policy document is based on a comprehensive situational analysis of the various factors affecting the health sector and addresses broadly the agenda for reform for policy implementation (MOH, 1994). To operationalize the document, the MOH developed the Kenya Health Policy Framework Implementation Action Plan (KHPFIAP) and established the Health Sector Reform Secretariat (HSRS) in 1996 under a Ministerial Reform Committee (MRC) in 1997 to spearhead and oversee the implementation process. The policy aimed at responding to the

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following constraints: decline in health sector expenditure; inefficient utilization of resources; centralized decision-making; inequitable management information systems; outdated health laws; inadequate management skills at the district level; worsening poverty levels; increasing burden of disease; and rapid population growth (KSPA Report, 2004). Sub-titled Investing in Health (MOH, 1994:27), KHPF’s theme was to be interpreted through policies designed to:

(i) Promote and improve the health status of all Kenyans; (ii) Make all health services more effective, accessible and affordable; (iii) Restructure the health sector to respond to the proposed reforms;

and (iv) Raise a population tuned to health seeking behaviour.

The aim of the policy framework is to ensure that the health status of the Kenyan population is improved. It sets out the policy agenda for the health sector up to the year 2010. This includes strengthening the central public policy of the MOH, adoption of an explicit strategy to reduce the burden of disease and definition of an essential cost effective care package. To operationalize this Health Policy Framework Paper, the National Health Sector Strategic Plan (NHSSP, 1991-2004) was launched. The strategic plan emphasizes the decentralization of the health care delivery through redistribution of health services to rural areas. The revised National Health Sector Strategic Plan II (NHSSP II-2005-2010) has been developed 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 services required support systems to deliver these services to the Kenyans. Major players in the health sector include the government represented by the MOH, the local government, private sector and NGOs (MOH, 2005).

The six strategic imperatives for reform include: Ensuring equitable allocation of government resources to reduce

disparities in health status; Increasing the cost effectiveness and the cost efficiency of resource

allocation and use; Continuing to manage population growth; Enhancing the regulatory role of the government in all aspects of health

care provision; Creating an enabling environment for increased private sector and

community involvement in health service provision and finance; and Increasing and diversifying per capita financial flows to the health

sector.

2.6.2 Organization of the health sectorThe organization of Kenya’s health care delivery systems revolves around three levels, namely the MOH headquarters, the provinces and districts. The

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headquarters sets policies; manages, monitors and implements the policies formulated; and coordinates the activities of the NGOs. 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, coordinates and controls all district health activities. In addition, it monitors and supervises the DHMBs which supervise the operation of health activities at the district level. The district level concentrates on the delivery of health care services and generates its own expenditure plans and budget requirements based on the guidelines from the headquarters through the provinces (MOH, 1994; GoK,1998; MOH, 2002 ) .

The three-tier health system operated until 1970, when the government established a system of comprehensive rural health services in which the health centres became the crucial points for which preventive, promotive and limited curative services are delivered. Today, alongside government services, missionaries and NGOs provide health services at delivery points that range from dispensaries to hospitals. The government’s health care delivery system is pyramidal with the national referral facilities at Kenyatta National Hospital and Moi Eldoret Teaching and Referral Hospital forming the peak, followed by provincial, district and sub-district hospitals with health centres and dispensaries at the base. In other words, health facilities under the MOH in Kenya are divided into three different levels. At the primary level, health care is provided in rural and municipal health centres and dispensaries. The secondary level, which serves as a referral point for primary level facilities, consists of district and sub-district hospitals. These hospitals provide both inpatient and outpatient services. Tertiary care is provided at both the Kenyatta National Hospital, and now the Moi Eldoret Teaching and Referral Hospital as well as by provincial hospitals (GoK, 1999).

2.6.3 Access and quality of health servicesThe MOH is the major financier and provider of health care services in Kenya. Out of over 4,500 health facilities in the country, the MOH controls and runs about 52 percent while the private sector, the mission organizations and the ministry of local government run the remaining 48 percent. The public sector controls about 79 percent of the health centres, 92 percent of the sub-health centres and 60 percent of the dispensaries. The NGO sector is dominant in health clinics, maternity and nursing homes (94%) and medical centres (86%). Both the public and the NGO sector have an almost equal representation of hospitals. However, the health sector is faceted with inequalities. Only 30 percent of the rural population has access to health facilities within 4 km, while such access is available to 70 percent of urban dwellers. The arid and semi-arid north and north eastern areas of Kenya are underserved due to a 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. Currently, there is a deliberate effort by the government to shift towards decentralization of health

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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 (Ngigi & Macharia, 2006).

2.6.4 HIV/AIDS policy and regulatory frameworkTo meet the challenge of the HIV/AIDS pandemic in the country, the Government, in September 1997, approved Sessional Paper No. 4 on AIDS in Kenya as part of the contemporary long term framework. Besides, after declaring AIDS a national disaster in 1999, the government established the National AIDS Control Council (NACC) to guide implementation of the National HIV/AIDS Strategic Plan 2000-2010. The Strategic Plan aims at ensuring that multi-sectoral policies and strategies are integrated into core government-wide process, including the poverty reduction strategies. The priorities of the Strategic Plan include: prevention and advocacy; treatment, continuum care and support; mitigation of the social and economic impacts of HIV/AIDS; monitoring, evaluation and research; and management and co-ordination. The co-ordination of the HIV/AIDS programme is spearheaded by NACC, which is currently housed in the Office of the President and draws membership from all sectors to ensure wide representation in the multi-sectoral approach to HIV/AIDS prevention, treatment and care activities. The organizational structure of NACC for delivery of services includes: Ministerial AIDS Control Units (ACUs); Provincial AIDS Control Committees (PACCs); District AIDS Control Committees (DACCs) and the Constituency AIDS Control Committees (CACCs) - IPAR Policy Brief, 2004.

Approval of Sessional Paper No.4 of 1997 on AIDS in Kenya was a clear intent of the government to support effective programmes to control the spread of AIDS, to protect the human rights of those with HIV and AIDS, and to provide care for those infected and affected by the pandemic (CBS et al., 2004). This was in view of the Third National AIDS Strategic Plan 2000-2005 which was launched in December 2000. Guidelines have been developed to support implementation in all critical areas including anti-retroviral therapy, voluntary counselling and testing, blood safety, condom promotion and HIV/AIDS education. The present government under the National Alliance Rainbow Coalition (NARC) has already devised a new anti-HIV/AIDS strategy by putting in place appropriate policies and programs. For example, at the beginning of 2003, the government established a Cabinet Sub-Committee on HIV/AIDS chaired by the president, to spearhead the battle against the HIV/AIDS pandemic. However, a fuller understanding of the gender dynamics in HIV/AIDS transmission and prevention will go a long way in guiding the formulation of pertinent policy options in HIV/AIDS prevention strategies. Extra challenges for HIV prevention arise from societal expectations that allow men to take risks; have frequent sexual intercourse (often with more than one partner) and exercise authority over women. These expectations, among others, encourage men to force sex on unwilling female partners and to reject condom use, among other risky behaviors regarding HIV/AIDS infection and

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prevention. On the other hand, due to their lack of social and economic power, many women and girls are unable to negotiate relationships based on abstinence, faithfulness and use of condoms (IPAR Policy Brief, 2004). Changing the commonly held attitudes and behaviors need to be part and parcel of the efforts to curb the AIDS pandemic.

2.7 Framework for reviewing health inequalities

Since the decade of 1980s, successive Kenya health status indicators have reflected a disturbing reversal of the remarkable attainments of the immediate post independence period, which had partially been spurred by the opportunities created by political liberation. In attempting to analyze the context of some of these reversals, the following discussion subscribes to the view that exclusive health sector interventions make a comparatively modest contribution to health status, the bulk of whose determinants are found in the individual’s or society’s socio-economic circumstances. The adverse economic impacts of the 1970s global oil crises coincided with weak governance in Kenya, which undermined socio-economic development; a phenomenon that afflicted most of the sub-Saharan Africa and other developing countries. Consequently, Kenya was among the countries that launched World Bank and International Monetary Fund (IMF) structural adjustment policies/programmes (SAPs) ostensibly to revive growth and development. Erratic implementation of the SAPs reflected a reluctant compliance often only ‘inspired’ by the prospects of related conditional aid inflows for reconstruction and restructuring. The essentially neo-liberal SAPs were designed to effect the state’s retreat to a largely regulatory and monitoring function, leaving the generation of economic growth in the hands of presumably efficient private sector. However, SAPs mandated the curtailment of government subsidies alongside the introduction of health and education user fees to recover some delivery costs (SID, 2006).

SAP-mandated health reforms in Kenya started in 1989 in the form of health care facility registration fee, which was, however, withdrawn in 1991 due to perceptions that it was impending access to public health care. The cost-sharing programme was put in place to:

(i) generate additional revenue for health facility operations; (ii) increase quality of health services in government facilities; (iii) strengthen the referral system and rationalize utilization of health

services; and (iv) improve equity and access to health.

The poor preparation ahead of the fee introduction led to poor, mismanaged revenues. The earliest studies of the impact of health care fees indicated a declined access to care justifying the programme’s suspension. Its re-launch in 1991 as a treatment fee failed to return use to the pre-1989 levels. It is possible that hard-pressed households had already discovered alternative ‘coping’

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mechanisms, including ‘doing nothing’ over a bout of illness (Mbugua, 1993; Collins et al., 1996). Into the 1990s, Kenya joined the global community in promoting anti-poverty initiatives, culminating in its own national poverty eradication plan published in the late 1990s. This was followed by the launch of the Medium Term Expenditure Framework/Poverty Reduction Strategy Paper (MTEF/PRSP) budgeting approaches. More recently, Kenya has subscribed to the global, time-bound, peer monitored MDGs initiative, which fortuitously for present concerns contains four narrow health sector goals, with the remaining ones covering interventions that are inescapably health care-enabling.Differences in health status are termed inequalities, while those in inputs to heath provisioning are termed inequities. Equity is an important criterion in evaluating health system performance. Developing a framework for equitable and effective resource allocation for health depends upon knowledge of service providers and their location in relation to the population they should serve (Noor et al., 2004). While political slogans and colloquia aspire for health equality, health status determinants adequately reflects the futility of endeavouring for such. The general socio-economic, cultural and environmental factors that facilitate health determinants include agriculture and food production; education; work environment; living and working conditions; unemployment; water and sanitation; health care service and housing. Health vulnerability is greatest in childhood and old age compared to the middle years and some illness of birth defy scientific advancements. After one’s biological ‘assets’, the most proximate set of factors determining one’s health status are one’s individual lifestyle factors. For example, nutrition lays the critical foundation in childhood that will largely determine the quality of life, contributing to fundamentals such as the development of the body’s immune system, as well as secondary factors such as education absorption. Yet, access to nutrition is determined by one’s status in their social and community networks-whether income-generating or poor as well as the general socio-economic, cultural and environmental conditions (SID, 2006).

Equity in health and health care has long been subject to various interpretations. Does equity mean equality, a decent minimum standard of service, or does it establish a system of entitlements? Though equity has always been an amorphous concept, since independence African governments have nonetheless attempted to create health care systems revolving around the idea of universal health services. Despite these equity values and policies, however, in practice there has been a persistent inequality, with health resources often concentrated in urban curative services - and particularly those serving urban elites - leaving rural dwellers underserved in terms of access to quality health services and basic health inputs. New health needs are further challenging these health inequalities. The devastating spread of HIV and AIDS has exacerbated inequity as poor households and vulnerable women and children have borne the greatest burden of the epidemic. At the same time, the epidemic has highlighted the pressing need for large-scale state responses to scale up and support

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community responses to prevention, treatment, and mitigation of the disease. Yet, given the increasing scarcity of health resources and the uncertainty surrounding the ongoing health reforms in the region, progress towards equity in health systems has been slow, uneven, and at times contradictory (EQUINET Report, 2007).

Conclusion

In Africa, amongst the most important components of the recent phase of globalization have been SAPs which have had the effect of further integrating countries into the global economy through the imposition of stringent debt repayments and liberalization of trade. SAPs have also resulted in significant macro-economic policy changes and public sector restructuring and reduced social provisioning, with negative effects on education, health and social services for the poor. Moreover, the majority of studies in Africa, whether theoretical or empirical, have proved negative towards structural adjustment and its effects on health outcomes.

The Government of Kenya (GoK) faces the dilemma of combating a growing burden of disease, regulating quality, and improving equity in health care distribution within the context of declining public financing that is forcing rationalization of health service delivery. Kenya still has a long way to go in tackling maternal mortality, infant mortality, HIV/AIDS and safe motherhood initiatives. Health issues in Kenya are governed by four main legislation; the Constitution, Medical Practitioners and Dentist Act (Cap 253), Nurses Act (Cap 257), and Pharmacy and Poisons Act (Cap 244). The constitution does not make provisions that facilitate the enjoyment of social, economic and cultural rights. Consequently, health is not listed as right within the Bill of Rights. Other laws governing health do not endorse adequate health as a right but merely regulate the environment and institutional and individual conduct within which the right to health is enjoyed. The law, despite the increasing recognition by the government, does not regulate the activities of traditional medicine practitioners. There is thus a need for their greater integration into the health care system. The rapidly collapsing physical, economic and social services have a negative impact on the health of the people and on the capacity of the health care system to respond to their increased needs. This situation renders the achievement of basic health needs difficult to meet and hence basic human rights will be prone to violation.

The health situation of Kenyans improved progressively after independence up to 1990 but has thereafter been deteriorating. Socio-economic analysis of poverty dimensions reveals that the main health challenge facing the poor is affordability. The Second Report on Poverty in Kenya revealed that an estimated 40 percent of the poor (39.5 percent of the urban poor and 43.8 percent of the rural poor) did not seek medical care when they were sick due to

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inability to cover the cost of medical care compared to only 2.5 percent who were constrained by distance to the health facility. Therefore, an important aspect of the recovery programme must therefore ensure that the fundamental concerns of equity, access, affordability and quality in the provision of basic health services are met. Increased funding would enable the country to expand immunization coverage, reduce mother and child mortality rates as well as malaria-related deaths, implement strategies to bring down HIV/AIDS prevalence and improve access to affordable drugs.

The policies that the government has pursued over the years have had a direct impact in improving the health status of Kenyans. However, the increases in population and demand for health care have outstripped the ability of the government to provide effective health services. The introduction of macro-economic reform measures including user fees for health care in the late 1980s adversely affected health care access and affordability of government health services by the poor. The government therefore, continuously faces the dilemma of combating a growing burden of disease, regulating quality, and improving equity in health care distribution within the context of declining public financing that is forcing rationalization of health service delivery. To help resolve the dilemma, it is postulated that Kenyan policymakers need a comprehensive understanding of the organization and financing of the country’s health care system, including the expenditures on health care made by donors, public sector entities, and the private sector, particularly households where most vulnerable women are those who have children aged five years and under. Moreover, the high percentage of household financing shows the burden vested on mostly poor households who have no means of accessing quality health care.

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. Currently, there is a deliberate effort by the government to shift towards decentralization of health care provision. The MOH should expedite the development of the legal and regulatory framework and capacity building to devolve the entire authority for planning and financial management to districts. In this way, more poor people can be able to access health care with ease. The MOH should also strive to develop guidelines that effectively support the implementation of the health policy in all critical areas that affect the poor especially women and their under five year old children living in informal settlements. Although the World Bank Research Report of 2001 documents that globalization has helped reduce poverty in a large number of developing countries; it must however, be harnessed better to help the world's poorest, most marginalized countries and improve the lives of their citizens.

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3.0 Nakuru District Profile

This section profiles an overall framework through which the study area is placed. It describes Nakuru district in terms of its location, size and population; topography, geology and climate; breakdown of health facilities; administration/organization of the district health sector; health information system; top ten causes of out-patient morbidity as recorded in 2003; health organization in the district; and the activities of the nutrition department. It is through looking at the overview of the whole district that we can understand the place of Kaptembwo informal settlement.

3.1 Location, size and population

Nakuru district is one of the eighteen districts of the Rift Valley Province. It lies within the Great Rift Valley and borders seven other districts namely: Kericho to the west, Koibatek and Laikipia to the north, Nyandarua to the east, Narok to the soutwest, and Kajiado and Kiambu to the south. The district covers an area of 7,242.3 km² and is located between longitudes 35º28' and 35º 36' East and latitude 0º13' North and 1º10' South.

The total inhabited area is 5,762 km². The rest are water masses. The table below shows the administrative units and area of the district by division.

Table 4: Administrative units and area of district by divisionDivision Area in

km²Locations

Sub-locations

No. of households

Population density (2002)

Mauche 161.04 4 8 3,468 118Lare 139.06 4 9 6,008 220Elburgon 436.04 3 8 15,521 166Nakuru Municipality

262.5 4 5 68,436 974

Bahati 564.06 4 14 32,214 282Njoro 313.06 4 7 19,222 279Mbogo-ini 386.05 3 6 12,570 170Naivasha 1,782.30 8 16 46,735 98Gilgil 1,055.10 4 7 22,385 96Molo 58.9 2 4 8,354 599Keringet 492.01 9 21 12,324 135Rongai 744.00 5 13 17,789 115Olenguruone 172.09 6 13 6,572 205Kuresoi 285.04 4 9 8,741 159Kamara 201.9 3 8 9,145 231Mau-Narok 185.01 2 3 6,967 179Total 7,238.16 69 151 296,451 181

Source: Nakuru District Development Plan 2002 - 2008

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Nakuru is one of the most populous districts in Kenya having a density of 181 persons per km². In 2003, Nakuru district’s population was projected to be 1,551,062. Nakuru Municipality is densely-populated with most of the people living in Kaptembwo, Langalanga, Ponda Mali and Mwariki, areas marked by low cost housing. The town’s population growth has been rapid but not in tandem with the provision of basic facilities including water, land, medical services and affordable food supply (Nakuru District Development Plan 2002 - 2008). The distribution of the population by age group is shown in the Figure below.

Figure 1: Number of people in Nakuru district by age group

Source: MOH Annual Health Report, Nakuru District 2003

3.2 Topography, geology and climate

The western part of the district which comprises mostly Molo, Mau Narok, Keringet, Kamara, Mauche, Elburgon, Njoro, Kuresoi, and Olenguruone divisions are situated on the Mau escarpment and generally lies at an altitude of 2,500m above sea level. The other divisions of Nakuru generally lie in the floor of the Rift Valley. It is characterized by very poor drainage mainly due to the porous nature of the pumiceous formations, which mantle the older rock surface. The geology and topography found in the district has a great impact on economic activities. In the areas where volcanic soils are found, agriculture and dairy farming are common. In the drier parts, livestock keeping is practiced in addition to other activities linked with tourism. The climatic

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conditions of Nakuru district are strongly influenced by altitude and physical features (escarpments, lakes - Nakuru, Naivasha and Elementaita - and volcanic peaks). There is considerable variation in climate throughout the district. The long rains fall between Mid-March and June. The amounts received vary from one year to the other and influence greatly the crop yields in the district and more significantly, the disease patterns (Nakuru District Development Plan 2002-2008).

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3.3 Breakdown of health facilities

Table 5 shows the health parameters in Nakuru district – 2003, while Table 6 is the breakdown of the health facilities that catered for the population.

Table 5: Health parameters in Nakuru district - 2003Description Rates/Numbers

1 Total population 1,551,0622 Crude birth rate 13.8 per 1,0003 Crude death rate 6.7 per 1,0004 Infant mortality rate 46 per 1,0005 Fertility rate (total) 6.6 per 1,0006 Literacy rate 91.29%7 Women of reproductive age (15-49

years) - 20%360,015

8 Immunization coverage 82%9 Number of children under 1 year 60,78010

Number of children under 5 years 360,014

11

Number of children (0-15 years) 678,449

12

Population growth rate 3.4%

13

HIV prevalence rate 10%

14

Safe water coverage rate 55%

15

Latrine coverage 48%

16

Maternal mortality 200/100,000

Source: Medical Officer of Health Office, Nakuru District 2003

Table 6: Type of health facilities in Nakuru district by 2003Type of facility No.GoK hospitals 8Private hospitals 6GoK rural health demonstration centres

2

GoK health centres 13GoK dispensaries 57NGO health centres 3NGO dispensaries 5Private nursing homes 6Local government health centre 1Local government dispensary 4Local government maternity 1Total 1063

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Source: MOH Office, Nakuru District 2003

3 Since 2003 there are more health facilities that have been constructed and are operational in the district. This is partly due to new health units opened during 2003 and other upcoming health units (proposed and under construction).

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Table 7 shows the divisional distribution of health facilities in the district.

Table 7: Divisional distribution of health facilitiesDivision Populatio

n (Est. 2002)

No. of health facilities

Population per facility

Nakuru Municipality

264,354 50 5,287

Olenguruone 36,613 4 9,153Naivasha 181,385 28 6,478Gilgil 105,084 10 1,051Molo 36,505 4 9,126Njoro 90,445 13 6,957Rongai 88,552 14 6,325Bahati 164,279 16 10,267Mbogo-ini 68,026 12 5,668Keringet 68,429 8 8,554Elburgon 74,660 5 14,932Kuresoi 46,780 2 23,390Mau-Narok 34,197 5 6,839Lare 31,695 2 639Kamara 48,331 3 16,110Mauche 17,593 2 8,797Total 1,356,928 178 134,873

Source: MOH Annual Health Report, Nakuru District 2003

The Government's Nakuru District Development Plan for 2001 indicated that the district's doctor-population ratio was 1:13,417. The document shows that attendance in private hospitals largely served the middle and high income groups, while the poor sought treatment in government health centres and hospitals, which are always congested. By 2001, half of the doctors working in the larger Nakuru District had their clinics in Nakuru Town. This means that most of the people in the rural areas were treated by clinical officers and nurses. The report says that in 1996, Nakuru Municipality had 52 out of the 57 government doctors working in the district. Olenguruone, Keringet, Njoro, Rongai, Bahati and Lower Subukia did not have any government doctors. According to the document, 13 out of the 16 private doctors in the district had clinics in Nakuru Town, while only three had clinics in the smaller towns - Naivasha, Molo and Njoro (Nakuru District Development Plan, 2001).

3.4 Administration/organization of the district health sector

Immediate responsibility for the daily management of the health sector in the district is with the District Health Management Team (DHMT) and the DHMB.

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The DHMT comprises of all departmental heads and is chaired by the District Medical Officer of Health (DMOH), whereas the District Health Administration Officer (DHAO) is the secretary. The team is charged with the daily management of the provisions of public health services within the district and regulation of quality of services within the private sector. Its schedule of meetings is as follows:1. Briefings - every Monday morning (except when there is a monthly DHMT meeting scheduled within the week);2. Every first Tuesday of the month - minutes of the monthly DHMT meeting

are revisited;3. Every 3 months - quarterly meeting of the DHMT team with rural health

workers in-charge; and4. Quarterly posting and disciplinary meetings.3.5 Health information system (HIS)

The district HIS office operated with one-health records and information officer and one technician through the year 2003. Table 8 provides a list of the distribution of records personnel in the district.

Table 8: Records personnel distribution in the district – 2003Health facility Health records

officersHealth records technicians

MOH office 2 0Naivasha Hospital - 6Molo Hospital - 3Elburgon Hospital - 2Gilgil General Hospital 1 4Olenguruone Hospital - 1Nakuru Provincial General Hospital

3 11

Dundori Health Centre - 1TOTAL 6 28

Source: Records staff establishment, MOH Annual Health Report, Nakuru District 2003

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3.6 Top ten causes of out-patient morbidity – 2003

Overall morbidity and mortality remain high, particularly among women and children. Malaria is the leading cause of outpatient morbidity in Kenya, accounting for one third of all new cases reported. After malaria, the most common illness seen in outpatient clinics are diseases of the respiratory system, skin diseases, diarrhea, and intestinal parasites. Recurrent out breaks of highland malaria and widespread emergency of drug resistance strains have aggravated the problem of malaria (KSPA Report, 2004). By 2003, malaria was the leading cause of out-patient morbidity, followed by upper respiratory diseases then skin diseases. Malaria is probably caused by the poor drainage system in many parts of the district especially in the informal settlements. The Figure below shows the top ten common diseases in Nakuru district by the year 2003 according to the MOH annual health report of morbidity patterns.

Figure 2: Morbidity trends and burden of disease in the district

TOP TEN DISEASES

020,00040,00060,00080,000

100,000120,000140,000160,000180,000200,000

Disease ofthe

respiratorysystem

Malaria Disease ofthe skin

Diarrhoealdisease

Accidents Pneumonia Poisoning Eyeinfection

Intestinalw orms

Dentaldisorders

DISEASES

CA

SE

S

2001

2002

2003

Source: HIS Reports, Nakuru District 2003According to Figure 2, the morbidity among out-patients is rising. This could be attributed to the poor economic status and lack of proper nutrition among the residents. The divisions in Nakuru also reported malaria as the leading cause of morbidity. The results are shown in Table 9.

Table 9: Disease morbidity patternPrevious reported

New cases

Cumulative

Malaria 74,112 48,048 122,160URTI 54,868 36,369 91,237Skin infection 9,200 10,564 19,764Diarrhoea 6,857 5,597 12,454Eye infections 4,999 4,570 9,569Intestinal worms 5,107 3,249 8,356Sexually Transmitted Infection (STI)

2,361 4,559 6,920

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Typhoid fever 2,222 2,296 4,518Gastroenteritis 2,098 1,703 3,801Tuberculosis 1,470 1,141 2,611Amoebiasis 818 674 1,492Food poisoning 628 342 970Bilharzias 8 1 9

Source: HIS Reports, Nakuru District 2003

Malaria continued to be the leading cause of morbidity in the district with a total of 122,160 cases with a peak during the months of June and July in parts of Rongai and Mbongoini divisions. It was followed by Upper Respiratory Tract Infections (URTI) with 91,237. Surveillance of priority diseases continued with annual non Polio AFP expected to be seven (7), detection rate of one, suspected and reported measles cases were 255 with no outbreak notified to the District Outbreak Management Unit (DOMU) within 48 hours. None tested positive for measles virus but 43 percent tested rubella positive. Neonatal tetanus was not detected during the year. Three (3) quarterly health meetings were held; three hundred and fourteen (314) health workers were sensitized in 12 sessions during supervisory visits; and a total of 158 dog bite cases were reported during the year (MOH Annual Health Report, Nakuru District 2003).

The district has several collaborators in HIV/AIDS prevention and control strategies amongst whom are Family Health International (FHI) with a regional office in Nakuru, funding an impact programme through the University of Nairobi, and strengthening STI management among sex commercial workers. AMREF is dealing with peer education for men at work sites and women at their income estate areas; Society for Women and AIDS in Kenya (SWAK) mobilizes women and girls in the fight against HIV/AIDS; PATH is specialized in theatre arts for Information, Education and Communication (IEC) among the youth. The Kenya NGO AIDS Consortium (KANCO) has set up a regional resources centre for HIV/AIDS in Nakuru where interested persons or groups can access information. Other Community Based Organizations (CBOs) and Non-Governmental Organizations (NGOs) collaborating in the effort include Family Planning Association of Kenya (FPAK), Marie Stopes, Catholic Diocese of Nakuru, Love and Hope, Upendo Widows Association, French Red Cross in Molo, The Association of People living with AIDS in Nakuru (TAPWAN), the AIDS Kids of Nakuru (AKIN) and Nakuru workers community support. This CBOS/NGOS are mainly focusing on home-based care (HBC), awareness creation, promotion and marketing of condom use.

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3.7 Health organization in the district

Nakuru district is now one of the decentralized districts which are pilots for the national health system framework. The districts’ main health package is financed through the Development and Recurrent Expenditure (DARE) support and the GoK. However, stakeholders such as FHI, International Committee of the Red Cross (ICRC), Faith-based Organizations (FBOs), NGOs and CBOs contribute to the health package. In future, the package requires to be harmonized in order to reflect one district health plan with one budget. The DHMB was de-gazetted during the year under review after its tenure in office expired. While in operation, it used to represent the communities’ interests especially examining how health services are delivered in the district through its three sub-committees i.e. financial, quality of curative care, public health and primary care. All hospital and sub-district hospitals have autonomous management boards while health centers and dispensaries have community committees which do almost the same work. Curative, preventive, rehabilitative and promotive services are offered; FBOs and CBOs have started home-based care while the health workers are being trained. VCT centers have been started all over the district while two institutions have started comprehensive care including ARVs for HIV and AIDS cases (MOH Annual Health Report, Nakuru District 2003).

3.8 Food security and nutrition

In Kenya, most nutrition problems stem from food insecurity, poor complementary feeding practices and poverty. The agricultural sector presents the greatest potential for achieving sustained improvement in the nutritional status of the rural poor. The nutritional status of young children is a sensitive indicator of health status and food availability in a given community. It gives the current status of the child in terms of immediate (acute) factors such as current inadequate food intake, childhood diseases and diarrhea leading to wasting while accumulated impact of chronic deprivation leads to stunting. Monitoring child nutrition provides an early indicator of distress and ill health within a community. Although a number of factors within a household may contribute to improved nutritional status, consumption of proteins such as milk by both children and adults is likely to contribute to better health and well being. Increasing opportunities for women to earn or control income will ensure household food security and this is likely to be beneficial to the children’s nutritional status (Mbagaya, Odhiambo and Oniang'o, 2004). Since landlessness is predominant in Kaptembwo informal settlement, for most households, alternative income generating projects would provide important sources of regular income. In addressing the problem of malnutrition, in this and any other community, a multifaceted approach embracing food, health, sanitation and health caring practices is necessary.

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Food security and nutrition are absolutely fundamental in any analysis of development in the region. Agriculture is still the dominant source of income for most people in the region and actions to secure food security dominate many lives. Poor nutrition whether over-nutrition or under-nutrition, is also a major cause of ill health and the reproduction of poverty in an area. Lack of food security and poor nutrition are both a cause and a reflection of the great inequalities in the region. Experiences from other parts of the world and historical precedents suggest that any successful intervention to reduce inequalities and inequities must start with improving the health and nutrition of the poor. Public policies have been shown to make a significant difference even in the context of poor overall economic growth. The HIV and AIDS epidemic is closely related to food security and nutrition. The impact of the epidemic is worsening the food security and nutrition situation whilst at the same time the lack of food security and poor nutrition is increasing vulnerability to HIV and AIDS. The present situation in the region with regard to food security and nutrition can only be understood in the context of global changes in the production and trade of agricultural products. A successful response to the huge challenges requires an analysis that integrates equity, health, food security and nutrition within the major global, regional and national trends. This analysis must be linked to a strong, organized demand for government responsiveness and accountability to social needs, and for government authority and action to safeguard social needs within global policy and corporate and commercial practices (ACC/SCN, 2004).

The following services, through the nutrition field workers and community technicians, were rendered in Nakuru District in the year 2003:1. Growth monitoring;2. Monitoring baby friendly activities in all institutions and hospitals;3. Upkeep and community use of demonstration kitchen gardens in hospitals

and health centres;4. Maternal and child health (MCH)/family planning (FP) nutrition lectures

done every morning before the day's activities start;5. Counseling of clients and relatives on various diets: diabetes, hypertension,

diarrhea etc;6. Supervising all GoK hospital kitchens to ascertain the preparation of

balanced diet food;7. Home visits and follow-ups; and8. Nutrition education was conducted in primary schools, chiefs’ barazas,

women group meetings, Nakuru Agricultural Show of Kenya (ASK), and churches.

The district nutritionist’s activities include:1. Giving lectures in syndromes management and HBC box for organizations like the ICRC, the Catholic Diocese of Nakuru (CDN) and the government even at provincial level;2. Attending nutrition meetings in Nairobi;

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3. Quarterly meetings with the District’s Nutrition Field Community Health Workers;4. Distribution of supplementary foods to the health facilities;5. Supportive supervision to the health facilities;6. Have been involved with women groups through FHI to sensitize them on HIV and AIDS;7. Attending DHMT morning briefs, Zonal Officers meetings and mobile meetings;8. Able to talk to nursing students on nutrition activities in the district; and9. Micronutrient: This is a new concept that was introduced by the MOH and the United Nations Children’s Fund (UNICEF).

The micronutrient project has taken off well in Nakuru district. The MOH has emphasized on Vitamin A and haematinics. Vitamin A is in general administered to children who attend hospitals, health centres and dispensaries for child welfare clinics whether they are sick or healthy. The following facilities have implemented the concept and progressed satisfactorily: Nakuru Provincial General Hospital, Dundori health centre, Olenguruone health centre, Gilgil Hospital, Banita Dispensary, Tinet Dispensary, Kipsyenan Dispensary, Engashura Dispensary, Lare Dispensary, Ogilgei Dispensary, Kapsumbeiywo Dispensary, Mogotio Rural Health Demonstration Centre (RHDC), Catholic Diocese of Nakuru Hospital, Molo District Hospital and Naivasha District Hospital (MOH Annual Health Report, Nakuru District 2003).

Some of the constraints that face the nutrition department include:

1. Staff shortage and poor deployment in some cases. For instance, the Medical Officer of Health serves the whole Nakuru Municipality division. Some areas have concentration of staff due to personal reasons e.g. marriage or proximity to urban centres;

2. The district nutritionist’s office is congested; more space is required;3. Inadequate logistics; lack of transport and staff uniform allowances;4. Reporting rate in the district is poor; some nutritionists do not write any

reports at all;5. Doubling as district nutritionist and giving lectures at the Kenya Medical

Training College (KMTC) is too strenuous for one person; 6. Reporting tools are not adequate especially for Vitamin A thus low reporting

rate;7. Shortage of nutrition staff in the district and this contributes to low or no

reports; and 8. Where there is no nutritionist, Child Health and Nutrition Information

System (CHANIS) I and CHANIS II reports are not given.

Kigutha (1995) conducted a study on the effects of a unimodal climatic pattern on household food availability among rural households with limited landholdings and low cash incomes. The study envisioned how this in turn

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affects food consumption and the nutritional status of the nutritionally vulnerable household members, namely preschool children, lactating women and the elderly. Research was carried out over a 15-month period in 1992/1993 among 94 households in Nakuru district, Rift Valley Province, Kenya. The results show that most of the smallholder rural households in the unimodal climatic areas of Kenya may be food insecure as they do not produce adequate amounts of food to last them from one harvest to the next. This is mainly due to such factors as limited landholdings, seasonality in rainfall patterns and large families, characteristic of many informal settlements in Kenya.

Conclusion

Nakuru Municipality is densely-populated with most of the people living in areas characterized with low cost housing. The town’s population growth has been rapid but not in tandem with the provision of basic facilities including water, land and medical services. There is uneven distribution of government health facilities in the district. Kaptembwo, an urban informal settlement, lacks a government health facility, and yet the poor are vulnerable to disease outbreaks. Low rates of access to medical care are attributable to state failures, such as the inability to provide adequate health infrastructure, or proper health insurance. There are gaps in information about the work being done in the area of HIV/AIDS in the district. Moreover, the distribution of organizations working in the area of HIV/AIDS in the district shows a lack of focus in the informal settlements. Health provisioning should not only be focused on the rural Nakuru and non-poor urban estates, but also among the poor people who live in urban informal settlements.

Malaria is the leading cause of outpatient morbidity in Kenya, accounting for one third of all new cases reported. In Nakuru, malaria is probably caused by the poor drainage system in many parts of the district especially in the informal settlements. The government through the DHMT should expedite the decentralization of the national health system framework to the districts so that Kaptembwo can benefit from proper medical services. In this way, the National Malaria Strategy (2001-2010), which was drafted following the Abuja Declaration by African Governments in 2000, would then be fully actualized so as to realize the reduction of malaria related morbidity and mortality. More efforts should be geared towards nutrition education among all people in the district and especially among women who have the burden of caring for their under-five children.

Food security and nutrition must be given high priority if actions to improve health equity and socio-economic development in Kenya are to succeed. Accordingly, the levels of poverty, hunger and under-nutrition should be improved to achieve the UN Millennium Development Goals. Improved nutrition and improved economic wellbeing should be able to curtail the vicious

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cycle of worsening poverty, hunger and under-nutrition. This will help in correcting the inequalities in income and health and subsequently decrease the vulnerability of the poor. Proven effective interventions indicate that public policy can make a difference, that nutritional improvements can be effected, even under conditions of poverty, and that these can have positive impacts on economic wellbeing. Implementing public policies that address food security provides an opportunity to deal with the demands of AIDS, the challenges of the competing signals from global trade to health and development, and the challenges to equitable public policy in the current governance of the food supply system. Confronting poverty and hunger provides one further area where alternatives can be built that promote policy objectives of justice and equity. Interventions are needed to build a multi-disciplinary and integrated response to food security and nutrition, with a focus on fair trade, gender inequalities and community control over productive resources. In other words, these interventions need to ensure food sovereignty. The above mentioned reasons suggest that equity in health will be difficult to achieve unless more explicit attention is paid to the underlying problems of under-nutrition and food security.

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4.0 Kaptembwo Informal Settlement

This chapter describes Kaptembwo informal settlement in terms of the reasons as to why it was chosen for the study; the history of the informal settlement; and the health provision points that were identified during the mapping exercise.

4.1 The choice of Kaptembwo

The choice of Kaptembwo informal settlement has been influenced by the experience of work conducted in Nairobi slum communities by the AIHD and other organizations. Amuyunzu-Nyamongo et al. (2007) have highlighted the risks faced by women living in slums to HIV transmission among other maladies. Those infected can hardly cope with AIDS due to poverty, poor environmental hygiene and sanitation, and inadequate access to food. For instance, the population of Kaptembwo is higher than the toilet facilities thus many people, including young children share facilities. Thus, there are rapid infections among young children increasing burden to their mothers. In another study conducted by the AIHD in Mitumba slum (2006), the women were found to encounter several difficulties that have critical implications on their health and that of their children. These problems included overcrowding, lack of a health facility and toilets in the informal settlement and women’s lack of employment and income generation opportunities. The choice of an informal settlement for this kind of study, will enable the project team to generalize the results of Kaptembwo informal settlement to other informal settlements that have similar characteristics.

4.2 About Kaptembwo

Kaptembwo estate (pictured) was initially a land buying company called the Kipsigis Turgen Farm led by estate Directors. The initial seven hundred acres of land was bought in 1964 and sub-divided in 1982 to 171 members of the association, each member getting 12 plots of 50x100 metres. The land provided public utilities that included Nakuru West secondary school, Kaptembwo primary school, Kaptembwo police post, Imani church and Evangelical Gospel Church (EGC). This was in view of the fact that the government then was concerned with the provision of education thus the schools, and security thus the police post. Public health facilities were not a requirement then since the government considered the Nakuru Provincial General Hospital as the nearest public health facility that could serve a larger population of the district, including the people of Kaptembwo. The people had to survive by walking long

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distances in search of water since the government then did not also consider water a public requirement. The Kipsigis community lived a traditional way, whereby girls and women had to fetch water from the river, while boys and men attended to livestock. Even though the farm was owned by a homogenous ethnic group, other ethnic groups have migrated into the area and settled on the small pieces of land making the farm an informal settlement.

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The main source of water for many people in Kaptembwo is River Ndarugú (pictured) which is used by both people and animals. The water is dirty and many diarrhoeal cases reported at the health provision points that were visited during the mapping exercise were said to be as a result of drinking unclean4 water from the river. For an alternative source of water, the residents of Kaptembwo line up for long hours in order to get clean water from a point that was constructed by the Nakuru Environmental Consortium and Waste Advisors. The tank has been erected next to the Kaptembwo bio-digester public toilet.

The Nakuru Municipal Council as the planning authority, set aside a piece of land which was to be used as a market centre. The place was located near Nakuru West village. However, the open place has since been misused by the plot owners who have and are still erecting shops. According to the area chief, the Kipsigis Turgen Farm will be dissolved once the Directors finish distributing the plots and surrendering the mandate to the Nakuru Municipal Council. The problem of space started cropping up since the sub-divisions of the land. Up to now there is no space to put up a health facility for the approximately 40,000 people of Kaptembwo informal settlement. The chief said:

In 2005, a donor came to this area with an intention of erecting a health facility and sinking four boreholes, but because of lack of space, the projects never materialized. Alternatively, the authorities then proposed that the project be taken to Menengai in Bahati division which could then serve the neighbourhood including Kaptembwo. The projects are yet to be started (Chief, Kaptembwo location, Nakuru Municipality Division).

4.3 Mapping of health provision points in Kaptembwo

The mapping exercise of health provision points in Kaptembwo included the private sector (private hospitals, clinics, dispensaries); over-the-counter drug sellers; drug peddlers; chemists/pharmacies; traditional healers; soothsayers and faith healers, among other alternative therapists. There were no traces of NGO facilities (both for profit and not for profit) in the community. The information on the mapping of health provision points focuses on the first research question as outlined in the proposal and the introductory part of this report.

4 The researchers watched some of the community members bathing, washing clothes and fetching water for domestic use from River Ndarugú. Animals also drank from the same river. A community member noted that during the heavy rainy season, dead human and animal bodies are normally found floating on the river.

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Methodology - Data were collected over a period of six days (August 22 – 27, 2007). The researchers visited the district offices and the communities to sensitize them about the research and at the same time mobilize people to take part in the exercise. The morning of the first day was spent in discussions at the Nakuru District headquarters with the District Commissioner and other staff. This was a useful meeting that provided an overview of development issues in the district as a whole. The second day was spent on talking to community members in a bid to understand the Kaptembwo informal settlement. The meeting was held at the area chief’s camp. The tools used for this exercise included a social map and an observational checklist as briefly described below:Social mapping - Community members converged at the Chief’s Camp, where they engaged in a focus group discussion (FGD) with the researchers in a mapping exercise. They later drew the social map of Kaptembwo (pictured) on the ground, which was later transferred on a manila paper. The map provided a visual representation of the community. The study participants used locally available materials (sticks, leaves, stones and manila paper) to indicate various institutions and resources in their community. The institutions and resources as indicated in the social map included health provision points, secondary and primary schools, a river, several churches, roads, the market place, shopping centers, a water point, a quarry (sand mine), a pubic toilet and a police post.

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Major issues discussed during the mapping exercise included lack of water, lack of a public health facility and a poor drainage system. The biggest problem in Kaptembwo is lack of clean and sufficient water since there is only one river that serves the village. The river water available is very dirty because animals also share it. Women have to cover the 5 km to fetch water for domestic use. Another issue that emerged was that there is no public health facility in the village. People have to travel to the Nakuru Provincial General Hospital, which is 7 km away. The abject poverty experienced by most informal settlement dwellers compounds the problem. Patients have to walk to the hospital due to lack of fare but when they are critically ill they use bicycles (boda boda)5. The drainage system, which has stagnant and dirty water, was viewed by the community members as the main source of breeding areas for mosquitoes that were notorious in spreading malaria especially in women and children under five years.

Observational checklist - On the third, fourth, fifth and sixth days the researchers took a transient walk through the informal settlement to find the health provision points and other amenities that had been plotted on the social map by the community members. Being in one community for four consecutive days allowed the researchers to follow-up on issues that were mentioned by the community members during the social mapping exercise. During the walk, the researchers used an observational checklist (See Annex 1) in the health provision points to find out the current activities, available staff capacity and gaps, the range of services offered, regularity of services, visiting hours, general atmosphere and the required capacity to offer services to the slum dwellers. The health provision points that were visited are briefly described below:

5 The boda boda business which has thrived in Nakuru is regarded as a saving mode of transport for many residents of the district. The people of Kaptembwo for instance, use them when they are critically ill since there are no public service vehicles plying Kaptembwo-PGH route. The women from the informal settlement said that it was however dangerous for them to carry children on the bicycles.

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4.3.1 Mother Kevin health centre - It is a Catholic mission health facility run by the Little Sisters of St. Francis of Assisi. It is located on the periphery6 of Kaptembwo informal settlement (lower side towards River Ndarugú). It offers curative and preventive treatment, MCH, antenatal and postnatal care, maternity services, laboratory services and prevention of mother to child transmission (PMTCT) services. The out-patient operates from 8.00 am to 5.00 pm while the in-patient is 24 hours every day. The facility has three enrolled nurses, two patient attendants (nurse aids), a registered nurse, a clinical officer, a laboratory technician and four subordinate staff. The health centre offers quality services to all clients at anytime of the day or night since the facility is situated in a needy place, and that most clinics operating in the slum make referrals to the facility. The three enrolled nurses have attended further training in PMTCT following the view that:

Since the medical field is very dynamic, refresher courses need to be emphasized. All medical personnel need to be updated on the new discoveries through seminars and workshops. If funds and time allow, all the personnel here should go for advanced training (Registered nurse, Mother Kevin health centre, Kaptembwo).

The health centre offers services to the residents in Nakuru Municipality division, although majority of the clients come from Kaptembwo. The management of the facility upholds cost-sharing and therefore the facility depends on user charges as their only source of income. Thus, the patients pay a consultation fee of Kshs. 30 and Kshs. 10 for a treatment card. The slum dwellers who frequent the facility (mostly women) cannot afford the charges because of abject poverty. The health centre does not have a waiver system but gives first-aid to the patients before referring them to the Provincial General Hospital (PGH). The time spent with each patient depends on the type of ailment that the patient has. The facility has a clean atmosphere, good reception and doctor-patient interaction. The health centre has equipment (incubator, delivery coaches, in-patient beds, thermometer and the Kenya Expanded Programme on Immunization [KEPI] fridge among others) which are in good working condition. At a glance, the health centre registers many cases of asthma, malaria, urinary tract infections (UTI) and high blood pressure among adults; threatened abortions among the youth; and malaria, respiratory tract infections (RTI), malnutrition, skin infections, diarrhea, typhoid and intestinal worms among children. The health centre does not have

6 It should be noted that Mother Kevin health centre, the only one and largest in Kaptembwo, is located on the periphery of the informal settlement. This is the only place where the Nakuru Municipal Council could allocate land for the construction of a spacious health centre. The rest of the estate households and structures are squeezed on small pieces of land as allocated by the Kipsigis Turgen Farm Directors.

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mobile/outreach services because the government, through PGH, provides the services. However:

The mobile services being offered by PGH are not sufficient for the population in Nakuru district. The hospital was initially designed to serve a few people in the district, but now has to contend with overwhelming numbers of people (Clinical Officer, Mother Kevin health centre, Kaptembwo).

The following Figure shows the monthly out-patient return of morbidity as recorded at the facility between January and July 2007.

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Figure 3: Monthly out-patient return of morbidity (2007)

Monthly out-patient return of morbidity (2007)

0

20

40

60

80

100

120

140

160

180

200

Mala

ria RTI

Diarrh

oea

Pneum

onia

Threa

tene

d ab

ortio

ns

Skin d

iseas

es

Accide

nts (

burn

s, fra

cture

s)

Typho

id

Chicke

n po

xUTI

Ear in

fecti

ons

Eye in

fecti

ons

Diseases

Cas

es

January

February

March

April

May

June

July

Source: Health Report, Mother Kevin Health Centre, Kaptembwo

Malaria was the leading cause of morbidity with a peak during the months of May and July. One of the interviewees said that:

Malaria is leading between May and July due to the long rains. After the rains, there is a lot of stagnant water which forms breeding sites for mosquitoes that spread the disease. There is a lot to be done to curb the menace of the major public health problems affecting women and children - malaria and diarrhoea among the under-fives and preventive services for maternal and child health among women (Registered nurse, Mother Kevin health centre, Kaptembwo).

Malaria was followed by Respiratory Tract Infections (RTIs), diarrhoea and skin infections especially among children under-five.

4.3.2 Mid – West medical clinic and laboratory services – It is a private clinic which operates from 8.00 am to 8.00 pm from Monday to Saturday, and from 10.00 am to 8.00 pm on Sundays and public holidays. It offers laboratory services, immunization, preventive and curative treatment, family planning (FP), antenatal and postnatal care and counselling. It has two staff members: a clinical doctor and a laboratory technician, who find the number of clients overwhelming at times. This is due to the fact that there is no public health facility within Kaptembwo and since PGH is 7 km away, most patients prefer going to the clinics. However, most of the time, many patients with

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complications are referred to PGH for further diagnosis and treatment. They charge a consultation fee of Kshs. 100.00 and a laboratory fee of Kshs. 150.00. Most patients come from other estates far from Kaptembwo because they personally know the doctor-in-charge. The residents of the slum cannot afford the payments due to abject poverty. According to the laboratory technician at the clinic, most women lack proper information on the variety of services offered at the clinic, and therefore there is need for awareness creation. The women also need economic empowerment so as to afford the services being offered in most private clinics located in their neighborhood. This is the reason why most of the people from the slum walk for more than 7 km to reach PGH so as to benefit from government subsidized medical services.

4.3.3 Magharibi clinic – It is a private clinic which operates from 8.00 am to 6.00 pm daily. It offers curative and preventive treatment and antenatal care. The four members of staff at the clinic cannot handle the large numbers of people who visit the facility. The clinic refers patients to PGH for specialized treatment because of lack of enough space and qualified personnel. The clinic is situated in an unclean environment and the time given to clients is not enough because the clinic does not operate at night. The clinic charges consultation fee of Kshs. 150.00 which is paid at the end of treatment. This is due to the fact that most people from Kaptembwo live below the poverty line thus:

The charges that include consultation fee and drugs are paid cumulatively. We do not tell patients about the consultation fee because they will shy away since they believe that the charges are high. We diagnose and give drugs. As a business retention strategy, we put all the charges together and the patient pays after all the services have been rendered (Nurse, Magharibi clinic, Kaptembwo).

The burden to women is unbearable since their husbands are idlers. Many women and their children come to the clinic with fractures and burns due to the impacts of domestic violence. The clinic registers many cases of common cold, malaria, urinary tract infections (UTIs), tuberculosis and diabetes among adults; and malaria, respiratory tract infections (RTIs), skin infections, diarrhea, typhoid, pneumonia and common cold among children. According to the service providers at the facility, access to health care for the community members has been hindered by poverty since many people cannot afford the drugs and consultation fees at the clinics. Many households in the slum lack clean and sufficient water and the poor drainage system exacerbates the occurrence of diarrhoeal-related cases and malaria especially among children under-five. The nurse-in-charge of the facility recommended that medical personnel offering services in the slum need to go for specialized training and refresher courses, especially in the major public health problems affecting women and children under-five (maternal and child health; and malaria and diarrhea respectively).

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4.3.4 Check point medical centre – It is a private health facility which operates from 8.00 am to 7.00 pm from Monday to Saturday and closes on Sundays. In cases where they have patients for brucellosis7 injections, they open from 10.00 am to 12.00 pm on Sundays to offer the services. They offer curative and preventive services, laboratory services, dental care and family planning. The clinic has four staff members: the doctor, clinical officer, laboratory technician and the dentist. The facility is situated on a dusty road which was designed as the main road serving Kaptembwo estate. Their equipment is not adequate in serving all clients who visit the clinic.

The clinic registers many cases of UTI, STIs, malaria, asthma in male adults; UTI, STIs, malaria, asthma and brucellosis in female adults; and diarrhea, vomiting, RTI and malaria in children. Like Magharibi clinic, the consultation fee and drugs are paid cumulatively after services have been rendered. This is geared to safeguard patient retention since most of them have in the past forfeited treatment for failure of raising the needed amount. The medical centre treats people from Kaptembwo and those from far away. Those who come from far personally know the doctor-in-charge. The doctor, who renders his daytime services at Egerton University, comes to the clinic from 4.00 pm till close time. He only comes when he has appointments with patients suffering from serious disease complications (stroke, liver and renal problems, paraplegia, complicated arthritis and chronic coughing). The health providers would like to offer MCH services and counselling but lack in capacity. They were of the opinion that they needed training in these areas which are mostly needed by the women of Kaptembwo. They also recommended refresher courses in the services already being offered at the facility.

4.3.5 Nakuru Provincial General Hospital (PGH)8 – It is the main referral centre for most cases in the district. The interviewees at the facility said that the people of Kaptembwo are normally referred for cases ranging from severe malaria; threatened abortions; STIs, soft tissue injury and eye infection due to assault in women; and dehydration, food poisoning, severe diarrhea and pneumonia in children. Severe cases are admitted while mild cases are treated as out-patient. The patients pay Kshs. 100.00 for treatment card and Kshs. 30.00 for subsequent visits. They buy the prescribed medicines from various chemists situated in Nakuru town or elsewhere. The in-patients are charged Kshs. 150.00 as admission fee. They hospital has a waiver system that caters for the poor. The under-five children pay Kshs. 50.00 for the treatment card;

7 Also called Malta fever, Mediterranean fever or undulant fever. It is a chronic disease of farm animals caused by bacteria of the genus brucella, which can be transmitted to man either by contact with an infected animal or by drinking nonpasteurized contaminated milk. Symptoms include headache, sickness, loss of appetite, and weakness, progressing to chronic fever and the swelling of lymph nodes. If untreated, the disease may last for years but prolonged administration of antibiotics is effective.8 The Nakuru Provincial General Hospital is not located in Kaptembwo. It is 7 km away from the informal settlement. It is included in this report because it is the main referral centre for many people in the district including those from Kaptembwo.

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and with the card X- ray, laboratory tests and treatment is free of charge. All admissions for under-five children are also free, as stipulated in the Kenya health policy framework (MOH, 1994).

4.3.6 Chemists/pharmacies – There were several pharmacies and chemists that were visited. These included Interland pharmacy, Suhgic pharmacy, Pearl pharmacy, Nene chemist, Alfamona chemist, Trompoy chemist and Dan Sam chemist. They sell drugs to the slum dwellers at a cheaper price but those who have prescriptions of more than Kshs. 500.00 are referred to PGH since they cannot afford the drugs. When asked about the kind of child diseases that are frequently treated with drugs bought from the chemists and pharmacies, one interviewee said:

Most women receive health talks concerning child diseases that include intestinal worms. Therefore, a majority of them deworm their children after every three months. We deal mostly with malaria and common cold but not with intestinal worms in children (Drug seller, Interland Pharmacy, Kaptembwo).

Many people buy drugs in the middle and end of month because of advance and salary payments. The drug sellers observed that since many people lack money to buy drugs, they persevere with the disease till the time they can be able to afford the drugs.

4.3.7 Traditional healers – There are four traditional healers serving the people of Kaptembwo: two at Soko mjinga market, one at Imani centre and another one at Nakuru West village. According to the herbalists, the power of treating people using herbal medicines was inherited from their grandparents. It is taboo to start this kind of work unless you have finished childbearing. They believe that if one handles the herbs when she/he is still bearing children, then the medicinal power is weakened.

Nakuru West village - He had travelled to Nairobi to attend to his clients. He operates from home and his centre referred to as Kokos herbals clinic is managed by Kenyan quality concept that is recognised by the Ministry of Health (MOH). Imani centre - She treats cancers; typhoid; malaria; allergy; ulcers; pancreas, liver and kidney problems; STIs; barrenness; skin diseases; and HIV/AIDS opportunistic diseases. One of her patients who had paid her a friendly visit said:

I had breast cancer for two years which was diagnosed at Kenyatta National Hospital after a referral from PGH. I came here in April 2006 and started the therapy up to November 2006 when I was completely healed. I thank God for this doctor since I had lost hope after my unpromising chemotherapy experience at Kenyatta National Hospital (Patient from Lanet, Nakuru).

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The herbalist also added that she had successfully treated a Mr. Samuel who works with Kenya Times Nakuru branch. The man was due for an operation in Nairobi due to throat cancer but has since been healed. The payments depend on the kind of disease that is treated. However, payments range from Kshs. 20.00 - 12,000.00. She treats people from all major towns in Kenya. Although many patients are treated during the day, a few receive these services at night. She offers these services in a separate room in her neighbourhood rented mainly for this purpose.

Soko Mjinga market - There were two herbalists here; a female and a male. The female one treats minor ailments including malaria, diarrhoea, typhoid, common cold and barrenness. She does not administer medications at night since most of the herbs require boiling and she does not boil any herbs in her house. Her clients pay between Kshs. 10.00 – 100.00 according to the ailment. Serious diseases and complications are referred to PGH for specialised treatment. She operates from 8.00 am to 5.00 pm from Monday to Friday except those days on which she travels.

The male herbalist treats toothache, malaria, backache, stomach-ache, hard stool, dysentery, athletes’ feet, skin diseases and other diseases from his herbal centre (pictured). For complicated wounds, he has to look at the symptoms that led to the wounds, and if it is a serious case he refers the patient to PGH for specialised treatment. He has a certificate in HIV/AIDS counselling. However, all the patients get tested at the voluntary counselling and testing (VCT) centre at PGH since Kaptembwo does not have a VCT centre. After diagnosis, those who suffer from opportunistic diseases are then treated with the herbal medicine. He also co-operates with other experts in treating barrenness and STIs. He said that the reasons as to why women do not get children include prolonged use of family planning pills and abortions. The patients who visit him with such cases first undergo counselling before being referred to PGH for diagnosis and treatment.

According to him ulcers occur in different shapes: intestinal, duodenum and stomach. The herbalist has to find out the symptoms of the ulcer and how long the patient has had it before administering the right medication. He also has a first aid kit which he uses on patients who suffer from cuts and burns. He also does home-based care as a volunteer. He has therefore bought syringes, hydrogen peroxide and antiseptic deodorant, neugrasin (antibiotic for wounds), gentian violet for mouth ulcers, adhesive plaster (zinc oxide), medicated spirit and potassium permanganate. The latter is used for treating joint dislocations.

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The cost of medication depends on the kind of disease one has, but the range is between Kshs. 200.00 – 500.00. However, many slum dwellers cannot afford the medicines even as cheap as they might seem. He said:

Sometimes I treat a patient because I realize how much he/she is suffering. But some patients disappear without paying for the services. The problem emanates from the fact that the freelance herbal medicine men or the so-called promoters sell their drugs for Kshs. 50.00. Thus, the people here have a mentality that all herbal medicines should not exceed Kshs. 50.00. Only those who understand the strength of these medicines and the pain we go through in looking for the herbs genuinely pay for the services (Male herbalist, Soko Mjinga market, Kaptembwo).

All clients have an easy access to this place since it is located at the main market centre that serves Kaptembwo. The clients are given his business card and therefore the message of his herbal services is spread to family members and friends of the client. He treats people from all major towns in Kenya. When he travels he carries herbal medicines that treat common ailments like malaria and common cold. He operates from 8.00 am to 6.00 pm daily. He got his permit in August 2006, but has an experience of eight years in the service.

4.3.8 Drug peddlers - The research team found only one drug peddler during the mapping exercise. However, the community members said that other drug peddlers or mobile drug sellers come to the settlement on different days to promote and sell drugs. They use public address systems and they teach groups of people who congregate around them to learn about types of drugs and the kinds of diseases they treat. The drug peddler revealed that they operate within Kaptembwo, Shabab estate and the town centre. They treat malaria and typhoid among adults, but children get treatment from their town centre clinic. The adults who are given medicines by the peddler must have prescriptions from the doctor. These are normally herbal medicines, but the peddler said that unless the drug is given for detoxification purposes, children are not given herbal medicines since they are stronger than the modern drugs.

4.3.9 Over-the-counter drug sellers – Most of the shops in Kaptembwo and its environs sell pain relievers that include Panadol, Actal, Hedex and Action.

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4.3.10 Soothsayers and faith healers – There were many churches that were mapped out during the field visit. These included: Full gospel churches of Kenya, Seventh Day Adventist church Kaptembwo, BCM gospel move-on international church, Victory word centre, Possibility word centre, Bemacah worship centre, Christ chapel, Emmanuel pentecostal gospel church, Integrity’s christian community chapel, Nema worship centre, Faith victory centre, Church of Christ, the Nakuru house of power church, Musamba holy ghost church of East Africa, Vineyard towers church, God’s glory centre, St. John’s Anglican church of Kenya crater parish, God of all grace worship centre and Christian revival church. Some of the community members who worship in these churches said that many believers have been healed through miracle revival prayers offered by pastors in these churches.

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5.0 Discussion and Conclusion

Global picture: Globalization under liberalized markets has generally benefited the industrialized or strong economies and marginalized the weak economies. Many countries are urgently conducting research on the effect of globalization on people’s living standards and health care (Nguyen et al. 2006). In this regard, economic globalization presents formidable challenges to the promotion of health. Coordinated, forthright, and determined advocacy by health workers and their associations at national and international levels could and should play a much greater role in mobilizing public and political opinion and in bringing pressure to bear on multinational companies and international

economic bodies. Their advocacy should include the promotion of “essential public health functions” - a basic package of services that should be available to all populations. It should also include the promotion of a health research agenda led by the health and policy needs of countries that bear the brunt of the world's ill health (World Bank Report, 1996).

A large proportion of illnesses in developing countries are entirely avoidable or treatable with existing medicines or interventions. However, most of the disease burden in developing countries finds its roots in the consequences of poverty, such as poor nutrition, indoor air pollution and lack of access to proper sanitation and health education. Tuberculosis, malaria and HIV/AIDS account for nearly 18 percent of the disease burden in the poorest countries (WHO, 2004). Respiratory infections caused by burning biomas fuels and low-grade coal in poorly ventilated areas also constitute a significant health burden for poor people. Globally, acute respiratory tract infections in children, particularly pneumonia represent the single most important cause of death in children under five years and account for at least two million deaths annually in this age group (Bruce et al., 2002).

Diarrhoeal diseases caused by poor sanitation which is endemic in economically deprived areas, may be easily and cheaply treated through oral re-hydration therapy. However, diarrhoeal diseases are the second biggest killer of children worldwide, after respiratory infections. If the environmental sanitation of the informal settlements is improved, then access to health care would improve the health condition of the slum dwellers. However, if environmental sanitation is not improved, provision of health care cannot bear fruit since children would still go back to live in the same squalid conditions, therefore being prone to diarrhoeal diseases. Malaria can be prevented through a combination of indoor residual spraying of dwellings with insecticides, the use of insecticide treated bed nets and the use of prophylactic medicines. However, malaria continues to affect people in informal settlements due to poor drainage system that harbors stagnant water - a breeding site for mosquitoes. The upgrading of the slum can help in improving the living

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conditions of the dwellers. Malnutrition particularly affects people in poor countries while micronutrient deficiencies contribute to illnesses and poor health. Vitamin A deficiency weakens the immune system, leaving children vulnerable to other illnesses such as diarrhea and measles. Estimates suggest that Vitamin A deficiency causes approximately 800,000 childhood deaths each year (Rice et al., 2004). The District’s Nutrition Field Community Health Workers should be utilized to reach more people through door-to-door nutrition education and distribution of the newly introduced micronutrient supplements. Appropriate micronutrient supplementation such as iron and folate pills, vitamin A capsules and iodized oil can be highly effective in overcoming vitamin and mineral deficiencies. Governments, on the overall, should put more emphasis on fighting the diseases of poverty as espoused in the MDGs that were endorsed in 2000.

National picture: The improvement in the political environment has resulted in a boost in available resources from international partners in support of Kenya’s efforts to curb the HIV epidemic. For instance, signing of the Global Fund Round 2; Phase 2 grant due to improved governance structures being put in place; the United States Government increased its HIV allocation by 30 percent between 2006 and 2007; and negotiations with the World Bank and United Kingdom’s Department for International Development (DFID) are near to finalization, for considerable additional support to the national response, through the NACC. AIDS is a severe problem in sub-Saharan Africa and this means that scarce health resources should be targeted primarily at those who are at the highest HIV risk. Thus, money and efforts should be concentrated on prevention and palliative care where it really matters (Chin, 2007). Moreover, efforts need to be directed to the poor so as to help in fighting the scourge.

Malaria continues to be a major problem in most parts of Kenya, a situation compounded by ARI (CBS et al., 2004). Maternal and child health are major commitments of the government as espoused through the National Development Plan (2002-2008), the National Malaria Control Programme (2005-2010), the National Malaria Strategy (2001-2010), the Roll Back Malaria Movement of 2005, the National Health Sector Strategic Plan (1999-2004), the Abuja Declaration of 2000 and the Millennium Development Goals endorsed in 2000. Increasing access to services is therefore critical to meeting any of the set health targets. Thus, the mobile clinic services and health advocacy are relevant to the needs of the people. Moreover, there is need for training more medical staff so as to scale up the provision of medical services in the country to reach more people.

On attaining independence in 1963, the Government of Kenya committed itself to providing free health services as part of its development strategy to alleviate poverty and improve the welfare and productivity of the nation. The Government committed itself to improving accessibility, equity, affordability

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and quality essential health care services for every Kenyan. To realize this objective, the 2005-2010 National Health Sector Strategic Plan was developed. The theme of this plan, "Reversing the Trend" was developed under the Kenya Health Policy Framework, the Economic Recovery Strategy and the health related targets of the MDGs. Of the eight MDG goals, three are related to the health sector: reduction of child mortality by two thirds by 2015; improvement in maternal health by three quarters in the same period; and combating HIV/AIDS, malaria and other diseases like Tuberculosis. The health sector reforms that have hitherto taken place (including introduction of the National Health Insurance Fund, free health services, cost-sharing, waivers and exemptions etc) have all aimed largely at addressing affordability and access to health care services. However, these ambitious programmes could not be sustained for long following the emergence of socio-economic crises in the late 1980s. Many countries in the sub-Saharan Africa (including Kenya) experienced declining GDP growth rates, negative growth in the GNP per capita, rising inflation, declining exports and gross domestic investment and savings as a percentage of GDP, among others. To avert the crises, the country implemented SAPs leading to reductions in government health spending and subsequently the introduction of cost-sharing in 1989. The policy was meant to encourage the users of public health facilities to meet part of the costs with a view to complement government funding (IPAR Policy Brief, 1999).

Spending to promote access to health care is crucial, given also that Kenya is a signatory to the WHO Abuja Declaration. The latter requires member countries to spend at least 15 percent of their national incomes (GDP) on health (Kenya spends approximately 9%). Although Kenya has not reached the WHO Abuja Declaration of spending 15 percent of their national incomes on health, Kenya has had increasing budgetary allocations for health from Kshs. 18.3 billion in 2002/2003 to Kshs. 34.3 billion in 2006/2007. This amount has been spent on different programmes resulting in enhanced delivery of health care services at all levels, with notable achievements (IRIN Report, 2007). However, even with such statistics, many Kenyans who live in squalid conditions like Kaptembwo continue to have no access to or cannot afford to pay for their health care needs. It is due to the failures of the past programs, that the National Social Health Insurance Fund (NSHIF) was conceptualized for implementation, with a view to enabling more effective provision of health cover to all Kenyans, at both in- and out-patient service levels. But, the benefits of this scheme do not trickle down to the poor. It is suggested that the NSHIF should be discussed again in Parliament since it was a good initiative which could see the government initializing mechanisms that could help the poor to access health care services. Existing services can be improved, extended and tailored to fit local conditions. For example, in the design and implementation of health programmes, attention can be paid to factors that have particular relevance to women because of biological and social

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influences: access and quality (including service provider competence, counseling, continuity of care and privacy).

At the inception of the cost-sharing programme in the public health sector in Kenya, it was recognized that charging user fees would lead to inequities in the provision of health care services. This is because the user fees constitute a financial burden to the poor and other vulnerable groups, restricting their access to health care services due to their inability to pay. The task of fee setting and adjustments hardly follows the required process, having shifted unofficially, from the MOH headquarters to the DHMBs. There is arbitrary and uncoordinated fee structure by the district hospitals (DHs) and PGHs, leading to a wide divergence between the actual fees being charged by these facilities and the MOH guidelines. Whereas the increases are relatively modest for some services, they are outrageous in others. This might be the reason as to why most residents in Kaptembwo cannot afford to pay the user charges demanded in the health provision points that were visited during the mapping exercise. The shifting of user fees and adjustments from the MOH to the DHMBs was a good idea, if only official guidelines were followed in order to efficiently reduce the backlog at the Ministry. However, it should be noted that the DHMBs need to step up the provision of health services at the grassroots level; and also appoint a reliable person who can provide human rights education to those who live in poor communities. In so doing, the poor people could have similar rights of accessing health care like their counterparts who reside in well-to-do areas.

On equity grounds, waivers and exemptions were introduced to cushion the poor and other vulnerable groups against adverse effects of the user fees. Granting of waivers to the poor and provision of exemptions by the Government are considered to be part of crucial components in poverty reduction strategies. The protection of the poor and other vulnerable groups notwithstanding, there are concerns that the safety nets (waivers and exemptions) programmes may not be reaching the targeted people. These concerns have been prompted by available evidence, which points to leakage of the benefits to ineligible households, weak administrative systems and inadequate support to potential beneficiaries, among others (IPAR Policy Brief, 2003).

In most facilities in the country, waivers and exemptions have not been fully effective in protecting the poor against the negative effects of user fees on their demand for health services, due to: limited volume of waivers granted; limited awareness by the target population; varied assessment procedures, with some procedures not able to identify accurately the targeted; lack of support by facility staff because of revenue loss, given that user fee revenues have become an important source of finance for non-wage recurrent expenditure at the public health facilities. This has resulted in very small amounts of waivers being granted to patients; and lack of enforcement of

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guidelines on waivers and exemptions by MOH, resulting in health facility managers exercising discretion during implementation (IPAR Policy Brief, 2003). This suggests that the equity objective, in the provision of health services, has not been fully achieved. The effectiveness of waivers and exemptions in promoting equity in the public health sector can be achieved if the waivers and exemptions programmes are publicized; MOH issued guidelines on waivers and exemptions are enforced; increase targeting efficiency through improved assessment and approval mechanisms; motivate facility staff to support the safety nets programmes; strengthening of collection efficiency; base allocations of MOH budget to facilities on needs criteria including poverty level, fee collection potential, and burden of diseases, among others. Use of such criteria would increase the availability of financial resources to the poor districts, facilitating granting of more waivers to the poor and other vulnerable groups by health facilities.

Local picture: During the mapping exercise, poverty came out as the main problem affecting people in Kaptembwo. Causes of poverty in Kaptembwo vary from HIV and AIDS prevalence, unemployment, destitution, squatter/landlessness to illiteracy. It is further characterized by low incomes, high child mortality and dependency ratio, poor infrastructure, corruption and domestic violence. These problems impinge on the livelihoods of the residents who largely survive on fragile financial bases. It was observed that although the women of Kaptembwo knew what constitutes proper medical care, they could ill-afford it and therefore had to make do with whatever was available. In this regard, we note that inadequate medical care is highly likely to affect the health of women who can hardly provide other basic needs such as proper nutrition for their children.

The health risks women face due to their disproportionate poverty, low social status and reproductive role merit increased attention. Improving women’s health has multiple external benefits that enhance the survival and well being of children and the productive capacity of the economy. Another problem is lack of timely and appropriate medical care for curative and preventive diseases, which are common among the poor. The service providers were of the opinion that many women of child bearing age were illiterate and therefore unable to fully understand the risks they exposed themselves to as a consequence of not seeking proper medical care for themselves and their children. However, women found themselves in circumstances beyond their control. For instance, the drug sellers said that the situation is worsened by the response women get from their husbands who do not encourage them to seek such services. Due to their husbands’ idleness, women’s lack of income generating activities and absolute poverty, most people were unable to afford medical care. In addition, poverty was also closely related to poor nutrition and at worst starvation and susceptibility to other diseases.

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6.0 References

ACC/SCN (2004). The 5th Global Nutrition Report. ACC/SCN: Geneva.

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Annex 1: Observational checklist for health facilities

Name of health facility_________________________________________________________________

1. Location of health facility____________________________________________________________2. The range of services offered (name them) _______________________________________________________________________________________________________________________________________________________________________________________________________________3. Regularity of services provided (number of days per weekdays) ____________________________4. Rate appropriateness of visiting hours__________________________________________________-Visiting hours’ codes (1= very appropriate, 2= moderately appropriate 3= inappropriate) 5. Rate age of service provider(s) _______________________________________________________-Age of service providers’ codes (1= 20s, 2=30s, 3=40s, 4= 50+)6. Rate capacity of service provider(s) to handle clients (number of staff, their professional qualifications versus number of clients) ______________________________________________________________________________________________________________________________________________-Capacity codes (1= Excellent, 2= Good, 3= Fair, 4=Poor)7. Rate capacity of facility to handle the number of clients (size of facility, availability of equipment) __________________________________________________________________________________________________________________________________________________________________-Capacity codes (1= Excellent, 2= Good, 3= Fair, 4=Poor)8. Rate quality of services provided_______________________________________________________________________________________________________________________________________-Quality of services codes (1= Excellent, 2= Good, 3=Fair, 4= Poor)9. Rate the general atmosphere at the health facility___________________________________________________________________________________________________________________________- Atmosphere codes (1= Relaxed, 2= Okay, 3= Intimidating)10. Rate the reception of clients by service provider(s) ________________________________________________________________________________________________________________________- Reception codes (1= Excellent, 2= Good, 3= Fair, 4=Poor)11. Observe gaps in capacity and service provision and required capacity to give services to slum dwellers___________________________________________________________________________

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__________________________________________________________________________________________________________________________________________________________________12. General observations and comments ___________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________

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