By Joyce Chimbi
The distance between Kenya’s most vulnerable populations and the health services they need to thrive and contribute fully within our society has always been wide. Our oldest and youngest citizens, people with disability, the chronically ill, people living in poverty, and women are too often left behind in our health system despite multiple programs and investments meant to ensure their care, including the Beyond Zero Initiative that sought to bring maternal and infant mortality down to zero.
Kenya’s capital, Nairobi is home to nearly 2.5 million people living in about 200 informal settlements, representing 60 percent of its population. Located just outside Nairobi CBD, Kibra, Africa’s biggest informal settlement and one of the biggest in the world, is home to an estimated 600,000 to 1,000,000 people.
“Very bad things happen to poor people. If you are a woman and a person with disability, you will face many problems such as discrimination. Maternity nurses quarreled with me for having four children, saying I could not afford them. Nurses will deliberately cut you (episiotomy) during childbirth claiming that the baby’s head is too big,” said Yvonne Anyango Ochieng’, a casual laborer in Kibra.
On family planning, she said, “Nurses will give you what is available and not what is best for you, causing problems such as bleeding. So, we end up refusing family planning methods because what we want is not available. Some years back, my sister was in that scandal where a big public hospital injected women with ‘air’ because they did not want to tell the women they had run out of ‘sindano’ (injectable family planning). My sister and others became pregnant. They do this to us because we are poor.”
Allegations against public health facilities
Born in Kibra, Ezekiel Nyakundi, a community health promoter, agrees that public health facilities have often faced serious allegations, including obstetric violence or the mistreatment of women during childbirth. Nearly 20 percent of women who give birth in Kenya experience obstetric violence.
Josephine Majani was verbally and physically abused after giving birth on the floor of Bungoma District Hospital in 2013 as all the beds were occupied. She was slapped and insulted for dirtying the hospital floor. A patient recorded and shared the incident, blurring her face but showing the health providers abusing the woman. Following a public outcry, she sued the hospital and was awarded 2.5 million shillings (USD19,185) in damages.
In 2020, a woman in labor pains arrived at the government-run Pumwani Maternity Hospital, the biggest and specialized health facility dedicated to maternity and newborn care in Kenya, handling an average of 120 deliveries per day. The security guards locked the gates and refused to let the woman in due to an ongoing labor strike. It was too late to rush her to another facility.
The woman gave birth outside the gate, in broad daylight and with the help of passers-by who then proceeded to break down the hospital gates. Health providers only emerged from inside the hospital to help the mother and newborn after an uproar from the public. These cases are all too common across the country including accusations that some health workers in crowded public hospitals solicit bribes to allow patients to jump long queues.
There have been cases of forced sterilization of women with disability and those living with HIV. For instance, in September 21, 2023, a Kenyan Court delivered a landmark judgment in a case over the forced sterilization of four women living with HIV, determining that it was a violation of their fundamental rights, including dignity, freedom from discrimination, the right to the highest attainable standard of health, and the right to establish a family.
The four were among a group of 40 women who reported being coerced and forcefully sterilized in 2009, in clinics across the country, including Pumwani Maternity Hospital. The women said they were told that they would not qualify for aid including baby formula and food portions for themselves.
Quality of services for the most vulnerable
Nyakundi, the community health worker, said that although the quality of services has improved over the years, such proven abuses have lingered and contributed to the widening distance between the most vulnerable and high-demand populations and formal healthcare. Stressing that negative past experiences have created fear of mistreatment or suspicions that health providers in public health facilities are not committed to providing quality health services and in a friendly manner.
“Nurses can be very rude especially when they feel you are uneducated or poor. We do not want to simply receive services. We also want to understand why and they are never willing to explain. I have had more children than I planned to have because I believed in what people said about family planning. They said it causes infertility and I was very afraid of being barren,” says Beryl Wekesa, a flower farm laborer in Nakuru County.
Family planning does not cause infertility, but this and many myths and misconceptions persist through word of mouth.
To address significant disparities in access to healthcare among these populations, whether in poor-urban settings, large rural multiethnic counties such as Nakuru, or pastoralist marginalized communities in Narok county within the Rift Valley region where distances to the nearest health facility can be more than 15 kilometers, Kenya has prioritized Primary Health Care (PHC) as a critical pathway to universal health coverage (UHC).
PHC aims at ensuring that all Kenyans have access to critical basic health services such as routine child immunization, labour and delivery and, treatment for chronic illnesses such as HIV/Aids and high blood pressure.
“Distance to health facilities can be both physical and mental. Vulnerable populations are often underserved either because they live far from health facilities or the health facilities nearby are mere brick and mortar without the human resource and medical commodities they need, when they need them,” said Rift Valley region-based Dr. Gladwell Chela Chebii at the Good Samaritan Mission Hospital.
Dr. Chebii said people in vulnerable populations may seek solutions in traditional medicine or with untrained traditional birth attendants. This practice, he said, leads to preventable illness and death due to a lack of professional preventive and curative care.
Highlights from the latest World Population Data Sheet
PRB’s 2024 World Population Data Sheet, which provides the latest population, health, and environment indicators for more than 200 countries and territories, stresses that such critical health services can best be provided through PHC as this is an approach that includes preventive measures that are crucial in delaying the onset of age-related diseases and maintaining older adults’ health while also reducing the long-term burden on health systems.
For youthful countries such as Kenya where 37 percent or more of the population is below 15 years old, the data sheet shows that PHC can provide maternal and newborn care that helps decrease mortality rates for mothers and young children and improve health outcomes across the life course.
“Vulnerable and high-demand populations are at risk of falling into poverty or deeper poverty from out-of-pocket health spending of 10 percent or more of their household budget. These populations are often already living below the World Bank’s $2.15 [per day income] international poverty line,” said Eric Kosgei, a public health official at the Ministry of Health.
According to the Kenya Demographic and Health Survey 2022, just one in four people have some form of health insurance. Kosgei said scaling up PHC interventions is critical, as nearly 90 percent of essential interventions for UHC can be delivered through a PHC approach without financial hardship.
Kosgei said UHC means all people have access to the full range of health services they need, where and when they need them and without challenges. Stressing that PHC is the most effective way to achieve this, Kenya has chosen to reduce the distance between her people and health facilities by linking low level facilities to higher facilities, and connecting these facilities to surrounding communities while ensuring that at any given time, no individual travel longer than five kilometers to access health services.
Kenya’s Primary Care Networks Model
Kenya’s Ministry of Health launched the Primary Care Networks (PCNs) model in 2021 across all 47 counties, after a 2018 pilot in four counties. Kenya’s health system is organized through a hierarchy of six levels, starting with level 1 for community services, operated by Community Health Promoters.
The community workers move door-to-door providing health promotive services and care for common concerns including access to family planning, prenatal checkups and conditions, emergency labor and delivery and diagnosis and prevention of common ailments.
Community health promoters have basic medical equipment such as a weighing scale for baby growth monitoring, a thermometer, and cord clamps to tie the umbilical cord to stop blood flow from the placenta to the fetus during an emergency delivery.
They also have a glucometer to measure blood sugar levels and connect people to care and treatment. High blood pressure, or hypertension, is one of the most pressing problems in Kenya, as nearly 78 percent of people diagnosed with hypertension are not on treatment, leading to preventable morbidity and premature death, as highlighted by the 2024 World Population Data Sheet.
Community workers can connect people to care because, in 2023, the Ministry of Health integrated 100,000 community health promoters across the six health facility levels and established a community health desk. The government’s goal in setting up these desks is to ensure a familiar and consistent presence that greets incoming patients.
Nyakundi says the community desks were set up in 2023 to formally integrate community health promoters into the Ministry of Health. Before, Community Health Promoters operated as outsiders. But today, they are attached to different health facilities and more so, facilities that serve vulnerable and hard-to-reach communities.
“They are our community doctors because after making their rounds in the community, they report back to the facility where they are attached. Some services can only be given by a nurse, such as injectable vaccines. During mass vaccination campaigns, we rely on community health promoters to help us access communities. If a nurse enters the community without them, they will not be successful because we are still working on strengthening relationships between the community and formal health care,” says Dr. Chebii.
Bringing Primary Health Care closer to the people
Level 2 in the PCN model includes dispensaries and clinics; level 3 is health centers and maternity and nursing homes. Level 4 includes sub-county hospitals and medium-sized private hospitals and level 5 has county referral hospitals and large private hospitals.
WHO research shows PHC interventions such as Kenya’s PCN model could increase the life expectancy by nearly 4 years on average by 2030, and that projected health gains could help Kenya make significant progress on the Sustainable Development Goals. The PCN model is helping address challenges revealed in the World Population Data Sheet towards multiplying health gains.
According to the Data Sheet, for every 10,000 Kenyans, we have one medical doctor, six nursing and midwifery personnel, and 16 community health workers or community health promoters. These numbers are below the global average of more than 17 medical doctors and nearly 38 nursing and midwifery personnel for every 10,000 people.
“PCN helps different facilities within one network to share scarce resources including human resources as each network operates as one team. One facility can borrow resources, such as vaccines, from another to avoid stock-outs. If a lower-level facility needs to perform a medical procedure, they can seek support from a health provider in a higher facility. This is crucial as certain procedures cannot be performed by one person,” says Dr. Chebii, a PCN implementor.
The networks are also facilitating referrals. For instance, she says, if a preferred family planning method is missing in one facility, a community health promoter can help trace it to another facility and facilitate access, reducing dissatisfaction and unintended pregnancies.
PRB’s Data Sheet shows that the average Kenyan woman gives birth to more than three children, against a global average of about two children per woman, and that some Kenyan women who want to use family planning are not able to do so.
Across the country, 160 PCNs have been successfully set up, and 41 more are in progress. To date, 41 of Kenya’s 47 counties have at least one operational PCN focusing on preventive care as a strategy to lower health expenditure while significantly improving health systems’ performance.
Kenya’s current UHC service coverage index of 53 percent as per the PRB Data Sheet means that there are significant pockets of unserved and underserved populations. The index measures average coverage of essential primary health care services among general and most-disadvantaged populations from 0 (worst) to 100 (best).
Investments in Community health care work
Ann Wilma, a Community Health Promoter and vice chair of Lindi Community Health Unit in Nairobi, says the PNC model’s investment in community health workers is critical to breaking down some of the barriers to quality health care for the most vulnerable groups in Kenya.
“When people get seriously sick, the first suspicion is that they were bewitched. Some religions do not want their children vaccinated at all. Others hide their newborns for the first 40 days and they cannot be attended to by a health provider within this time even if sick. This is why community health promoters are important. We work in the communities where we live and are able to address such harmful beliefs and connect people to health facilities from a place of understanding,” she expounds.
Sera Maria in Narok County opted for a home delivery for fear of exposing herself to a man at the hospital due to her conservative religious beliefs. Wilma says community health promoters live and work in the same community and understand such sensitivities as well as other myths and misconceptions and can guide accordingly.
“I delivered my firstborn in the hospital and was slapped on the thighs and abused by the nurses in 2016. I delivered the second one at home in 2019 with a mkunga (untrained and unsupervised traditional birth attendant). In 2023, I delivered twins at a public hospital free of charge. The experience was very good and all because of our community health worker who encouraged me to deliver in hospital,” says Salome Nyambura, an Early Childhood Education teacher in Kaptembwo, Nakuru County.
To multiply such gains and significantly improve community health service delivery, the Ministry of Health has equipped community health promoters with digital tools such as eCHIS (Electronic Community Health Information). The tool helps in real-time data monitoring as community workers move door-to-door collecting and populating the tool.
Kosgei says by looking at the household data, the ministry’s central system can quickly detect the onset of a disease outbreak as was the case with the polio and cholera outbreaks in 2022/2023. Early detection through data collected by community health workers led to expeditious responses, including robust mass polio and cholera vaccination campaigns that decisively stopped the outbreaks, saving lives.
Budgeting for primary health care work
Although Kenya has made strides and was revealed by the PRB data sheet to have directed 55 percent of its total health budget to PHC in the 2018-2022 period, significant challenges prevail towards connecting its most vulnerable populations to health care. A spot check of health facilities and interviews with community members, community health providers and health workers revealed that health facilities often face stock outs of critical health commodities.
The National Syndemic Disease Control Council has already raised the alarm that the country’s public and private hospitals are currently facing severe shortages of Atazanavir, a crucial HIV drug, state-sponsored condoms, BCG vaccines for newborns; and most HIV-testing equipment after depleting stocks during the Christmas holiday season. A troubling development in a country where nearly 1.378 million people are living with HIV in Kenya.
Moreover, the ongoing reforms under the 2024 UHC scheme have disrupted services, making it even more difficult for vulnerable, high-demand populations to access critical services as they rely on free or subsidized health care. The recent phasing out of the Linda Mama programme that provided free maternity care for women in all public facilities is likely to increase infant, child and maternal mortality rates.
“Over the years, we have had many small health programs like Linda Mama within the health system to provide special services to a special group. But it seems the government is trying to have a one-size-fits-all approach where you just walk into a facility and receive whatever services you want and they are very keen to close the physical distance. But a health facility without medicine and enough health providers is not helpful. Children these days are missing out on vaccines and people have to buy medicine from private pharmacies. There is a private pharmacy next to every public health facility, and the poor cannot afford these medicines. We still have a very long way to go and many challenges to overcome to reach universal health coverage,” said Kibra community health worker, Nyakundi.
