Following the Second Annual Right to Health Conference, my colleague Amanda Cary and I have been on the ground searching for innovative approaches to comprehensive women’s health care; models for service provision that move away from the “vertical approach” and integrate critical services such as family planning and HIV&AIDS counseling and testing.  This integration helps to break down the many barriers women face when accessing health care.  It’s a new way of thinking about health and about the systems that are designed to promote it — imagining every patient as a holistic person, with legitimate demands upon the health system and fundamental rights within it that must be respected, protected and promoted.

In order to examine these models further, we’re visiting NGO outreach sites in rural areas, government facilities in the heart of Nairobi, faith-based organizations in the capital’s slum areas and holding interviews with a wide array of service providers.  Here’s a brief glimpse into what we’ve discovered… so far:  the story of Emma and Eunice.

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Eunice lives on the outskirts of Nairobi, along the dusty, crowded industrial road linking Kenya’s capital to the coastal port of Mombasa.  Every six weeks she goes with her newborn daughter, Stella, to the health center for their regular check-ups.  It isn’t easy to access health care in Kenya – health facilities are often far away and transport is expensive.  Even when a woman does manage to reach the facility, the medicines, services and even health workers may not be there.  Eunice is one of the lucky ones – she lives nearby to a government health facility in the Industrial Area.  But she chooses another facility for her care.  She chooses to pay extra fare, to take extra time and to travel into the heart of Nairobi to visit Nurse Emma Kariuki at Loco Health Center.

Loco Health Center is at the very end of a tarmac road falling slowly into disrepair.  The pavement eventually turns into dust, and cars become fewer and fewer as the road narrows towards a small footbridge leading over the railway tracks.  Under this footbridge, next to the old railway supplies warehouse is Loco Health Center.  The facility is made up of only a few buildings – one larger concrete building for general consultations, and several smaller trailers housing the child welfare clinic, antenatal care clinic and tuberculosis clinic and laboratory, as well as space for a support group for people living with HIV&AIDS.

Emma Kariuki has been a nurse at this small, bare bones facility for years.  And it was Emma who pioneered the integration of services for women who visited the facility – matching up the services she offered with her own, holistic view of the clients who came to seek her advice and support.  In Emma’s words, “I asked myself, if I’m genuine about HIV, the women who are coming for family planning are telling me they’re sexually active, and if they’re sexually active, then I’m denying them an opportunity to get to know their status.” One of her first clients was a woman whom she had tested for HIV as part of prevention of mother-to-child transmission.  The client was HIV negative.  The next time she was tested, three years later, she was HIV positive.  According to Emma, “That gave me the energy to continue.”  Emma was determined to take advantage of future opportunities for all her clients, no matter what services or needs brought them to the health center.

So Emma sought out training on HIV counseling and testing, and began to integrate it into her own family planning services.  Initially, her colleagues felt that offering HIV testing to people in the family planning clinic would deteriorate the demand for family planning services.  But Emma persisted, and proved them wrong.  “It was the opposite.  Clients began to come to us from other clinics.  Those that I tested would go and tell others in the community, and they’d come to me and tell me ‘Sister, I hear you’re offering VCT and family planning.  I’m not your family planning client, but I’ve come for VCT.’  Instead of the numbers going down, they started to go up.”

This is why Eunice comes to Loco, instead of her own, closer health facility.  When she arrives here with Stella, she can get a full package of care.  She has her reproductive health needs met, and she can feel confident that her other needs, such as HIV counseling and testing, will be met.  Another client at Loco, Felista, feels the same way.  She tells other women to come to Loco because “here they can be free, just as I am free.”  At Loco, women are viewed holistically – they are viewed as rights holders and as partners in health service provision, not simply as beneficiaries.  Both Eunice and Felista, through regular visits for family planning, have been counseled and receive regular HIV tests.  Now, they both want to bring their husbands to be tested at the facility as well.  This type of comprehensive care has ripple effects – by skipping a small stone across the pond, the waves have eventually reached the farthest shores.

In the eyes of providers such as Emma and women such as Eunice and Felista, providing comprehensive services for women is by no means impossible.  Women want to receive the services, health providers want to give them, and yet the system just simply isn’t designed for it.  Major challenges exist: health workers must be trained in counseling and testing for HIV, and there must be enough health workers in the facility to handle the influx of clients that will follow and spend the necessary time with each. Furthermore, health facilities must have enough commodities to instill faith in clients that when they do manage to make a visit, they won’t go home empty-handed and uninformed, and there must be enough space to ensure privacy and confidentiality.  Yes, there are major gaps and major needs; however, health workers such as Emma are changing the paradigm and demanding more from the system within which they work, looking for the simplest, most cost-effective way to provide the needed services.  Indeed, they are blazing a trail for the rest of us to follow.

Emma sought out extra training on HIV counseling and testing, as well as community and home-based care, and paid for it herself.  The Clinton Foundation provided Loco Health Center with the 2 extra trailers necessary to create the space needed for confidential counseling and testing.  With simple interventions such as this, Emma was finally able to provide the care that she felt respected the integrity of the women who sought her services.  Women do not simply receive information and services, they demand them as well.  We should all follow Emma’s lead, advocating for health systems that allow health workers to encourage, engage with, and respond to these demands.

Eunice, Felista and Emma have begun this process, and service integration is simply one method with which we can begin to meet the needs of both health workers and the communities they serve.  Let us support Emma and Eunice in this journey – let us recognize their challenges and acknowledge that they should not be fighting this battle on their own.  Let us follow Eunice’s lead, and seek out models that promote both women’s rights and women’s good health.  Let us look to the end of the road and under the bridge, to small, simple, unassuming models such as Loco Health Center.  Here, a woman is more than a body in need, a health worker is more than a stop along the way, and the right to health is looking more and more like a reality every day.

During and after the HERAF conference, I found an interest in better understanding the political issues of Kenya. For those who have developed a similar interest – I have summarized some of the historical and political highlights I reviewed from multiple sources on the net.

Kenya is a nation formed of an extremely complex tribal and ethnic mixture. This past spring, after the Presidential election violence broke out. The current violence and many of the on-going problems are the result of centuries of tension and conflict between various factions and groups.

Background:

There are many tribes within the nation- as many as 70. These tribes account for 98% of the population (less than 2% are of British or Asian descent) and are divided into three main language groups:

• Bantu-speaking tribes:
  Kikuyu, Akamba, Meru, Embu, Tharaka, Mbere, Gussi, Kuria, Luhya, Mikikenda, Swahili, Pokomo, Segeju, Taveta, and Taita
• Nilotic-speaking tribes:
  Maasai, Samburu, Teso, Turkana, Elmolo, Njemps, Kalenjin, Marakwet, Tugen, Pokot, Elkony, Kipsigis, Luo, Nandi, and Kipsigis. (FYI- Barack Obama’s grandmother is Sarah Onyango, a Luo, although every Kenyan we met lays some claim to Mr. Obama. ie: “He’s my wife’s cousin.”)
• Cushitic-speaking tribes:
  Rendille, Somali, Boran, Gabbra, Orma, Boni, El Molo, Boran, Burji Dassenich, Sakuye, Wata, Yaaka, Daholo, Rendille, and Galla.

Some of the tribal/ethnic groups are associated more directly with certain land areas, the largest land holders are the Cushitic people and the Nilotic people. Others, notably the Bantu groups, have spread throughout the country during the past 2000 years. The largest of the tribes, the Kikuyu make up about one-fifth of the overall population and in the last two centuries this tribe developed a settled agricultural-based and trading economy and became expert at defense and adaption to reduce conflict with the nomadic herding tribes (the Nilotic and Cushitic groups.) The Kikuyu are of the Bantu language group which today makes up two-thirds of the population. Some of the more nomadic tribes have kept closer to traditional lifestyles, particularly Nilotic groups such as the Masai. This language group accounts for about one-third of the population. The smallest group, the Cushitic language group makes up less than 5% of the population and hold more than twenty percent of the land.

Modern history was marked first by German, then British colonialism beginning in the1800’s. Kenya became a Republic in 1963 and was led by the Kenyan African National Union headed by Jomo Kenyatta (the Kenyan “George Washington”) who was a member of the largest tribe- the Kikuyu. The Bantu-speakers make up the largest population and Swahili and English are the official languages of Kenya.

Based on their wealth and negotiating skills, developed as traders, it is no wonder the Bantu and the Kikuyu particularly have dominated Kenyan politics. However, through cultural exchange, intermarriage and as more people adopt Western life styles, tribal identity is becoming less critical.

The vote was very close and there were allegations of impropriety on both sides. The incombent, Mwai Kibaki had been President since 2002, when his election ended 24 years of rule by Daniel Moi. Mr. Kibaki was previously with the Kenya African National Union and the Democratic Party, now called the Party of National Unity. He claimed victory over the opposition Raila Odinga of the Orange Democratic Movement. Some analysts have claimed the differences are based on tribal affiliation (Mr. Moi was Kalenjin, Mr. Kibaki is Kikuyu and Mr. Odinga is from the Luo tribe.) However, there are greater complexities in the political differences and some of those we met said they did not vote along their tribal lines, but were motivated to vote according to their beliefs about what was best for the nation during the Presidential election.

The violence has settled down, although about 300,000 people remain displaced from their homes and are unlikely to return. The government of Kenya is working to provide compensation and relocation for those families displaced due to the violence. The government has established dual ministries and separated the roles of each in order to develop a “power-sharing.” It is currently rather confused according to people who are working within and with the ministries, but the people we met seem hopeful that arrangements will remain peaceful.

After HERAF came to an end our work continued with visits to a couple of very exciting agencies and then we toured an outlying district hospital.

The first agency visit was with the Population Council where we learned about their work for more than fifty years in reproductive health, including women’s rights to safe pregnancy. This is where issues related to women’s rights really hit the ground. Some of the topics they have taken up include gender-based violence which is an issue not only within families, but is often culturally sanctioned such as female genital cutting (female “circumcision”.) They have also developed innovative approaches to care, including the integration of HIV testing and counseling into family planning visits.

We traveled a bit further to meet with representatives of Marie Stopes, Kenya. Not a person, this is a British agency that offers significant family planning and health services, including post-abortion care. It is estimated that up to 40% of maternal deaths are associated with abortions and MSK is one of the few agencies that provides medical care for these women, particularly in rural areas.

Marie Stopes doctors have perfected a ten minute tubal ligation procedure done under local anesthetic which has provided voluntary permanent sterility to many women. The staff discussed an example of a woman who had 18 babies, but was not able to insist on condoms or to use other birth control with her husband. The agency also offer safe circumcision which has been shown to reduce HIV transmission, and vasectomies. MSK provides 80% of the tubal ligations performed in Kenya and has advanced a number of other innovations, particularly in marketing of vasectomies, etc. An example is the special condoms which they market under the name “pleasure”.

Shockingly, considering the level of work that is done by the Marie Stopes agency and the fact that this is the only health care provider in many rural areas (they have 25 active clinics), the US government has recently announced stoppage of all support for MSK. Invoking the 1985 Kemp-Kasten Ammendment allowing the President to deny funds to organizations that support coercive abortion or involuntary sterilization, the Bush administration has added MSK to the exclusion from support. This is based on a determination that like the United Nations Population Fund (UNPF) which provides some services in China, Marie Stopes International also provides support to people in China. This is the connection which the US cites to cut funds and in fact to ban funds for any agency that might peripherally work with MSK. It is the first time the amendment has been used to deny funding to any group other than the UNPF.

It is not possible to really comprehend the loss of life this apparently small yet outrageous decision by the US administration will cause. Fewer condoms, especially in rural areas will equal more deaths due to HIV, as well as the certain increase in abortions due to unwanted pregnancies with all the resulting infections and deaths. Studies indicate that MS prevented over 12 million unintended pregnancies in Africa in 2007.

The people we met with are hopeful for real change in these policies with the new administration coming in January.

Our final visit was to a district hospital. We drove for a couple of hours over a very busy and extremely “washboard” road. We were so jostled my jaw ached from holding my teeth tight so they did not clatter. The hospital was large and included outpatient as well as inpatient services. Near the check in desk was a sign: “Huduma Bora Ni Haki Yako” (Good Service is Your Right) – the goal we all hold for patients in Kenya and at home.

On a warm dusty Friday afternoon, members of the PHR delegation jumped in a VW-style bus and headed to a local hospital 2 hours outside of Nairobi. We settled in for the ride…, Boni, our skilled driver, three American health care workers (the US PHR delegates), PHR staff (Lissy and Amanda!), and two remarkable colleagues…Stephen Rulisa, a prominent Rwandan doctor and rising leader, and Margaret Byabakama-Muyinda, a seasoned and passionate nurse advocate based at Mulago Hospital in Uganda. As the city ebbed away, boisterous lorry trucks emblazoned with bright Swahili, English, Arabic, and Hindi phrases rumbled past us en route to Mombasa and occasional herds of camel and goats spotted the unfolding landscape. But inside our comfortable matatu, we were engrossed in conversation, collectively processing lessons from the Kenyan conference on health rights that had concluded the day before.

We attempted to make sense of statistics…like the estimated 40% of maternal deaths among women in Kenya attributable to complications of unsafe abortions, which contributes to Kenya’s adjusted maternal mortality rate (MMR) of 560 out of every 100,000 pregnant women. [by comparison, the US MMR is 15, (although it's 39.2 among black women in the US). Cuba 's MMR is 45].

We attempted to understand the structural barriers to equity and health…in Kenya, for instance, where a poorly funded public medical system often charges fees to patients in order to stay afloat, a woman who has suffered sexual assault or rape is charged 3000 Kenyan shillings (nearly $38 US dollars) to submit a paper form documenting the crime. Given that more than half the country lives on less than $2 a day and many less than that, it’s no surprise that the majority of sexual assault cases go unreported in Kenya. Along with other structural barriers, this powerful financial disincentive drives the rights and health of women into the shadows.

We attempted to process the stark consequences of missed opportunity. Unlike many countries in Africa that lack adequate numbers of qualified health care workers, Kenya produces a relative abundance of trained nurses. But the problem is that a lack of funding, clear policies, and effective implementation has prevented the public health sector (hospitals, clinics, dispensaries) from employing these nurses. So Kenya’s health infrastructure remains thirsty for workers in a sea of relative plenty, and patients continue to pay the ultimate price.

But our discussion on the road to Kenya’s Eastern Province wasn’t centered on these statistics and stories. Instead, we kept returning to a few central themes…politics, leadership, governance, and power. These themes possessed a powerful gravity…we couldn’t help but discuss them. It was as if our ideas of health and equity and results revolved in tight orbit around the larger central sun of civic and political life. Empowerment and governance, fairness and transparency, participation and accountability…each of these concepts became the foundation of our free-flowing conversation of health and human rights.

As the asphalt road turned to bumpy gravel, Stephen told us of Rwanda’s governance reforms after the 1994 genocide. For instance, since evidence shows that women are often central agents of change in terms of health and civic life, he said, the Rwandan government focused on women’s participation…it’s a results-oriented approach to rights and health that too few countries around the world have employed. Now, Rwanda, a country that most Westerners associate with the horrors of genocide, leads the world with the highest percentage of women in elected office. (By comparison, as of 2002, the US ranked 52nd out of 179 countries with regards to women in national legislatures. Kenya’s percentage is 8%, one of the world’s lowest) Arguably, some of Rwanda’s post-genocide advancements in health and their emphasis on the role of women in governance and community engagement are not coincidental.

Fairness, accountability and the link to the right to health…like the ochre-hued dust from the road traffic, these concepts swirled around us. Over the past week, virtually every doctor, nurse and health advocate I spoke with brought up a major current news story about Kenyan ministers of parliament (MPs). And it captured our attention on the bus as well. In Kenya, apparently MPs are among the highest paid elected officials in the world earning more than $10,000 a month. But they’re only required to pay tax on their basic pay of $2500, and some don’t even pay that tax. In June, these leaders unanimously voted in rare cross-party unity AGAINST a proposal to require MPs to pay reasonable tax. Reports now suggest that many Kenyans view their leaders as unscrupulous, ineffective, and self-serving. And Kenyan health workers are adding their voice to the mix…if precious shillings paid by the public are disappearing into personal bank accounts or programs-to-nowhere, how can a struggling health care system hope to finance and mobilize needed programs? As our matatu jostled along, we asked…aren’t sustainable advances in health and human rights dependent upon and enabled by participation and transparency in governance?

We answered the question as soon as it was asked with an emphatic yes. As a middle-aged gentleman drove past us in a blue sedan, I noticed a picture of a beaming Obama plastered on his back window. It’s one of dozens of Obama stickers we’d seen in less than a week. In fact, so far, we’ve met more proud “cousins” of Pres-elect Obama than one would probably find in Hawaii or Kansas. I couldn’t help but wonder about the parallels in US and Kenyan civic life and these lessons of participation and governance for health care workers and human rights advocates. In the US, congressional leaders and President Bush have enjoyed historically low levels of public support…in part because of Americans’ frustration with a style of governance that had been relatively opaque and unresponsive. As President-elect Obama, who won by mobilizing and reshaping the American electorate, transitions to power, his attempts to increase transparency and community participation in US governance (see change.gov) hold interesting lessons and opportunities for health rights advocates. Isn’t participation of those who often feel powerless to change an opaque and unresponsive health system, particularly the most vulnerable of working families, the necessary means by which we achieve real progress in rights-based health reform?

In Kenya, where the public and health care workers lack faith in their parliamentary leaders, some advocates at the Kenyan health rights conference were calling for an Obamanian style of community engagement and civic advocacy around principles of participation, transparency and equity in health care. (for an excellent example of this kind of advocacy, check out a blog by Lukoye Atwoli, a prominent Kenyan doctor and mental health advocate). For example, one doctor mentioned that Kenyans should do more than just celebrate Obama’s victory in the US…they need to find and support their own Obamas.

We reached our destination and our delegation poured out of the matatu and onto the sprawling grounds of Machakos District Hospital, one of the highest level referral facilities in Kenya’s Eastern province. As we toured the colonial-era hospital and were greeted by patients and health workers, we started asking about the details…how many staff?, what patient care protocols existed? what’s the patient volume? what kinds of programs exist? and so on. We focused on important yet relatively technical topics that health workers are usually very comfortable discussing. I couldn’t help but think about how our conversation in the matatu about governance and leadership en route to the hospital was linked to our interest in health care services at our destination. The former discussion had highlighted the necessary means to achieve the ends we seek in our roles as health care workers. For our international group of health workers and rights advocates, our tour of Kenya reaffirmed this basic principle…if our destination is health and equity, we must lend our voice to others in civil society and travel down the road of participation, empowerment, and good governance.

I go back to Los Angeles now, slightly fatigued but enthusiastic. Through community-based tools like the South Los Angeles Declaration of Health and Human Rights or national efforts like the Rx Vote Campaign, I look forward to plugging back into our work and informing it with the powerful stories and lessons from our time in Kenya.

I had a great conversation with 2 of the nurses about how patients’ rights are acknowledged, discussed and put into practice in the hospital facilities and in the community. One of the comprehensive HIV/AIDS care nurses explained how she discusses rights with the patients she sees , often providing them with their first introduction to their own rights. In response to my question about the impact of rights education, she simply said that when people know their rights, they come and seek care. When people do not know their rights, they do not seek care. This HIV/AIDS nurse further explained that her patients often reference the rights discussed and displayed throughout the hospital though feedback given at a “customer care” desk and suggestion box in the waiting areas. It is clear that the education provided in this hospital is a simple, but powerful way to promote better health outcomes.

The next observation that struck me at this district hospital was the way in which it integrated counseling and testing for HIV into the family planning services provided. We saw the counseling and testing rooms right in the maternal child health building and the youth reproductive health building where family planning services are provided. The nurses explained that the health professionals in this facility initiate a conversation about counseling and testing for HIV and provide the services to everyone who accepts. Since women are particularly vulnerable to HIV/AIDS due to conditions that make prevention, care and treatment inaccessible, the integration of services into a “one stop shop” is a critical intervention needed to ensure women’s right to health.

As an advocate, it was encouraging to see some of the rights-based strategies promoted by PHR currently in practice. While talking to the nurses we met, it became clear that many of the most powerful interventions to stem the AIDS epidemic are brilliantly simple, moreover they are already working. What is lacking is the political and financial support needed to implement these interventions systemically so that everyone can enjoy the same rights based care, prevention and treatment. Funding and strategies to support an educated and empowered workforce is essential to promote the education and empowerment of the entire community to access health systems. Furthermore, deliberate strategies to upscale integration of HIV/AIDS services with reproductive health and family planning services is critical to ensure that all women can access acceptable, rights-based health care. Key to this implementation is the immediate repeal of the global gag rule which, either directly through funding restrictions or indirectly through perceived limitations, hinders comprehensive family planning within US funded disease specific programs if the programs support safe abortion practices and policies.

Along that bumpy road, we found an amazing group of health professionals who demonstrated the feasibility and successes of a rights-based approach to health. Now it’s time for our US policymakers to learn from these Kenyan health professionals and support system wide improvements and expansions of rights-based programs.

I am delighted to have attended this conference on right to health, where it was reported that high numbers of people who cannot afford to access health in Kenya where 56% of people live under $2 per day and 30% live under absolute poverty. This conference has forced me to think about where the real answers lie for this problem.

I think while advocating for the right to health, the control of population growth should also be considered. Most health problems proportionally rise as the ratio of dependents for each breadwinner in the community increases. Poverty related diseases such as HIV, TB & Malaria are the major causes of morbidity and mortality in most developing countries. Control of these diseases should be from where they are (at the community level), and not from the top. Communities should be educated on basic disease mechanisms and control.  This is where the strong role of leadership comes in mobilizing and equipping people with the knowledge and skills to combat these diseases.

A good example of this is the empowerment of women since at the community level as women bear the biggest burden of working and feeding the family.  If women are empowered and educated, they could help in fighting these diseases and hence foster development. Community health insurance, like the system that we have initiated in Rwanda, is one of the basic tool for which we must advocate. Once people are insured it increases health seeking behavior.  People do not have to fear for the charges once they go for treatment, and this alone serves in poverty alleviation and disease control.

Take an example of malaria -  early diagnosis and treatment are major tools in combating malaria for it enables the patient to get cured early and faster and go back to their jobs. It also shortens the period of transmission of the disease to other members of the family, which can help the control of the disease leading to increased productivity and a healthy workforce. Poverty can be combated if more hours are spent working rather than in the hospital sick or caring for a family member who is sick. For this to be effective there must be a strong leadership from above to empower those below to participate in their own affairs of disease control and prevention.

I enjoyed meeting my colleagues in Kenya who are also interested in promoting health rights, and I look forward to working with them in the future.

Hi all…for my first blog entry from the second annual Kenya Health Rights conference I’m beginning at the end..in other words, the best way to start to synthesize the vast amount of data and the number of powerful stories of health rights violations and opportunities presented over the last two days is to look back from the finish line…particularly because we ended with the most salient rationale for a rights-based approach to health…simply put, it works.

Anand Grover, the new UN Special Rapporteur on the Right to Health and a prominent lawyer and health rights leader in India, ended the conference by walking attendees through this results-based rationale for health rights. As Grover laid it out, whether you’re a health worker and/or citizen of Kenya or India (or, for that matter, the US), it turns out that we’ve already got waves of evidence that reveal the ineffectiveness and inefficiencies of non-rights based health systems.

Example: health system financing…During the conference, for instance, we learned that more than half of all Kenyans pay for health care out-of- pocket. In a country where 56% of Kenyans live on less than $2 a day, the lack of a health financing system based on principles of equity, access, and affordability has direct visceral consequences for a population that already live on the margin. Got asthma?…cough up the money for your life-saving preventive and curative treatments. Break your leg? Expect a crippling assault on your life’s savings and your kids’ chances to eat. Without a rational health financing system, the default is a out-of-pocket system that penalizes the poor and helps to exacerbate rather than address illness and inequity. The absence of rights, speaker after speaker powerfully voiced, equals the absence of health .

What’s the alternative? In Kenya, it turns out the problem is not the absence of alternative health financing tools.. in fact, we heard a variety of local NGO leaders and health care workers debate the merits and drawbacks of several health financing options that exist in some form in Kenya already. We learned of the tax-financed supply-side system largely used to staff public facilities…we learned of a demand-side insurance schemes, including one known as the National Hospital Insurance Fund…we learned of innovative community-based health financing models tied to micro-credit enterprises (which, in its largest example, covers 200,000 people in one of Kenya’s provinces). we learned of the private for-profit insurance programs that differentially select (or cherry-pick) the healthiest patients by excluding others with pre-existing conditions (like HIV)…in fact, like in the US, Kenya has a dizzying fragmented collection of health financing options. and, like in the US, Kenyan patients, especially the most vulnerable, continue to fall through the cracks.

But, as Dr.Lukoye Atwoli and other rising leaders for health rights in Kenya voiced during the conference, the challenge before Kenyan health care workers and patients is to learn how to demand and help achieve long-sought and needed results for all Kenyans. With this results-oriented focus, health workers, patients, and advocates can cut through the noise of health financing options and ask, quite simply, what works?

So with a pragmatic eye to results, a few presenters over the last two days shared examples of what’s worked. In some parts of Kenya, for instance, certain communities have begun to implement a recent initiative by the Kenyan government to strengthen local village and district-level governance and management. While evaluations are underway, anecdotal evidence indicates that community engagement, a key driver of any rights-based approach to health, may be working. At the international level, we learned of countries that have successfully applied for and, in cases like Rwanda, invested Global Fund money in programs that enhance affordability, access, quality, and equity through rights-based health financing structures and health workforce development programs. And, not surprisingly, concrete improvements in health have followed.

For me, as a physician and health rights advocate in Los Angeles, the argument for a rights-based approach to health advanced here in Kenya is powerful precisely because of this focus on results. Regardless of personal or political beliefs or nationality, health workers who are committed to the best results for our patients are becoming increasingly aware that the way to results is through rights. And, if we agree that human rights are indivisible and interdependent, then so too are rights-based solutions. An advance in rights in one corner of the world bolsters efforts in another. As HERAF takes a step forward in health rights in Nairobi, I and other colleagues in Los Angeles and elsewhere look forward to walking with them. After all, it’s what works.

For more info on Dr.Atwoli, check out his blog at

http://kenyanpsychiatrist.blogspot.com/

The Conference day opened with an overview of the current Kenyan health financing system by three speakers, Burkard Koemm, Julia Ouko and Peter Nyarango. Mr. Koemm included a description of the various types of insurance financing available and noted a system must provide a method of collecting funding as well as a method for distributing payments.

Ms. Ouko reviewed the current National Hospital Insurance Fund which has provided hospitalization coverage (not outpatient services) for forty years. The NHIF functions similarly to the US Medicare system in some ways. For example, this agency establishes the payment for services and contracts with hospitals to provide services. Recognized issues include high costs (NHIF administrative costs run as much as 57%, leaving less than half for payment of services) and There are discussions about expanding the NHIF to include coverage for outpatient services and to expand the fund to cover all Kenyans by 2014.

Mr. Nyarango was a bit more critical of the current system and the need to consider complete change. He pointed out that although the NHIF covers 80% of the formally employed through employer/employee contributions, only about 10% of the Kenyan population are formally employed. More than 56% of the population lives at or below the poverty level of $2 daily. The indigent are not covered by NHIF, and only 25% of the self-employed voluntarily purchase the insurance.

The rest of the morning was spent reviewing issues related to health care workers resources. Patrick Mbindyo presented some research noting the over-emphasis on ethnicity and political affiliation resulted in problems during the post-election violence. He and others called for more professionalism in order to build more respect and recognition for the health care workers as professionals to transcend the tribal differences. There were also calls for help for health care workers who were traumatized during the terrible aftermath of the post-election violence and the need for better preparation for future disasters.

Emily Bancroft of PHR reviewed methods that have been used by others to leverage the Global Fund monies to strengthen overall health systems, including increasing health care worker resources through salary support and skills building. Chris Rakuom reviewed the importance of nurses and the challenges of training and certifying nurses. Nurses are the basis of care, providing 80-90% of healthcare services, according to the World Health Organization. He noted that nurses are often among the only public servants in many rural areas (alongside teachers and security personnel.) WHO recommends 200/100,000, yet in Kenya there are only 49/100,000, a shortfall of about 47,000 nurses. Yet, Kenya actually exports trained nurses abroad. Mr. Rakuom explained that the government is working on methods to improve nursing retention in the nation and in specific rural areas.

In the afternoon we had breakouts. My group was led by Dr. Andrew Suleh, who is on the board of the NHIF. Our output statement was that the “NHIF in its current form is able to deliver social health insurance.” We tied that to three activities:

• HERAF should advocate for quick introduction of out patient services.
• HERAF should advocate for revisions of contributions and government subsidies for the poor.
• HERAF should advocate for better information about benefits to be made public.

There was discussion about keeping private insurance available for “competition” as in the US.

A caution related to the concept of having a “pluralistic” response to health insurance- A downside of trying to allow private insurers to compete with publicly funded is the concept of cherry picking. Cherry picking occurs when private insurers make eligibility criteria that excludes the individuals who have more costly needs. In that setting, the private insurers “cherry pick” or take only the healthiest who have less risk of developing expensive illness and exclude those with more costly diseases. That leaves the ill, those with expectations of higher health services costs, to rely on the public-subsidized plans. Therefore rather than sharing the risks equally, the risks are distributed with those with higher risk and higher costs left on the “NHIF” plan, while those with lower risks and thus lower costs are welcomed to the private side. While these private plans may be used to “supplement” a basic universal plan, I believe there is a significant problem in allowing the private insurance companies to directly compete with the NHIF.

We closed with some comments from the UN Special Rapporteur on the Right to Health, Anand Grover who is a health rights attorney from India and has studies in India that closely tied women’s empowerment to reducing HIV transmission. In all the conference was very enlightening and it is my hope that the Kenyan HERAF will be able to move forward this next year.

“In every adversity there is an hidden seed of advantage.”

Early this morning I was up and resumed my early morning ritual of watching news programming as I prepare for the day. Unlike my first 2 days in Kenya my anxiety level was such that I felt relaxed enough to explore a bit. I decided to get the Kenyan perspective on the news. I found the above quote on TV K-24 (all Kenyan all the time). My time is Kenya has quickly taught me that the Kenyan people espouse to the philosophy inherent in the quote. They are can do sort of people who don’t let the barriers (limited supplies, shortage of health workers, etc. ) create obstacles.

For example, earlier this week we visited the Liverpool VCT. I sat in awe as the staff discussed their scope of service provision including hotlines for youth, post-rape care, programs for MSMs and prisoners, and most noteworthy: services for disabled persons. The staff were engaged, committed, and innovative in their approach. They talked of being committed to the goal of testing 80% of the Kenya population for HIV by 2010. The rate is 37% up from 14% just 2 years ago. Yeah! They spoke passionately about their services for the disabled making it clear why disabled persons may be more vulnerable to HIV. Some may say that it’s no surprise VCT has a large staff and a rather sizable budget. But I say the key is in the people. The staff’s commitment to upholding human rights principles—principles such as accessibility, respect for autonomy, justice, etc. They have invested human capital in upholding these principles.

Yet they are not alone. As I observed at the HERAF conference there are many Kenyans who remain committed to health as a right. The psychiatrist who continued to put forth the need to create access to available and quality health mental health services; he continued to put forth that all important agenda. The persons living with HIV/AIDS who gave voice to their concerns about addressing confidentiality and reducing stigma and discrimination. The program director who so eloquently made the case that advancing contraceptive technology for women is essential to adequately addressing the HIV/AIDS pandemic. One nurse spoke about her stance that quality care must be provided to rural persons despite any limitation that governmental regulations and limited resources may impose. “I have to do my best. That’s why I have to prepare myself to do my best and to be my skillset. The people in my rural community must have it.” These are just a few among many who have decided to advance a human rights agenda. These folks have made “walking the talk” a personal priority despite any structural and systemic barriers that may exist in the current health care system.

Health Rights Advocacy Forum (HERAF)

Day 1

Attendees:

Health professionals; public health officials; people living with AIDS; the Campaign for Microbicides; health professional students; health workers living with AIDS; disability advocates; hospital officials, including Kenyatta National Hospital and other outlying hospitals; teachers; members of the media; health and human rights organizations, including the Action Group for Health, Human Rights and HIV/AIDS (AGHA); mental health specialists; women’s rights and reproductive health advocates; and sex worker advocates, among others.

Participants are from Uganda, Sudan, Rwanda, Tanzania, and across Kenya, including the Western, Central and Coastal regions.

Please see HERAF’s website for more information: http://www.heraf.or.ke/

Report:

The first speaker, Sister Elizabeth Bundala, with Medical Missionaries of Mary, reviewed the difficulties of providing care to approximately 1.5 million poor who live in the slums of Nairobi. One facility has seen more than 16,000 out-patients in 2008. The adult services saw 70 patients per healthcare worker per day, while the pediatric services have seen 156 patients per day per healthcare worker. One of her specific concerns was the fact that some government-funded clinical facilities that were completed as long as two years ago remain empty and without staff, leaving it to faith-based and other non-governmental organizations to provide care. Sister Bundala noted a concern that external funding is not reliable and relying on fluctuating gifts is not sustainable. She stated that NGOs should not be used in place of the government as a health care services strategy.

Hon. Prof. Peter Anyang’ Nyong’o, Minister of Medical Services, was scheduled to speak, but sent a  thoughtful and articulate representative from the Ministry, Dr. Stephen Muleshe, to read the Minister’s speech. He discussed the UN definition (Part of the UN’s International Bill of Human Rights) of the right to health as “thehighest attainable standard of physical and mental health,” noting that the right to health requires government to provide policies to aid the achievement of health.

The Minister’s representative reported that the significant improvements in Kenyan national health status that had been achieved by the early 1990s have been reversed by the high prevalence of HIV/AIDS. Some comments after the presentation by the Minister indicated some disagreement with this, as it was noted that the health dispensaries were short on staff prior to the epidemic. Other concerns were the task shifting that has occurred with nurses being required to do tasks for which they are not properly trained or experienced. There was a call for proper training and protection of nurses and patients in terms of job description expansion.

The Minister’s representative clearly and importantly stated that health rights is a central pillar of the government’s planning, including health rights as a central pillar of economic recovery. Kenya has extreme levels of poverty with half of the population living below the poverty level, with education, sanitation and nutritional needs in addition to health care needs. The national goal (in agreement with the UN’s Abuja target) of 15% GDP toward health has not been achieved, although the current 9% is an improvement. He also spoke of trying to reduce bureaucratic barriers, including an agreement in principle to move financing directly from the Ministry of Finance to health facilities rather than being directed through the Ministry of Health.

After tea, Mette Kjaer of HENNET provided a thorough review of the Health Sector Reforms, as well as Vision 2030, whichinclude efforts to decentralize health care services and to focus more on preventative rather than simply curative efforts. She reviewed the need for health sector reform and coordination of private sector and public health efforts, including an agreement or “Code of Conduct” with clarification of roles between government and non-governmental agencies. Her focus for going forward is to help bring rights implementation to the health sector. She also spoke about reducing the number of indicators from over 300 to about 40 to monitor program effectiveness. Currently, too often monitoring is of outputs not outcomes.

Each of the morning speakers reminded me of the difficulties of providing equitable health services without a plan for universal accessibility, including affordability of care. Of course the US is lagging far behind all the developed countries of the world in this arena. Kenya is developing a plan, but is seemingly having some confusion about how to proceed with an insurance plan to pay for private and public care versus government funding of care.

Dr. Otieno Nyunya from the Kenya Medical Association discussed sexual and reproductive health rights in Kenya.  He discussed“safe motherhood,” which includes work on gender-based violence, prenatal care,  assistance with unwanted pregnancies, etc. He noted that maternal mortality estimates are as high as 1,000/100,000, and 30-40% of maternal deaths in Kenya are thought to be associated with abortion.  Dr. Nyunya noted that widespread sexual violence may be associated with the high numbers of abortions. He indicated that theNairobi police recorded between 2,800 and 3,000 cases of rape in 2004 and 2005 , compared to hospital data from the same period recording over 16,000 per year.

Cultural issues, such as wife inheritance (which occurs when a man dies and  his brother “inherits” the widow), were discussed as a serious problem resulting in  increased vulnerability of women to HIV. Other cultural concerns discussed included women’s empowerment to say no or insist on condom usage.

We also heard from Steven Rulisa of Rwanda and Margaret Byabakama-Muyinda of Uganda, who both described some of the successes and challenges of meeting health needs in their countries. One of the remarkable efforts of the new Rwandan society was a constitutional mandate for a minimum of 34% women in their parliament which encouraged women to try for office and has resulted in women elected to 54% of the seats in parliament!

In the afternoon we heard from Dr. Irene Mukui from the National AIDS and STD Control Programme (NASCOP) on the situation of pediatric access to ART in Kenya. She reported that only about one-third of children who should be on anti-retroviral therapy are receiving that treatment (about 20,000 of 60,000 who are eligible for ART.) We also heard from Pauline Irungu from PATH International, who reported on the use of female condoms and the status of microbicidal research.

Energetic discussions followed most of the presentations. As we heard the issues today, it seems that an advocacy agenda is starting to develop. I anticipate tomorrow will be very productive.