V.Availability and Accessibility of Services

An equitable, well-resourced, accessible (physically and financially) and integrated health system is widely accepted as being a vital context for guaranteeing women’s access to the interventions that can prevent or treat the causes of maternal deaths and injuries such as obstetric fistula.[177]

Kenya has taken many positive steps to advance women’s and girls’ maternal and reproductive health. These initiatives include eliminating charges for public family planning services, antenatal and postnatal care, and prevention of mother-to-child HIV transmission. The government has also eliminated charges for delivery in dispensaries and health centers to encourage women to deliver in medical facilities with a skilled birth attendant. In addition, by introducing a system of full or partial fee waiver for access to government hospitals, the government has taken steps to increase access to health care for indigent patients. However, slow and sometimes absent progress in certain key areas calls into question whether Kenya is living up to its obligation with respect to the right to health. Many of the problems affecting the health sector in Kenya have persisted for many years. They include shortage of medical staff, mal-distribution of available staff and health facilities to the disadvantage of rural and poor regions, frequent shortages of supplies including family planning supplies, and failure to ensure health services are accessible to the poor.

Family Planning

Family planning is recognized by experts as key in reducing maternal mortality, improving women’s general wellbeing and accelerating progress toward achieving the Millennium Development Goals. For example, family planning can reduce the number of times a woman becomes pregnant. Generally speaking, women who have had three births or more face greater risks in pregnancy. Family planning reduces the number of unintended and unwanted pregnancies, which are far more likely to end in induced abortions, and are far less likely to receive adequate prenatal care than planned pregnancies. In addition, family planning can be targeted to reduce the number of pregnancies to women in groups at increased risk of maternal death, such as women who are too young or older, and women who have had more than five previous births.[178]

Women and girls in Kenya face a number of obstacles in accessing family planning, one being lack of sufficient facilities offering a wide variety of family planning methods. Current available data indicates that “the proportion of health facilities offering any temporary modern methods of family planning declined to 75 percent in 2004 from 88 percent in 1999.”[179]

Another challenge is contraceptive stocks. The family planning findings of the Kenya Service Provision Assessment Survey found that as of 2004 (more recent data is not available), “19 percent [of facilities] providing combined oral contraceptives and 18 percent of facilities providing progestin-only injectables reported a stock out sometime in the six months before the survey.”[180]

In August 2009, media reports revealed that contraceptives were largely out of stock across the country. For example, Muraguri Muchira, the director of programs at Family Health Options Kenya, one of the largest providers of family planning in the country, was quoted saying that injectables, one the most common methods of contraception in Kenya, were not readily available then: “We don’t have enough of them in the government supplies or even the Non Governmental Organisations. In our (Family Health Options) case, we are sometimes forced to buy from the private sector which is very expensive and we can’t afford to buy enough quantities to meet the demands.”[181] According to Muchira, “The biggest challenge we have as a country is the sourcing of contraceptives. Kenya depends highly on development partners and each one of them brings their supplies in their own different channels. So it’s very difficult to know how much is being brought in the country at any one time. And as far as I know nobody has come up with a solution.”[182]

In Kenya, as elsewhere in sub-Saharan Africa, the past decade has seen a weakening prioritization of contraceptive programs, undermining access to services.[183] An analysis of the 2009/2010 Kenyan budget by Deutsche Gesellschaft für Technische Zusammenarbeit (German Technical Cooperation, GTZ) indicated that, “Against the general trend, the allocation for Family Planning, Maternal and Child Health is declining by 15%. Only 1.8% of the overall government expenditures on health are spent on this issue.… This is clearly contradictive to policy objectives.”[184]

Human Resource Constraints

The availability, quality, comprehensiveness, and utilization of health services, including maternity services, offered at a health facility depend, in large part, on the number of health workers at that facility. The Kenyan health sector suffers from longstanding human resource shortages, especially in rural areas.[185] According to the Human Resource for Health Strategic Plan, “there are overall staff shortages (47,247 staff against an estimated minimum requirement of about 72,234). Shortfalls are heavily concentrated in parts of Coast, North Eastern Rift Valley and Nyanza Provinces, areas that have the lowest health indicators.”[186] The two health ministries note that “government personnel remain heavily skewed in favour of hospitals and the better-off districts.”[187] Hospitals and high-level facilities have more qualified staff.[188]

In 2005, it was estimated that “[d]ispensaries have a median of one enrolled midwife while health centers have a median of one enrolled nurse and one enrolled midwife. Hospitals have a median of three doctors.”[189] Two of the dispensaries we visited in Machakos and Kisumu had only one nurse attending to all categories of patients. When we arrived at the dispensary in Machakos, there was a long queue of men and women with children waiting to be attended to by the one nurse, who informed us that she was late because she had to purchase some supplies. At the Machakos General Hospital, a nurse in the gynecology ward had to ask a nurse from another ward to assist in giving patients medicine because she was alone in ward of about forty patients, and she was not able to attend to all of them in a timely manner.

Another challenge is that health facilities serve very large populations: “The median population in a hospital catchment area is more than 100,000, while dispensaries, which have limited staff, serve a catchment population of around 8,000.”[190]Many of the doctors, nurses and experts we interviewed reiterated this concern. There are also problems with retaining staff in hard-to-reach and rural areas.

In order to make substantial progress in reducing maternal mortality and morbidity, the Kenyan government should be developing and implementing a plan that aims to ensure that there is a sufficient quantity of qualified health workers available, whose services can be provided in a fair and equitable distribution throughout the country.

Poor Access to Emergency Obstetric Care

Another critical problem that women face in accessing maternal health services, and thus avoiding fistula, is lack of adequate facilities offering delivery and emergency services. Only about 38 percent of facilities offer normal delivery services. Hospitals, which are usually located in urban and peri-urban areas, offer most of these services.[191] Facility-based 24-hour delivery services are available in 64 percent of health centers in the country.[192]

Many women in Kenya have poor access to emergency obstetric care that could save both their lives and prevent stillbirths in case of complications during pregnancy or childbirth. Women with obstructed labor, which can lead to fistula, need emergency obstetric care such as Cesarean sections.[193] The 2004 Kenya Service Provision Assessment Survey concluded that capacity to manage common or serious complications of labor and delivery is weak in all facilities, including hospitals.[194] Less than 10 percent of medical facilities in the country were able to offer basic emergency obstetric care as of 2004.[195] The national coverage rate for basic emergency obstetric care was 2.7 per 500,000 population (well below the recommended level of four per 500,000 population) in most provinces.[196] Only six percent of medical facilities can provide comprehensive emergency obstetric care.[197]

Poor Transport and Referral System for Women and Girls in Labor

Transport availability and poor road infrastructure influence the ability of pregnant women, especially those in rural areas, to deliver in health facilities and to access emergency obstetric services.[198] Jessica Momanyi, nursing officer in charge of reproductive health at Kisii General Hospital, told us: “We see many cases that come here and they are too late. They delay too much at the community level because of transport issues.”[199] Transport is a major problem at night. Some women told us about having to walk long distances while in labor to get to the nearest health facility and others said distance to facilities and lack of transport forced them to deliver under TBAs. More than half of fistula patients we interviewed cited transport problems.

Lack of transport between health facilities is common, and interferes with referrals for emergency obstetric care in higher level facilities. Many health facilities, particularly dispensaries and health centers, do not have ambulances.[200] Even in cases where there are ambulances, there are other problems such as lack of fuel. Beatrice N. started labor at 3 a.m. and quickly went to the nearest dispensary. They told her she would deliver at noon, which did not happen. At 6 p.m. they told her mother to take her to Kisii General Hospital. She said, “They said their car did not have fuel. We hired a car.”[201] Other times, there is delay at the referral facility. A nurse at Rabuor dispensary in Kisumu told us, “Sometimes you call the district hospital and they delay. I had a woman who had serious problems and they took over four hours to arrive.”[202] A nurse at a district hospital remarked, “Fuel is a challenge. I have heard the drivers say on several occasions that there is no fuel when dispensaries call for patients. This leads to delay in women getting help.”[203] A doctor also noted, “Unless we give attention to dispensaries and health centers [by equipping them with ambulances], women will continue to get fistula.”[204]

The Kenyan government is in the process of finalizing a referral strategy that aims to improve communication and transportation between lower level and higher level referral health facilities through purchase and distribution of ambulances, and “To develop service providers’ capacity to offer services and appropriately refer at each level of the healthcare system.”[205] The government should prioritize the completion of this policy as well its implementation, with a focus on rural and marginalized regions. In addition, the government should also prioritize implementation of the referral component of the community strategy, which would empower communities and families to prepare for obstetric emergencies.[206]

Facility and Staffing Challenges for Fistula Repairs

Efforts to address fistula in Kenya are largely focused on training surgeons to provide repair surgeries. In spite of ongoing efforts, lack of trained fistula surgeons remains a major challenge to addressing fistula in Kenya. Obstetric fistula is not a key area of gynecological training; doctors do not come out of university as competent fistula surgeons. Countrywide, there are about ten trained fistula surgeons and only four (one of whom is a retired private consultant) are considered experts able to handle complicated cases and to train others. Three of the experts are based in Nairobi and only occasionally travel to provincial or district hospitals during camps to assist in surgery and to train other doctors. Many people interviewed by Human Rights Watch said there is a general lack of interest in fistula training among doctors because the specialty brings little monetary gain.[207]

In addition, there are few hospitals equipped to handle the surgeries. Those that exist often lack equipment and supplies necessary for fistula repair. Availability of operating theater facilities is a common problem. Because fistula surgery is not considered an emergency, it is not prioritized. Dr Paul Mitei, a fistula surgeon at Kisumu Provincial General Hospital told us, “To do this work in a public hospital is not easy because there are many competing interests…. You may find there is no anesthetist, no theater table. On the day you have your elective [fistula surgery] if there are emergencies … you just put off.”[208]

Routine fistula surgery is rare. Although a number of hospitals have the capacity to offer routine repairs, countrywide, fistula surgery is mainly done routinely in only three facilities: Kenyatta National Hospital (KNH) in collaboration with the Africa Medical Research Foundation (AMREF), Moi Referral and Teaching Hospital (national level public facilities) and at Jamaa Hospital, a mission facility. KNH and Jamaa are both based in Nairobi, even though most women needing surgery are from rural areas, far away from Nairobi.

Repair surgeries are done mainly through fistula camps, which are chiefly meant to be training camps on fistula repair and management for a mixed skill team of doctors, nurses, physiotherapists, anesthetists, and other medical support staff.[209] Trained surgeons (mainly gynecologists) are then supposed to begin routine fistula surgery, but this hardly happens. However, many doctors, NGO representatives, and government officials we spoke to acknowledged that while fistula camps are good for training, they are not sustainable in the long run nor are they the best way of ensuring all women and girls living with fistula get timely treatment.[210]

One of the reasons why fistula surgeons do not offer routine surgery includes lack of long-term mentoring. Some of the doctors we interviewed felt that the once a year training they received was inadequate and others added that this problem is compounded by the lack of continued support following the training to further improve their skills. According to the WHO, “A continuous partnership between the trainees and the trainers is important in maintaining and improving skills, and in acquiring new skills.”[211] Dr. Khisa Wakasiaka, a fistula surgeon and trainer working with AMREF, told Human Rights Watch: “Mentoring and monitoring those surgeons who are trained is a challenge. It’s difficult to follow up on them to find out how they are doing and help them to further develop their skills.”[212]

Women normally have to travel long distances to reach the few facilities that conduct fistula surgery. Women and girls need transport money, and often, if they have never travelled out of their villages, they may want to be accompanied by a relative. Some women may be deterred from going to hospitals far away from their homes. One health provider told us, “Women find far away hospitals alien. There is fear of not knowing where you are going; not knowing what to do.”[213] Two women told us that when they were told they could get treatment at KNH, they feared going there because it is in Nairobi and they do did know anyone there.[214] A nurse confirmed that women fear traveling far for treatment: “Women ask, ‘how do I get there? Who will I stay with? Who [will] I talk to?’”[215]

Health System Financing, Funding for Maternal Health Care and Fistula Repairs

Kenya is obliged under international law to take steps, to the maximum of its available resources, to progressively realize the right to health. This requires making appropriate allocations from available budgets to health care, including reproductive and maternal health services. One measure of the adequacy of health care is its accessibility, including in terms of cost. International law also requires that the government provide free services where necessary to ensure women’s right to safe motherhood.[216]

The fact that poor women and girls and those residing in rural areas continually fail to access maternity and reproductive health services due to cost constraints implies the government has not been successful in ensuring equitable access to health.

The government has put in place policies such as waivers and exemptions for poor women and girls who cannot afford health charges, but these are ineffective in removing barriers to financial accessibility in cases where women continue to be charged informal user fees, are not aware of the waivers or exemptions, or are sometimes denied them. Lack of adequate oversight mechanisms to monitor and evaluate implementation of these and other policies undermine the progressive realization of the right to health.

A variety of mechanisms are used to fund public health services in Kenya, in line with the 1994 health policy framework: taxation, through the government of Kenya budget; development partner funding; and cost-sharing with users, both through insurance and through user fees.[217] The government has recently initiated policy changes aimed at improving health care financing. Efforts include expanding the output based approach (discussed in more detail below), to expand benefits under the National Hospital Insurance Fund (NHIF) to cover outpatient health services and to include people in the informal labor sector.[218]The focus of NHIF has been mainly on formal sector employees. This has left out many Kenyans working in sectors such as the informal sector, agriculture, and pastoralists. The government plans to transform the current NHIF to a National Social Health Insurance Fund (NSHIF) as a way of ensuring equity and access to health services by all Kenyans, especially the poor and those in the informal sector.[219]

The budget is the government’s single most important policy instrument as it shows the true priorities of the government. The budget can reveal whether the government is serious about its commitment to improving maternal and reproductive health care by allocating the necessary resources. Further, the budget can show whether funds are targeting the real challenges of and gaps in reducing maternal mortality and morbidity.[220] Human Rights Watch is not in a position to do a detailed analysis of the budget. However, generally, funding for the health sector is considered inadequate by many, including donors, health providers, and government officials.[221] The Kenya government’s own policies and documents indicate insufficient budgetary allocation as a key and longstanding challenge to improving health service delivery.[222] There is no Kenya government budget allocated to fistula. Funding for fistula repair services is all from foreign donors, although UNFPA channels its resources through the government. Government support for fistula repairs includes provision of hospital space and staff such as nurses and anesthetists.

There is no direct budget line for maternal and reproductive health, save for family planning. The health budget does not provide details of what aspects of maternal and reproductive health are funded by the government. In addition, in Kenya, drugs for all medical conditions, including maternity-related ones, are centrally bought, and this type of expenditure is not reflected in the health budget.[223] The above make it difficult to determine what percentage of the health budget is being allocated to maternal health care and what areas are prioritized, and whether these are in line with interventions needed to reduce maternal mortality and morbidity. The Kenya government should develop a clear budget line for maternal health, with a particular focus on the poor and those living in rural areas. In addition, it should establish a system to track annual budget allocations for maternal health care, including information on what proportion of the health budget and total government budget is allocated to reproductive and maternal health care.

Lack of Reintegration Assistance

The World Health Organization recommends that countries addressing obstetric fistula attend to the reintegration and rehabilitation needs of women and girls who have undergone repair.[224] Women need continued emotional and psychological support to ensure they regain self-esteem and happiness, to ensure reduced stigma and participation in social and religious life, to regain fertility and sexual life as desired, and to ensure future safe deliveries after fistula repair. While there have been achievements in making treatment available, the above needs are not being addressed. Currently there are no initiatives by the government or other service providers to facilitate social reintegration into the community.[225] One doctor commented, “Now the interest is in surgery, tell me, who is doing rehabilitation? So the cause of the fistula may be social and economic. You do the surgery meticulously and you release the women into same environment which gave her the fistula and the factors are still in operation. We have seen women repaired. They go and heal and come back with another fistula.”[226]

Support for reintegration is particularly vital for women experiencing high levels of stigma, those with unsuccessful repairs, or those who are not continent after repair. Women and girls can experience stress incontinence after repair; this can be very traumatic and women may think the surgery was unsuccessful. The consequences may be the same as with actual fistula.[227] Furthermore, women with such conditions may continue to experience stigma, discrimination, and even violence.

Costs to Users in the Public Health System

Poverty is one of the main reasons some women and girls cannot access quality maternal care services. Kenya is ranked 147 out of 182 countries on the United Nations Development Programme’s Human Development Index.[228]Per capita income is roughly US$770 per year, which is about $2 per day.[229]Forty-six percent of Kenyans are living below the food poverty line.[230]The country has been hard-hit by rising fuel prices, in turn affecting transport costs and food prices. According to the Health Financing Policy and Strategy, out-of-pocket health expenditure is high in Kenya, particularly among rural and poor populations, and accounts for a large share of total health expenditure.[231]

 

User Fees

User fees, as part of cost-sharing in the health sector in Kenya, have been operational since 1992. In an effort to lessen the negative impact of user fees, Kenya introduced a user fees reduction policy in 2004 commonly referred to as the 10/20 policy, which made health services from the lowest-level facilities (dispensaries and health clinics) very affordable. Under the policy, services at dispensaries and health centers are to be free for all citizens, except for a minimum registration fee of KSH 10 at dispensaries and KSH 20 at health centers (approximately $0.13 and 0.27 respectively).[232]

Removing user fees for maternity services can greatly improve access to care.[233] Kenya has taken the important step of making childbirth free in dispensaries and health centers, but there is a charge for delivery in higher-level public hospitals. There, charges for normal delivery range from KSH 1,500to KSH 3,000 (roughly $20 and $40) while Cesarean section births average KSH 6,000 to KSH 8,000 (approximately $80 to $106).

The cost of fistula surgery in public hospitals is about the same as for a Cesarean section operation. These fees exclude the cost of transportation to the hospital and post-operative care that is vitally important to prevent infection. User fees create a significant barrier to women’s access to quality reproductive and maternal health services and put them at risk of death or injury when they are forced by poverty to deliver at home under unskilled care. Except for the few who hear announcements about free fistula repair camps, cost can deter women living with the condition from seeking treatment.

User Fee Exemptions

The government has implemented a user fee exemption policy.[234] In addition to childbirth in dispensaries and health centers, other services exempted include treatment of children aged below five years, and care for specific health conditions such as malaria, antiretroviral treatment for HIV/AIDS, and tuberculosis.[235]

Fully exempt reproductive health services in all levels of government facilities include antenatal care, postnatal care, and family planning. A proposal for a broader maternal health care exemption, which would make delivery in all government facilities free, by the former Minister for Health, did not succeed.[236] Although supposedly an exempt service, women do incur both formal and informal fees when accessing family planning services.[237] The government has not instituted monitoring mechanisms to ensure that health facilities do not charge for exempt services.[238]

User Fee Waivers

The government has implemented a general waiver system in public facilities for those who cannot meet their medical costs. The policy says: “A waiver … is a release from payment based on financial hardship at a particular point in time and it is not automatic. Patients must request a waiver and judgment must be made as to whether or not the patient is truly a hardship case.”[239] The aim of the policy is to “ensure that no patient is denied essential health care because of inability to pay.”[240] Priority is supposed to be given to vulnerable groups such as children under the age of five, street families, maternal and child health services, and referral cases.[241] There are no defined health providers authorized to grant waivers. The hospital administrator is charged with the duty of assigning responsibility to grant waivers.[242] Human Rights Watch interviews with two government officials, doctors, and nurses indicate that waivers are administered by a wide range of health providers, including medical social workers, health administration officers, and nursing officers.[243]

Human Rights Watch found that implementation of the waiver policy is poor for a number of reasons. The criteria for determining the financial need of a patient—such as mode of dress—are vague and easily manipulated by patients and hospital reviewers.[244] Furthermore, hospitals do not always publicize the availability of waivers despite a government requirement to do so.[245] The three public hospitals visited by Human Rights Watch did not tell patients that they could apply for waivers. Hospitals fear misuse of the waiver service, hence the failure to publicize. Emily Wasungu, the nursing officer in charge of the labor ward at Kisumu Provincial General Hospital told us, “We don’t give them information because it can be misused.”[246] Another health provider had a similar comment: “[There are] big fears on misuse of service.” He explained: “Patients want the waiver all the time and tell friends and relatives. Staff members misuse the waiver. Chiefs [community-level provincial administrators] write letters for people who are not in need and patients will go extra miles such as dressing in old clothes to appear poor.”[247] A government official told us, “Members of staff in a good number of hospitals collude with or try to influence decisions on waiver.”[248]

For the waiver system to be effective in enhancing access to health care for the poor, the population should be informed about the existence of such a policy. Almost all the women we spoke to had never heard about the waiver policy. One woman had asked for a waiver in a hospital and was told it did not exist:

I asked at Machakos if they could do the repair for free because I did not have any money and I was told I needed KSH 6,000 ($80). But I had no money.… I asked the nurse, “I hear you can help poor people.” She told me, “That [does] not happen here.” My only option was to sell land but I would rather stay with the problem than sell my land because it is my only source of food.[249]

Although one of the doctors said he had obtained a waiver for a woman needing fistula surgery,[250] our research found that the waiver system has not made a great difference in ensuring poor women and girls access maternal health services. Addressing cost as a barrier to fistula repair, Dr Josephine Kibaru, the head of the Department of Family Medicine in the Ministry of Public Health and Sanitation noted that majority of fistula survivors are poor and remarked, “There should be no discussion. These [fistula survivors] are waiver cases.”[251]

Health care facilities usually absorb the costs of both administering the waiver system and providing the services they have waived, limiting its effectiveness:

The important role for user-fees as a mechanism for healthcare financing is curtailed largely due to lack of third party payment for the cost of waivers and exemptions instituted to protect and guarantee access by the needy. As a result, the fee levels have been kept low, thereby undermining its revenue generating potential, and consequently its ability to support increased provision and availability of quality services. [252]

Another problem in the implementation of waivers is that some health care users tend to have little knowledge about the existence and implementation of the waiver system. Although the waiver policy says that hospitals should assign people responsibility to grant waivers, our interviews with nurses, doctors and hospital administrators show that this is not always the case. While many of them knew about the existence of the waiver policy, some of them could not tell us the process of obtaining a waiver or who, in their respective health facilities makes the decision to grant the waiver. A government official acknowledged that these information gaps exist and commented, “It is true that some staff are not aware [about the application of the waiver policy]. Those that were trained have left. We realize the need for catch-up training.”[253]

The Kenya government should publicize the existence of the waiver system and procedures for obtaining one. All health facilities should be required to publicly display such information. The government should also develop and implement mechanisms to monitor health facilities’ compliance with the waiver policy.