Out in the field: Mark Foster sees how DFID is working to reduce Child Mortality in Kenya
Commissioner Mark Foster writes about his visit to Kenya as part of the report into Child Mortality Reduction.
Our ICAI study had a particular focus on the various interventions funded by the UK to help reduce infant and maternal mortality and meet the UN MDG 4 goals. We were looking at both the impact of global vertical activities such as the immunisation and malaria bednet distribution programmes funded by GAVI and The Global Fund as well as the effectiveness of country-level programmes to reinforce the national health system. Our trip took in the suburbs and slums of Nairobi, the malarial western region of Kisumu on the shore of Lake Victoria and the upland hill region around Nyeri, in the shadow of Mount Kenya, several hours north of the capital.
Overall there has been a lot of progress at a global level in meeting the goals of infant mortality (with proportions of early deaths halving over the past fifteen years) but Kenya, as with much of sub-Saharan Africa, is lagging behind. Also within the country there are huge disparities between the relative success of actions in urban Nairobi and Nyeri (where the numbers are as low as 50 deaths per 1,000 children) and the high endemic regions and poorer slums (where the numbers are three times as high). Our visit took in many beneficiary discussions with young mothers and explorations of health centres, district Hospitals and large provincial referral hospitals We spoke with senior health stakeholders and politicians as well as members of the donor, NGO and multilateral communities.
The meetings with the young mothers across the country were certainly the most valuable part of the trip. The good news was that virtually all of those we met had access to basic healthcare services for ante-natal, natal and post-natal care. They were recipients of routine bed net distributions (a big benefit in certain regions for both mothers and babies) and the regular first year immunisations for BCG, pentavalent, diptheria and latterly pneumonia. Awareness among the young mothers we met of health issues was surprisingly high and there was a lot of evidence of knowledge regarding related topics such as family planning, sanitation and nutrition.
The shocking part of the testimony though related to the standards of care and respect that some of the mothers received, especially in the larger referral hospitals where most deliveries take place. We heard of mothers in labour being turned away, being left outside by callous nursing staff or being abused by midwives, and of mothers and babies dying while queuing for services. It was clear that the recent introduction of free healthcare for mothers and children under five had encouraged many to utilise the healthcare system, and thereby reduced the risk of unattended births, but the system capacity has not been increased accordingly.
Overworked staff and the few qualified doctors and nurses are definitely struggling to cope and the state of facilities is also an issue. We heard first-hand stories from mothers who had had to share a labour bed, sometimes with two other mothers, and of deaths in Caesarian procedures and post birth complications that went unexplained. We came away with a picture of two sets of differing contexts with regard to child mortality – one in the more remote regions where the issue remains access to basic services and where both reach and awareness still need to be enhanced, and the other, where the issue has shifted to creating a culture of care and focusing more on the vital first vulnerable month of life after birth.
The visits to the various levels of facilities confirmed these impressions. We saw the local health clinics largely doing a good job in terms of routine antenatal care and immunisations. They were pretty well stocked with basic drugs and vaccines and staffed by experienced nursing staff but their services were limited by space, levels of qualified personnel and accessibility. There were also good stocks of bed nets and proof of a pretty effective supply chain. The biggest provincial hospitals on the other hand were sprawling campuses of often run-down buildings with cramped wards and pressurised staff. They seemed to need to be as focused on revenue collection as much as care and were clearly struggling with funding and staff numbers.
The district facilities were caught in the middle and, while we met some of the most motivated young health professionals at this level, they were having real difficulties securing steady funding and confirming their scope of services in a system in great flux. The Kenyan health system is in the vanguard of the national shift towards devolved county-level government, which has been rolled out in an accelerated fashion over the past year since the election. The provinces have been largely disbanded and 47 new county-level structures have been empowered as the next direct level after the national administration. The overall government health budgets (which represent about half of the spend in the sector in the country) have been devolved to the counties. We heard a lot about funds that were yet to trickle down and financial management disciplines which lag the pace of the reform. The good news from devolution, though, is clearly the opportunity we saw for more localised infrastructure and funding choices and the potential for donors such as the UK to engage with the new local governments to help fill the gaps.
It is also clear that the health needs in Kisumu, where malaria and HIV are endemic, are very different from the respiratory health challenges in the cool, wet mountain air of Nyeri. We also met with a team working up in the far north county of Mandera, close to the Somali border, where the issues are how to provide services to nomadic communities in terrains which are often inaccessible and where conflict and famine add to the mix of health risks.
It is notable how the security situation in Kenya, which has been challenged since the election violence of 2008 and recently exacerbated by the terrorist attack on the Westgate Mall in Nairobi, makes delivering services very tough for all involved.
The report is available here: https://icai.independent.gov.uk/reports/dfids-contribution-reduction-child-mortality-kenya/