Health Rights in Kenya

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.