Health Rights in Kenya

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.

On Friday, the team had a great experience with several nurses and health professionals at a hospital in one of Nairobi’s neighboring districts 60 km away. After a 2 hour journey on a brain bogglingly bumping road, we arrived at the district hospital, comprised of several buildings surrounded by lush greenery. We were immediately greeted by nurses we had met at the HERAF conference the days before who offered to show us the facilities and answer our many questions about the work they do. This particular hospital has implemented many of the evidenced-based public health and human rights practices for which PHR advocates, including human rights education and integrated family planning and HIV/AIDS counseling and testing. In fact one of the first observations that struck me while visiting the hospital was the list of patients’ rights prominently displayed in most hallways and waiting areas, as well as a patients’ charter listing the appropriate wait times for various health needs.

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.

PHR launched this blog a year ago, when we attended the First Annual Kenya Health Rights Conference. We’re attending again this year, and from December 2–5, PHR members and staff will be blogging from the Second Annual Conference. The conference is being held by PHR’s partner group, the Kenya Health Rights Advocacy Forum (HERAF), a network of health professionals committed to promoting health rights in Kenya.

Last year, PHR brought three of its US health professional members to the conference so that they could learn how health professionals in Kenya are working to address the human rights violations fueling the AIDS epidemic in East Africa. These PHR members visited clinics, met with NGOs, and participated in HERAF’s conference – leading them to become better advocates for health rights here in the US.

We are thrilled to be bringing a new group of health professionals with us to Kenya again this year to attend HERAF’s Second Annual Health Rights Conference. This year’s conference promises to be incredible. HERAF and the organizing committee have recruited a great group of presenters to bring to the attendees bold new ideas about policy reform, universal access to HIV treatment in Kenya, health financing, and advocacy. With lots of time for discussion and debate, it promises to be an exciting two days.

The three PHR members from the US will be joined by two health professionals from our partner groups in Uganda and Rwanda. Together, the group will visit clinics that are providing integrated services to women and children, meet with NGOs to explore the latest research on HIV, women’s health, and strong health systems, and share their own ideas and lessons learned about health professional advocacy in their communities.

Keep checking this site. We will have posts each day from conference participants, as well as photos and reflections from our members who are visiting Kenya. We will provide opportunities for learning and ideas for new ways to engage. Thanks for joining us.

Sarah and I have been back from Kenya for a few weeks now and have had time to reflect on our trip—our many site visits, the HERAF conference, meetings we had with colleagues and a special breakfast with medical/nursing students.

The lessons learned were many and the importance of our partnership with HERAF clear. PHR’s commitment to building an international movement of health professionals dedicated to the right to health for all remains strong and energized as a result of these experiences.

In one of the closing sessions of the conference, I had the privilege of reading a letter written by Paul Farmer (PDF), an HAA advisor. He applauded HERAF, and all those health professionals in attendance, for their commitment to health as a human right. He stated:

A lack of health infrastructure is no reason for inaction; rather, it is a clarion call to action! Let’s talk about food, about sutures, medications, electricity, water and other basic goods…we must link all of our projects to re-building health systems, poverty alleviation and food security to governments and global health policy.

His final statement was: “So, let’s get going!”

In keeping with this message HERAF acknowledged that it has significant work to do in 2008—and the momentum and energy to make it happen. At the end of the conference, HERAF National Coordinator Miano Munene outlined several education and advocacy campaigns which HERAF will move forward over the next year. These include:

• Continuing to build a movement of health workers from across Kenya who are mobilized to advocate for health rights
• Raising awareness of health rights through education, outreach and media engagement
• Advocating for increased and effective health sector financing and improved civil society participation in the budget making process
• Addressing stigma in health settings through education and training as well as through policy promotion, especially around the HIV/AIDS Act of 2006
• Advocating for a strong national health workforce policy in Kenya to ensure quality, equitable health care delivery for all
• Supporting polices and programs that address women and girls unique vulnerability to HIV/AIDAS, and the human rights violations that fuel this vulnerability

These plans may seem ambitious, and they are. But we think HERAF and PHR can do it. We invite you all to join us on this continuing journey—keep checking the PHR Health Action AIDS page for updates, ideas and opportunities for collaboration, and please contact us if you have ideas or thoughts moving forward.

Together, we can change the health rights outcomes for millions and make the world a more equitable, healthy, prosperous place.

After a week in Kenya, on Thursday I attended a number of different institutions and discussions. Perhaps most moving and concerning was that involving a group of lawyers who researched and discussed violations against women in the Kenyan Healthcare system in a report entitled Failure to Deliver (PDF). Over a hundred women were interviewed about their experiences in the healthcare system, and the stories were frightening. They reported being hit, yelled at, bitten and ridiculed by healthcare workers for being pregnant. Those at highest risk were those also infected with HIV. Such discrimination and abuse was sobering, and although it is likely linked to the poor working conditions of the healthcare staff (underpaid, twenty hour workdays, hundreds of patients, poor facilities, lack of supplies), such behavior is intolerable and demands attention and support.

We also visited a group called WOFAK (Women fighting AIDS). They are doing front-line work by providing care, support, job training and referrals for thousands of women and girls who are living with HIV/AIDS. Again they struggle with lack of resources, staff and discrimination against women, but are committed to their work and are excited about a facility that will be built by the Italians in the year to come.

I am so impressed by the work being done by these organizations, but feel overwhelmed by the task facing them. I am excited to return to the states to advocate for continued support and increased funds for the work being done in East Africa. This epidemic is far from over, and the socioeconomic issues continue to fuel this fire. The staff of PHR and HERAF have been inspirational in their work. I look forward to working with them in the future. There’s much work to be done!

The HERAF Conference is over, but it was another full day for the Health Action AIDS delegation. Here is an overview of what we did today.

8:30 a.m. – 9:30 a.m. Meeting with the USAID Capacity Project
The Capacity Project is funded by USAID, and works with the Ministry of Health in Kenya to build and sustain the health workforce. Capacity Project works to improve workforce policies and planning, develop better education and training programs for the workforce, and strengthen systems to support workforce performance. Currently, the Capacity Project has implemented low-cost work climate improvement interventions in 5 sites throughout Kenya (it is expanding), which will provide a foundation for understanding what determines performance of the health workforce. Capacity Project staff members are very interested in workplace culture among health professionals in Kenya, as well as a pervasive negative attitude among health workers, an area that HERAF members have also identified as an advocacy priority.

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Lissy and Sarah have been telling you about what the Health Action AIDS delegation has been doing. The delegation includes Physicians for Human Rights staff, but it is also made up of three health professional members of the Health Action AIDS Campaign. In this post, I’d like to give you a brief introduction to the health professionals who have come from the US to be part of this delegation.

• Suzanne Jed, MSN, APRN-BC is an Instructor in clinical Family Medicine at the University of Southern California. She currently provides care to HIV-infected adult and pediatric patients at the Maternal, Child, and Adolescent/Adult Virology and Infectious Disease Clinic and is Program Development Director for the USC Pacific AIDS Education and Training Center. Born in San Jose, Costa Rica, Suzanne is a native Spanish speaker. She relocated to the United States to pursue her nursing education. A graduate of Vanderbilt University School of Nursing, she practiced family medicine for five years prior to transitioning into the field of HIV/AIDS care and education. She has traveled extensively and has provided training and mentoring in HIV/AIDS nursing in Ethiopia.

• Mark Rolfe, MD is a family medicine practitioner with a special interest in HIV medicine. He established his practice in this area in 2001, and treats over 100 adults with HIV in rural Maine. He is board certified by the American Board of Family Medicine and board certified in HIV medicine by the American Academy of HIV Medicine.

• Christopher Shaw, RN is an HIV/AIDS certified nurse in the Infectious Disease Department at Massachusetts General Hospital in Boston. Christopher has been working in the HIV field since 1985, when he cared for patients in a South Bronx hospital and a hospice in Greenwich Village. Among many projects, he has helped set up HIV treatment sites in South Africa, educated health workers about treatment in Ethiopia, and co-founded “Sibusiso” (a Zulu word meaning blessing) a non-profit organization based in Boston that partners with HIV programs in the KZN and the Eastern Cape provinces of South Africa to support health care workers.

Pat Daoust, MSN, RN is Campaign Director of the Physicians for Human Rights Health Action AIDS Campaign.