Health Rights in Kenya

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.

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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!

Inspirational, motivational, phenomenal…..are a few of the words shouted out by participants on Thursday afternoon when asked by the facilitator to describe their experience at the 1st annual HERAF conference. She paused, looked at the group and said: “and so are all of you!”

For 2 days our HAA delegation has had the privilege of sitting alongside 70 health care workers who traveled from across Kenya to address a shared vision: a country where “health is recognized as a fundamental human right with access to equitable, affordable health services for all.” The passion and commitment we witnessed to reaching this goal was remarkable.

We listened and learned as they challenged one another, confronted their government leaders and questioned policies that fail to promote human rights…. including the US policy that prohibits a person with HIV to freely travel to the US!

We discussed human resource shortages: inadequate government funding needed to build strong health care systems, stigma and discrimination within the healthcare work place and gender inequity. These barriers to the fulfillment of HERAF’s vision and the challenges ahead were candidly acknowledged, but I could not help note that the resolve for change was unwavering.

Of the many excellent presentations made there was one that resonated deeply for me…. “The Right to Health: Influencing the Gender Agenda in the Kenyan Health Care Setting,” given by Dr Peninah Ogada. Dr Ogada is an older woman who described herself as “recycled material.” Widowed at a young age in rural Kenya, she dedicated herself to her children’s well-being and education. She farmed, sold portions of her crops for money and worked hard to make ends meet. She recalled the many times she had to travel miles, often on foot, to the closest health clinic with a sick child, wait in long lines, pay fees she could not afford and then was frequently treated disrespectfully by those who called themselves “caregivers.”

Dr. Peninah Ogada speaks at a session of the HERAF conference.

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I have worked in HIV care for over 20 years and for the past 6 years I have spent much time working in HIV care and treatment programs in sub-Saharan Africa. But I haven’t been so openly exposed to human rights issues in a setting like this, where rights are discussed and debated among health care workers, human rights activists and policy makers, as I am at this conference. I am grateful to Physicians for Human Rights for opening my eyes and ears to concepts that previously never made it past the thinking stage.

Chris Shaw and Abel Onyango talk during a break in the conference

It’s the end of day, and I am tired and jet lagged, yet I can’t stop thinking about what has transpired in both the formal presentations and the personal conversations. I want to review my notes and remember what was communicated among and by my Kenyan counterparts who live and breathe these challenging issues of inequality, limited resources, human rights dilemmas and violations—some entrenched in their own policies or lack of policies and some emanating from the West and US policies that further stigmatize people and obstruct social, psychological and human progress.

In his keynote presentation Maina Kiai, Chairman of the Kenyan National Commission on Human Rights, spoke passionately on the barriers to health care and human rights. He reminded conference participants that government does not have money per se, that any money available belongs to the people and government is but an agent of allocating and ensuring available money is equitably delivered to the people. He challenged the participants to hold government accountable for the ethical delivery of this funding. He acknowledged the burden of poverty as an obstacle to ensuring human rights and health care, and he addressed the problem of corruption as one of many obstacles.

Chairman Kiai openly discussed the previous government’s diversion of 130 billion Kenya shillings from health coffers to overseas accounts, which to this day have not been returned. He detailed the types of health services and programs the stolen money could potentially have funded, and he encouraged all in attendance to be proactive in ensuring health service accountability. “When people in government take money hard questions must be asked.” Chairman Kiai used the Kenyan elections—known as “3 in 1,” whereby the President, Ministers of Parliament and local officials are elected together, based on party affiliation, rather than on indvidual merit or on their commitment to the people—as an example of not challenging and changing the status quo, even when the end result either hurts them and serves no direct benefit to them or their community.

Paul M is an openly HIV positive man who has been an energetic presence at the conference. He is so justifiably angry when he speaks to us about the unjust US policy requiring HIV positive individuals to have their condition stamped on their visas and limiting their US visits to two weeks. This policy further stigmatizes an already over-stigmatized group of people. It doesn’t make sense to him or to anyone else at the conference, which is packed with nurses, doctors, journalists, anthropologists, ministry of health officers, pastors, social workers, policy makers, human rights activists and people living with HIV and or AIDS and their collective energetic frustration and anger is encouraging.

We spent yesterday at the Health Rights Advocacy Forum Conference. The agenda was phenomenal, including well-known Kenyan speakers and a range of topics including: basic health rights, advocacy for health care workers, the impact of development partners on health worker policies and health sector reforms. The sessions were informative, yet overwhelming. It was all I could do to try to soak it all in and attempt basic processing of the information.

One of the topics touched on throughout the day was the issue of brain drain, the loss of trained health care workers from developing nations to wealthier nations. Health care worker shortage in Kenya is a complex issue. Kenya actually has a surplus of trained nurses but a shortage of funding to provide positions for all of them.

[Suzy Jed, MSN, APRN-BC and the American and Kenyan teams in the Kenyatta National Hospital HIV Comprehensive Care Clinic Laboratory]
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Political theorist John Rawls poses an intriguing question about human rights: If none of us knew where we would be born, if we would be rich or poor, healthy or ill, male or female, short or tall, American or Kenyan or Indian or Chilean, what human rights would we want to be guaranteed? What choices would we want to have about how to live our one wild and precious life?

Today for me was all about the choices we have in America—and the choices Kenyans have, and what that means for health and human rights and the way we live and work and grow and play and celebrate. So what do I mean by choice?

[Sarah Kalloch, HERAF Chairman Andrew Suleh, MD and Suzy Jed, MSN, APRN-BC at Mbagathi District Hospital]

The Choice to Live: In 1997, Mbagathi District Hospital, near Kibera slum, opened its first AIDS centre. Options were limited: there was no treatment, no ART, but there was counseling and psychosocial support—and a special kind of community dealing with sickness, and despair and death mixed with glimmers of hope. Ten years later, people living with AIDS who come to Mbagathi have a choice. The hospital’s Comprehensive Care Clinic has 3500 people on ART. We met one patient—a man in his 20’s or early 30’s named Boniface. Boniface is HIV Positive. But Boniface has choices. His CD4 count when he began ART at Mbagathi in 2004 was about 200. It is now over 800. Boniface has chosen to celebrate by becoming a peer counselor at the hospital: a few minutes after he left our delegation, we saw him giving a talk to patients in the AIDS clinic waiting room, coaching them, supporting them, connecting them, and making them feel like they can fight this disease. People with AIDS in Kenya have a choice now: they can get treatment. They can live for years and years. They can take care of their families and be part of their communities. We know prevention is critical, and many argue it is more cost effective than treatment, especially in Africa. But I wouldn’t want to tell Boniface that—would you?

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After our visit to Mbagathi District Hospital, we went on to Kenya’s largest referral, teaching and research hospital: Kenyatta National Hospital. The facility has ten floors of wards, and a staff of 4,000. In fact, KNH is overstaffed. A mere five minutes away from Mbagathi District Hospital, the halls of KNH are filled with white coats, and specialists crowd the stairways. The Comprehensive Care Center is two stories tall—a gleaming white building on the sprawling KNH grounds.

And while a single ward may be ready with 10 senior physicians, Kenyans have great difficulty getting care at the hospital. It is a tertiary facility—the last stop in Kenyan healthcare—if you manage to afford the referrals, transport and patient fees. While all services at the Mbagathi CCC are completely free, the CCC at KNH requires patients to pay a monthly consultation fee of 300 Kenyan Shillings, about 4 US dollars. This is a prohibitive cost for most Kenyans: it’s just not possible. And yet KNH receives nearly 50% of all government funding to the health sector in Kenya.

Beyond the numbers and underneath the paint lies a very different, and often unexpected, story. Improving AIDS care in Kenya is not just about the size of the CCC, or the quality of CD 4 machines, or the salaries for staff. US dollars and Kenyan Shillings don’t translate to the improved access and quality so desperately needed. The solutions involve looking beyond the individual facilities and the medicines and the most obvious numbers. We will not find all the problems at one clinic, and we won’t find the solutions in one place either.

[The Health Action AIDS delegation with staff at Kenyatta National Hospital]

I woke up this morning thinking that I knew what to expect. But you can never know what to expect, and I’m grateful that I was wrong.

I thought I’d visited Mbagathi before. I’d seen the grounds and spoken with physicians and clinicians, but I hadn’t understood the true strength of the facility and the Comprehensive Care Center. We were lucky enough to share experiences with health workers at the Mbagathi CCC, including nutritionists, peer educators, counselors, HIV/AIDS trainers, and physicians. The facilities were minimal—simple tents set up for group counseling; one room with three wooden benches for discussions on second-line treatment and training health workers on HIV/AIDS-related stigma.

[Lissy Desantis, HERAF Chairman Dr. Andrew Suleh and Pediatric AIDS Counselor Judy Ouko at Mbagathi Hospital, Nairobi]

In the women’s general ward, there are 30 beds. This morning, there were 50 patients, and nearly every bed had 2 women sleeping head to toe, wrapped in their own blankets. Yet Mbagathi is much more than overcrowded wards and the bare minimum facilities. Mbagathi is a model Comprehensive Care Center in Kenya, not because of the quality of its training room or the videos it has playing in the children’s waiting room. It is a model CCC because of the staff that comes to work every day. Including Judy, who counsels children receiving ART and conducts anti-stigma training among her fellow health workers, reminding them that “Before we point a finger, [health workers] must realize that we are all at risk.” Also Boniface, a peer educator at the CCC living positively with HIV. His CD 4 count has increased from 200 to 887 in eighteen months on treatment at Mbagathi. And Dr. A.J. Suleh, Chair of the Health Rights Advocacy Forum and Practitioner in Internal Medicine at Mbagathi, one of the only staff actually employed by the Kenyan Government.

And that’s the twist to the story: the majority of the dedicated and motivated staff at Mbagathi, all of whom work in tiring conditions with minimal facilities, are set to be moved from the facility in February of 2008. They are employed by Médcins Sans Frontières, whose three-year agreement with the Kenyan government has come to an end. It’s now the government’s responsibility to staff this clinic, to promote the comprehensive care of HIV positive patients, and to promote the well-being and psychosocial support of its health workers. And while there is pressure on the government to do this, the workers at Mbagathi who will remain after February are worried. The numbers of patients will only increase, training needs will only increase, and the need for psychosocial support—for patients and providers—will only increase. The Kenyan government’s promises aren’t enough for these health workers. And they won’t be enough for the patients seeking care either.

This week is a very exciting week for us here in Kenya. The Health Rights Advocacy Forum (HERAF) will be hosting the first conference of its kind in Kenya, assessing Kenya’s commitment to the right to health. Health workers from throughout the country will be attending the conference in Nairobi, and we have a group of doctors, nurses and PHR staff coming from the United States to support the conference and stand in solidarity with Kenyan colleagues.

The Kenyan health sector faces incredible challenges, but HERAF’s work over the past seven months has shown that Kenyan health workers are up to the task. The annual conference will address 4 key issues in Kenya: realization of the right to health, financing for health, support for the health workforce, and stigma and discrimination in the health setting.

The Health Action AIDS Campaign doctors and nurses will also visit Kenyatta National Hospital, the largest referral and teaching hospital in Kenya, and Mbagathi District Hospital, a flagship comprehensive care center for HIV/AIDS. However, these visits are just the beginning. They’ll also have a chance to meet with key partners in health workforce development and HIV-prevention among women and girls, to share PHR’s work across the globe and to learn from the experience of service providers on the ground here in Kenya.

Through Saturday, I’ll be posting an overview of what the Health Action AIDS Campaign has planned each day, and the doctors and nurses and others will blog with their perspectives on these experiences. This is an incredible opportunity to build connections across continents and forge the partnerships necessary to change the way health is imagined, demanded and delivered in both the United States and Africa.

Lissy Desantis is Kenya Program Associate for the Health Action AIDS Campaign, Physicians for Human Rights.

Welcome to PHR’s blog covering the first health and human rights conference for health workers in Kenya. The conference is being held by PHR’s partner group, the Kenya Health Rights Advocacy Forum (HERAF). We invite you to be part of this historic event.

This work began as a simple yet revolutionary idea: human rights violations are fueling the AIDS epidemic in East Africa. Health workers stand at the front lines of the epidemic, armed with knowledge and expertise on the most effective medical interventions—but are not necessarily connected to policy makers in charge of national programming. But combine health workers’ medical expertise with human rights knowledge and an advocacy orientation—and you have a powerful constituency for change.

In 2002, PHR met and partnered with a Ugandan AIDS activist who believed that if health workers in his country were educated on health and human rights, and mobilized, the health landscape in Uganda could change for the better. In the years since, health workers in Uganda have created a vibrant movement that melds their medical expertise with human rights advocacy to increase health funding, tackle the human resource crisis and end stigma in health settings.

This week we celebrate the growth and strength of a new network in Kenya—HERAF—which has been in operation for a year and has already engaged hundreds of health workers and students and held trainings and workshops on stigma, health financing, the human resource crisis, women’s rights and AIDS, and more. This conference will give members a chance to further explore key health rights issues facing Kenya and unite to fight them through innovative advocacy and engagement at the regional, national and international levels.

Keep checking this site. We will have posts each day from a number of conference participants, as well as photos—providing challenges, opportunities for collaboration and ideas for action.

Health workers worldwide are standing up for health and human rights: be part of this movement.

Sarah Kalloch is Senior Coordinator for the Health Action AIDS Africa Program, Physicians for Human Rights