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.

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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As promised in my previous post, I’ll be sharing the plans of the Health Action AIDS delegation each day. Today our group will visit two hospitals and meet with two partner organizations.

9:00 a.m. – 11:00 a.m. Visit to Mbagathi District Hospital

This tour will be led by Dr. A.J. Suleh, Chairman of the Health Rights Advocacy Forum and Chairman of the Kenya Medical Association’s Nairobi branch. Mbagathi District Hospital is a key health facility in Nairobi, and has been at the heart of providing comprehensive HIV/AIDS care in the face of the unfolding epidemic in Kenya. Mbagathi handles 10,000 patients, 1,000 of whom are children. The hospital also has 5,000 adults and 500 children on antiretroviral therapy and performs 150 consultations daily. Mbagathi District Hospital offers VCT, DTC, PICT, and PMTCT services, as well as TB care and counseling, among other services.

Mbagathi is a public health facility funded by the Kenyan government, and it also receives support from the international donor community, including the Clinton Foundation. As a provider of comprehensive HIV/AIDS care and treatment, a recipient of public funding and a target for international funding, Mbagathi District Hospital is critical for identifying advocacy needs for health workers in Kenya.

The PHR delegation will first meet with senior MDH staff for an overview of services offered, as well as recent successes and challenges in providing HIV/AIDS prevention, treatment and care. The delegation will then tour the complete hospital facilities, including the wards, and have a chance to shadow MDH nurses and doctors and exchange with Kenyan colleagues.
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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.