Women as caregivers: the consequences of

changes in health provisioning on food and

nutrition security among women in poor urban
settings in Kenya

Case study
 December 2007

Contents

Page
Abbreviations...................................................................................iv
1.0 Background...............................................................1
1.1 Introduction...............................................................................1
2.0 Literature review and policy analysis............................3
2.1 Globalization..............................................................................3
2.2 Poverty......................................................................................5
2.3 Education...................................................................................5
2.4 Health........................................................................................6
2.4.1 Expenditure on health.............................................................7
2.4.2 Overview of the National Health Accounts (NHA)......................11
2.4.3 HIV and AIDS...........................................................................12
2.5 Brief overview of Kenya’s health care system.............................13
2.6 Kenya health policy overview.....................................................14
2.6.1 Health policy evolution and framework....................................14
2.6.2 Organization of the health sector.............................................15
2.6.3 Access and quality of health services.......................................16
2.6.4 HIV/AIDS policy and regulatory framework...............................16
2.7 Framework for reviewing health inequalities...............................17
3.0 Nakuru district profile.................................................21
3.1 Location, size and population........................................................21
3.2 Topography, geology and climate.................................................22
3.3 Breakdown of health facilities.....................................................23
3.4 Administration/organization of the district health sector..............24
3.5 Health information system (HIS).................................................25
3.6 Top ten causes of out-patient morbidity – 2003...........................25
3.7 Health organization in the district...............................................27
3.8 Food security and nutrition.........................................................27
4.0 Kaptembwo informal settlement..................................31
4.1 The choice of Kaptembwo..........................................................31
4.2 About Kaptembwo......................................................................31
4.3 Mapping of health provision points in Kaptembwo.......................32
5.0 Discussion and conclusion...........................................40
6.0 References................................................................44

List of Tables

Table 1: WHO health statistics of 2003................................................6

Table 2: Kenya health development index (HDI) rank – 152..............9
Table 3: Health expenditure ratios ...................................................10
Table 4: Administrative units and area of district by division.............21
Table 5: Health parameters in Nakuru district – 2003........................23
Table 6: Type of health facilities in Nakuru district by 2003...............23

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Table 7: Divisional distribution of health facilities..............................24

Table 8: Records personnel distribution in the district – 2003.................25
Table 9: Disease morbidity pattern......................................................26

List of Figures

Figure 1: Number of people in Nakuru district by age group..............22

Figure 2: Morbidity trends and burden of disease in the district.........25
Figure 3: Monthly out-patient return of morbidity (2007)...................35

Annex 1: Observational checklist for health facilities.......................49

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Abbreviations

ACU - Aids Control Unit

AFP - Acute Flaccid Paralysis
AIDS - Acquired Immuno Deficiency Syndrome
AIHD - African Institute for Health and Development
AKIN - AIDS Kids of Nakuru
AMREF - African Medical and Research Foundation
ARI - Acute Respiratory Infection
ARV - Anti-Retroviral
ASAL - Arid and Semi-Arid Land
ASK - Agricultural Society of Kenya
CACC - Constituency Aids Control Committee
CBO - Community-Based Organization
CBS - Central Bureau of Statistics
CDN - Catholic Diocese of Nakuru
CHAK - Christian Health Association of Kenya
CHANIS - Child Health and Nutrition Information System
DACC - District Aids Control Committee
DARE - Development and Recurrent Expenditure
DFID - Department for International Development
DH - District Hospital
DHAO - District Health Administration Officer
DHMB - District Health Management Board
DHMT - District Health Management Team
DMOH - District Medical Officer of Health
DOMU - District Outbreak Management Unit
EGC - Evangelical Gospel Church
EQUINET - Regional Network on Equity in Health in East and
Southern Africa
ERS - Economic and Recovery Strategy
FBO - Faith Based Organization
FGD - Focus Group Discussion
FHI - Family Health International
FP - Family Planning
FPE - Free Primary Education
FPAK - Family Planning Association of Kenya
FY - Financial Year
GATS - General Agreement on Trade in Services
GAVI - Global Alliance for Vaccines and Immunization
GDP - Gross Domestic Product
GER - Gross Enrollment Rate
GFATM - Global Fund against AIDS, Tuberculosis and Malaria
GNP - Gross National Product

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GoK - Government of Kenya

HBC - Home-based Care
HCFD - Health Care Financing Division
HDI - Human Development Index
HIS - Health Information System
HIV - Human Immune Virus
HMIS - Health Management Information Systems
HPI - Human Poverty Index
HSR - Health Sector Reforms
HRD - Human Resources and Development
HSRS - Health Sector Reform Secretariat
ICRC - International Committee of the Red Cross
IEC - Information Education and Communication
IMF - International Monetary Fund
IPAR - Institute of Policy Analysis and Research
IRIN - Integrated Regional Information Networks
JPPI - Joint Public – Private Initiative
KANCO - Kenya NGO AIDS Consortium
KDHS - Kenya Demographic Health Survey
KEPI - Kenya Expanded Programme on Immunization
KHPF - Kenya Health Policy Framework
KHPFIAP - Kenya Health Policy Framework Implementation Action
Plan
KMTC - Kenya Medical Training College
KSPA - Kenya Service Provision Assessment
LA - Local Authorities
MCH - Maternal and Child Health
MDG - Millennium Development Goal
MOF - Ministry of Finance
MOH - Ministry of Health
MRC - Ministerial Reform Committee
MTEF - Medium Term Expenditure Framework
NACC - National Aids Control Council
NARC - National Rainbow Coalition
NASCOP - National AIDS and STI Control Programme
NCAPD - National Coordinating Agency for Population and
Development
NGO - Non-Governmental Organization
NHA - National Health Accounts
NHIF - National Health Insurance Fund
NHSSP - National Health Sector Strategic Plan
NSHIF - National Social Health Insurance Fund
OOP - Out-of-Pocket
PACC - Provincial Aids Control Committee
PGH - Provincial General Hospital

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PMTCT - Prevention of Mother to Child Transmission

PRSP - Poverty Reduction Strategy Paper
RHDC - Rural Health Demonstration Centre
RTI - Respiratory Tract Infection
SAP - Structural adjustment programme
SID - Society for International Development
SSA - Sub-Saharan Africa
STI - Sexually Transmitted Infection
SWAK - Society for Women and AIDS in Kenya
TAPWAN - The Association of People living with AIDS in Nakuru
TB - Tuberculosis
TRIPS - Trade-related Intellectual Property Rights
UN - United Nations
UNAIDS - The Joint United Nations Programme on HIV/AIDS
UNDP - United Nations Development Programme
UNESCO - United Nations Educational, Scientific & Cultural
Organization
UNICEF - United Nations Children’s Fund
UPE - Universal Primary Education
URTI - Upper Respiratory Tract Infection
UTI - Urinary Tract Infection
VCT - Voluntary Counselling and Testing
WHO - World Health Organization
WMS - Welfare Monitoring Study
WTO - World Trade Organization

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1.0 Background

1.1 Introduction

Statistics from Kenya’s Ministry of Health (MOH) show an increasing share of

health expenditure which is taking place outside of the public sector in the form
of out-of-pocket payments, especially among poor people (MOH, 2002). This
report is part of the study that looks at the impact of health reforms on health
provisioning in Kenya. The report endeavours to bring out the link between
health provision and food and nutrition security among poor women in informal
settlements in Kenya. The current health care patterns in Kenya are also linked
to the past and the progress the MOH has made. The general objective,
hypothesis and the research questions of the study are as outlined below:

General objective: To explore the consequences of globalisation led reforms

in health care provisioning on women’s caring and health promoting roles,
burdens and capabilities, and the consequences for household health and food
security in poor urban Kenya.

Hypothesis to be tested: Globalisation led reforms in health provisioning

have increased women’s roles and workloads of care with inadequate returns
for their own health and nutrition and for that of their children under five years.

Research questions
1. What changes related to health reforms have occurred in the provisioning of
health services over the last 10 years?
a. What is the range of public and private health care services (Non-
governmental organization [NGO] and individual owned facilities)
available to women in urban informal settlements of Nakuru?
b. What specific changes have occurred in public and private health care
services as a result of commercialization of services in these areas
focusing on cost and time?
c. What range and quality of services do each of the different providers
offer? What gaps are there in health care provisioning among different
providers and across major providers generally and specifically in
relation to the major public health problems affecting women and
children (focusing on malaria and diarrhoea among the under-fives and
preventive services for maternal and child health - MCH)?
d. What cadre of providers are available in the different facilities
(including outreach/mobile services)?
2. How does the nature of health provisioning affect women’s access to and use
of health care services focusing on acute conditions among under-five
children (malaria and diarrhoea) and preventive health services in terms of
full coverage of vaccinations and ante-natal care?

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a. What are the barriers and facilitators to access and use of the curative
and preventive services?
b. How do the women access information about health services?
c. What trade-offs do women make in using or not using the available
health care services?
3. How do user charges in public health facilities and cost of private health care
affect women’s caring workloads?
a. What do women do when faced with acute illnesses (diarrhoea and
malaria) for their under-five children?
b. What do women do to meet their health promotion needs around
pregnancy and child immunization and nutrition?
c. What roles, workloads and resources are associated with the actions
the women take (time and money spent on health care)?
d. What role does consideration of cost play in the options for health care
available to women during their children’s illnesses and for preventive
actions?
e. How do these health care roles, workloads and resources affect their
personal and household dietary patterns?

The report is two-pronged. The first part entails a background literature review
and policy analysis, while the second part provides details on the mapping of
health provision points in Kaptembwo informal settlement. The review included
some key informant interviews at the national and district levels focusing on
health reforms and the situation in informal settlements. The review also
assessed the nature of health care changes and provisioning at the global,
national and district levels. The second part involved the research team’s visit to
Kaptembwo in Nakuru district to map the health provision points. The process
utilized observation and checklists (capturing the conditions of the various
facilities). At the health provision points, the focus was on the type of services
provided, the interaction between the health seekers and the providers,
duration it takes to serve a client, and the status of the health facilities
(equipment, materials and cleanliness).

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2.0 Literature Review and Policy Analysis

The process proposed for data collection for the Kaptembwo study is one that
envisages building on information and refining the tools and questions as the
study progresses. The first step as documented in the proposal entails
background literature review and policy analysis. This section therefore details
globalization; poverty, education and health situations in Kenya including the
impact of HIV and AIDS; a brief overview of Kenya’s health care system and
health policy; the framework for reviewing health inequalities; and a brief
discussion on the entire section.

2.1 Globalization

Globalization, defined at its simplest, describes a constellation of processes by

which nations, businesses and people are becoming more connected and
interdependent across the globe through increased economic integration and
communication exchange, cultural diffusion (especially of Western culture) and
travel. It is an inescapable and primarily benign process of global economic
integration, in which countries increasingly drop border restrictions on the flow
of capital, goods and services. It is taken to be the process whereby national
and international policy-makers promote domestic deregulation and external
liberalization. The shift towards such a policy paradigm began in the 1980s with
the adoption of domestic deregulation, trade liberalization, and privatization, the
last often taking the form of cross-border acquisitions by multinational firms.
The process intensified in the 1990s with the removal of barriers to international
trade, foreign direct investments, and short-term financial flows. Globalization
has a complex influence on health. Its effects are mediated by income growth
and distribution, economic instability, the availability of health and other social
services, stress and other factors. Health status is also affected by the initial
conditions of each reforming country, i.e. the size and international
specialization of its economy, the availability and distribution of assets, its
human capital and infrastructure, and the quality of its domestic policies. Global
market forces work efficiently in settings where access to public health services
is widespread and social safety nets are in place. Countries like Mexico,
Uruguay, Zimbabwe, Kenya, India and the Philippines, for example, all
witnessed serious declines in income, and corresponding increases in poverty
and poor health, among their rural populations following liberalization
(reference?). Globalization may improve human health and development in
some circumstances but damage it in others, especially when liberalization has
been rapid and without government support to affected sectors and populations
(Cornia & Paniccia, 2000).

Globally, the major vehicles or processes through which contemporary

globalization operates are imposed macroeconomic policies. One category
consists of the Structural adjustment programmes (SAPS) of the World Bank and

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IMF, which were the precursors to and a key component of today’s ‘free trade’
agenda, and the more recent Poverty Reduction Strategy Papers (PRSP)
program of the World Bank and IMF, required for debt relief and, increasingly,
for development assistance. A second category consists of enforceable trade
agreements (notably those administered by the World Trade Organization -
WTO) and associated trans-border flows in goods, capital and services. Third,
official development assistance represents a form of wealth transfer for public
infrastructure development in poorer nations. Fourth, there are ‘intermediary
global public goods’ – the numerous yet largely unenforceable multilateral
agreements we have on human rights, environmental protection, women’s
rights, and children’s rights. These vehicles, in turn, have both positive and
negative health effects on domestic policy space, by increasing or decreasing
public sector capacity or resources and regulatory authority. Key domestic
policies that condition health outcomes include universal access to education
and health care, legislated human and labour rights, restrictions on health-
damaging products, such as tobacco, or exposure to hazardous waste and
environmental protection (Breman & Shelton, 2001).

Liberalization, whether through trade agreements or SAPs, lowers tariffs on

imported goods. This has been particularly hard on developing countries, which
derive much of their national tax revenue from tariffs and which lack the
capacity to institute alternative revenue-generating sources. This affects their
abilities to provide the public health, education and water/sanitation services
essential both to health and to economic development. Global and regional
trade agreements, in turn, are increasingly circumscribing the social and
environmental regulatory options of national governments. National policies and
resource transfers affect the abilities of regional or local governments to
regulate their immediate environments, provide equitable access to health-
promoting services, enhance generic community capacities (community
empowerment) or cope with increased and usually increasingly rapid
urbanization. At the household level, all of the above determine in large
measure family income and distribution (under conditions of poverty, for
example, when women control household income, children’s health tends to be
better), health behaviors and household expenditures (both in time and in
money) for health, education and social programs (Breman & Shelton, 2001).

In Africa, SAPs have had the effect of integrating countries into the global
economy through the imposition of stringent debt repayments and liberalization
of trade. SAPs have also resulted in significant macro-economic policy changes
and public sector restructuring and reduced social provisioning, with negative
effects on education, health and social services for the poor. A recent review of
available studies on structural adjustment and health for a WHO commission
states: “The majority of studies in Africa, whether theoretical or empirical, are
negative towards structural adjustment and its effects on health outcomes”.
Other instruments of globalization have further undermined the ability of
developing country governments to provide health care for their populations.

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For example, the development of agreements under the WTO, notably Trade-
related Intellectual Property Rights (TRIPS) and its interpretation by powerful
corporate interests and governments, have already threatened to circumscribe
countries’ health policy options. The best known case relates to the recent legal
battle around the attempt by South Africa to secure pharmaceuticals, especially
for HIV/AIDS, at a reduced cost. In 1997 Nelson Mandela signed into legislation a
law aimed at lowering drug prices through “parallel importing” - that is
importing drugs from countries where they are sold at lower prices - and
“compulsory licensing”, which would allow local companies to manufacture
certain drugs, in exchange for royalties. Both provisions are legal under the
TRIPS agreement as all sides agreed that HIV/AIDS is an emergency. This was
confirmed during the WTO meeting in Doha in 2001. The USA administration did
not bring its case to the WTO but instead, acting in concert with the
multinational pharmaceutical corporations, brought a number of pressures (e.g.
threats of trade sanctions and legal action) to bear on the South African
Government to rescind the legislation. This followed similar successful threats
against Thailand and Bangladesh. However, an uncompromising South African
Government, together with a vigorous campaign mounted by local and
international AIDS activists and progressive health NGOs, forced a climb-down
by both the US Government and the multinational pharmaceutical companies.
Notwithstanding this important victory, the provisions of the WTO, particularly
TRIPS and the General Agreement on Trade in Services (GATS) hold many
threats for the health and health services of developing countries (Breman &
Shelton, 2001).

Accompanying neoliberal reforms of the macro-economy have been health

sector reforms (HSR). Key components of HSR include decentralization of
management responsibility and/or provision of health care to local level,
improvement of national ministry of health's functioning, broadening health
financing options through, for example, user fees, insurance schemes and
introduction of managed competition; and rationing of health care through the
identification of public health and clinical “packages”, comprising a set of
interventions. The combined effect of the above interventions together with the
impact of HIV/ AIDS on the health workforce has resulted in a significant
reduction in public provision of social (including health) services in SSA, and
there is mounting evidence of a general decline in access to health services,
affecting particularly the poor. This is starkly illustrated by immunization
coverage, a sensitive marker of health service coverage, which has fallen during
the 1990s. In recognition of the growing global health divide between North and
South, the crisis imposed by HIV/AIDS and the resurgence of TB and malaria, as
well as the inability of both governments and increasingly cash-strapped
multilateral (UN) agencies to invest in health services, a number of Joint Public -
Private Initiatives (JPPIs) have been recently launched. The best-known of these
in health are GAVI (Global Alliance for Vaccines and Immunization) and the
GFATM (Global Fund against Aids, Tuberculosis and Malaria) - (Hong, 2000).

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2.2 Poverty

Despite recent indications of economic resurgence in some sectors of the

economy, the cumulative impact of 15 years of stagnating per capita income
growth has meant that little progress has been made in reducing overall
poverty, and it is likely that the conditions of some of the most vulnerable
groups may have worsened. The rural poverty lines are Kshs. 1,667 and Kshs.
2,228 (food and food together with basic goods respectively) and the urban
equivalents are Kshs. 2,255 and Kshs. 4,761 respectively. Poor economic
growth, together with increasing inequality in the distribution of income and
increasing rates of unemployment, has led to a rise in poverty levels such that
the population in absolute poverty1 is currently at 17 million (46%) of the 36.9
million Kenyan population (GoK 2007a; 2007b). Poverty therefore remains a
major impediment to fulfillment of basic needs of Kenyans especially women
and children. On the one hand, the high incidence of poverty has greatly
undermined the government’s ability to address the pressing needs in such
critical sectors as primary health care, nutrition, and basic education. On the
other hand, poor health and malnutrition serve to entrench poverty due to low
productivity. Hence, only a rapid economic growth can lift the country out of this
vicious circle of poverty. Governance, corruption, and inefficient use of public
resources still remain critical barriers to the achievement of the national targets
of poverty reduction (Ole Leliah, 2005).

The Human Poverty Index (HPI – 1) Value (%) for developing countries
measures deprivations in three aspects of human development as the
Human Development Index (HDI) (longevity, life expectancy, and a decent
standard of living). Deprivations in longevity are measured by the
percentage of newborns not expected to survive to age 40. Deprivations in
knowledge are measured by the percentage of adults who are illiterate.
Deprivations in a decent standard of living are measured by two variables:
the percentage of people not using improved water sources and the
percentage of children below the age of five who are underweight. A higher
HPI value means a greater level of poverty. The HPI-1 value for Kenya, 35.5,
ranks 60th among 102 developing countries for which the index was calculated
(Kenya Human Development Report of 2007-2008).

2.3 Education

Within the Human Resources and Development (HRD) component, the

education objectives of the Economic and Recovery Strategy (ERS) focus on the
provision of Universal Primary Education (UPE), the enhancement of secondary
1
According to the Central Bureau of Statistics (2005), the worst poverty hotspots are in
Nyamira, Central Kisii and Gucha Districts of Nyanza Province; Vihiga, Butere-Mumias and
Kakamega Districts in Western Province; Embu, Meru South and Machakos Districts in
Eastern Province; and a few small areas near Mombasa in Coast Province.

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transition and the improvement of public resource utilization. The education

targets set out in the PER 2004 are: achieve 100 percent net primary enrolment;
increase net enrolments for boys and girls; reduce the rate of primary drop out
for boys and girls; reduce incidence of primary repetition; and increase
transition rate to secondary schools from 47.3 percent in 2002 to 70 percent by
2008. According to the Paper read by the Permanent Secretary of the Ministry of
Education at a conference on, “Strengthening Quality and Innovation in
Education” in Brussels-Belgium (20 – 24 November, 2007), after FPE was
introduced in 2003, enrolment increased from 5.9 to 7.5 million children. The
Gross Enrolment Rate (GER) rose from 88.2 percent to 107 percent in 2006, and
the Net Enrolment Rate (NER) increased from 77 percent in 2002 to nearly 84
percent in 2007. GER in secondary education is 29.8 percent while drop out rate
is at 7.1 percent. As a result of the FPE, secondary education experiences
regional and gender disparities due to the imbalance between primary and
secondary schools that has grown more acute particularly in urban areas.
Enrolment is particularly low in Arid and Semi-Arid Lands (ASALs) for girls, and
concerns have arisen regarding the quality of teaching and learning (UNICEF
Report, 2004 – 2008).

2.4 Health

Kenya’s health and development indicators have been on the decline in the last
two decades. Child health indicators have deteriorated over the years to the
extent that presently 20 percent of under-fives are underweight, almost one in
three (30 percent) are stunted and 6 percent are wasted. In Kenya, the
prevalence of stunting, wasting and underweight, according to the 1998 Kenya
Demographic Health Survey (KDHS), was 33 percent, 6 percent and 22 percent
respectively. The situation has since slightly improved by dropping to a
prevalence of 30 percent and 20 percent in stunting and underweight,
respectively, as shown by the 2003 KDHS (Kirogo, Wambui, & Muroki 2007).
The World Health Organization (WHO) presents the 2003 child health statistics
as follows:

Table 1: WHO Health Statistics of 2003

Indicator Value (year
2003)
Children under five years of age stunted for 35.8
age (%)
Children under five years of age 16.5
underweight for age (%)
Children under five years of age overweight 5.8
for age (%)
Source: WHO Health Statistics Report, 2007

According to UNICEF, infant mortality stood at 78 deaths per 1,000 live births in
2001 and under-five mortality at 122 deaths per 1,000 live births (UNICEF,

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2003). Infant mortality rose from 63 per 1,000 live births in 1990 to 78.5 in
2004, while under-five mortality stood at 115 deaths per 1,000 live births. Life
expectancy declined from 57 to 48 years during the same period, in part due to
the HIV/AIDS pandemic. Depending on the type of facility, immunization
services are expected to be available five days a week for any child less than
five years of age (GoK, 1999). However, only 57 percent of Kenyan children are
fully immunized. Measles vaccination coverage reduced from 84 percent in the
1990s to 76 percent in 2000 and to 74 percent in 2003. According to the 2003
KDHS the percentage of infants reaching their first birthday that have been fully
immunized against measles stands at 73 percent. Measles vaccination is
particularly low in Western and Nyanza provinces – 58 percent and 68 percent in
2000, respectively (CBS et al. 2004; GoK & UNDP, 2003).

The major childhood diseases responsible for high childhood mortality are
malaria, acute lower respiratory infections, diarrhoea, dehydration, measles and
also HIV/AIDS. Other contributing factors include poor hygienic conditions, lack
of access to safe drinking water, inadequate exclusive breastfeeding,
inadequate cleaning of bottle teats and over-diluted-milk. As of 1999, 40
percent of Kenyan children below five years of age were iron deficient and about
73 percent suffered from anaemia. The time spent by mothers away from their
babies due to wage or self-employment, collecting water and looking for food,
limits the time they spend caring for their children hence increasing children’s
vulnerability to diseases and malnutrition (CBS et al. 2004). In addition, there is
evidence that parents and other caregivers are not stimulating and caring for
their young children as they used to do in the traditional societies. Therefore,
the decline in the quality of parental care may be one of the factors contributing
to increased under-five mortality rates (Koech & Njenga, 2006).

According to a study conducted by Amuyunzu-Nyamongo and Nyamongo (2006)

in Nairobi informal settlements, prompt and appropriate health seeking is critical
in the management of childhood illnesses. The study shows that mothers
classify childhood illnesses into four main categories: (1) not serious - coughs,
colds, diarrhoea; (2) serious but not life-threatening - malaria; (3) sudden and
serious - pneumonia; and (4) chronic and therefore not requiring immediate
action - malnutrition, tuberculosis, chronic coughs. This classification is reflected
in the actions taken and time it takes to act. Shops are used as the first source
of health care, and when the care moves out of the home, private health
facilities are used more compared to public health facilities, while even fewer
mothers consult traditional healers. Consequently, they concluded that there is
a need to train mothers to recognize potentially life-threatening conditions and
to seek appropriate treatment promptly. Drug vendors should be involved in
intervention programs because they reach many mothers at the critical time of
health seeking.

2.4.1 Expenditure on health

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Total health care financing in Kenya in 1994 is estimated to have been about
Kshs. 31 billion or US$ 560 million. This was equivalent to about 8.4 percent of
Gross National Product (GNP), or Kshs. 1,170 per capita (US$ 21). This estimate
of total financing includes a number of important gaps and data adjustments.
Household out-of-pocket spending estimated from the 1994 Welfare Monitoring
Study-2 (WMS-2) was adjusted downward by 25 percent to reflect suspected
overestimation due to recall bias common to such surveys. The 1994 estimate
of health financing as a share of GNP is very high for several reasons. First,
health spending relative to income in Kenya is particularly high for a low income
country. Second, GNP in 1994 was unusually low by Kenyan standards. If the
average per capita GNP from 1991 to 1997 is used for 1994, the estimated
health financing level would have been 7 percent of GNP. However, these
caveats do not affect the estimated absolute level of spending or the shares of
different sectors, providers, or functions. The Kshs. 31 billion mobilized in the
health sector did not just pass directly from the sources to the providers.
Approximately one-third of funding first passed through financial intermediaries
before being transferred to the final users. For most sources, funds were
transferred to more than one financing intermediary. The major intermediaries
in the flow of funds were the MOH, local councils, private insurance agencies,
NGOs, and the social insurance scheme, which is managed by the National
Health Insurance Fund (NHIF2). However, some employer spending and most
household spending passed directly to the ultimate providers of care.

The estimated population in 1994 was 26,762,000 (GOK/CBS, 1996). The

average per capita GNP for the years 1991-1997 was about US$ 300 (World
Bank World Development Reports, 1993-1998). The five major pathways of
financing were as follows:
1. From the GOK to MOH facilities through the MOH Appropriations Budget (18%
of financing);
2. From donors to the MOH and NGOs (7% of financing);
3. From employers to on-site care and company self-insurance schemes (17% of
financing);
4. From households to hospital facilities through the social insurance scheme
(4% of financing); and,
5. From households through out-of-pocket spending directly to retail providers of
pharmaceuticals,
private hospitals and outpatient centers (49% of financing).

The first pathway consisted of GOK financing, in which funds were transferred to
the MOH Appropriations Budget via the Ministry of Finance (MOF), and on to
MOH facilities. Few GOK funds were transferred to private sector intermediaries.
The second major pathway consisted of donor funding, of which 61 percent
went to the MOH and 18 percent went to NGOs. Together, these two channels
2
The NHIF is a mandated hospital insurance programme, which, in 1994, was financed through a
two percent payroll tax on those earning taxable wages of Kshs. 1,000 or more per month.

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accounted for about one quarter of total health sector financing. The third major
pathway consisted of contributions made by parastatal and private employers to
cover the costs of on-site outpatient care for employees and their dependents
as well as to fund company-managed health insurance schemes. The fourth
major pathway consisted of social insurance funding. Approximately seven
percent of household funding went to the NHIF, which reimburses hospitals,
both public and private, for services provided to members. The NHIF invests the
contributions it receives from its members and, in 1994 the fund returned Kshs.
101 million on these investments. Out of the total NHIF revenues of Kshs. 1.3
billion, 85 percent were used to reimburse for hospital services, 10 percent were
spent on administrative functions, and 5 percent remained in the fund.

The NHIF is intended to cover inpatient care only (Berman et al., 1995, p. 60).
As these payments are not voluntary, and contributors have no control over the
allocation of the money collected, contributions to the NHIF can be regarded as
a form of hypothecated tax for health services. This form of taxation differs from
general revenue funding of health services in that eligibility for use of the fund
is restricted to contributors. Most, if not all, social health insurance schemes in
middle to high income countries receive governmental subsidies to supplement
contributions. In those countries with universal coverage, such transfers
generally are used to subsidize health insurance for members of the population
outside of the formal employment sector (Rannan-Eliya et al., 1997). However
in Kenya, the government does not provide these subsidies to the NHIF. The
most important pathway consisted of direct household funding of provider
services. Virtually all providers in Kenya’s health care system earned revenues
from out-of-pocket spending by households, but most of these transfers (93%)
went to private providers including non-profit/volunteer facilities, private-for-
profit facilities, traditional healers, and retail providers of pharmaceuticals and
other medical goods. User fees to government facilities accounted for only a
small share of total household out-of-pocket spending. Presently, employee
contributions to the NHIF are based on a somewhat progressive tax system. A
large amount of NHIF payouts were made to small private hospitals, where it is
uncertain that the funds were only used to cover inpatient services. Thus,
inpatient spending may be over-estimated. A contributor’s eligibility to receive
benefits is conditional upon the event of becoming sick and needing to obtain
diagnosis and treatment, the payment for which the fund makes at least partial
reimbursement. Retail providers of pharmaceuticals and other medical goods
include private pharmacies, dispensaries and shops (Annual Health
Pamphlet/Brochure, 2005).

Within the health component the primary focus is on the provision of basic
health services, which is to be achieved by revisiting health sector financing to
reduce out-of-pocket (OOP) expenditure by the poor and vulnerable, which
escalated following the adoption of cost recovery within the health sector,
through the adoption of a major new Social Health Insurance Scheme. The
emphasis is on investments to benefit the poor and vulnerable, and to improve

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 December 2007

health indicators by re-allocation of resources to promotive, preventive and

basic health services, and to increase efficiency and effectiveness by combining
government and partners’ investments, a strategy articulated in the second
National Health Sector Strategic Plan (NHSSP II). The goal is to increase total
government spending to 12 percent of total public expenditure, the figure
estimated to address MDGs and respond to inadequate previous levels of
expenditure and at the same time to carry out a re-allocation of resources
within the sector to primary health.

In 2001, the total per capita expenditure on health care was $114 (7.8% of
GDP). According to the WHO Health report of 2004, the overall health system
performance score placed Kenya 140/191 countries. This composite measure of
overall health system attainment is based on a country’s goals relating to
health, responsiveness, and fairness in financing. The measure varies widely
across countries and is highly correlated with general levels of human
development as captured in the human development index (WHO World Health
Report, 2004). In 2004/2005 the WHO Health Statistics Report estimated the
total population of Kenya as being 34,256,000; the Gross national income per
capita (PPP international $) as 1,170; probability of dying under five (per 1,000
live births) as120; total expenditure on health per capita (International $, 2004)
as 86 and total expenditure on health as % of GDP (2004) as 4.1 (WHO Health
Statistics Report, 2007). Aggregate funding in this sector is very low, with public
per capita expenditure on health totaling only US$6.2, compared to the US$34
recommended by WHO. Public health spending accounts for 8 percent of total
health spending, below the Abuja target of 15 percent of total spending
allocated to health (MOH Draft PER 2005, cited in NHSSP II).

The 2005/2006 allocation to the health sector was Kshs. 30 billion, of which
Kshs. 20.2 billion was recurrent. Although recurrent allocations increased from
Kshs. 9.3 billion to Kshs. 16 billion between 1999/2000 and 2003/2004, this
increase was not significant in real terms given high demand and commitment
to pro-poor services. As a percentage of GDP, the health sector’s budget, has
remained essentially flat, rising from 1.44 to 1.91 percent between 2000/2001
and 2004/2005, with the increase in spending being accounted for by an
increase in development allocations from 0.12 to 0.62 percent, while recurrent
expenditure remained stable at 1.3 percent over the period (UNICEF Report,
2004 – 2008).
The Kenyan government vowed to raise its spending on health services by 30
percent during the 2005/2006 financial year in a bid to improve medical care
and make it readily available to the poor. The following table represents the
Human Development Index as indicated in the WHO Health Report of
2007/2008.

Table 2: Kenya Human Development Index (HDI) Rank -

152
Human development index (HDI) value, 2004 0.491

11
 December 2007

Life expectancy at birth (years) (HDI), 2004 47.5

Adult literacy rate (% ages 15 and older) (HDI), 73.6
2004
Combined gross enrolment ratio for primary, 601
secondary and tertiary schools (%), 2004
GDP per capita (PPP US$) (HDI), 2004 1,140
Life expectancy index 0.37
Education index 0.69
GDP index 0.41
GDP per capita (PPP US$) rank minus HDI rank 7
Source: WHO Health Report, 2007/2008

However, the Human Development Index Report of 2007/2008 ranks Kenya 148
out of 177 countries in the achievement of medium human development. HDI
measures achievements in terms of life expectancy, educational attainment and
adjusted real income. The following table shows the expenditure rations from
1996 to 2005 as presented in the World Health Organization – National Health
Accounts Series Report of 2006.

Table 3: Health Expenditure Ratios

Yea Total Total Gene Gene Priva General Gene Socia Private Private External
r expendit exp. on ral ral te gov. ral l exp. on househol resources
ure on health gov. gov. secto exp. gov. secur health ds' out- on
health as (THE) exp. exp. r exp. (GGE) exp. ity (PvtHE) of-pocket health as
% of GDP on on on on funds payment % of THE
healt healt healt healt as % as % of
h h h as h as of PvtHE
(GGH (GGH % of % of GGHE
E) E) as THE GGE
% of
GDP
19 4.4 30 512 11 38.0 62.0 150 7.7 7.4 18 917 83.0 8.2
96 596 576

19 4.4 34 056 12 36.6 63.4 169 7.4 8.8 21 576 82.7 10.8
97 480 772

19 4.1 34 848 16 45.9 54.1 195 8.2 6.0 18 840 79.6 10.8
98 008 000

19 3.8 34 588 14 41.7 58.3 345 4.2 16.4 20 180 79.3 13.7
99 408 040

20 4.4 42 344 19 47.0 53.0 175 11.4 11.5 22 460 80.1 8.5
00 884 120

20 4.3 43 722 18 43.2 56.8 232 8.1 14.6 24 850 80.5 15.7
01 872 920

20 4.6 46 989 20 44.0 56.0 225 9.2 9.2 26 295 80.0 16.4
02 694 760

20 4.4 49 503 19 38.8 61.2 264 7.3 9.9 30 285 82.5 15.6
03 218 140

20 4.1 53 215 22 42.7 57.3 275 8.2 8.4 30 515 81.9 18.3
04 700 440

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 December 2007

20 4.0 56 700 23 41.4 58.6 296 7.9 7.9 33 200 82.8 20.5
05 500 350

Source: World Health Organization – National Health Accounts Series (2006)

The share of the budget spent by the GOK no longer comprises the dominant
share of total health spending from all sources. The private sector is becoming
an increasingly more important component of total spending. The World Bank
estimated that over two-thirds of curative services were provided by non-
governmental entities, including hospitals, clinics and individual practitioners.
This represented an increase from 60 percent estimated in 1993. Thus, it is
likely that more than half of all registered health care workers in Kenya work in
the private sector. However, despite the growth of the private sector, more than
half of Kenyans do not have access to affordable health care. Moreover, little is
known about the quality of services provided in the private sector as many
essential standards either have yet to be legislated or are not enforced
sufficiently (Deolalikar, 1997).

Although Kenya’s health infrastructure expanded massively following

independence, the increase in population and demand for health care have
outstripped the ability of the government to provide effective health services.
Concerns requiring attention include inadequate health personnel, financing,
drugs, health infrastructure, inefficiency in health delivery, and inequality in
delivery of health care to an overwhelming majority of the poor. About 70
percent of the population in rural areas and 81 percent in urban areas cannot
afford private health care; and 20 percent of the urban poor and 8 percent of
the rural poor find even public health charges unaffordable. The introduction of
macro-economic reform measures including user fees for health care in the late
1980s adversely affected health care access and affordability of government
health services by the poor (Kimalu et al. 2004). The Government of Kenya
(GoK) therefore, faces the dilemma of combating a growing burden of disease,
regulating quality, and improving equity in health care distribution within the
context of declining public financing that is forcing rationalization of health
service delivery. To help resolve this dilemma, it is postulated that Kenyan
policymakers need a comprehensive understanding of the organization and
financing of the country’s health care system, including the expenditures on
health care made by donors, public sector entities, and the private sector,
particularly households (MOH, 2005).

2.4.2 Overview of the National Health Accounts (NHA)

The National Health Accounts (NHA) is a tool that the government is using to
understand health care expenditures. It is an internationally accepted
framework for tracking the expenditures from their sources to their end uses.
Kenya conducted its first NHA estimation in 1998, using 1994 data. Prior to this,
key policymakers assumed that the GoK was the major financier of health care
services. However, the 1998 NHA revealed that more than 53 percent of health

13
 December 2007

care spending actually came from households, with the Kenyan government
financing only 19 percent. The high household expenditure finding was
particularly alarming and spurred Kenyan policymakers to further investigate
health care equity issues. Consequently, the government commissioned a series
of in-depth studies on the burden of health financing in the country. The GoK
also undertook a second NHA exercise, using expenditures from fiscal year (FY)
2002. This NHA round was more ambitious than that done in 1998; it included
detailed data on household
spending gleaned from a household health care utilization and expenditure
survey and extended the NHA framework to estimate expenditures on HIV/AIDS
health care, a pressing national policy issue. Its findings should be of use to all
health care stakeholders – public, private, and donor – who seek to efficiently
and equitably distribute their health care resources (MOH, 2005).

The findings from Kenya’s NHA 2002 report show that in terms of the overall
health resource envelope, Kenya spent 5.1 percent of its gross domestic
product (GDP) on health. This is comparable to other countries in sub-Saharan
Africa, which average 5.7 percent, but well below the high-income OECD
countries’ average of 9.8 percent. Per capita spending is Kshs. 1,506 (US$19),
which translates to a 10 percent decline from spending level in 1998 (Kshs.
1,170; US$21). The NHA household health care utilization and expenditure
survey found that households in the poorer income quintiles use less health
care than do households in the richest quintile – more than a third of the poor
who were ill did not seek care compared to only 15 percent of the rich. This
suggests that inability to pay is contributing to lower utilization rates by the
poor. The FY 2002 NHA exercise found that more than half of health care
financing (51 percent) comes from households. This is significant considering
that 56 percent of the population (estimates of 2006) is poor, and, like the
survey findings, it raises concerns about financial accessibility to health care by
that segment of the population (MOH, 2005).

Although public facilities receive 60 percent of all spending on health care,

public sources of funds account for only 30 percent of total health expenditures,
or approximately 8 percent of all spending by the government. This share of
public spending on health care falls appreciably short of the 15 percent goal
outlined in the Abuja Declaration. The other major financiers of health care in
Kenya were the donor community, which contribute 16 percent of total health
expenditures, and employers, who contribute 3 percent. With these findings,
NHA identified the magnitude of issues facing policymakers. NHA estimations
now are being used to explore alternative and sustainable financing
mechanisms to encourage equity in financial access to care. Currently, the
government is using NHA findings to inform allocative formulas for health care
resources in its design of a social health insurance scheme and community-
based health insurance programs. With over half the population considered
poor, it is alarming that 51 percent of all health care expenditures in Kenya are
borne by households. HIV-infected persons pay nearly half of HIV/AIDS

14
 December 2007

treatment costs, and donors fund more than half of Kenya’s HIV/AIDS
expenditures overall. Such National Health Accounts findings reveal a need to
address sustainability and equity of health care resource allocation (MOH,
2005).
2.4.3 HIV and AIDS
HIV/AIDS remains one of the most serious public health challenges facing Kenya
today and it has an impact on health policy. The pandemic poses a serious
threat to Africa’s existence. Approximately 95 percent of people with HIV/AIDS
live in developing nations, with Sub-Saharan Africa remaining the worst affected
region in the global Aids epidemic. In Kenya, the first AIDS case was reported in
1984. HIV/AIDS has remained a national crisis in Kenya with many challenges to
all the sectors of the society. Trends indicate that the annual number of AIDS
related deaths is still rising steeply and has doubled over the past six years to
about 150 000 deaths per year because of the high number of people who were
infected in the 1990s. New infections, however, which had peaked to over
200,000 per year, have now dropped to well below 100,000 per year. According
to the report of “AIDS in Kenya” 7th Edition published by National AIDS and STI
Control Programme (NASCOP) of the Ministry of Health in 2005, the total
number of people living with HIV in Kenya includes 1.1 million adults aged 15-20
years, another 60,000 aged over 50 years and approximately 100,000 children.
The majority of new infections occur among the youth; especially young women
aged 15 - 24 and young men under the age of 30. HIV infection among adults in
urban areas stands at 10 percent and is almost twice as high as in rural areas
where the average rate averages 6 percent. It is estimated that 7.5 percent of
married couples are discordant for HIV. The total number of HIV/AIDS orphans is
estimated at 1.6 million (Christian Health Association of Kenya [CHAK] Report,
2006).

However, as the world marked World Aids Day on 1st Dec. 2007, the 2007
UNAIDS estimates stand at 33.2 million people living with HIV worldwide,
including 2.5 million children. This is fewer than original estimates of close to 40
million infected people globally. During 2007 some 2.5 million people became
infected with the virus. Around half of all the people who become infected with
HIV do so before they are 25 years and die before they are 35 years of age. The
country has been able to demonstrate a clear trend of decreasing HIV
prevalence over the past several years. Although HIV prevalence rate has
dropped from 13.4 percent in 2001 to 7 percent in adults aged 15-49 years in
2003 according to the report of the 2003 KDHS, the social economic status and
disease burden are enormous. The prevalence ranges from 1 percent in North
Eastern Province to 15 percent in Nyanza Province (CBS et al. 2004). HIV
prevalence in Kenya has declined to 5.1 percent in 2007 from 5.9 percent in
2006 and 6.1 percent in 2005, and HIV prevalence among women in the country
is 7.7 percent, compared with 4 percent among men (National Aids Control
Council (NACC) Report; Mwai, East African Standard/AllAfrica.com, 10/12, 2007).
During the past three years, critical HIV services have been scaled up and as a
result, general awareness and knowledge of HIV transmission are nearly

15
 December 2007

nationwide. In 2006, 760,000 adult Kenyans underwent HIV testing, and

110,000 (35%) of those in need of treatment had access to it, including about
6,000 children. Up to 40 percent of pregnant women who attended antenatal
care clinics in 2004 benefited from prevention of mother-to-child transmission
services. Increased resources have been allocated to impact mitigation
nationwide; specifically to programmes supporting orphans and other children
made vulnerable by HIV (UNAIDS Report, 2007). Thus, the decrease in HIV
prevalence was attributed to several initiatives, including voluntary HIV testing
and counseling and programs to prevent mother-to-child HIV transmission
(Xhinua/People's Daily, 10/13, 2007). It was also noted that 1.4 million pregnant
women need HIV counseling and testing annually so they can know their status:

There is an increase in the number of children being born infected with HIV,
meaning that there is still a large number of women who have not fully
understood the message (Alloys Orago, NACC Acting Director).

The latest NACC statistics also show a 9.6 percent HIV prevalence in urban
areas, compared with 4.6 percent HIV prevalence in rural areas
(Nation/AllAfrica.com, 10/12, 2007). But in terms of absolute total number of
people infected, the effect is greatest on rural areas where over 79 percent of
Kenya’s population lives, and, more importantly, to 85 percent of the poor (GoK,
2007a). Orago said the statistics show that the HIV prevalence of 4.5 percent
among girls and women aged 15 - 24 is particularly high, compared with a HIV
prevalence of 0.8 percent among boys in the same age group. This implies that
young women are particularly more vulnerable to HIV infection than young men.
The peak prevalence among women is at age 25-29 years (13%), while among
men the prevalence rises gradually with age, to peak at age 40-44 (9%). Only in
the 45-49 year age group does HIV prevalence become higher among men (5%)
than for women - 4% (Institute of Policy Analysis and Research -IPAR- Policy
Brief, 2004). The critical thing to note is that the most vulnerable women are
those who have children aged five years and under.

The burden of care for the infected and affected on the family and health care
providers has increased tremendously. There have been a number of
comprehensive reviews of the impacts of the HIV and AIDS epidemic on food
security. The evidence from these reviews indicates that: the disproportionately
severe effects of AIDS on relatively poor households increases rural inequality. A
reduction in household assets and wealth due to AIDS leads to less capital-
intensive cropping systems for severely affected communities and households.
The epidemic further undermines nutritional status and health as diets worsen
because of decreased food security, and also because of a shift to less nutritious
but more easily cultivated crops such as cassava (UNAIDS Report, 2003).

2.5 Brief overview of Kenya’s health care system

16
 December 2007

Since independence in Kenya (1963), continuous attempts have been made to

create an equitable health care system. It was clear that access to formal health
services was a major problem to the bulk of the population, 95 percent of who
were listed as rural in the 1962 census (Mburu, 1980). Despite declining
economic growth, high population growth rates and an increasingly
overwhelmed and under-resourced health system, Kenya was able to realize
precipitous and sustained declines in infant and child mortality between 1960
and the early 1990s (Mburu, 1980; Owino, 1997). In 1994, the Government of
Kenya launched its proposal for health sector reform placing greater emphasis
upon decentralized priority setting and equitable allocation of resources. The
health sector reform required a combined epidemiological and micro-economic
framework to develop standard geographic criteria for resource allocation (MOH,
1994).

Kenya recognizes that good health is a pre-requisite to the socio-economic

development of the country. According to the current National Development
Plan (2002-2008), health policy in Kenya revolves around two critical issues
namely, how to deliver a basic package of quality health services to a growing
work force and their dependants; and how to finance and manage these
services in a way that guarantees their availability, accessibility and affordability
to those most in need of them. Therefore, health policies and strategies are
aimed at reducing the incidence of disease and improving the health status of
Kenyans as indicated by increases in life expectancy, reduction in mortality
rates and improvement in the nutritional wellbeing of the general population
and children in particular between 1992 and 1993. The overall goal of the
government is therefore to promote and improve the health status of all
Kenyans by making all health services more effective, accessible and affordable
(Kimalu, 2001).

While high-income countries are able to fund and integrate new information
tools to guide national health policy, low-income countries, who bear the
majority of the global burden of disease, have inadequate and poorly
performing Health Management Information Systems (HMIS). Many countries in
sub-Saharan Africa (SSA) have embraced the need to develop broad health
sector reforms linked to poverty reduction strategies (Owino, 1997; Bossert,
1998; Agyepong, 1999). Targets are established by national governments to
reach specific goals of mortality reduction through equitable access to services.
The strategies adopted to achieve these goals should be based upon knowledge
of existing services, disease burden and equity. In practice, the extent to which
the evidence base for these decisions can be developed is often limited (Murray,
1995; Owino & Munga,1997; WHO, 2000; Niessen et al., 2000).

2.6 Kenya health policy overview

Since independence the government has given high priority to the improvement
of the health status of Kenyans. In a number of government policy documents

17
 December 2007

and in successive National Development Plans, it has set forth that the provision
of health services should meet the basic needs of the population, be geared to
providing health services within easy reach of Kenyans and place emphasis
upon sustainable and quality preventive, promotive, rehabilitative and curative
services.

2.6.1 Health policy evolution and framework

In 1965 fee collection in health facilities was abolished. In 1970 the MOH took
over the health centers and dispensaries run by local authorities without a
corresponding transfer of budget from local authorities to the MOH. The MOH
has the responsibility of ensuring the provision, improvement and promotion of
health for all Kenyans. Different policy initiatives have had mixed success. One
initiative was cost-sharing which was introduced in 1989. It introduced
consultation fees in government health facilities and it was later modified in
1992 to convert user charges from consultation fee to treatment fee. The aim of
the program was to increase the level of resources available at the local level for
improving the functions of the health system. Three quarters of the revenue are
used at the collecting facility, and one quarter is set aside for district level
expenditure on primary health care. However, with the poverty level in the
country, many people are unable to access the health facilities as they cannot
afford (Owino, 1998). In 1992, District Health Management Boards (DHMBs)
were created by legal notice to provide local insight of the cost-sharing
program. In 1993 the MOH adopted the civil service health manpower reform
which sought to trim the size of the civil service on a voluntary basis for those in
lower job groups. The decline in resource availability and to some extent the
mismanagement of resources limited the implementation of policy and
expected benefits were therefore not fully realized. The government is no longer
able to provide unlimited free care as budgetary allocations are insufficient to
meet rising costs (Ngigi & Macharia, 2006).

Despite the expansion in health care delivery systems since independence, it is

widely recognized that increasing population and demand for health care
outstrip the government’s ability to provide effective services. In 1994, the
government approved the Kenya Health Policy Framework (KHPF) as a blueprint
for developing and managing health services. This policy document is based on
a comprehensive situational analysis of the various factors affecting the health
sector and addresses broadly the agenda for reform for policy implementation
(MOH, 1994). To operationalize the document, the MOH developed the Kenya
Health Policy Framework Implementation Action Plan (KHPFIAP) and established
the Health Sector Reform Secretariat (HSRS) in 1996 under a Ministerial Reform
Committee (MRC) in 1997 to spearhead and oversee the implementation
process. The policy aimed at responding to the following constraints: decline in
health sector expenditure; inefficient utilization of resources; centralized
decision-making; inequitable management information systems; outdated
health laws; inadequate management skills at the district level; worsening
poverty levels; increasing burden of disease; and rapid population growth (KSPA

18
 December 2007

Report, 2004). Sub-titled Investing in Health (MOH, 1994:27), KHPF’s theme was
to be interpreted through policies designed to:
(i) Promote and improve the health status of all Kenyans;
(ii) Make all health services more effective, accessible and affordable;
(iii) Restructure the health sector to respond to the proposed reforms; and
(iv) Raise a population tuned to health seeking behaviour.

The aim of the policy framework is to ensure that the health status of the
Kenyan population is improved. It sets out the policy agenda for the health
sector up to the year 2010. This includes strengthening the central public policy
of the MOH, adoption of an explicit strategy to reduce the burden of disease and
definition of an essential cost effective care package. To operationalize this
Health Policy Framework Paper, the National Health Sector Strategic Plan
(NHSSP, 1991-2004) was launched. The strategic plan emphasizes the
decentralization of the health care delivery through redistribution of health
services to rural areas. The revised National Health Sector Strategic Plan II
(NHSSP II-2005-2010) has been developed to reflect the poverty reduction
strategy paper (2001-2004) agenda. The new plan focuses on the essential key
priority packages based on the burden of disease and the services required
support systems to deliver these services to the Kenyans. Major players in the
health sector include the government represented by the MOH, the local
government, private sector and NGOs (MOH, 2005).

The six strategic imperatives for reform include:

• Ensuring equitable allocation of government resources to reduce
disparities in health status;
• Increasing the cost effectiveness and the cost efficiency of resource
allocation and use;
• Continuing to manage population growth;
• Enhancing the regulatory role of the government in all aspects of health
care provision;
• Creating an enabling environment for increased private sector and
community involvement in health service provision and finance; and
• Increasing and diversifying per capita financial flows to the health sector.

2.6.2 Organization of the health sector

The organization of Kenya’s health care delivery systems revolves around three
levels, namely the MOH headquarters, the provinces and districts. The
headquarters sets policies; manages, monitors and implements the policies
formulated; and coordinates the activities of the NGOs. The provincial tier acts
as an intermediary between the central ministry and the districts. It oversees
the implementation of health policy at the district level, maintains quality
standards, coordinates and controls all district health activities. In addition, it
monitors and supervises the DHMBs which supervise the operation of health
activities at the district level. The district level concentrates on the delivery of

19
 December 2007

health care services and generates its own expenditure plans and budget
requirements based on the guidelines from the headquarters through the
provinces (MOH, 1994; GoK,1998; MOH, 2002).

The three-tier health system operated until 1970, when the government
established a system of comprehensive rural health services in which the health
centres became the crucial points for which preventive, promotive and limited
curative services are delivered. Today, alongside government services,
missionaries and NGOs provide health services at delivery points that range
from dispensaries to hospitals. The government’s health care delivery system is
pyramidal with the national referral facilities at Kenyatta National Hospital and
Moi Eldoret Teaching and Referral Hospital forming the peak, followed by
provincial, district and sub-district hospitals with health centres and dispensaries
at the base. In other words, health facilities under the MOH in Kenya are divided
into three different levels. At the primary level, health care is provided in rural
and municipal health centres and dispensaries. The secondary level, which
serves as a referral point for primary level facilities, consists of district and sub-
district hospitals. These hospitals provide both inpatient and outpatient services.
Tertiary care is provided at both the Kenyatta National Hospital, and now the
Moi Eldoret Teaching and Referral Hospital as well as by provincial hospitals
(GoK, 1999).

2.6.3 Access and quality of health services

The MOH is the major financier and provider of health care services in Kenya.
Out of over 4,500 health facilities in the country, the MOH controls and runs
about 52 percent while the private sector, the mission organizations and the
ministry of local government run the remaining 48 percent. The public sector
controls about 79 percent of the health centres, 92 percent of the sub-health
centres and 60 percent of the dispensaries. The NGO sector is dominant in
health clinics, maternity and nursing homes (94%) and medical centres (86%).
Both the public and the NGO sector have an almost equal representation of
hospitals. However, the health sector is faceted with inequalities. Only 30
percent of the rural population has access to health facilities within 4 km, while
such access is available to 70 percent of urban dwellers. The arid and semi-arid
north and north eastern areas of Kenya are underserved due to a limited
number of health facilities. The quality of health services is reputedly low due to
inadequate supplies and equipment as well as lack of personnel. Moreover,
regulatory systems and standards are not well developed. Currently, there is a
deliberate effort by the government to shift towards decentralization of health
care provision. The MOH has embarked on developing the legal and regulatory
framework and capacity building to devolve the entire authority for planning
and financial management to districts (Ngigi & Macharia, 2006).

2.6.4 HIV/AIDS policy and regulatory framework

To meet the challenge of the HIV/AIDS pandemic in the country, the
Government, in September 1997, approved Sessional Paper No. 4 on AIDS in

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 December 2007

Kenya as part of the contemporary long term framework. Besides, after

declaring AIDS a national disaster in 1999, the government established the
National AIDS Control Council (NACC) to guide implementation of the National
HIV/AIDS Strategic Plan 2000-2010. The Strategic Plan aims at ensuring that
multi-sectoral policies and strategies are integrated into core government-wide
process, including the poverty reduction strategies. The priorities of the
Strategic Plan include: prevention and advocacy; treatment, continuum care
and support; mitigation of the social and economic impacts of HIV/AIDS;
monitoring, evaluation and research; and management and co-ordination. The
co-ordination of the HIV/AIDS programme is spearheaded by NACC, which is
currently housed in the Office of the President and draws membership from all
sectors to ensure wide representation in the multi-sectoral approach to HIV/AIDS
prevention, treatment and care activities. The organizational structure of NACC
for delivery of services includes: Ministerial AIDS Control Units (ACUs); Provincial
AIDS Control Committees (PACCs); District AIDS Control Committees (DACCs)
and the Constituency AIDS Control Committees (CACCs) - IPAR Policy Brief,
2004.

Approval of Sessional Paper No.4 of 1997 on AIDS in Kenya was a clear intent of
the government to support effective programmes to control the spread of AIDS,
to protect the human rights of those with HIV and AIDS, and to provide care for
those infected and affected by the pandemic (CBS et al., 2004). This was in view
of the Third National AIDS Strategic Plan 2000-2005 which was launched in
December 2000. Guidelines have been developed to support implementation in
all critical areas including anti-retroviral therapy, voluntary counselling and
testing, blood safety, condom promotion and HIV/AIDS education. The present
government under the National Alliance Rainbow Coalition (NARC) has already
devised a new anti-HIV/AIDS strategy by putting in place appropriate policies
and programs. For example, at the beginning of 2003, the government
established a Cabinet Sub-Committee on HIV/AIDS chaired by the president, to
spearhead the battle against the HIV/AIDS pandemic. However, a fuller
understanding of the gender dynamics in HIV/AIDS transmission and prevention
will go a long way in guiding the formulation of pertinent policy options in
HIV/AIDS prevention strategies. Extra challenges for HIV prevention arise from
societal expectations that allow men to take risks; have frequent sexual
intercourse (often with more than one partner) and exercise authority over
women. These expectations, among others, encourage men to force sex on
unwilling female partners and to reject condom use, among other risky
behaviors regarding HIV/AIDS infection and prevention. On the other hand, due
to their lack of social and economic power, many women and girls are unable to
negotiate relationships based on abstinence, faithfulness and use of condoms
(IPAR Policy Brief, 2004). Changing the commonly held attitudes and behaviors
need to be part and parcel of the efforts to curb the AIDS pandemic.

2.7 Framework for reviewing health inequalities

21
 December 2007

Since the decade of 1980s, successive Kenya health status indicators have
reflected a disturbing reversal of the remarkable attainments of the immediate
post independence period, which had partially been spurred by the
opportunities created by political liberation. In attempting to analyze the context
of some of these reversals, the following discussion subscribes to the view that
exclusive health sector interventions make a comparatively modest contribution
to health status, the bulk of whose determinants are found in the individual’s or
society’s socio-economic circumstances. The adverse economic impacts of the
1970s global oil crises coincided with weak governance in Kenya, which
undermined socio-economic development; a phenomenon that afflicted most of
the sub-Saharan Africa and other developing countries. Consequently, Kenya
was among the countries that launched World Bank and International Monetary
Fund (IMF) structural adjustment policies/programmes (SAPs) ostensibly to
revive growth and development. Erratic implementation of the SAPs reflected a
reluctant compliance often only ‘inspired’ by the prospects of related conditional
aid inflows for reconstruction and restructuring. The essentially neo-liberal SAPs
were designed to effect the state’s retreat to a largely regulatory and
monitoring function, leaving the generation of economic growth in the hands of
presumably efficient private sector. However, SAPs mandated the curtailment of
government subsidies alongside the introduction of health and education user
fees to recover some delivery costs (SID, 2006).

SAP-mandated health reforms in Kenya started in 1989 in the form of health

care facility registration fee, which was, however, withdrawn in 1991 due to
perceptions that it was impending access to public health care. The cost-sharing
programme was put in place to:

(i) generate additional revenue for health facility operations;

(ii) increase quality of health services in government facilities;
(iii) strengthen the referral system and rationalize utilization of health
services; and
(iv) improve equity and access to health.

The poor preparation ahead of the fee introduction led to poor, mismanaged
revenues. The earliest studies of the impact of health care fees indicated a
declined access to care justifying the programme’s suspension. Its re-launch in
1991 as a treatment fee failed to return use to the pre-1989 levels. It is possible
that hard-pressed households had already discovered alternative ‘coping’
mechanisms, including ‘doing nothing’ over a bout of illness (Mbugua, 1993;
Collins et al., 1996). Into the 1990s, Kenya joined the global community in
promoting anti-poverty initiatives, culminating in its own national poverty
eradication plan published in the late 1990s. This was followed by the launch of
the Medium Term Expenditure Framework/Poverty Reduction Strategy Paper
(MTEF/PRSP) budgeting approaches. More recently, Kenya has subscribed to the
global, time-bound, peer monitored MDGs initiative, which fortuitously for

22
 December 2007

present concerns contains four narrow health sector goals, with the remaining
ones covering interventions that are inescapably health care-enabling.
Differences in health status are termed inequalities, while those in inputs to
heath provisioning are termed inequities. Equity is an important criterion in
evaluating health system performance. Developing a framework for equitable
and effective resource allocation for health depends upon knowledge of service
providers and their location in relation to the population they should serve (Noor
et al., 2004). While political slogans and colloquia aspire for health equality,
health status determinants adequately reflects the futility of endeavouring for
such. The general socio-economic, cultural and environmental factors that
facilitate health determinants include agriculture and food production;
education; work environment; living and working conditions; unemployment;
water and sanitation; health care service and housing. Health vulnerability is
greatest in childhood and old age compared to the middle years and some
illness of birth defy scientific advancements. After one’s biological ‘assets’, the
most proximate set of factors determining one’s health status are one’s
individual lifestyle factors. For example, nutrition lays the critical foundation in
childhood that will largely determine the quality of life, contributing to
fundamentals such as the development of the body’s immune system, as well
as secondary factors such as education absorption. Yet, access to nutrition is
determined by one’s status in their social and community networks-whether
income-generating or poor as well as the general socio-economic, cultural and
environmental conditions (SID, 2006).

Equity in health and health care has long been subject to various
interpretations. Does equity mean equality, a decent minimum standard of
service, or does it establish a system of entitlements? Though equity has
always been an amorphous concept, since independence African
governments have nonetheless attempted to create health care systems
revolving around the idea of universal health services. Despite these equity
values and policies, however, in practice there has been a persistent
inequality, with health resources often concentrated in urban curative
services - and particularly those serving urban elites - leaving rural dwellers
underserved in terms of access to quality health services and basic health
inputs. New health needs are further challenging these health inequalities.
The devastating spread of HIV and AIDS has exacerbated inequity as poor
households and vulnerable women and children have borne the greatest
burden of the epidemic. At the same time, the epidemic has highlighted the
pressing need for large-scale state responses to scale up and support
community responses to prevention, treatment, and mitigation of the
disease. Yet, given the increasing scarcity of health resources and the
uncertainty surrounding the ongoing health reforms in the region, progress
towards equity in health systems has been slow, uneven, and at times
contradictory (EQUINET Report, 2007).

Conclusion

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 December 2007

In Africa, amongst the most important components of the recent phase of

globalization have been SAPs which have had the effect of further integrating
countries into the global economy through the imposition of stringent debt
repayments and liberalization of trade. SAPs have also resulted in significant
macro-economic policy changes and public sector restructuring and reduced
social provisioning, with negative effects on education, health and social
services for the poor. Moreover, the majority of studies in Africa, whether
theoretical or empirical, have proved negative towards structural adjustment
and its effects on health outcomes.

The Government of Kenya (GoK) faces the dilemma of combating a growing

burden of disease, regulating quality, and improving equity in health care
distribution within the context of declining public financing that is forcing
rationalization of health service delivery. Kenya still has a long way to go in
tackling maternal mortality, infant mortality, HIV/AIDS and safe motherhood
initiatives. Health issues in Kenya are governed by four main legislation; the
Constitution, Medical Practitioners and Dentist Act (Cap 253), Nurses Act
(Cap 257), and Pharmacy and Poisons Act (Cap 244). The constitution does
not make provisions that facilitate the enjoyment of social, economic and
cultural rights. Consequently, health is not listed as right within the Bill of
Rights. Other laws governing health do not endorse adequate health as a
right but merely regulate the environment and institutional and individual
conduct within which the right to health is enjoyed. The law, despite the
increasing recognition by the government, does not regulate the activities of
traditional medicine practitioners. There is thus a need for their greater
integration into the health care system. The rapidly collapsing physical,
economic and social services have a negative impact on the health of the
people and on the capacity of the health care system to respond to their
increased needs. This situation renders the achievement of basic health
needs difficult to meet and hence basic human rights will be prone to
violation.

The health situation of Kenyans improved progressively after independence up

to 1990 but has thereafter been deteriorating. Socio-economic analysis of
poverty dimensions reveals that the main health challenge facing the poor is
affordability. The Second Report on Poverty in Kenya revealed that an estimated
40 percent of the poor (39.5 percent of the urban poor and 43.8 percent of the
rural poor) did not seek medical care when they were sick due to inability to
cover the cost of medical care compared to only 2.5 percent who were
constrained by distance to the health facility. Therefore, an important aspect of
the recovery programme must therefore ensure that the fundamental concerns
of equity, access, affordability and quality in the provision of basic health
services are met. Increased funding would enable the country to expand
immunization coverage, reduce mother and child mortality rates as well as

24
 December 2007

malaria-related deaths, implement strategies to bring down HIV/AIDS

prevalence and improve access to affordable drugs.

The policies that the government has pursued over the years have had a direct
impact in improving the health status of Kenyans. However, the increases in
population and demand for health care have outstripped the ability of the
government to provide effective health services. The introduction of macro-
economic reform measures including user fees for health care in the late 1980s
adversely affected health care access and affordability of government health
services by the poor. The government therefore, continuously faces the
dilemma of combating a growing burden of disease, regulating quality, and
improving equity in health care distribution within the context of declining
public financing that is forcing rationalization of health service delivery. To help
resolve the dilemma, it is postulated that Kenyan policymakers need a
comprehensive understanding of the organization and financing of the country’s
health care system, including the expenditures on health care made by donors,
public sector entities, and the private sector, particularly households where
most vulnerable women are those who have children aged five years and under.
Moreover, the high percentage of household financing shows the burden vested
on mostly poor households who have no means of accessing quality health care.

The quality of health services is reputedly low due to inadequate supplies and
equipment as well as lack of personnel. Moreover, regulatory systems and
standards are not well developed. Currently, there is a deliberate effort by the
government to shift towards decentralization of health care provision. The MOH
should expedite the development of the legal and regulatory framework and
capacity building to devolve the entire authority for planning and financial
management to districts. In this way, more poor people can be able to access
health care with ease. The MOH should also strive to develop guidelines that
effectively support the implementation of the health policy in all critical areas
that affect the poor especially women and their under five year old children
living in informal settlements. Although the World Bank Research Report of
2001 documents that globalization has helped reduce poverty in a large number
of developing countries; it must however, be harnessed better to help the
world's poorest, most marginalized countries and improve the lives of their
citizens.

25
 December 2007

3.0 Nakuru District Profile

This section profiles an overall framework through which the study area is
placed. It describes Nakuru district in terms of its location, size and population;
topography, geology and climate; breakdown of health facilities;
administration/organization of the district health sector; health information
system; top ten causes of out-patient morbidity as recorded in 2003; health
organization in the district; and the activities of the nutrition department. It is
through looking at the overview of the whole district that we can understand the
place of Kaptembwo informal settlement.

3.1 Location, size and population

Nakuru district is one of the eighteen districts of the Rift Valley Province. It lies
within the Great Rift Valley and borders seven other districts namely: Kericho to
the west, Koibatek and Laikipia to the north, Nyandarua to the east, Narok to
the soutwest, and Kajiado and Kiambu to the south. The district covers an area
of 7,242.3 km² and is located between longitudes 35º28' and 35º 36' East and
latitude 0º13' North and 1º10' South.

The total inhabited area is 5,762 km². The rest are water masses. The table
below shows the administrative units and area of the district by division.

Table 4: Administrative units and area of district by division

Division Area in Location Sub- No. of Populatio
km² s locatio househo n
ns lds density
(2002)
Mauche 161.04 4 8 3,468 118
Lare 139.06 4 9 6,008 220
Elburgon 436.04 3 8 15,521 166
Nakuru 262.5 4 5 68,436 974
Municipality
Bahati 564.06 4 14 32,214 282
Njoro 313.06 4 7 19,222 279
Mbogo-ini 386.05 3 6 12,570 170
Naivasha 1,782.30 8 16 46,735 98
Gilgil 1,055.10 4 7 22,385 96
Molo 58.9 2 4 8,354 599
Keringet 492.01 9 21 12,324 135
Rongai 744.00 5 13 17,789 115
Olenguruone 172.09 6 13 6,572 205
Kuresoi 285.04 4 9 8,741 159
Kamara 201.9 3 8 9,145 231
Mau-Narok 185.01 2 3 6,967 179
Total 7,238.1 69 151 296,451 181
6

26
 December 2007

Source: Nakuru District Development Plan 2002 - 2008

Nakuru is one of the most populous districts in Kenya having a density of 181
persons per km². In 2003, Nakuru district’s population was projected to be
1,551,062. Nakuru Municipality is densely-populated with most of the people
living in Kaptembwo, Langalanga, Ponda Mali and Mwariki, areas marked by low
cost housing. The town’s population growth has been rapid but not in tandem
with the provision of basic facilities including water, land, medical services and
affordable food supply (Nakuru District Development Plan 2002 - 2008). The
distribution of the population by age group is shown in the Figure below.

Figure 1: Number of people in Nakuru district by age group

140000

120000

100000

80000
n
rs
e N
.fP
o

Male Female

60000

40000

20000

Age N/S 80+ 70 to 74 60 to 64 50 to 54 40 to 44 30 to 34 20 to 24 10 to 14 0 to 4 5 to 9 15 to 19 25 to 29 35 to 39 45 to 49 55 - 59 65 - 69 75 - 79

Age Group

Source: MOH Annual Health Report, Nakuru District 2003

3.2 Topography, geology and climate

The western part of the district which comprises mostly Molo, Mau Narok,
Keringet, Kamara, Mauche, Elburgon, Njoro, Kuresoi, and Olenguruone divisions
are situated on the Mau escarpment and generally lies at an altitude of 2,500m
above sea level. The other divisions of Nakuru generally lie in the floor of the Rift
Valley. It is characterized by very poor drainage mainly due to the porous nature
of the pumiceous formations, which mantle the older rock surface. The geology
and topography found in the district has a great impact on economic activities.
In the areas where volcanic soils are found, agriculture and dairy farming are
common. In the drier parts, livestock keeping is practiced in addition to other
activities linked with tourism. The climatic conditions of Nakuru district are

27
 December 2007

strongly influenced by altitude and physical features (escarpments, lakes -

Nakuru, Naivasha and Elementaita - and volcanic peaks). There is considerable
variation in climate throughout the district. The long rains fall between Mid-
March and June. The amounts received vary from one year to the other and
influence greatly the crop yields in the district and more significantly, the
disease patterns (Nakuru District Development Plan 2002-2008).

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 December 2007

3.3 Breakdown of health facilities

Table 5 shows the health parameters in Nakuru district – 2003, while Table 6 is
the breakdown of the health facilities that catered for the population.

Table 5: Health parameters in Nakuru district - 2003

Description Rates/Numbers
1 Total population 1,551,062
2 Crude birth rate 13.8 per 1,000
3 Crude death rate 6.7 per 1,000
4 Infant mortality rate 46 per 1,000
5 Fertility rate (total) 6.6 per 1,000
6 Literacy rate 91.29%
7 Women of reproductive age (15-49 360,015
years) - 20%
8 Immunization coverage 82%
9 Number of children under 1 year 60,780
1 Number of children under 5 years 360,014
0
1 Number of children (0-15 years) 678,449
1
1 Population growth rate 3.4%
2
1 HIV prevalence rate 10%
3
1 Safe water coverage rate 55%
4
1 Latrine coverage 48%
5
1 Maternal mortality 200/100,000
6
Source: Medical Officer of Health Office, Nakuru District 2003

Table 6: Type of health facilities in Nakuru district by

2003
Type of facility No.
GoK hospitals 8
Private hospitals 6
GoK rural health demonstration 2
centres
GoK health centres 13
GoK dispensaries 57
NGO health centres 3
NGO dispensaries 5
Private nursing homes 6
Local government health centre 1
Local government dispensary 4
Local government maternity 1
Total 1063

29
 December 2007

Source: MOH Office, Nakuru District 2003

3
Since 2003 there are more health facilities that have been constructed and are operational
in the district. This is partly due to new health units opened during 2003 and other upcoming
health units (proposed and under construction).

30
 December 2007

Table 7 shows the divisional distribution of health facilities in the district.

Table 7: Divisional distribution of health facilities

Division Populatio No. of Population
n health per
(Est. faciliti facility
2002) es
Nakuru 264,354 50 5,287
Municipality
Olenguruone 36,613 4 9,153
Naivasha 181,385 28 6,478
Gilgil 105,084 10 1,051
Molo 36,505 4 9,126
Njoro 90,445 13 6,957
Rongai 88,552 14 6,325
Bahati 164,279 16 10,267
Mbogo-ini 68,026 12 5,668
Keringet 68,429 8 8,554
Elburgon 74,660 5 14,932
Kuresoi 46,780 2 23,390
Mau-Narok 34,197 5 6,839
Lare 31,695 2 639
Kamara 48,331 3 16,110
Mauche 17,593 2 8,797
Total 1,356,928 178 134,873
Source: MOH Annual Health Report, Nakuru District 2003

The Government's Nakuru District Development Plan for 2001 indicated that the
district's doctor-population ratio was 1:13,417. The document shows that
attendance in private hospitals largely served the middle and high income
groups, while the poor sought treatment in government health centres and
hospitals, which are always congested. By 2001, half of the doctors working in
the larger Nakuru District had their clinics in Nakuru Town. This means that
most of the people in the rural areas were treated by clinical officers and nurses.
The report says that in 1996, Nakuru Municipality had 52 out of the 57
government doctors working in the district. Olenguruone, Keringet, Njoro,
Rongai, Bahati and Lower Subukia did not have any government doctors.
According to the document, 13 out of the 16 private doctors in the district had
clinics in Nakuru Town, while only three had clinics in the smaller towns -
Naivasha, Molo and Njoro (Nakuru District Development Plan, 2001).

3.4 Administration/organization of the district health sector

Immediate responsibility for the daily management of the health sector in the
district is with the District Health Management Team (DHMT) and the DHMB.

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 December 2007

The DHMT comprises of all departmental heads and is chaired by the District
Medical Officer of Health (DMOH), whereas the District Health Administration
Officer (DHAO) is the secretary. The team is charged with the daily
management of the provisions of public health services within the district and
regulation of quality of services within the private sector. Its schedule of
meetings is as follows:
1. Briefings - every Monday morning (except when there is a monthly DHMT
meeting scheduled within
the week);
2. Every first Tuesday of the month - minutes of the monthly DHMT meeting are
revisited;
3. Every 3 months - quarterly meeting of the DHMT team with rural health
workers in-charge; and
4. Quarterly posting and disciplinary meetings.
3.5 Health information system (HIS)

The district HIS office operated with one-health records and information officer
and one technician through the year 2003. Table 8 provides a list of the
distribution of records personnel in the district.

Table 8: Records personnel distribution in the district – 2003

Health facility Health records Health records
officers technicians
MOH office 2 0
Naivasha Hospital - 6
Molo Hospital - 3
Elburgon Hospital - 2
Gilgil General Hospital 1 4
Olenguruone Hospital - 1
Nakuru Provincial General 3 11
Hospital
Dundori Health Centre - 1
TOTAL 6 28
Source: Records staff establishment, MOH Annual Health Report, Nakuru District
2003

32
 December 2007

3.6 Top ten causes of out-patient morbidity – 2003

Overall morbidity and mortality remain high, particularly among women and
children. Malaria is the leading cause of outpatient morbidity in Kenya,
accounting for one third of all new cases reported. After malaria, the most
common illness seen in outpatient clinics are diseases of the respiratory
system, skin diseases, diarrhea, and intestinal parasites. Recurrent out breaks
of highland malaria and widespread emergency of drug resistance strains
have aggravated the problem of malaria (KSPA Report, 2004). By 2003,
malaria was the leading cause of out-patient morbidity, followed by upper
respiratory diseases then skin diseases. Malaria is probably caused by the poor
drainage system in many parts of the district especially in the informal
settlements. The Figure below shows the top ten common diseases in Nakuru
district by the year 2003 according to the MOH annual health report of
morbidity patterns.

Figure 2: Morbidity trends and burden of disease in the district

TOP TEN DISEASES

200,000
180,000
160,000
140,000
120,000
CASES

100,000
80,000 2001
60,000
40,000 2002
20,000 2003
0
Disease of Malaria Disease of Diarrhoeal Accidents Pneumonia Poisoning Eye Intestinal Dental
the the skin disease infection w orms disorders
respiratory
system
DISEASES

Source: HIS Reports, Nakuru District 2003

According to Figure 2, the morbidity among out-patients is rising. This could be
attributed to the poor economic status and lack of proper nutrition among the
residents. The divisions in Nakuru also reported malaria as the leading cause of
morbidity. The results are shown in Table 9.

Table 9: Disease morbidity pattern

Previous New Cumulative
reported cases
Malaria 74,112 48,048 122,160
URTI 54,868 36,369 91,237
Skin infection 9,200 10,564 19,764
Diarrhoea 6,857 5,597 12,454
Eye infections 4,999 4,570 9,569
Intestinal worms 5,107 3,249 8,356
Sexually Transmitted 2,361 4,559 6,920

33
 December 2007

Infection (STI)
Typhoid fever 2,222 2,296 4,518
Gastroenteritis 2,098 1,703 3,801
Tuberculosis 1,470 1,141 2,611
Amoebiasis 818 674 1,492
Food poisoning 628 342 970
Bilharzias 8 1 9
Source: HIS Reports, Nakuru District 2003

Malaria continued to be the leading cause of morbidity in the district with a total
of 122,160 cases with a peak during the months of June and July in parts of
Rongai and Mbongoini divisions. It was followed by Upper Respiratory Tract
Infections (URTI) with 91,237. Surveillance of priority diseases continued with
annual non Polio AFP expected to be seven (7), detection rate of one, suspected
and reported measles cases were 255 with no outbreak notified to the District
Outbreak Management Unit (DOMU) within 48 hours. None tested positive for
measles virus but 43 percent tested rubella positive. Neonatal tetanus was not
detected during the year. Three (3) quarterly health meetings were held; three
hundred and fourteen (314) health workers were sensitized in 12 sessions
during supervisory visits; and a total of 158 dog bite cases were reported during
the year (MOH Annual Health Report, Nakuru District 2003).

The district has several collaborators in HIV/AIDS prevention and control

strategies amongst whom are Family Health International (FHI) with a regional
office in Nakuru, funding an impact programme through the University of
Nairobi, and strengthening STI management among sex commercial workers.
AMREF is dealing with peer education for men at work sites and women at their
income estate areas; Society for Women and AIDS in Kenya (SWAK) mobilizes
women and girls in the fight against HIV/AIDS; PATH is specialized in theatre arts
for Information, Education and Communication (IEC) among the youth. The
Kenya NGO AIDS Consortium (KANCO) has set up a regional resources centre for
HIV/AIDS in Nakuru where interested persons or groups can access information.
Other Community Based Organizations (CBOs) and Non-Governmental
Organizations (NGOs) collaborating in the effort include Family Planning
Association of Kenya (FPAK), Marie Stopes, Catholic Diocese of Nakuru, Love and
Hope, Upendo Widows Association, French Red Cross in Molo, The Association of
People living with AIDS in Nakuru (TAPWAN), the AIDS Kids of Nakuru (AKIN) and
Nakuru workers community support. This CBOS/NGOS are mainly focusing on
home-based care (HBC), awareness creation, promotion and marketing of
condom use.

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 December 2007

3.7 Health organization in the district

Nakuru district is now one of the decentralized districts which are pilots for the
national health system framework. The districts’ main health package is
financed through the Development and Recurrent Expenditure (DARE) support
and the GoK. However, stakeholders such as FHI, International Committee of the
Red Cross (ICRC), Faith-based Organizations (FBOs), NGOs and CBOs contribute
to the health package. In future, the package requires to be harmonized in order
to reflect one district health plan with one budget. The DHMB was de-gazetted
during the year under review after its tenure in office expired. While in
operation, it used to represent the communities’ interests especially examining
how health services are delivered in the district through its three sub-
committees i.e. financial, quality of curative care, public health and primary
care. All hospital and sub-district hospitals have autonomous management
boards while health centers and dispensaries have community committees
which do almost the same work. Curative, preventive, rehabilitative and
promotive services are offered; FBOs and CBOs have started home-based care
while the health workers are being trained. VCT centers have been started all
over the district while two institutions have started comprehensive care
including ARVs for HIV and AIDS cases (MOH Annual Health Report, Nakuru
District 2003).

3.8 Food security and nutrition

In Kenya, most nutrition problems stem from food insecurity, poor

complementary feeding practices and poverty. The agricultural sector presents
the greatest potential for achieving sustained improvement in the nutritional
status of the rural poor. The nutritional status of young children is a sensitive
indicator of health status and food availability in a given community. It gives the
current status of the child in terms of immediate (acute) factors such as current
inadequate food intake, childhood diseases and diarrhea leading to wasting
while accumulated impact of chronic deprivation leads to stunting. Monitoring
child nutrition provides an early indicator of distress and ill health within a
community. Although a number of factors within a household may contribute to
improved nutritional status, consumption of proteins such as milk by both
children and adults is likely to contribute to better health and well being.
Increasing opportunities for women to earn or control income will ensure
household food security and this is likely to be beneficial to the children’s
nutritional status (Mbagaya, Odhiambo and Oniang'o, 2004). Since landlessness
is predominant in Kaptembwo informal settlement, for most households,
alternative income generating projects would provide important sources of
regular income. In addressing the problem of malnutrition, in this and any other
community, a multifaceted approach embracing food, health, sanitation and
health caring practices is necessary.

35
 December 2007

Food security and nutrition are absolutely fundamental in any analysis of

development in the region. Agriculture is still the dominant source of income for
most people in the region and actions to secure food security dominate many
lives. Poor nutrition whether over-nutrition or under-nutrition, is also a major
cause of ill health and the reproduction of poverty in an area. Lack of food
security and poor nutrition are both a cause and a reflection of the great
inequalities in the region. Experiences from other parts of the world and
historical precedents suggest that any successful intervention to reduce
inequalities and inequities must start with improving the health and nutrition of
the poor. Public policies have been shown to make a significant difference even
in the context of poor overall economic growth. The HIV and AIDS epidemic is
closely related to food security and nutrition. The impact of the epidemic is
worsening the food security and nutrition situation whilst at the same time the
lack of food security and poor nutrition is increasing vulnerability to HIV and
AIDS. The present situation in the region with regard to food security and
nutrition can only be understood in the context of global changes in the
production and trade of agricultural products. A successful response to the huge
challenges requires an analysis that integrates equity, health, food security and
nutrition within the major global, regional and national trends. This analysis
must be linked to a strong, organized demand for government responsiveness
and accountability to social needs, and for government authority and action to
safeguard social needs within global policy and corporate and commercial
practices (ACC/SCN, 2004).

The following services, through the nutrition field workers and community
technicians, were rendered in Nakuru District in the year 2003:
1. Growth monitoring;
2. Monitoring baby friendly activities in all institutions and hospitals;
3. Upkeep and community use of demonstration kitchen gardens in hospitals
and health centres;
4. Maternal and child health (MCH)/family planning (FP) nutrition lectures done
every morning before the day's activities start;
5. Counseling of clients and relatives on various diets: diabetes, hypertension,
diarrhea etc;
6. Supervising all GoK hospital kitchens to ascertain the preparation of balanced
diet food;
7. Home visits and follow-ups; and
8. Nutrition education was conducted in primary schools, chiefs’ barazas,
women group meetings, Nakuru Agricultural Show of Kenya (ASK), and
churches.

The district nutritionist’s activities include:

1. Giving lectures in syndromes management and HBC box for organizations like
the ICRC, the Catholic Diocese of Nakuru (CDN) and the government even at
provincial level;
2. Attending nutrition meetings in Nairobi;

36
 December 2007

3. Quarterly meetings with the District’s Nutrition Field Community Health

Workers;
4. Distribution of supplementary foods to the health facilities;
5. Supportive supervision to the health facilities;
6. Have been involved with women groups through FHI to sensitize them on HIV
and AIDS;
7. Attending DHMT morning briefs, Zonal Officers meetings and mobile
meetings;
8. Able to talk to nursing students on nutrition activities in the district; and
9. Micronutrient: This is a new concept that was introduced by the MOH and the
United Nations Children’s Fund (UNICEF).

The micronutrient project has taken off well in Nakuru district. The MOH has
emphasized on Vitamin A and haematinics. Vitamin A is in general administered
to children who attend hospitals, health centres and dispensaries for child
welfare clinics whether they are sick or healthy. The following facilities have
implemented the concept and progressed satisfactorily: Nakuru Provincial
General Hospital, Dundori health centre, Olenguruone health centre, Gilgil
Hospital, Banita Dispensary, Tinet Dispensary, Kipsyenan Dispensary, Engashura
Dispensary, Lare Dispensary, Ogilgei Dispensary, Kapsumbeiywo Dispensary,
Mogotio Rural Health Demonstration Centre (RHDC), Catholic Diocese of Nakuru
Hospital, Molo District Hospital and Naivasha District Hospital (MOH Annual
Health Report, Nakuru District 2003).

Some of the constraints that face the nutrition department include:

1. Staff shortage and poor deployment in some cases. For instance, the Medical
Officer of Health serves the whole Nakuru Municipality division. Some areas
have concentration of staff due to personal reasons e.g. marriage or
proximity to urban centres;
2. The district nutritionist’s office is congested; more space is required;
3. Inadequate logistics; lack of transport and staff uniform allowances;
4. Reporting rate in the district is poor; some nutritionists do not write any
reports at all;
5. Doubling as district nutritionist and giving lectures at the Kenya Medical
Training College (KMTC) is too strenuous for one person;
6. Reporting tools are not adequate especially for Vitamin A thus low reporting
rate;
7. Shortage of nutrition staff in the district and this contributes to low or no
reports; and
8. Where there is no nutritionist, Child Health and Nutrition Information System
(CHANIS) I and CHANIS II reports are not given.

Kigutha (1995) conducted a study on the effects of a unimodal climatic

pattern on household food availability among rural households with limited
landholdings and low cash incomes. The study envisioned how this in turn

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affects food consumption and the nutritional status of the nutritionally

vulnerable household members, namely preschool children, lactating women
and the elderly. Research was carried out over a 15-month period in
1992/1993 among 94 households in Nakuru district, Rift Valley Province,
Kenya. The results show that most of the smallholder rural households in the
unimodal climatic areas of Kenya may be food insecure as they do not
produce adequate amounts of food to last them from one harvest to the
next. This is mainly due to such factors as limited landholdings, seasonality
in rainfall patterns and large families, characteristic of many informal
settlements in Kenya.

Conclusion

Nakuru Municipality is densely-populated with most of the people living in areas

characterized with low cost housing. The town’s population growth has been
rapid but not in tandem with the provision of basic facilities including water, land
and medical services. There is uneven distribution of government health
facilities in the district. Kaptembwo, an urban informal settlement, lacks a
government health facility, and yet the poor are vulnerable to disease
outbreaks. Low rates of access to medical care are attributable to state failures,
such as the inability to provide adequate health infrastructure, or proper health
insurance. There are gaps in information about the work being done in the area
of HIV/AIDS in the district. Moreover, the distribution of organizations working in
the area of HIV/AIDS in the district shows a lack of focus in the informal
settlements. Health provisioning should not only be focused on the rural Nakuru
and non-poor urban estates, but also among the poor people who live in urban
informal settlements.

Malaria is the leading cause of outpatient morbidity in Kenya, accounting for one
third of all new cases reported. In Nakuru, malaria is probably caused by the
poor drainage system in many parts of the district especially in the informal
settlements. The government through the DHMT should expedite the
decentralization of the national health system framework to the districts so that
Kaptembwo can benefit from proper medical services. In this way, the National
Malaria Strategy (2001-2010), which was drafted following the Abuja
Declaration by African Governments in 2000, would then be fully actualized so
as to realize the reduction of malaria related morbidity and mortality. More
efforts should be geared towards nutrition education among all people in the
district and especially among women who have the burden of caring for their
under-five children.

Food security and nutrition must be given high priority if actions to improve
health equity and socio-economic development in Kenya are to succeed.
Accordingly, the levels of poverty, hunger and under-nutrition should be
improved to achieve the UN Millennium Development Goals. Improved nutrition
and improved economic wellbeing should be able to curtail the vicious cycle of

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worsening poverty, hunger and under-nutrition. This will help in correcting the
inequalities in income and health and subsequently decrease the vulnerability of
the poor. Proven effective interventions indicate that public policy can make a
difference, that nutritional improvements can be effected, even under
conditions of poverty, and that these can have positive impacts on economic
wellbeing. Implementing public policies that address food security provides an
opportunity to deal with the demands of AIDS, the challenges of the competing
signals from global trade to health and development, and the challenges to
equitable public policy in the current governance of the food supply system.
Confronting poverty and hunger provides one further area where alternatives
can be built that promote policy objectives of justice and equity. Interventions
are needed to build a multi-disciplinary and integrated response to food security
and nutrition, with a focus on fair trade, gender inequalities and community
control over productive resources. In other words, these interventions need to
ensure food sovereignty. The above mentioned reasons suggest that equity in
health will be difficult to achieve unless more explicit attention is paid to the
underlying problems of under-nutrition and food security.

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 December 2007

4.0 Kaptembwo Informal Settlement

This chapter describes Kaptembwo informal settlement in terms of the reasons

as to why it was chosen for the study; the history of the informal settlement;
and the health provision points that were identified during the mapping
exercise.

4.1 The choice of Kaptembwo

The choice of Kaptembwo informal settlement has been influenced by the

experience of work conducted in Nairobi slum communities by the AIHD and
other organizations. Amuyunzu-Nyamongo et al. (2007) have highlighted the
risks faced by women living in slums to HIV transmission among other maladies.
Those infected can hardly cope with AIDS due to poverty, poor environmental
hygiene and sanitation, and inadequate access to food. For instance, the
population of Kaptembwo is higher than the toilet facilities thus many people,
including young children share facilities. Thus, there are rapid infections among
young children increasing burden to their mothers. In another study conducted
by the AIHD in Mitumba slum (2006), the women were found to encounter
several difficulties that have critical implications on their health and that of their
children. These problems included overcrowding, lack of a health facility and
toilets in the informal settlement and women’s lack of employment and income
generation opportunities. The choice of an informal settlement for this kind of
study, will enable the project team to generalize the results of Kaptembwo
informal settlement to other informal settlements that have similar
characteristics.

4.2 About Kaptembwo

Kaptembwo estate (pictured) was initially a land

buying company called the Kipsigis Turgen Farm
led by estate Directors. The initial seven
hundred acres of land was bought in 1964 and
sub-divided in 1982 to 171 members of the
association, each member getting 12 plots of
50x100 metres. The land provided public utilities
that included Nakuru West secondary school,
Kaptembwo primary school, Kaptembwo police
post, Imani church and Evangelical Gospel Church (EGC). This was in view of
the fact that the government then was concerned with the provision of
education thus the schools, and security thus the police post. Public health
facilities were not a requirement then since the government considered the
Nakuru Provincial General Hospital as the nearest public health facility that
could serve a larger population of the district, including the people of
Kaptembwo. The people had to survive by walking long distances in search

40
 December 2007

of water since the government then did not also consider water a public
requirement. The Kipsigis community lived a traditional way, whereby girls
and women had to fetch water from the river, while boys and men attended
to livestock. Even though the farm was owned by a homogenous ethnic
group, other ethnic groups have migrated into the area and settled on the
small pieces of land making the farm an informal settlement.

41
 December 2007

The main source of water for many people in

Kaptembwo is River Ndarugú (pictured) which is
used by both people and animals. The water is
dirty and many diarrhoeal cases reported at the
health provision points that were visited during
the mapping exercise were said to be as a result
of drinking unclean4 water from the river. For an
alternative source of water, the residents of
Kaptembwo line up for long hours in order to get
clean water from a point that was constructed by
the Nakuru Environmental Consortium and Waste Advisors. The tank has
been erected next to the Kaptembwo bio-digester public toilet.

The Nakuru Municipal Council as the planning authority, set aside a piece of
land which was to be used as a market centre. The place was located near
Nakuru West village. However, the open place has since been misused by
the plot owners who have and are still erecting shops. According to the area
chief, the Kipsigis Turgen Farm will be dissolved once the Directors finish
distributing the plots and surrendering the mandate to the Nakuru Municipal
Council. The problem of space started cropping up since the sub-divisions of
the land. Up to now there is no space to put up a health facility for the
approximately 40,000 people of Kaptembwo informal settlement. The chief
said:

In 2005, a donor came to this area with an intention of erecting a health

facility and sinking four boreholes, but because of lack of space, the projects
never materialized. Alternatively, the authorities then proposed that the
project be taken to Menengai in Bahati division which could then serve the
neighbourhood including Kaptembwo. The projects are yet to be started
(Chief, Kaptembwo location, Nakuru Municipality Division).

4.3 Mapping of health provision points in Kaptembwo

The mapping exercise of health provision points in Kaptembwo included the

private sector (private hospitals, clinics, dispensaries); over-the-counter drug
sellers; drug peddlers; chemists/pharmacies; traditional healers; soothsayers
and faith healers, among other alternative therapists. There were no traces of
NGO facilities (both for profit and not for profit) in the community. The
information on the mapping of health provision points focuses on the first
research question as outlined in the proposal and the introductory part of this
report.

4
The researchers watched some of the community members bathing, washing clothes and
fetching water for domestic use from River Ndarugú. Animals also drank from the same
river. A community member noted that during the heavy rainy season, dead human and
animal bodies are normally found floating on the river.

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Methodology - Data were collected over a period of six days (August 22 – 27,
2007). The researchers visited the district offices and the communities to
sensitize them about the research and at the same time mobilize people to take
part in the exercise. The morning of the first day was spent in discussions at the
Nakuru District headquarters with the District Commissioner and other staff.
This was a useful meeting that provided an overview of development issues in
the district as a whole. The second day was spent on talking to community
members in a bid to understand the Kaptembwo informal settlement. The
meeting was held at the area chief’s camp. The tools used for this exercise
included a social map and an observational checklist as briefly described below:
Social mapping - Community members converged at the Chief’s
Camp, where they engaged in a focus group
discussion (FGD) with the researchers in a
mapping exercise. They later drew the social
map of Kaptembwo (pictured) on the ground,
which was later transferred on a manila paper.
The map provided a visual representation of the
community. The study participants used locally
available materials (sticks, leaves, stones and
manila paper) to indicate various institutions and
resources in their community. The institutions
and resources as indicated in the social map included health provision points,
secondary and primary schools, a river, several churches, roads, the market
place, shopping centers, a water point, a quarry (sand mine), a pubic toilet and
a police post.

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 December 2007

Major issues discussed during the mapping exercise included lack of water, lack
of a public health facility and a poor drainage system. The biggest
problem in Kaptembwo is lack of clean and sufficient water since there is
only one river that serves the village. The river water available is very
dirty because animals also share it. Women have to cover the 5 km to
fetch water for domestic use. Another issue that emerged was that there
is no public health facility in the village. People have to travel to the
Nakuru Provincial General Hospital, which is 7 km away. The abject
poverty experienced by most informal settlement dwellers compounds
the problem. Patients have to walk to the hospital due to lack of fare but
when they are critically ill they use bicycles (boda boda)5. The drainage
system, which has stagnant and dirty water, was viewed by the
community members as the main source of breeding areas for
mosquitoes that were notorious in spreading malaria especially in women
and children under five years.

Observational checklist - On the third, fourth, fifth and sixth days the
researchers took a transient walk through the informal settlement to find the
health provision points and other amenities that had been plotted on the social
map by the community members. Being in one community for four consecutive
days allowed the researchers to follow-up on issues that were mentioned by the
community members during the social mapping exercise. During the walk, the
researchers used an observational checklist (See Annex 1) in the health
provision points to find out the current activities, available staff capacity and
gaps, the range of services offered, regularity of services, visiting hours, general
atmosphere and the required capacity to offer services to the slum dwellers.
The health provision points that were visited are briefly described below:

5
The boda boda business which has thrived in Nakuru is regarded as a saving mode of
transport for many residents of the district. The people of Kaptembwo for instance, use them
when they are critically ill since there are no public service vehicles plying Kaptembwo-PGH
route. The women from the informal settlement said that it was however dangerous for
them to carry children on the bicycles.

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 December 2007

4.3.1 Mother Kevin health centre - It is a

Catholic mission health facility run by the Little
Sisters of St. Francis of Assisi. It is located on
the periphery6 of Kaptembwo informal
settlement (lower side towards River Ndarugú).
It offers curative and preventive treatment,
MCH, antenatal and postnatal care, maternity
services, laboratory services and prevention of
mother to child transmission (PMTCT) services.
The out-patient operates from 8.00 am to 5.00
pm while the in-patient is 24 hours every day. The facility has three enrolled
nurses, two patient attendants (nurse aids), a registered nurse, a clinical officer,
a laboratory technician and four subordinate staff. The health centre offers
quality services to all clients at anytime of the day or night since the facility is
situated in a needy place, and that most clinics operating in the slum make
referrals to the facility. The three enrolled nurses have attended further training
in PMTCT following the view that:

Since the medical field is very dynamic, refresher courses need to be emphasized.
All medical personnel need to be updated on the new discoveries through seminars
and workshops. If funds and time allow, all the personnel here should go for
advanced training (Registered nurse, Mother Kevin health centre, Kaptembwo).

The health centre offers services to the residents in Nakuru Municipality division,
although majority of the clients come from Kaptembwo. The management of the
facility upholds cost-sharing and therefore the facility depends on user charges
as their only source of income. Thus, the patients pay a consultation fee of Kshs.
30 and Kshs. 10 for a treatment card. The slum dwellers who frequent the
facility (mostly women) cannot afford the charges because of abject poverty.
The health centre does not have a waiver system but gives first-aid to the
patients before referring them to the Provincial General Hospital (PGH). The
time spent with each patient depends on the type of ailment that the patient
has. The facility has a clean atmosphere, good reception and doctor-patient
interaction. The health centre has equipment (incubator, delivery coaches, in-
patient beds, thermometer and the Kenya Expanded Programme on
Immunization [KEPI] fridge among others) which are in good working condition.
At a glance, the health centre registers many cases of asthma, malaria, urinary
tract infections (UTI) and high blood pressure among adults; threatened
abortions among the youth; and malaria, respiratory tract infections (RTI),
malnutrition, skin infections, diarrhea, typhoid and intestinal worms among
children. The health centre does not have mobile/outreach services because the
government, through PGH, provides the services. However:
6
It should be noted that Mother Kevin health centre, the only one and largest in Kaptembwo,
is located on the periphery of the informal settlement. This is the only place where the
Nakuru Municipal Council could allocate land for the construction of a spacious health
centre. The rest of the estate households and structures are squeezed on small pieces of
land as allocated by the Kipsigis Turgen Farm Directors.

45
 December 2007

The mobile services being offered by PGH are not sufficient for the population in
Nakuru district. The hospital was initially designed to serve a few people in the
district, but now has to contend with overwhelming numbers of people (Clinical
Officer, Mother Kevin health centre, Kaptembwo).

The following Figure shows the monthly out-patient return of morbidity as

recorded at the facility between January and July 2007.

46
 December 2007

Figure 3: Monthly out-patient return of morbidity (2007)

200
Source: Health Report, Mother Kevin Health Centre, Kaptembwo

180
Malaria was the leading cause of morbidity with a peak during the months of
May and July. One of the interviewees said that:

Malaria is leading between May and July due to the long rains. After the rains,
there is a lot of stagnant water which forms breeding sites for mosquitoes that
spread the disease. There is a lot to be done to curb the menace of the major
public health problems affecting women and children - malaria and diarrhoea
among the under-fives and preventive services for maternal and child health

160
among women (Registered nurse, Mother Kevin health centre, Kaptembwo).

Malaria was followed by Respiratory Tract Infections (RTIs), diarrhoea and skin
infections especially among children under-five.

4.3.2 Mid – West medical clinic and laboratory services – It is a private

clinic which operates from 8.00 am to 8.00 pm from Monday to Saturday, and

140
from 10.00 am to 8.00 pm on Sundays and public holidays. It offers laboratory
services, immunization, preventive and curative treatment, family planning (FP),
antenatal and postnatal care and counselling. It has two staff members: a
clinical doctor and a laboratory technician, who find the number of clients
overwhelming at times. This is due to the fact that there is no public health
facility within Kaptembwo and since PGH is 7 km away, most patients prefer
going to the clinics. However, most of the time, many patients with

120 47
 December 2007

complications are referred to PGH for further diagnosis and treatment. They
charge a consultation fee of Kshs. 100.00 and a laboratory fee of Kshs. 150.00.
Most patients come from other estates far from Kaptembwo because they
personally know the doctor-in-charge. The residents of the slum cannot afford
the payments due to abject poverty. According to the laboratory technician at
the clinic, most women lack proper information on the variety of services offered
at the clinic, and therefore there is need for awareness creation. The women
also need economic empowerment so as to afford the services being offered in
most private clinics located in their neighborhood. This is the reason why most
of the people from the slum walk for more than 7 km to reach PGH so as to
benefit from government subsidized medical services.

4.3.3 Magharibi clinic – It is a private clinic which operates from 8.00 am to

6.00 pm daily. It offers curative and preventive treatment and antenatal care.
The four members of staff at the clinic cannot handle the large numbers of
people who visit the facility. The clinic refers patients to PGH for specialized
treatment because of lack of enough space and qualified personnel. The clinic is
situated in an unclean environment and the time given to clients is not enough
because the clinic does not operate at night. The clinic charges consultation fee
of Kshs. 150.00 which is paid at the end of treatment. This is due to the fact that
most people from Kaptembwo live below the poverty line thus:

The charges that include consultation fee and drugs are paid cumulatively. We do
not tell patients about the consultation fee because they will shy away since they
believe that the charges are high. We diagnose and give drugs. As a business
retention strategy, we put all the charges together and the patient pays after all the
services have been rendered (Nurse, Magharibi clinic, Kaptembwo).

The burden to women is unbearable since their husbands are idlers. Many
women and their children come to the clinic with fractures and burns due to the
impacts of domestic violence. The clinic registers many cases of common cold,
malaria, urinary tract infections (UTIs), tuberculosis and diabetes among adults;
and malaria, respiratory tract infections (RTIs), skin infections, diarrhea, typhoid,
pneumonia and common cold among children. According to the service
providers at the facility, access to health care for the community members has
been hindered by poverty since many people cannot afford the drugs and
consultation fees at the clinics. Many households in the slum lack clean and
sufficient water and the poor drainage system exacerbates the occurrence of
diarrhoeal-related cases and malaria especially among children under-five. The
nurse-in-charge of the facility recommended that medical personnel offering
services in the slum need to go for specialized training and refresher courses,
especially in the major public health problems affecting women and children
under-five (maternal and child health; and malaria and diarrhea respectively).

4.3.4 Check point medical centre – It is a private health facility which

operates from 8.00 am to 7.00 pm from Monday to Saturday and closes on

48
 December 2007

Sundays. In cases where they have patients for brucellosis7 injections, they open
from 10.00 am to 12.00 pm on Sundays to offer the services. They offer curative
and preventive services, laboratory services, dental care and family planning.
The clinic has four staff members: the doctor, clinical officer, laboratory
technician and the dentist. The facility is situated on a dusty road which was
designed as the main road serving Kaptembwo estate. Their equipment is not
adequate in serving all clients who visit the clinic.

The clinic registers many cases of UTI, STIs, malaria, asthma in male adults; UTI,
STIs, malaria, asthma and brucellosis in female adults; and diarrhea, vomiting,
RTI and malaria in children. Like Magharibi clinic, the consultation fee and drugs
are paid cumulatively after services have been rendered. This is geared to
safeguard patient retention since most of them have in the past forfeited
treatment for failure of raising the needed amount. The medical centre treats
people from Kaptembwo and those from far away. Those who come from far
personally know the doctor-in-charge. The doctor, who renders his daytime
services at Egerton University, comes to the clinic from 4.00 pm till close time.
He only comes when he has appointments with patients suffering from serious
disease complications (stroke, liver and renal problems, paraplegia, complicated
arthritis and chronic coughing). The health providers would like to offer MCH
services and counselling but lack in capacity. They were of the opinion that they
needed training in these areas which are mostly needed by the women of
Kaptembwo. They also recommended refresher courses in the services already
being offered at the facility.

4.3.5 Nakuru Provincial General Hospital (PGH)8 – It is the main referral

centre for most cases in the district. The interviewees at the facility said that the
people of Kaptembwo are normally referred for cases ranging from severe
malaria; threatened abortions; STIs, soft tissue injury and eye infection due to
assault in women; and dehydration, food poisoning, severe diarrhea and
pneumonia in children. Severe cases are admitted while mild cases are treated
as out-patient. The patients pay Kshs. 100.00 for treatment card and Kshs.
30.00 for subsequent visits. They buy the prescribed medicines from various
chemists situated in Nakuru town or elsewhere. The in-patients are charged
Kshs. 150.00 as admission fee. They hospital has a waiver system that caters
for the poor. The under-five children pay Kshs. 50.00 for the treatment card; and
with the card X- ray, laboratory tests and treatment is free of charge. All

7
Also called Malta fever, Mediterranean fever or undulant fever. It is a chronic disease of farm
animals caused by bacteria of the genus brucella, which can be transmitted to man either by
contact with an infected animal or by drinking nonpasteurized contaminated milk. Symptoms
include headache, sickness, loss of appetite, and weakness, progressing to chronic fever and the
swelling of lymph nodes. If untreated, the disease may last for years but prolonged administration
of antibiotics is effective.
8
The Nakuru Provincial General Hospital is not located in Kaptembwo. It is 7 km away from
the informal settlement. It is included in this report because it is the main referral centre for
many people in the district including those from Kaptembwo.

49
 December 2007

admissions for under-five children are also free, as stipulated in the Kenya
health policy framework (MOH, 1994).

4.3.6 Chemists/pharmacies – There were several pharmacies and chemists

that were visited. These included Interland pharmacy, Suhgic pharmacy, Pearl
pharmacy, Nene chemist, Alfamona chemist, Trompoy chemist and Dan Sam
chemist. They sell drugs to the slum dwellers at a cheaper price but those who
have prescriptions of more than Kshs. 500.00 are referred to PGH since they
cannot afford the drugs. When asked about the kind of child diseases that are
frequently treated with drugs bought from the chemists and pharmacies, one
interviewee said:

Most women receive health talks concerning child diseases that include intestinal
worms. Therefore, a majority of them deworm their children after every three
months. We deal mostly with malaria and common cold but not with intestinal
worms in children (Drug seller, Interland Pharmacy, Kaptembwo).

Many people buy drugs in the middle and end of month because of advance and
salary payments. The drug sellers observed that since many people lack money
to buy drugs, they persevere with the disease till the time they can be able to
afford the drugs.

4.3.7 Traditional healers – There are four traditional healers serving the
people of Kaptembwo: two at Soko mjinga market, one at Imani centre and
another one at Nakuru West village. According to the herbalists, the power of
treating people using herbal medicines was inherited from their grandparents. It
is taboo to start this kind of work unless you have finished childbearing. They
believe that if one handles the herbs when she/he is still bearing children, then
the medicinal power is weakened.

Nakuru West village - He had travelled to Nairobi to attend to his clients. He

operates from home and his centre referred to as Kokos herbals clinic is
managed by Kenyan quality concept that is recognised by the Ministry of Health
(MOH).
Imani centre - She treats cancers; typhoid; malaria; allergy; ulcers; pancreas,
liver and kidney problems; STIs; barrenness; skin diseases; and HIV/AIDS
opportunistic diseases. One of her patients who had paid her a friendly visit
said:

I had breast cancer for two years which was diagnosed at Kenyatta National
Hospital after a referral from PGH. I came here in April 2006 and started the
therapy up to November 2006 when I was completely healed. I thank God for this
doctor since I had lost hope after my unpromising chemotherapy experience at
Kenyatta National Hospital (Patient from Lanet, Nakuru).

The herbalist also added that she had successfully treated a Mr. Samuel who
works with Kenya Times Nakuru branch. The man was due for an operation in

50
 December 2007

Nairobi due to throat cancer but has since been healed. The payments depend
on the kind of disease that is treated. However, payments range from Kshs.
20.00 - 12,000.00. She treats people from all major towns in Kenya. Although
many patients are treated during the day, a few receive these services at night.
She offers these services in a separate room in her neighbourhood rented
mainly for this purpose.

Soko Mjinga market - There were two herbalists here; a female and a male.
The female one treats minor ailments including malaria, diarrhoea, typhoid,
common cold and barrenness. She does not administer medications at night
since most of the herbs require boiling and she does not boil any herbs in her
house. Her clients pay between Kshs. 10.00 – 100.00 according to the ailment.
Serious diseases and complications are referred to PGH for specialised
treatment. She operates from 8.00 am to 5.00 pm from Monday to Friday
except those days on which she travels.

The male herbalist treats toothache, malaria, backache, stomach-ache, hard

stool, dysentery, athletes’ feet, skin diseases and
other diseases from his herbal centre (pictured).
For complicated wounds, he has to look at the
symptoms that led to the wounds, and if it is a
serious case he refers the patient to PGH for
specialised treatment. He has a certificate in
HIV/AIDS counselling. However, all the patients
get tested at the voluntary counselling and
testing (VCT) centre at PGH since Kaptembwo
does not have a VCT centre. After diagnosis,
those who suffer from opportunistic diseases are then treated with the herbal
medicine. He also co-operates with other experts in treating barrenness and
STIs. He said that the reasons as to why women do not get children include
prolonged use of family planning pills and abortions. The patients who visit him
with such cases first undergo counselling before being referred to PGH for
diagnosis and treatment.

According to him ulcers occur in different shapes: intestinal, duodenum and

stomach. The herbalist has to find out the symptoms of the ulcer and how long
the patient has had it before administering the right medication. He also has a
first aid kit which he uses on patients who suffer from cuts and burns. He also
does home-based care as a volunteer. He has therefore bought syringes,
hydrogen peroxide and antiseptic deodorant, neugrasin (antibiotic for wounds),
gentian violet for mouth ulcers, adhesive plaster (zinc oxide), medicated spirit
and potassium permanganate. The latter is used for treating joint dislocations.
The cost of medication depends on the kind of disease one has, but the range is
between Kshs. 200.00 – 500.00. However, many slum dwellers cannot afford the
medicines even as cheap as they might seem. He said:

51
 December 2007

Sometimes I treat a patient because I realize how much he/she is suffering. But
some patients disappear without paying for the services. The problem emanates
from the fact that the freelance herbal medicine men or the so-called promoters
sell their drugs for Kshs. 50.00. Thus, the people here have a mentality that all
herbal medicines should not exceed Kshs. 50.00. Only those who understand the
strength of these medicines and the pain we go through in looking for the herbs
genuinely pay for the services (Male herbalist, Soko Mjinga market, Kaptembwo).

All clients have an easy access to this place since it is located at the main
market centre that serves Kaptembwo. The clients are given his business card
and therefore the message of his herbal services is spread to family members
and friends of the client. He treats people from all major towns in Kenya. When
he travels he carries herbal medicines that treat common ailments like malaria
and common cold. He operates from 8.00 am to 6.00 pm daily. He got his
permit in August 2006, but has an experience of eight years in the service.

4.3.8 Drug peddlers - The research team found only one drug peddler during
the mapping exercise. However, the community members said that other drug
peddlers or mobile drug sellers come to the settlement on different days to
promote and sell drugs. They use public address systems and they teach groups
of people who congregate around them to learn about types of drugs and the
kinds of diseases they treat. The drug peddler revealed that they operate within
Kaptembwo, Shabab estate and the town centre. They treat malaria and typhoid
among adults, but children get treatment from their town centre clinic. The
adults who are given medicines by the peddler must have prescriptions from the
doctor. These are normally herbal medicines, but the peddler said that unless
the drug is given for detoxification purposes, children are not given herbal
medicines since they are stronger than the modern drugs.

4.3.9 Over-the-counter drug sellers – Most of the shops in Kaptembwo and

its environs sell pain relievers that include Panadol, Actal, Hedex and Action.

4.3.10 Soothsayers and faith healers – There were many churches that were
mapped out during the field visit. These included: Full gospel churches of
Kenya, Seventh Day Adventist church Kaptembwo, BCM gospel move-on
international church, Victory word centre, Possibility word centre, Bemacah
worship centre, Christ chapel, Emmanuel pentecostal gospel church,
Integrity’s christian community chapel, Nema worship centre, Faith victory
centre, Church of Christ, the Nakuru house of power church, Musamba holy
ghost church of East Africa, Vineyard towers church, God’s glory centre, St.
John’s Anglican church of Kenya crater parish, God of all grace worship centre
and Christian revival church. Some of the community members who worship in
these churches said that many believers have been healed through miracle
revival prayers offered by pastors in these churches.

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5.0 Discussion and Conclusion

Global picture: Globalization under liberalized markets has generally benefited

the industrialized or strong economies and marginalized the weak economies.
Many countries are urgently conducting research on the effect of globalization
on people’s living standards and health care (Nguyen et al. 2006). In this
regard, economic globalization presents formidable challenges to the promotion
of health. Coordinated, forthright, and determined advocacy by health workers
and their associations at national and international levels could and should play
a much greater role in mobilizing public and political opinion and in bringing
pressure to bear on multinational companies and international economic bodies.
Their advocacy should include the promotion of “essential public health
functions” - a basic package of services that should be available to all
populations. It should also include the promotion of a health research agenda
led by the health and policy needs of countries that bear the brunt of the world's
ill health (World Bank Report, 1996).

A large proportion of illnesses in developing countries are entirely avoidable or

treatable with existing medicines or interventions. However, most of the disease
burden in developing countries finds its roots in the consequences of poverty,
such as poor nutrition, indoor air pollution and lack of access to proper
sanitation and health education. Tuberculosis, malaria and HIV/AIDS account for
nearly 18 percent of the disease burden in the poorest countries (WHO, 2004).
Respiratory infections caused by burning biomas fuels and low-grade coal in
poorly ventilated areas also constitute a significant health burden for poor
people. Globally, acute respiratory tract infections in children, particularly
pneumonia represent the single most important cause of death in children
under five years and account for at least two million deaths annually in this age
group (Bruce et al., 2002).

Diarrhoeal diseases caused by poor sanitation which is endemic in economically

deprived areas, may be easily and cheaply treated through oral re-hydration
therapy. However, diarrhoeal diseases are the second biggest killer of children
worldwide, after respiratory infections. If the environmental sanitation of the
informal settlements is improved, then access to health care would improve the
health condition of the slum dwellers. However, if environmental sanitation is
not improved, provision of health care cannot bear fruit since children would still
go back to live in the same squalid conditions, therefore being prone to
diarrhoeal diseases. Malaria can be prevented through a combination of indoor
residual spraying of dwellings with insecticides, the use of insecticide treated
bed nets and the use of prophylactic medicines. However, malaria continues to
affect people in informal settlements due to poor drainage system that harbors
stagnant water - a breeding site for mosquitoes. The upgrading of the slum can
help in improving the living conditions of the dwellers. Malnutrition particularly

54
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affects people in poor countries while micronutrient deficiencies contribute to

illnesses and poor health. Vitamin A deficiency weakens the immune system,
leaving children vulnerable to other illnesses such as diarrhea and measles.
Estimates suggest that Vitamin A deficiency causes approximately 800,000
childhood deaths each year (Rice et al., 2004). The District’s Nutrition Field
Community Health Workers should be utilized to reach more people through
door-to-door nutrition education and distribution of the newly introduced
micronutrient supplements. Appropriate micronutrient supplementation such as
iron and folate pills, vitamin A capsules and iodized oil can be highly effective in
overcoming vitamin and mineral deficiencies. Governments, on the overall,
should put more emphasis on fighting the diseases of poverty as espoused in
the MDGs that were endorsed in 2000.

National picture: The improvement in the political environment has resulted

in a boost in available resources from international partners in support of
Kenya’s efforts to curb the HIV epidemic. For instance, signing of the Global
Fund Round 2; Phase 2 grant due to improved governance structures being put
in place; the United States Government increased its HIV allocation by 30
percent between 2006 and 2007; and negotiations with the World Bank and
United Kingdom’s Department for International Development (DFID) are near to
finalization, for considerable additional support to the national response,
through the NACC. AIDS is a severe problem in sub-Saharan Africa and this
means that scarce health resources should be targeted primarily at those who
are at the highest HIV risk. Thus, money and efforts should be concentrated on
prevention and palliative care where it really matters (Chin, 2007). Moreover,
efforts need to be directed to the poor so as to help in fighting the scourge.

Malaria continues to be a major problem in most parts of Kenya, a situation

compounded by ARI (CBS et al., 2004). Maternal and child health are major
commitments of the government as espoused through the National
Development Plan (2002-2008), the National Malaria Control Programme (2005-
2010), the National Malaria Strategy (2001-2010), the Roll Back Malaria
Movement of 2005, the National Health Sector Strategic Plan (1999-2004), the
Abuja Declaration of 2000 and the Millennium Development Goals endorsed in
2000. Increasing access to services is therefore critical to meeting any of the set
health targets. Thus, the mobile clinic services and health advocacy are relevant
to the needs of the people. Moreover, there is need for training more medical
staff so as to scale up the provision of medical services in the country to reach
more people.

On attaining independence in 1963, the Government of Kenya committed itself

to providing free health services as part of its development strategy to alleviate
poverty and improve the welfare and productivity of the nation. The
Government committed itself to improving accessibility, equity, affordability and
quality essential health care services for every Kenyan. To realize this objective,

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the 2005-2010 National Health Sector Strategic Plan was developed. The theme
of this plan, "Reversing the Trend" was developed under the Kenya Health Policy
Framework, the Economic Recovery Strategy and the health related targets of
the MDGs. Of the eight MDG goals, three are related to the health sector:
reduction of child mortality by two thirds by 2015; improvement in maternal
health by three quarters in the same period; and combating HIV/AIDS, malaria
and other diseases like Tuberculosis. The health sector reforms that have
hitherto taken place (including introduction of the National Health Insurance
Fund, free health services, cost-sharing, waivers and exemptions etc) have all
aimed largely at addressing affordability and access to health care services.
However, these ambitious programmes could not be sustained for long following
the emergence of socio-economic crises in the late 1980s. Many countries in the
sub-Saharan Africa (including Kenya) experienced declining GDP growth rates,
negative growth in the GNP per capita, rising inflation, declining exports and
gross domestic investment and savings as a percentage of GDP, among others.
To avert the crises, the country implemented SAPs leading to reductions in
government health spending and subsequently the introduction of cost-sharing
in 1989. The policy was meant to encourage the users of public health facilities
to meet part of the costs with a view to complement government funding (IPAR
Policy Brief, 1999).

Spending to promote access to health care is crucial, given also that Kenya is
a signatory to the WHO Abuja Declaration. The latter requires member
countries to spend at least 15 percent of their national incomes (GDP) on
health (Kenya spends approximately 9%). Although Kenya has not reached
the WHO Abuja Declaration of spending 15 percent of their national incomes
on health, Kenya has had increasing budgetary allocations for health from
Kshs. 18.3 billion in 2002/2003 to Kshs. 34.3 billion in 2006/2007. This
amount has been spent on different programmes resulting in enhanced
delivery of health care services at all levels, with notable achievements (IRIN
Report, 2007). However, even with such statistics, many Kenyans who live in
squalid conditions like Kaptembwo continue to have no access to or cannot
afford to pay for their health care needs. It is due to the failures of the past
programs, that the National Social Health Insurance Fund (NSHIF) was
conceptualized for implementation, with a view to enabling more effective
provision of health cover to all Kenyans, at both in- and out-patient service
levels. But, the benefits of this scheme do not trickle down to the poor. It is
suggested that the NSHIF should be discussed again in Parliament since it
was a good initiative which could see the government initializing
mechanisms that could help the poor to access health care services. Existing
services can be improved, extended and tailored to fit local conditions. For
example, in the design and implementation of health programmes, attention
can be paid to factors that have particular relevance to women because of
biological and social influences: access and quality (including service
provider competence, counseling, continuity of care and privacy).

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At the inception of the cost-sharing programme in the public health sector in

Kenya, it was recognized that charging user fees would lead to inequities in
the provision of health care services. This is because the user fees constitute
a financial burden to the poor and other vulnerable groups, restricting their
access to health care services due to their inability to pay. The task of fee
setting and adjustments hardly follows the required process, having shifted
unofficially, from the MOH headquarters to the DHMBs. There is arbitrary and
uncoordinated fee structure by the district hospitals (DHs) and PGHs, leading
to a wide divergence between the actual fees being charged by these
facilities and the MOH guidelines. Whereas the increases are relatively
modest for some services, they are outrageous in others. This might be the
reason as to why most residents in Kaptembwo cannot afford to pay the user
charges demanded in the health provision points that were visited during the
mapping exercise. The shifting of user fees and adjustments from the MOH
to the DHMBs was a good idea, if only official guidelines were followed in
order to efficiently reduce the backlog at the Ministry. However, it should be
noted that the DHMBs need to step up the provision of health services at the
grassroots level; and also appoint a reliable person who can provide human
rights education to those who live in poor communities. In so doing, the poor
people could have similar rights of accessing health care like their
counterparts who reside in well-to-do areas.

On equity grounds, waivers and exemptions were introduced to cushion the

poor and other vulnerable groups against adverse effects of the user fees.
Granting of waivers to the poor and provision of exemptions by the
Government are considered to be part of crucial components in poverty
reduction strategies. The protection of the poor and other vulnerable groups
notwithstanding, there are concerns that the safety nets (waivers and
exemptions) programmes may not be reaching the targeted people. These
concerns have been prompted by available evidence, which points to
leakage of the benefits to ineligible households, weak administrative systems
and inadequate support to potential beneficiaries, among others (IPAR Policy
Brief, 2003).

In most facilities in the country, waivers and exemptions have not been fully
effective in protecting the poor against the negative effects of user fees on their
demand for health services, due to: limited volume of waivers granted; limited
awareness by the target population; varied assessment procedures, with some
procedures not able to identify accurately the targeted; lack of support by
facility staff because of revenue loss, given that user fee revenues have become
an important source of finance for non-wage recurrent expenditure at the public
health facilities. This has resulted in very small amounts of waivers being
granted to patients; and lack of enforcement of guidelines on waivers and
exemptions by MOH, resulting in health facility managers exercising discretion
during implementation (IPAR Policy Brief, 2003). This suggests that the equity
objective, in the provision of health services, has not been fully achieved. The

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effectiveness of waivers and exemptions in promoting equity in the public

health sector can be achieved if the waivers and exemptions programmes are
publicized; MOH issued guidelines on waivers and exemptions are enforced;
increase targeting efficiency through improved assessment and approval
mechanisms; motivate facility staff to support the safety nets programmes;
strengthening of collection efficiency; base allocations of MOH budget to
facilities on needs criteria including poverty level, fee collection potential, and
burden of diseases, among others. Use of such criteria would increase the
availability of financial resources to the poor districts, facilitating granting of
more waivers to the poor and other vulnerable groups by health facilities.

Local picture: During the mapping exercise, poverty came out as the main
problem affecting people in Kaptembwo. Causes of poverty in Kaptembwo vary
from HIV and AIDS prevalence, unemployment, destitution,
squatter/landlessness to illiteracy. It is further characterized by low incomes,
high child mortality and dependency ratio, poor infrastructure, corruption and
domestic violence. These problems impinge on the livelihoods of the residents
who largely survive on fragile financial bases. It was observed that although the
women of Kaptembwo knew what constitutes proper medical care, they could
ill-afford it and therefore had to make do with whatever was available. In this
regard, we note that inadequate medical care is highly likely to affect the health
of women who can hardly provide other basic needs such as proper nutrition for
their children.

The health risks women face due to their disproportionate poverty, low social
status and reproductive role merit increased attention. Improving women’s
health has multiple external benefits that enhance the survival and well being of
children and the productive capacity of the economy. Another problem is lack of
timely and appropriate medical care for curative and preventive diseases, which
are common among the poor. The service providers were of the opinion that
many women of child bearing age were illiterate and therefore unable to fully
understand the risks they exposed themselves to as a consequence of not
seeking proper medical care for themselves and their children. However,
women found themselves in circumstances beyond their control. For instance,
the drug sellers said that the situation is worsened by the response women get
from their husbands who do not encourage them to seek such services. Due to
their husbands’ idleness, women’s lack of income generating activities and
absolute poverty, most people were unable to afford medical care. In addition,
poverty was also closely related to poor nutrition and at worst starvation and
susceptibility to other diseases.

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Annex 1: Observational checklist for health facilities

Name of health
facility_________________________________________________________________

1. Location of health
facility____________________________________________________________
2. The range of services offered (name them)
_____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Regularity of services provided (number of days per weekdays)
____________________________
4. Rate appropriateness of visiting
hours__________________________________________________
-Visiting hours’ codes (1= very appropriate, 2= moderately appropriate 3=
inappropriate)
5. Rate age of service provider(s)
_______________________________________________________
-Age of service providers’ codes (1= 20s, 2=30s, 3=40s, 4= 50+)
6. Rate capacity of service provider(s) to handle clients (number of staff, their
professional qualifications versus number of clients)
_____________________________________________________________
_________________________________________________________________________________
-Capacity codes (1= Excellent, 2= Good, 3= Fair, 4=Poor)
7. Rate capacity of facility to handle the number of clients (size of facility,
availability of equipment)
_________________________________________________________________________________
_________________________________________________________________________________
-Capacity codes (1= Excellent, 2= Good, 3= Fair, 4=Poor)
8. Rate quality of services
provided______________________________________________________
_________________________________________________________________________________
-Quality of services codes (1= Excellent, 2= Good, 3=Fair, 4= Poor)
9. Rate the general atmosphere at the health
facility__________________________________________
_________________________________________________________________________________
- Atmosphere codes (1= Relaxed, 2= Okay, 3= Intimidating)
10. Rate the reception of clients by service provider(s)
_______________________________________
_________________________________________________________________________________
- Reception codes (1= Excellent, 2= Good, 3= Fair, 4=Poor)
11. Observe gaps in capacity and service provision and required capacity to give
services to slum
dwellers________________________________________________________________________
___

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_________________________________________________________________________________
_________________________________________________________________________________
12. General observations and comments
_________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

66