KENYA COUNTRY REPORT ON REPRODUCTIVE HEALTH AND REPRODUCTIVE RIGHTS

Emphasis on HIV/AIDS

Peter W. Thumbi
National Council for Population & Development
Nairobi, KENYAA.

A. INTRODUCTION

Kenya is committed to improve the quality of live and the well being of her people. In this regard the country has been formulating and implementing population policies and programmes. The policies are reformulated from time to time in order to satisfy the population and development aspirations of the country.

The Programme of Action of the International Conference on Population and Development (ICPD) was domesticated in the National Population Policy for Sustainable Development. National Population Policy For Sustainable Development outlines the population and development goals, objectives and targets to guide its implementation up to the year 2010 in the country. Broad goals and objectives included are among others in the area of; reproductive health and reproductive rights, adolescents reproductive health, gender perspectives, and HIV/AIDS.

The country has made progress in re-orienting programmes to be in line with the recommendations of the Programme Of Action. Despite the success challenges still persists.

This report documents progress made by Kenya in population matters, reproductive health and reproductive rights. Constraints faced during implementation of the population programme and future challenges are also highlighted in the report. The report concludes by proposing some recommendations which can strengthen population programmes in Africa.

B. DEMOGRAPHIC AND SOCIO-ECONOMIC SITUATION AND TRENDS

i) Demographic Situation And Trends

The population of Kenya was 5.4 million in 1948. It increased to 8.6 million in 1962, 10.1 million in 1969, 15.6 million in 1979, 21.4 million in 1989 and 28.9 million in 1999. Currently, it is estimated to be 30.4 million.

Population growth rate increased steadily from 2.5 percent in 1948 and peaked in 1979 when a growth rate of 3.8 percent was recorded. This was one of the highest growth rates ever recorded. Demographic transition begun in 1989 when population growth rate declined to 3.4 percent, and further to 2.5 percent in 1999.

The high population growth experienced in the country is attributable to high fertility and low and declining mortality. Fertility was highest in Kenya in 1979 when Total Fertility Rate (TFR) of 8 children per woman was recorded. This implied that a woman could have given birth to 8 children during her reproductive period. A Kenyan woman today can only give birth to about half the number of children a women could have given birth to in 1970s. In 1998 TFR was 4.7 children per woman. The decline in fertility is partly explained by the increase in the use of family planning methods and improved educational status of women.

Mortality has declined steadily in Kenya with Crude Death Rate (CDR) declining from 25 deaths per 1000 population in 1948 to the current 11 deaths per 1000 population However, recent statistics indicate that the country may be loosing the gains achieved on the survival programmes probably due to the impact of HIV/AIDS. Infant mortality increased from 64 deaths per 1000 live births in 1993 to 72 deaths per 1000 live births in 1998.

The above demographic trends have resulted in a youthful population. People under 15 years constitute 44 percent of the population while age 15-24 forms ... of the population. Youth is the fastest growing segment of the population and contributes the highest fertility.

The proportion of the elderly people , those above 65 years, is 4 percent of the population and this proportion is not expected to change soon due to expanding population base. Their number will however increase rapidly estimated 1 million to 1.3 million in 2005.

Although Kenya is still basically a rural population, urban population is expanding rapidly. In 1999, 37 percent of Kenyans lived in urban areas, an increase from 15 percent in 1979 and 19 percent in 1989. This rapid urbanization has been contributed mainly by urban rural migration and increase in the number of urban centres. Fifty five percent of the urban populations live in informal urban settlements where basic utilities such as clean water, and sanitation are insufficient resulting in high environmental degradation.

By Africa's standards Kenya has a fairly literate population. Sixty five percent of the population can read and write. In the 1970s the country undertook a massive public campaign to achieve universal primary education. By the 1880s, enrollment in primary schools reached 100 percent although enrolment for girls was lower at 97 percent. The enrolment has dropped and sex disparity widened to 96 for males and 97 for females due to widespread poverty and adoption of cost sharing policy being implemented as part of the broad Structural Adjustment Programme.

Kenya is a multi-ethnic country. It has forty three ethnic groups. Christianity is the main religion affliated to by 90 per cent of the population, Islam is affliated to by 8 per cent, and other minority religion by 2 per cent.

The 1990s was the worst period for the Kenya's economy. Below average economic performance which was much lower than the growth rate in GDP was registered. The growth rate was 1.8 per cent in 1998,1.2 percent in 1999 and -0.3 percent in 2000. A combination of several factors contributed to poor economic performance in the 1990s competition from imported goods These include draught, electricity interruptions, dilapidated infrastructure, low investor confidence, and lack of direct foreign investment.

As reflected by the huge decline in per capita income, from US $ 440 in the 1970s to US$ 280 currently, poverty has increased over time. According to the Welfare Monitoring Survey of 1997, 52 percent of Kenyans were living below poverty line, an increase from 42 percent in 1994.

Agriculture is the main economic activity accounting for 26 per cent of Gross Domestic Product (GDP) while manufacturing accounts for 14 per cent of GDP. Major foreign exchange earners are Tea, Tourism, Horticulture and Coffee.

The performance of Kenya's economy has been mixed. Kenya enjoyed very impressive economic growth in the first decade of independence in 1963. Annual growth rate of Gross Domestic Product (GDP) was 6.2 percent per annum and the period was characterized by low inflation, high employment creation, and a healthy balance of payments position.

The rate of growth in GDP fell in the period between, 1973-1980 to 5.2 per cent due to some internal and external imbalances. Up to this time the country enjoyed economic growth rate, which was much higher than population growth rate which translated into a high and rapidly increasing per capita income.

Resulting from high cost of oil, global recession political disturbances in 1982, and draught in 1984, the period 1980-1985 was characterised by sluggish growth in GDP of 2.5 percent per annum. Following the implementation of far-reaching adjustment programmes in agriculture, trade and financial sectors, the growth in GDP improved to 5.8 percent in 1986 and 4.1 percent in 1987.

Health care in Kenya is delivered through an expansive system comprising 3,500 health facilities operated by the government, Non Governmental Organisations and the private sector.

Quality of care is low particularly in government run facilities because lack of supplies/ stocks. Lack of supplies is attributed to insufficient budgetary allocation. Government per capita expenditure on health care has declined in real terms from US $ 10 in the 1980s to around US $ 3 currently.

Accessibility to health care is high with 42 percent of the population live within 4 kilometers of a health facility, and 75 percent within 8 kilometers, the utilization of the health facilities is low probably due to high cost of health care coupled with poverty. Only, for example, 42 percent of births are delivered at a health facility.

The road transport network in Kenya consists of over 63000 km of classified road system and about 87600 km. Of unclassified road system. This system of transport accounts for over 80 percent of the country's passenger and 76 percent of freight traffic. Due to inadequate public funding the road system has deteriorated thus adversely affecting efficient delivery of services. Delivery of services has also been affected by insecurity in some parts of the country.

C. POLICIES AND INTERVENTIONS IN

REPRODUCTIVE RIGHTS AND REPRODUCTIVE HEALTH.

Immediately after Cairo, Kenya embarked on a process of domesticating the ICPD Programme of Action. This process culminated in the development of a consensus policy document titled, The National Population Policy for Sustainable Development, which was approved by Parliament as a Sessional paper No. 1 of 2000. Included in this paper are strategies and objectives in the areas of; fertility, mortality, family planning, reproductive health and reproductive rights, gender perspectives and HIV/AIDS.

The government of Kenya has fully embraced the concept of reproductive health in the delivery of care. Currently three-quarters of facilities in Kenya provide a full range of reproductive and child health services. Some facilities which have trained personnel are now offering integrated reproductive health services and training is being strengthened to ensure quality of care.

As a follow up to the recommendations of the ICPD-PA the National Reproductive Health Strategy was developed in 1996. This was the first activity to operationalise the reproductive health agenda as recommended by the ICPD. The overall goal of the Strategy is : "Provision of a Comprehensive and integrated system of reproductive health care, that offers a full range of services by the government, NGOs, and the private sector as outlined by the National Population Policy for Sustainable Development and the Kenya Health Policy Framework of 1994". As a first step to operationalise the strategy, the publication was disseminated widely among the District Health Management Teams.

According to the strategy reproductive health includes the following main components; Family planning and Unmet Needs, Safe motherhood And Child survival Initiatives, Promotion of Adolescent And Youth Health, Gender And Reproductive Rights, Management Of STIs/HIV/AIDS, Management of Infertility, and Other Reproductive Health Issues.

Policy Guidelines for service providers in family planning developed in the 1980s were revised to reflect the broader concept of reproductive health. Reproductive Health / Family Planning and Standards for Service Providers was released in 1997. A National Reproductive Health Implementation Plan for the years 1999-2003 has been developed to guide reproductive health needs in the country. In the year 2000 a study of health facilities was conducted in some eight districts to determine what is required in order to improve quality of care.

The following is a brief discussion of progress made in the implementation of various components of reproductive health.

i) Family Planning And Unmet Needs.

Family planning knowledge is almost universal. Ninety six percent of women age, 15-49 and 98 percent of men age 15-54 know at least one modern method of family planning. These men and women are able to develop rational approach to planning their families. The pill is the best-known family planning method followed by are injectables, and condoms.

Contraceptive use, especially of modern methods, has increased sharply in Kenya. In 1989 Contraceptive Prevalence Rate for modern methods was 18 percent, it increased to 27 percent in 1993, and further to 32 per cent in 1998. The rate of increase in contraceptive use has however slowed down.

Despite these achievements much unmet need for family planning persists. Twenty four percent of Kenyan women who would like to either space or limit births are not using a method of family planning reflecting a high unmet need for family planning.

Family Planning starved of financial resources as most previously allocated for funding the programmes were diverted to HIV/ AIDS prevention. Without sufficient financial support to the family planning programme there is a real threat for loosing the gains the country had achieved.

ii) Adolescent Reproductive Health.

The most common adolescent and youth reproductive health problem are early child bearing, STIs/HIV/AIDS and unsafe abortion. Adolescent Reproductive Health Policy is in the process of being formulated but currently reproductive health needs for youth focus on promotion of responsible sexual behavior. Youth in schools are reached through family life education, components of which are integrated in carrier subjects. Peer education programmes are also being implemented in some districts. These programmes provide youth with life saving skills they need to protect themselves from unplanned pregnancies, STIS/HIV/AIDS. Reproductive health needs for youth out of schools are provided at youth friendly clinics and at youth centres established in some districts. Call-in weekly programmes targeting the youth are also aired on the national radio. Despite these efforts, reproductive health needs for the youth have not been adequately addressed in Kenya. It should be noted that opposition by religious groups has prevented the Family Life Education to be taught in schools.

iii) Gender and Reproductive Rights

Substantial improvements in the health status of men, women and children have been realized. Despite these improvements, disparities still persists especially in relation to women's reproductive health. Many women in Kenya die as a result of pregnancy and childbirth related disorders. Teenage girls, age 15-49 are more likely to experience pregnancy related complications. According to 1998 KDHS, girls have sexual debut at an early age the 1998 KDHS showed that 21 percent of girls age 15-19 were either pregnant or mothers at the time of the survey.

One of the goals of the National Reproductive Health Strategy is "to eliminate all forms of discrimination against women and the girl child to enable them exercise their rights to sexual and reproductive health and promote their equal representation at all levels of political and public life".

The right for all couples and individuals to decide freely and responsibly the number and spacing of their children is clearly spelt out in The National Population Policy for Sustainable Development. Couples and individuals are given access to information and education they need to make informed decisions and wide range of family planning methods are given free of charge to people who need to regulate their own fertility.

Kenyans now desire to have smaller families than a decade ago. The reported ideal family size among married declined from 4.4 children in 1989 to 3.8 children in 1998.

Provision of reproductive health services is hampered by harmful practices including female genital mutilation (FGM) of female circumcision. Thirty eight percent of women age 15-49 have undergone the practice . Although the practice is declining nationally it is still deep rooted among the Kisii, Kalenjin Maasai, and the Meru. According to the 1998 KDHS, 97 percent of Kisii women, 62 percent of Kalenjin, 89 percent Maasai and 54 percent Meru women are circumcised. Female circumcision causes life long reproductive health risks among girls and women and studies have shown that infant and maternal mortality is highest among the practicing communities.

The campaign against FGM in Kenya has included adoption of various plans of action including the National Plan Of Action For The Elimination of Female Genital Mutilation in Kenya, 1999-2019. FGM has also been outlawed by the recently passed children' bill. Strategies for the elimination of FGM have included information and education mainly targeting the practicing communities. Alternative rites of passage involving exchange of gifts or a slight scratch are promoted rather than FGM. Safety nets are provided to girls who say no to circumcision or to forced marriage

In African set-up involvement of men is crucial for successful implementation of reproductive health programmes, reduction of sexual and domestic violence, including sexual abuse of minors and FGM. The activities being implemented to enhance male involvement in reproductive health include male only clinics and information and education urging men to encourage and support their spouses/ partners in reproductive health. For sexually abused women legal advice may be given to those who need it.

iv) Safe Motherhood And Child Survival

Maternal mortality in Kenya is unacceptably high. Five hundred and ninety (590) women per 100,000 live births die due to pregnancy and child birth related causes. The goal for Safe motherhood and Child Survival programmes is "reduction of both maternal and child morbidity and mortality" Components of this programme are family planning, antenatal care, clean and safe delivery and essential obstetric care.

Activities being implemented include training midwives and other health providers, including, TBAs, in life-saving skills to provide quality delivery care. In collaboration with donors, Ministry of Health is implementing a safe motherhood programme, which involves sensitizing communities to seek services of trained health for delivery assistance. TBAs are also being equipped to provide safe and clean maternity services in communities. Referral system is being strengthened to handle complications efficiently.

v) Other Reproductive Health Issues

Cancer of the cervix and breast is a common reproductive health issue in Kenya. If detected early, cancer can be treated. However, often women report when it is too late because they have no information to help them make informed decision regarding seeking care. Lack of screening services, both equipment and knowledge, has also created problems for the process. Programmes being implemented include strengthening and expanding screening and management of cancers. Activities include awareness creation on the need for regular screening of reproductive cancers. Doctors and nurses are being trained and up-dated regularly on the management of cancers. Health facilities are being equipped and stocked.

vi) Management of Infertility

Activities being implemented for the management of infertility include awareness creation on causes of and prevention of infertility. Management of STIs is being improved and health workers are being trained in the management of infertility.

(a) Impact of HIV/AIDS

AIDS in Kenya kills 700 people daily and up to the present time the disease has killed a total of 1.5 million people. It is estimated that 2.2 million or one in fourteen people are HIV positive in Kenya. HIV prevalence is highest among women age 20-24 and among men age 30-39.

HIV/AIDS is the biggest socio-economic challenge in Kenya. The disease has negatively impacted on all sectors.. One of its worst impacts is an increase in orphans as young adults die. It is estimated that there are 1.3 million AIDS orphans in Kenya and the number is projected to increase to 1.5 million by 2005. These children will lack parental love, care, and supervision they need at the critical development stage of their lives. Tremendous strain will be experienced by the social systems to cope with such a large number of orphans. Pressure will also be borne by the society as they provide services for these children including health care and school fees. Many of the children may miss the services completely.

AIDS has already threatened to reverse recent gains Kenya has made on child survival programmes. AIDS is a worse killer of children in Kenya than measles or malaria. It is estimated that annual number of child deaths are 50,000 due to AIDS. Measles and malaria respectively kill and increased in the last decade probably due to AIDS. . Infant mortality rate increased from 68 deaths per 1000live births in 1993 to 74 deaths in 1998 and. Under-five mortality rate increased, in the same period, from 99deaths per 1000 live births to 112 deaths. With AIDS it is expected that mortality will increase further before it stabilises.

Arising from the spread of HIV the number of Tuberculosis (TB) cases has increased. A recent study at the Kenyatta National Hospital, (the main referral hospital in Kenya) showed that the proportion of TB cases among all patients doubled from 8 percent in 1988/89 to 16 percent in 1997. The study also showed that TB was the most costly disease to treat. The increase in TB prevalence will definitely drain resources from other essential services.

The impact of AIDS on companies in Kenya has been very negative. Increased company expenditures on staff recruitment and training , funeral expenses, medical costs and increased employee's benefits have negatively impacted on company profits. A World Bank Strategy report, AIDS Prevention And Mitigation In Sub-Saharan Africa that AIDS costs to Companies can be enormous. According to the report a Kenyan company spends an equivalent of 8 percent of its profits on HIV/ AIDS related costs.

HIV/AIDS has also negatively affected Kenya's micro-economic situation in various ways, most noticeably through decline in productivity as morbidity and mortality affect the most reproductive labour force. It is difficult to quantify the AIDS impact on the Kenyan economy precisely but it is estimated that the total cost of AIDS to the economy was 4 percent of GDP in 1991, and has now increased to about 15 percent. This implies that with AIDS Kenya's GDP is about 15 percent lower while per capita income has declined by 10 percent.

Agriculture, the predominant economic activity in Kenya has not been spared. AIDS is likely to have adverse effects on the sector through loss of labour supply, and decline in labour productivity. Cumulative cases of AIDS in the agro-estates accounts for as high as 30 percent of the work force in Nyanza province, 12 percent in Rift Valley and 3 percent in Eastern provinces.

(a) Knowledge of AIDS.

Knowledge of AIDS in Kenya is almost universal as almost all women and men (99 percent) know of AIDS. Majority of the people know that AIDS can be avoided through abstinence, use of condoms, and avoidance of multiple sexual partners. The proportion of Kenyans who know of somebody with AIDS or who has died of AIDS has increased from 42 percent women and 40 percent men in 1993 to 72 percent and 70 percent respectively in 1998 reflecting the spread of AIDS tragedy in Kenya.

(b) HIV/AIDS Interventions and Programmes

It is very clear to the government of Kenya that the impact of AIDS can be devastating and its spread has to be slowed down. Prevention intervention programmes put in place include the adoption of a national HIV/ AIDS policy approved by parliament as a Sessional Paper. The goal of the paper is to " provide a policy framework within which AIDS prevention and control efforts will be undertaken for the next 15 years". An important strategy of this policy is fostering a strong political commitment at the highest level and promoting a multi-sectoral prevention and control approach. The prevention and control programmes have been strengthened by the adoption of a strategic plan for the national HIV/AID & STDs control, 1999- 2004.

The Strategic Plan envisages to reduce the national sero- prevalence of HIV/AIDS by the year 2004 and to increase the level of care and support activities for the infected and the affected. Strategies being pursued to achieve those objectives include: advocacy and promotion of behaviour change, blood safety, continuum of care and support, treatment and control of Sexually Transmitted Diseases (STDs), epidemiology and research, prevention of mother to Child Trasmission of HIV, and mitigation of the socio-economic impact.

Advocacy and promotion of bahaviour change

The country has put in place advocacy and information and education strategy to address change of behaviour including promoting use of condom. These programmes have however had limited success as shown by the 1998 KDHS. Only 6 percent of women and 21 percent of men reported using a condom during the last sexual encounter. Some of the factors which influence sexual mode of transmission of HIV/AIDs include cultural beliefs and practices. Ignorance , myths and misconceptions of how the diseas e is transmitted also militate against successful implementation of IEC programmes for behaviour change. Advocacy and IEC interventions being implemented include social mobilisation activities targetting opinion leaders at all levels, leaders, women and youth groups, religious leaders and the media.

To strengthen IEC interventions government proposes to formulate policy instruments to promote behaviour change. The instrument wiill also address non- sexual modes of transmission such as circumcision.

Blood Safety

AIDS situation in Kenya has affected blood collection in the country. Blood collection in the country has declined from 150000 units in 1986 to less than 70000 units in 1996 while demand for blood is estimated at 210000 units. There has also been an increase in HIV prevalence among blood donors from 1.5 percent in 1987 to 6,5 percent in 1996.

The problem of quality assurance and in recruitment and retention of blood donors persists although a great deal of effort has been made to ensure that most of the blood for transfusion is screened. The government plans to 100% safe blood supply for purposes of transfusion by the end of 2004.

Continuum of Care

The number of people who are HIV and who have blown up AIDS has expanded rapidly creating many problems for the health system in the country. At present about 60 percent of hospital bends are occupied by people suffering from HIV/AIDS related diseases and the proportion will increase as more people who are now HIV positive develop fully blown up AIDS. This has necessitated the establishment of Home Based Care where clinical, and nursing care counselling and social support are provided.

Treatment And Control Of STDs.

STDs significantly increase the spread of HIV in both men and women if left untreated. Studies have shown that ulcerative sexually transmitted infections increases risk of getting HIV infection. This has called for increased effort in the management of STDs as end in itself and as means to control spread of HIV/AIDS. However obstacles to effective management of STD case management persists especially in rural areas. The obstacles include lack of STDs laboratory diagnostic facilities, well-trained staff, and high workload and shortage of drug supplies. Concerted campaign on STDs has resulted in the number of people going to facilities for treatment increasing significantly from...in....to.....in......The government is now strengthening the treatment STDs through syndromic management.

Epidemiology and Research.

The reported HIV/AIDS cases in Kenya reflect gross under-estimate. It is believed that the level of under estimation is by a factor of five. For this reason the reported AIDS figures are not used for planning purposes. They are used for advocacy purposes. Figures for planning and policy formulation are obtained from blood screening records available in the 78 blood screening centres in Kenya. It is a requirement to screen all blood for HIV before transfusion. Sentinel Surveillance System is another source of HIV/ AIDS. Under this system anonymous HIV tests are conducted on a blood samples of pregnant women. Data on STDs/ HIV/ AIDS are also generated through ad-hoc research studies conducted by various institutions. Despite these efforts, reporting of HIV/AIDS cases remains inefficient. This problem is compounded by lack of testing facilities and qualified personnel to conduct the tests.

Prevention Of Mother to Child Transmission Of HIV

There is little information on mother to child transmission of HIV. However it is estimated that about 30 percent of babies born to HIV positive mothers will themselves be infected. HIV transmission can occur during pregnancy, at birth or during breast-feeding. Apart HIV other STDS such as syphilis, gonorrhea can be transmitted to a child by the mother. Breast feeding is the best way to feed a child particularly if the mother is HIV negative. However, HIV positive mothers are advised to replace breast milk with locally available alternatives. Mother to child transmission is also prevented through a complete package of care including strengthened family planning and maternity services, ante-natal care, counselling and testing for HIV, and use of anti-retroviral. It is however worth to note that anti-retroviral are beyond the reach of the many poor Kenyan mothers because they are quite expensive. The government is developing modalities of making these drugs more affordable to Kenyans. These measures include reviewing law to enable the country to import cheaper un-branded drugs.

Mitigation Of The Socio-Economic Impact

The disease threatens to reverse the many gains that Kenya had achieved. Mortality is increasing rapidly and economic growth is depressed by AIDS. The number of orphans is increasing by the day as young adults die of AIDS. To reduce the social economic impact of AIDS some strategies are being pursued. Policy guidelines on the care of orphans, on youth and some targeting various sectors of the economy are in the process of being developed. Communities are being sensitised on the social economic impact of AIDS so that they are prepared to cope with the situation. They are also being mobilised so that they can understand their roles in mitigating socio -economic impact of AIDS. Other activities have included establishment of community based care programmes for windows and orphans. It is also proposed to strengthen household and community coping capacity to enable them care for people living with AIDS and orphans.

DEVELOPMENT FRAMEWORKS AND POPULATION MATTERS .

(i) Key population Issues

Substantial progress has been achieved in the implementation of population policies and programmes. This success is manifested by a decline in fertility in several African countries. Substantial decline in fertility has been experienced in Kenya Botswana, Zimbabwe, and Namibia. Fertility, however, remains high in Malawi, Uganda, Angola and Niger where women have on average seven children. Decline in fertility has mainly resulted from increased use of family methods and greater access to services. Despite the many achievements that the African countries have achieved they still face many challenges. These include :-

Recommendations

In order address those challenges and to improve reproductive health services delivery in Africa, the following recommendations are made:-