COVID-19 Series: The challenges of maintaining health services and scaling up to respond to COVID-19 – the experience of Kenya - Maintains

Supporting maternal health in Lodwar, Kenya.
Credit: Russell Watkins/DFID

The number of COVID-19 cases in Kenya continues to rise. In response, the Government of Kenya is showing leadership, through the Ministry of Health, and is implementing a range of measures to try to halt the epidemic. These include the following:

  • Specialised isolation and treatment centres have been established in Nairobi at Mbagathi County Hospital, Kenyatta National Hospital, and the recently opened Kenyatta University Teaching, Referral & Research Hospital, all providing free COVID-19 care. In Mombasa county, there are 409 beds in free public facilities, 30% of which are already occupied, while other county referral hospitals are being upgraded in line with the geographical spread of the virus and increasing caseload. For non-critical cases, boarding schools have been recruited as candidate isolation centres for patients suspected or confirmed to be infected, and are currently being equipped.The Ministry of Health is making efforts to scale up mass testing among health workers, truck drivers, and high-risk groups; over 2,000 tests are being conducted daily. However, there is resistance to testing from communities and commercial motor riders, who fear the impact of a positive result, and kits are not always readily available due to disrupted supply chains.
  • Procurement of essential supplies has been challenging, resulting in major gaps in personal protective equipment (PPE). The private sector and donors are now working with the Ministry of Trade and Industry to provide oxygen, masks, and PPE, including manufacturing some of these items locally to ensure self-sustainability.
  • There is a well-established disease surveillance system with data uploaded to a centralised dashboard and a detailed situation report produced. However, unlike in other countries, the dashboard and sitreps are not publicly available: the only public reports available are the daily updates from the Ministry of Health.
  • The estimated 57,000 health workers in Kenya are mostly skilled and well educated, but there is a long history of strikes, which could be repeated if frontline healthcare providers continue to find themselves without adequate PPE and other critical supplies. In addition, only 60% of all public sector healthcare positions were filled prior to the outbreak. It remains unclear how the US$10 million allocated to hire extra staff will be operationalised, and so as an interim step the Ministry of Education has appealed to universities to release health staff.
  • The Government has resisted a total lockdown in an effort to support the market-based economy and is using a targeted approach by restricting movement into and out of high-risk counties with COVID-19 cases.

While the Government has emphasised the importance of wearing masks, reducing physical contact, social distancing, and improving hygiene practices, these simple measures pose an insurmountable challenge for many vulnerable families, particularly in urban informal settlements. The practical difficulties are compounded by low levels of trust in the Government, which has been underscored recently by a strong use of force to enforce the curfew.

Impacts on essential service delivery

There has been much discussion of the trade-off between lockdowns to reduce infection rates and the impact on business and economies – this debate needs to be expanded to also include the impact on non-COVID-19 deaths and illness. As the World Health Organization notes, ‘People, efforts, and medical supplies all shift to respond to the emergency, such that people with health problems unrelated to the pandemic find it harder to get access to health care services.’ In the 2014 outbreak of Ebola in West Africa, antenatal care coverage decreased by 22%, postnatal care by 13%, family planning by 6%, and facility delivery by 8%.

Even at this comparatively early stage we are starting to see this in Kenya, as the usage rates for essential routine medical services have been severely affected. For example, immunisation, family planning, as well as HIV prevention and treatment services were down to 30% to 35% of the normal level in March 2020, while in-hospital delivery rates were reportedly down by over 50%.

Reasons for reduced demand in health services include fear of facility-acquired infection, curfew and movement restrictions, and fear of police harassment.  From the supply side, health workers in non-COVID-19 areas feel unprotected because PPE is prioritised for COVID-19 activities and there have been examples of ostracisation of health workers attending COVID-19 patients. There is also a move to de-congest facilities by seeing patients by appointment only, or solely for critical cases. At the same time, healthcare staff previously allocated to essential routine care have been moved to build COVID-19 surge capacity.

A study in the Lancet finds that the diversion of health services is very likely to lead to large increases in maternal and child deaths in this COVID-19 outbreak. There are already signs of this in Kenya due to the curfew: while medical emergencies are permitted to override curfew restrictions, there have been examples of the police harassing, if not arresting, private transport providers, such that women cannot access health services, or opt to wait until morning, sometimes with disastrous results. In Kilifi county, avoidable maternal deaths have led to the establishment of an emergency hotline and UN Population Fund (UNFPA) is providing fuel for ambulances transport. It remains to be seen how scalable this system will be, as prior to the advent of COVID-19, ambulance services in Kenya were patchy at best.

Recommendations

In terms of managing the COVID-19 response, the highly centralised governance of the response should be addressed. This could be done by improving coordination between the national and county governments, increasing transparency to support decision-making, and drawing in development partners who can provide support to strengthen the implementation of services. Programme and policy planners should work with religious and community leaders, who are highly organised and lead a range of local groups and community structures that provide and advocate for services, support health-seeking behaviour, as well as providing data on residential populations and facilities.

In terms of other health needs, the particular vulnerability of maternal and child services to disruption, and their substantial consequences for mortality, highlight the need to ensure provision of these services throughout the pandemic, and to support citizens to use these services as safely as possible. Supporting and incentivising the Community Health System is crucial at this time. Once the pandemic is over, health systems must be supported to recover quickly. The longer coverage reductions continue, the more lives will be lost, and even short gaps in vaccination coverage can be dangerous. This crisis underscores the need to build resilient health systems, with increased preparedness for future pandemics.

All Maintains evidence and articles relating to COVID-19 can be found here.

About Maintains

Maintains aims to save lives and reduce suffering for people in developing countries affected by shocks such as pandemics, floods, droughts, and population displacement. This five-year programme, spanning 2018–2023, is building a strong evidence base on how health, education, nutrition, and social protection systems can respond more quickly, reliably, and effectively to changing needs during and after shocks, whilst also maintaining existing services. With evidence gathered from six focal countries – Bangladesh, Ethiopia, Kenya, Pakistan, Sierra Leone, and Uganda – Maintains is working to inform policy and practice globally. It also provides technical assistance to support practical implementation.

This output has been funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government’s official policies. Maintains is implemented through a consortium led by Oxford Policy Management www.opml.co.uk.

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