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By Rosalind McCollum,

Kenya has made excellent progress towards reducing child mortality, with under-five mortality rates having reduced from 111 deaths per 1000 live births in 2003 to 52 deaths per 1000 live births in 2014. However, these improvements mask an increasing relative inequity, with urban child survival gaps between the richest and poorest children having doubled in recent years. In fact Kenya is reported to have some of the most inequitable cities globally for health. These gaps between rich and poor are not isolated to urban areas, but exist between and within counties.

What is health equity?

Health equity means that all people have equal access to health services according to their needs. They have equal use of services according to their needs and they receive equal quality of care regardless of where they live, their gender, age, occupation, race, religion, level of education, social connections, income level, (dis)ability or sexual orientation.

What are the reasons?

Health inequities in Kenya, as all over the world, occur as a consequence of a multitude of inter-related reasons. However, in the most recent Kenyan DHS (2014) differences in the use of health services are described based on a person’s location, poverty level, education level, gender and age. For example there are considerable differences for delivery rates with a skilled provider among live births in the previous five years. Mothers over 35 years (53.9%) are less likely to deliver with a skilled provider compared with younger mothers (63.1% for mothers aged 20-34 years), as are mothers living in rural area (50.4%) compared with mothers in urban area (82.4%), mothers with no education (26.4%) compared with mothers with secondary education (85.1%) and the poorest mothers (31.1%) compared with the richest mothers (92.7%).

Moving towards equity for health is a complex process and one which most high income countries are yet to achieve. However, there are features of Kenya’s health system which contribute towards lack of progress in this vital area.

Kenya continues to under-invest in health. Despite having signed up to the Abuja declaration (2001) and committed to allocate 15% of the national GDP on health, spending for health in Kenya is consistently below 5%. As a consequence of low government investment in health, people are forced to pay for health care. This is sometimes termed out of pocket (OOP) payments for health services, with OOP payments accounting for almost a quarter of all health expenditure in 2010. This regressive form of financing for health means the poorest and most vulnerable end up bearing the greatest burden, pushing many into impoverishment as they pay for healthcare. The recent elimination of user fees at dispensaries and health centres and free maternity for all in 2013 will go some way towards reducing this burden.

Where are inequities found?

Inequities exist across levels in the health system. There are marked differences between the 47 counties in the availability of the essential health package, health facilities and health workers, resulting in inequities in service use. For example, there is less than one health facility per 10,000 population in Bungoma County, compared with over 3.5 health facilities per 10,000 population in Mombasa County. This trend continues within counties, with those living in the most remote areas often having lower access and use of health services compared with those living closer to a facility. Even within a single community there are some who are underserved by health services compared with their neighbours.

What can be done?

Primary and community health care have been shown to improve health equity, for example when Community Health Workers (CHWs) were introduced in Malindi and Lamu districts in Kenya, use of their services for malaria treatment was highest among the poor and most poor. Community health services are promoted as a means to improve equity of access and use of health services by those in hard-to-reach areas and among traditionally underserved groups. Not only this but CHWs are uniquely placed to enter their neighbour’s homes and observe the social determinants of health, allowing them to provide targeted health promotion and disease prevention education which can potentially help to address some of these underlying factors.

Kenya describes the need for a shift from curative to preventive care and has pronounced the benefits of a primary and community health care approach, although secondary and tertiary facilities have historically been allocated 70% of the budget. In recent years however, there has been a degree of increased investment in primary health care with per capita outpatient visits subsequently increasing. Kenya also introduced a Community Health Strategy, however there has been limited financial backing or commitment of funds for community health from within the Government. Even vertical programmes like HIV have shifted resources away from community interventions to facility based interventions.

As a result, within certain counties those living in the most remote areas do not have access to community health services, which have been developed primarily for their benefit. This occurs as a consequence of heavy partner involvement, which permits partners to select their operational areas, with some deciding to establish community services in more readily accessible communities.

What next for Kenya?

Kenya’s decision to vote for devolution has the potential to transform longstanding inequities. In order to tackle some of these the Government has introduced an equalisation fund, equivalent to 0.5% of funds which is distributed among 14 priority counties. Analysis of key health indicators for these 14 counties reveals that in general they have higher mortality rates and lower service utilisation rates than the 33 remaining counties and so have the most to gain through these additional funds.

Furthermore, each county government now has the power to determine which services are prioritised within their county. This is a fantastic opportunity for investment and change in community and primary health care. A potentially exciting and transformative period for health equity in Kenya as funds are no longer allocated based upon national decisions but on county decisions, informed directly by community participation and county priorities.

However, there is the possibility that funds will not be used for the benefit of the whole population, as some politicians may want to demonstrate to their constituents the ‘good use’ of county funds and so may decide to prioritise tangible, visible services such as ambulances and upgrading of hospitals over less visible, but more equitable community health services. This will result in tough decisions to be made in each and every county, as county health management teams must advocate and demonstrate the benefit of community and primary health care for improving health equity and demonstrating health care results.

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Why do health inequities persist in Kenya? What difference can community health workers make?