Rural Service Delivery and Groundbreaking Research in Nyanza Province, Kenya

Nyanza Visit, August 11

On Day 2 of its three day visit to Kenya the CARE/CSIS delegation divided in two, with one group led by Helene Gayle and including Congressman Keith Ellison, heading north to Nyanza Province in northwestern Kenya. Nyanza is one of Kenya’s poorest areas with 63% of the population living on less than $1 a day. The province has the highest HIV prevalence rate in Kenya (14%), a significant burden of malarial disease and among the lowest life expectancies in the country – according to the director of the district hospital, age 43 for women and 37 for men. Household economies are largely supported by subsistence farming and fishing along the shores of Lake Victoria. However, Nyanza has been hard-hit by Kenya’s current drought, with both maize and sorghum harvests considerably constrained, posing further nutritional challenges at the household level.

After a pre-dawn departure from Nairobi, the delegation arrived in Kisumu City (Nyanza’s regional hub) by air and immediately headed 90 minutes north by road to Siaya District, one of Nyanza’s most impoverished areas and the home of President Obama’s father’s family. As the roads became increasingly narrow, rugged and pot-marked, eventually turning into dusty dirt tracks, the delegation came face to face with the reality of rural poverty and the challenges of providing accessible, basic health services in a region where electricity and clean water are luxuries.

First stop – the Tiwani Health. The group is greeted by the “Obama Nannies” a union of women roughly ages 40 to 60 caring for their orphaned grandchildren as well as other kids whose parent(s) have died of AIDS. The women, almost all illiterate, speak with dignity and conviction about their challenges in raising a generation of kids without parents, the struggle to secure some small source of external income to cover school fees and other expenses and the fact that people in the village are still dying of AIDS. CARE supports a group savings and loan program that has provided the women with both financial and psycho-social support and President Obama is also said to have made a donation to the program following his visit to the region as senator in 2005. Indeed, when the delegation arrives, it is granted by a chorus of women signing “Obama is great” in the local Dholuo dialect.

The group moves on to visit the local clinic which receives direct support from PEPFAR through CDC for HIV care and treatment. Both clinic staff and patients say ARVs are readily available (PEPFAR supported and at no-cost) and the clinic’s doctor makes a real effort to integrate family planning, VCT and PMTCT services. However, despite a strong effort to improve HIV programming, services for malaria treatment, the most acute cause of illness in the province, lag and there are frequent stock-outs of the anti-malarial drug, Coartem. More fundamentally, the clinic has no source of clean running water and no means to easily refer a pregnant woman with complications to more advanced care.

The delegation takes a walk through the village and stops to see two families in their homes – one a grandmother caring for five kids ages four to thirteen . The grandmother is in her forties, but looks much older. She supports herself through money earned via participation in the CARE group savings and loan program which has also replaced her thatched roof dwelling with a more substantial structure. A small patch of maize grows in an adjoining plot and chickens roam among the visitors. Despite the fact that this household lives less than a 10 minute walk from the local clinic, the thirteen year-old grand-daughter, born HIV positive, has already developed drug resistance to her first line ARVs. Her access to second line drugs seems uncertain.

Next stop – the Bar Olengo Dispensary, a further 20 minute drive down a dirt track. This is a “front line” facility in the Kenyan medical system, operating at a more rudimentary level than the just-visited Tiwani Clinic. For example, HIV testing is offered once a week instead of everyday. The dispensary is run by inspiring, dedicated Kenyan staff with a clear commitment to patient service. Painted on the wall of the clinic waiting room is a patient bill of rights and fee schedule detailing the clinic’s commitment to serving the community.

The group meets with the Barracka HIV/AIDS Support Group (no relation to the U.S. president). Sitting in a church meeting hall, about 40 members of the support group, mostly women, but also some men, have assembled to share their stories. The discussion quickly turns to stigma and HIV testing – a huge issue in this part of Kenya where an estimated 80% of people still do not know their status. When asked by the delegation why he decided to get tested, one man volunteers, “So I could live my life with courage. Before, I lived in fear.” The answer seems to resonate with the rest of the audience. The group agrees that stigma against people living with HIV has improved and that more people are getting tested, but a dissenter emerges. Transitioning quickly from the local dialect to fluent English, a young man addresses the delegation directly. He asserts that nothing has really changed and that until the support group can meet in the center of the village market, stigma will remain an issue. He says the group has no long-term advocacy plan and that in Kenya there is no approach for systematically strengthening community based organizations which have to drive the response to HIV at the local level. The discussion ends and the delegation moves to a tour of the dispensary, but before the group can leave one of the other support group members, introducing himself as a local pastor, approaches some of the visitors separately. He apologizes for the outburst, and says that things are getting better. He says he preaches about HIV every week in his congregation, but knows that many members are still resistant to getting tested. He asks that the delegation support the role that small community groups and churches can play in helping get people the information and services they need.

Last stop on our tour of district facilities is a brief visit to the Siaya District Hospital, serving a catchment area of 500,000 people. The group hears a brief report from the District Medical Officer – an employee of the Ministry of Public Health and Sanitation, one of Kenya’s two health ministries. She reviews statistics for the region as well as the overall structure of the health care system. More than 75 facilities are linked directly to the hospital. She highlights the burden malaria poses, as well as the struggle of getting women into local PMTCT programs, noting delays in referrals and stock-outs of drugs as key barriers. She flags as a triumph the creation of a surveillance system that surveys 18 priority conditions/diseases every two weeks in a selected population which is supported by CDC. The delegation does a quick stop-by of the outpatient pediatric clinic where the question of record-keeping, surveillance and measuring impacts surfaces again. There is evidence of a number of different record keeping systems, but not enough time for a meaningful discussion to try to understand how the different parts of the measurement puzzle fit together.

Before heading back to Kisumu the group makes a quick detour to the newly-established site of a pediatric malaria vaccine trial on the hospital grounds. Run by CDC in collaboration with GSK Pharmaceuticals and the Malaria Vaccine Initiative, the site opened in April and aims to enroll 1,800 under five year-olds in a phase three clinical trial of one of the most promising malaria vaccines – the RTS,S vaccine. The trial is also operating simultaneously in six other African countries. While results won’t be known for 3-4 years, the vaccine’s impact could be profound, particularly in an area like Nyanza where 40% of children under 5 years of age have malaria parasites in their blood. Currently, more than 36,000 Kenyan children die of malaria every year. An effective vaccine could have a huge impact in reducing this mortality. If the trial is successful, the vaccine could be introduced by GAVI and included in the routine childhood immunization package by 2015.

The group ends its day at the Kenyan Medical Research Institute (KEMRI) a research and training entity formally part of the MOH that has operated in collaboration with CDC since 1979. Through its work with KEMRI, CDC aims to build and sustain Kenyan public health capacity. CDC works primarily through its Field Epidemiology and Laboratory Training Program (FELTP) and its International Emerging Infections Program (IEIP). The IEIP operates an extensive surveillance network tracking the health status of more than 55,000 individuals in both Nyanza and the Kibera area of Nairobi. The IEIP provides the critical baseline and on-going data (a household survey is taken every two weeks) required to measure disease trends and to start to assess program impacts. The FELTP has trained more than almost 50 experienced lab technicians over the last four years; however, shockingly, the delegation learns that there are now less than 20 fully trained epidemiologists in the entire Ministry of Health. The group does a quick tour of KEMRI’s state of the art lab facilities and meets with a number of the “graduates” of CDC’s training programs who are impressive and clearly share a vision for how to translate their work, whether in the field or the lab, into improved health outcomes.

Before the day ends the delegation has one last opportunity to hear from a number of Nyanza-based implementers, providers and researchers. Over dinner, the delegation gets to learn more about some of the programs it has visited earlier in the day, but just as important, gets to talk with staff from other USG-supported efforts that were not a part of the day’s schedule. In particular, there is an opportunity to hear more about the burden TB poses in an area so heavily impacted by HIV as well as to learn about the APHIA-II program’s efforts to better integrate, HIV with maternal and reproductive health programs.

By evening’s end, several key themes emerge:

• Good information is a key to good programming and knowing what works. Having adequate surveillance and measurement systems is critical for developing solid baselines, on-going monitoring and evaluation and impact assessment.
• Investments in training and capacity development, whether in epidemiology or other program delivery/management skills sets, pay real dividends and must be sustained and expanded.
• The most effective programs are those that integrate program implementation with research and training. This type of integration happens too randomly and should be systematized.
• Programs work best if they bring services closest to the populations they serve. (Thus, the overwhelming acceptance of home-based HIV testing, including in communities that had previously been quite resistant.) New models need to be developed for bringing care closer to those communities most in need and providing that care in a more integrated fashion similar to what APHIA has piloted.
• Improved access to family planning could play a critical role in improving a host of maternal and child health outcomes. In Nyanza, as in some other parts of Kenya, only 17% of women have access to family planning services. A major push to make family planning more accessible should be a prominent feature of future USG efforts. More generally, putting women more squarely at the center of U.S-funded development efforts would pay multiple dividends.

The delegation’s visit to Nyanza, while brief, equipped the group with critical insights and powerful images of the challenges of providing quality, comprehensive health care in a poor, hard to reach, rural setting. The group heard compelling personal stories, got to see how individuals are served by the existing health system, and was able to interact with both medical care providers and program managers. Like the experience of visiting Kibera the day before, delegation members left Nyanza with a deep appreciation for the courage and resilience of local communities, a renewed respect for the dedicated volunteers, civil society organizations and health workers who struggle to provide good care despite limited resources, and a better understanding of the powerful potential for U.S.-funded programs to help drive further change and improve lives.