Reflections on US Assistance to Kenya's Health Sector

September 3, 2009

As a Commissioner on the CSIS Commission on Smart Global Health Policy, I participated in last month's visit to Kenya. Our purpose was to observe how US investments in health are being implemented and to gather ideas to improve program integration and maximize impact in Kenya, a key US development assistance partner.

During our three-day visit, we met with officials from USAID, CDC, PEPFAR, the Kenyan Ministry of Health, and nongovernmental and community-based organizations. Most importantly, we met with the beneficiaries of US Government assistance. It's impossible to comprehensively assess the effectiveness of US assistance to Kenya based on such a short visit, so this is only a "snapshot" of my thoughts, but it draws upon my 25 years of work in HIV in Africa.

Key Successes

Since the 1980s, the United States has provided financial, technical, and research support to Kenya that has contributed to the reduction in HIV incidence and prevalence in the country. Current PEPFAR assistance of about $500 million annually makes Kenya one of the largest beneficiaries of US foreign aid.

PEPFAR supports the provision of antiretroviral therapy to 190,000 people, nearly two-thirds of those who are known to need treatment. One successful program in Eldoret, a collaboration between US and local institutions, has placed 90,000 on treatment. However, US funding supports much more than antiretroviral therapy. It also contributes wrap-around services, purchases commodities, strengthens technical cooperation, and rehabilitates health infrastructure.

US support for Kenya's response to HIV and AIDS is increasingly integrated. With sustainability a key objective, many programs are addressing the broader health and life needs of communities. The CSIS delegation visited the USAID-funded AIDS, Population, and Health Integrated Assistance (APHIA II) program in Coast Province, an excellent example of service integration. APHIA II, managed by Family Health International, provides integrated services for HIV/AIDS, sexually transmitted infections, maternal and child health, family planning, TB, and malaria. The program also coordinates provision of food supplements to disadvantaged people in HIV-affected communities. An additional striking element of this program is its extensive and highly engaged network of community-based peer educators who are reaching out to populations most at risk of HIV infection. The ROADS project, also supported by USAID, is another example of an integrated health development program. ROADS partners with both the private sector and communities to develop sustainable income-generating activities.

Challenges to Kenya's response to HIV

Many Kenyan stakeholders we spoke to listed important challenges Kenya faces in making its HIV/AIDS as effective as possible. For example, the country's two health ministries (Public Health and Sanitation and Medical Services), whose creation resulted from a power-sharing agreement between the country's president and prime minister, are seen by stakeholders at all levels as costly and dysfunctional. Critics also say the procurement system is broken, corrupt, and ineffective, and that it contributes to commodity shortages and an underspent government health allocation. Further, politically motivated expansion of district boundaries has made decentralized planning and health service delivery unwieldy.

Another impediment is stigma, one that we in the HIV world have been combating since the beginning of the epidemic. Kenyan national policies hinder implementation of programs to reach injecting drug users, sex workers, men who have sex with men, and victims of gender-based violence. Kenyan policies prohibit needle exchange and methadone treatment, despite the known effectiveness of these harm-reduction programs and their global acceptance. Gender-based violence continues to be a major public health problem, and the 2008 post-election violence escalated the issue.

Enhancing Kenya's HIV Response

My view is we must scale up the response to the epidemic in Kenya even further. Prevention is still the best medicine, so we must make more effort to engage key populations who are at greatest risk of contracting HIV, including individuals whose participation in the healthcare system may be impeded by stigma. Currently, an estimated 110,000 people living with HIV need antiretroviral therapy, and this number will grow without a more robust prevention effort. Increasing demand for antiretroviral therapy, a pervasive treatment-prevention gap, costly yet necessary second-line therapies, and recent research that indicates HIV-positive individuals should start treatment earlier in their disease progression, all contribute to Kenya's "HIV treatment mortgage." Because antiretroviral therapy is a lifetime commitment, the treatment mortgage is certain to become more costly.

Increased integration of health services with other development interventions is another crucial component of a heightened response. After all, what good is antiretroviral therapy to a person if she is unable to feed herself and her family? US-supported programs that integrate services and strengthen health systems need to be evaluated and scaled up to ensure that the health and development needs of Kenyans are approached comprehensively.

The United States has developed a partnership framework with Kenya to guide future HIV/AIDS assistance. Because of Kenya's remarkable technical capacity and leadership potential, I am optimistic that this partnership will succeed. With heightened commitment from both the international community and the Kenyan government, continued strong funding support, and soundly designed and implemented evidence-based programs and policies, Kenya's response to the epidemic can become a model for other countries.

Related Content

• What form will the U.S.-Kenyan Partnership Take in the Coming Years?
• CSIS Forum on Advancing U.S. Leadership in Global Health
• Video: On the Ground with the Global Health Iniative in Kenya: Examining Progress and Challenges in Kenya