A recent report by the Global Initiative for Economic, Social and Cultural Rights (GI-ESCR) on the effects of commercialization of healthcare in Kenya on access and quality of care points out that for most people living in urban settlements, health care remains out of reach. The same communities are affected by extremely harsh social and environmental determinants of health that lead to widespread presence of respiratory illnesses or vision-related diseases, among other things.
While the public health system should in theory provide coverage for all those in need of care, in practice it is underfunded and lacks the technical and human resources to provide overarching, good quality care. The state of the public system pushes people towards a network of private providers, mostly too expensive for a vast majority of people, and a poorly regulated web of semi-formal providers. The People’s Health Dispatch talked to Sharon Joan, a resident of the Kibera urban settlement in Nairobi, who contributed to the creation and sharing of the report results, to learn more about the issues encountered by those trying to access health care in Kenya.
People’s Health Dispatch (PHD): The GI-ESCR report puts a major focus on the environmental determinants of health, such as air quality, exposure to pollutants, etc. Can you tell us more about how environmental determinants are being experienced by communities?
Sharon Joan (SJ): Environmental and living conditions deeply impact our lives. They tend to create an environment that is not conducive to our health and also cause mental issues to our health. For example, where the air is polluted and where there are other pollutants, we see health problems such as respiratory diseases, heart diseases, and children and pregnant women being much more vulnerable. They find themselves at much higher risk of developing health related problems, due to the environmental pollutants and also of the air pollutants.
For example, poor management of waste has been a key problem in the informal settlements. You’ll often find that you’re living in a setup that is so crowded with people, without any drain for waste or other disposal systems for waste materials. So people will throw waste anywhere: in the waters, in the dams, in the rivers, and with doing that, they will also pollute the water that is meant for consumption of human beings. These practices don’t lead to the required standard of human living. They put people at risk of developing many diseases.
There is also the issue of the industrial companies around the informal settlements, which tend to pollute the environment in terms of the air we breathe, and also make the environment toxic in other ways. Because industrial waste is sometimes disposed of in the dams, people living in the slums end up using this water for doing their washing, for cleaning up. And you see clearly that this water is not clean enough for consumption.
These are some of the main issues, and then there is also the issue of an unhealthy food environment in the informal settlements. Food is sold in different places, everywhere basically, so it is often compromised. You see someone selling vegetables, for example, and then there’s a heap of garbage just beside her. The way food and water reach people make them unfit for consumption. They tend to be polluted, not clean and not safe for consumption.
Essentially this means there’s little space to uphold hygiene standards and that we’re exposed to water-borne and food-borne diseases. Of course, if there is no waste disposal system, how would we not be vulnerable to this kind of infection? When you have an unhealthy food environment or access to clean water, how would you not be at risk of developing diseases like cholera, diarrhea, and so forth?
PHD: And once the illnesses appear in the communities, is the health system able to address them and provide care?
SJ: As for my thinking, and also for my knowledge, the health system is responsible for promoting the health and the lifestyles of the people, researching diseases and also responding to infectious diseases. But to some point, this is not happening because access to health workers, or to medicines, in public health facilities is a real problem. You will often find that a patient might go to the public health facility to get treatment or medication, and after a long queue from morning to evening, they don’t find the medicines they need at the facility. You’ll go to the facility at around 6 am and you’ll be able to see a doctor around 6 pm, and then you’ll be told that at this particular facility, you cannot do the laboratory tests that you need. You’ll find that they don’t do all the lab tests there, so you’ll be sent elsewhere, and repeat everything again.
That pushes people to go to private facilities or other, less formal facilities to get the medication. So you see there’s insufficient capacity in the public health system, and people end up not wanting to even go to the public system because of that. For example, there’s not a good follow-up or referral system, not even for pregnant women, for children or the elderly. These are people who really need someone to hold their hand while they are walking around the hospital and trying to access departmental laboratories. And you find that no one can really do that. No one is there to care or hold their hands as they seek the care they need.
PHD: So the private system is able to provide better equipment and more health workers because it has more money to operate upon. But how many people from informal settlements can actually afford to see private doctors?
SJ: The private sector is a preferred option because of the resources which it has, but not many people can afford it. Not even the middle class so much, because the prices are really expensive. But even so, people will prefer to go to the private sector because of the follow-up or the warm treatment they get, because the medical care they receive is immediate, and fundraise to get the bill paid. You know, through different philanthropic organizations, people can raise funds for covering the cost of their medication or treatment.
So even if the cost is very high, especially for those living in the informal settlements, people really prefer to go to the private sector in order to receive immediate care and take a chance with the bill, try to raise the money from different entities once they’ve been given the medication or something else.
PHD: And how did the difference between available equipment and staff between public and private play out during the COVID-19 pandemic?
SJ: Let’s start with the fact that in Kenya, we don’t have all the medical machines needed for certain medical procedures. We’ve seen that again as we were working on the report. So those who can will travel to other countries, India for example, to get surgeries or medical procedures. During the pandemic, this meant that there were not enough ventilators when we needed them. So we lost many lives, and that should have been an alarm bell. It should have shown us that we really need measures and strategies in place to make sure that everyone has access to the medical devices they need. At the moment, the equipment which exists is concentrated in private health facilities, and those are not intended to care for people who live in slums.
Even in the public sector, many people are at risk of not even getting the services which do exist, because of affordability. You see, in terms of medical coverage, public health facilities should be covered by the National Health Insurance (NHI), and that’s supposed to cover most of the expenses, but then it turns out it really doesn’t – you’re supposed to pay additionally for medication, or something like that. And if you have the money to get private health insurance coverage, it’s not like that, they will cover most of the expenses as promised.
So what the policy makers and government really need to do is ensure that the NHI, which is supposed to protect most people and serve the public interest, does its job. It should cover all costs of medication and treatment for people who cannot afford to pay for their medical care out of pocket. Everyone should have access to healthcare, the vulnerable should not be excluded just because they cannot pay. The government really needs to invest in the public health facilities and in the human resources for health as well. That is the work ahead, they really need to find ways and strategies to train medical practitioners to ensure that they provide efficient medical services to the people, as much as they have to equip the public health system. If all that is not done, we are losing many lives.
PHD: Do you see the research and outreach work done through compiling the report as contributing towards such a different vision of the health system?
SJ: Actually, yes, the report is very useful because people who are living in the informal settlements, they don’t really have that platform to get to understand and learn about what policy makers plan for them. Through that report, at my own level and capacity, I’m also able to educate people who are my neighbors, who are living in the informal settlements, to encourage them and show them the importance of this kind of public participation.
People’s active participation in these discussions is really important, because it helps us see the things that we would otherwise miss. So for example, as part of the discussion on budget allocation for different health issues, in a recent discussion we were talking to a group of young people who were pointing out that the budget for youth mental health is so, so low. It shows a gap between where we are and what we need, and shows which is the space where we need to intervene together.
As a community, we are using every platform to raise awareness about issues like that. We get in the community, as well as within people around our communities, to advocate for uptake of better healthcare. So the report was really helpful because people from our communities, such as the village elders, the community leaders, people who are most often not perceived to be relevant speakers by policy makers and government officials, they learned how to raise our concerns and take them up in the right places, so we would be able to improve access to healthcare and define the care we need.
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