policy and governance landscape -maternal health

7/27/2019 Policy and Governance Landscape -Maternal Health

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ISSUES AND PERSPECTIVES ARISING FROM AN ANALYSIS OF THE

POLICY AND GOVERNANCE LANDSCAPE IN KENYA THAT

RELATES TO THE RIGHT TO HEALTH AND DIGNIFIED CARE

DURING CHILDBIRTH


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ACKNOWLEDGEMENTS

No woman should die while giving birth. Addressing the policy and legal framework in Kenya in so far asprovision of respectful childbirth services to pregnant mothers is concerned is vital in meeting MDG 5,

reduction of maternal mortality and morbidity all women should be aware of their right to be treated with

respect and dignity before, during and while giving birth.

FIDA Kenya is grateful to Milly Odongo, our Consultant for conducting this desk review study which goes a

long way in enhancing our previous work on Failure to Deliver in the wake of the Constitution 2010.

We are grateful to our Transformative Justice Team for editing the report. We appreciate our Heshima

Project partners - Nurses Association of Kenya, National Council of Nurses and the Division of

Reproductive Health and the Ministry of Public Health and Sanitation for their invaluable input in this report.

We deeply appreciate Population Council through the Heshima Project for their financial support which

made this study possible.


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LIST OF ACRONYMNS AND ABBREVIATION

AIDS Acquired Immune Deficiency SyndromeANC Antenatal Care

APHRC African Population and Health Research Center

ASRH Adolescent sexual and Reproductive Health

ART Anti retroviral therapy

CIA Central Intelligence Agency

D&A Disrespect and Abuse

ICPD International Conference on Population and Development

FP Family Planning

FGM Female Genital Mutilation

HIV Human Immuno-Deficiency Virus

ICESCR International Covenant on Economic, Social and Cultural Rights

KDHS Kenya Demographic and Health Survey

MMR Maternal Mortality Ratio

MOH Ministries of Health (Ministry of Medical Services; Ministry of Public Health and Sanitation)

MDG Millennium Development Goal

NMR Neonatal Mortality Rate

NRHS National Reproductive Health Strategy

PMTCT Prevention of Mother to Child Transmission

RTI/STI Reproductive Tract Infection/Sexually Transmitted Infection

RH Reproductive HealthRHRA Reproductive Health and Rights Alliance

SRH Sexual and Reproductive Health

SRR Sexual Reproductive Rights


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TABLE OF CONTENTS

ACKNOWLEDGEMENTS 2

LIST OF ACRONYMS AND ABBREVIATIONS ...3

1.0 INTRODUCTION 5

1.1 Overview 5

2.0 THE POLICY AND GOVERNANCE FRAMEWORK5

2.1 Background and Context 5

2.2 The operationalization of dignified child birth; Kenyan Context 9

2.3 Key Provisions 10

2.4 The Policy and Governance Landscape: A review of its Gaps and Contradictions 11

2.4.1 Review of Legal Framework for Health Standards 11

2.4.2 Financing of Health Services 13

2.5 The Philosophy of Maternal Health Rights 14

2.5.1 Kenyan Practice 16

3.0 TARGETED APPROACHES TO ACCELERATION PROGRESS AND MINIMIZE

OPPORTUNITIES 18


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________________________________________________________________

1.0 INTRODUCTION

1.1 Overview

This report presents the findings of an analysis of the policy and governance landscape as well as rules and systems

that need to be put in place in order to bring the current health standards into full effect. It points to key policy

questions that are relevant to providing respectful care during childbirth.

2.0 THE POLICY AND GOVERNANCE FRAMEWORK

2.1 Background and Context

Evidence suggests that in addition to financial, geographic and cultural barriers, a major factor inhibiting pregnant

women from seeking a facility delivery is due to the disrespectful and abusive treatment carried out by health care

providers in maternity units. Although quality improvement mechanisms have been introduced over the last two

decades, this has failed to encourage women to give birth in a facility and an increase in skilled birth attendance - a

major target for meeting MDG 5. Despite acknowledgement of these behaviours by policy makers, program staff, civil

society groups and community members, the problem appears to be widespread but the drivers of disrespect and abuse

in childbirth and the prevalence are not well documented.

The Kenyan government has stepped up initiatives that offer room to improve womens reproductive health and rights.

Thi i d d b h S h i ifi d k i i l h i h i d h l i f h


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In reality, this position has not changed much despite the ratification of various treaties and even with the promulgation

of the Kenyan Constitution in 2010 which in its provisions aims to correct these shortcomings. In the current national

Reproductive Health Strategy (2009-2015) - (RHS), NHSSP, Kenya Family Planning Policy, National CoordinatingAgency for Population and Development policy Brief 9, maternal death is on the rise in Kenya, the government

recognizes these shortcomings in its foreword by accepting that there have been growing concerns in the reversals in

reproductive health since the 1980s and early part of 1990s and its objective aim is to address these concerns.

Noteworthy is the fact that the current Reproductive Health Strategy indicates the reproductive health concerns include

the following: social and cultural beliefs and practices, lack of womens empowerment, lack of male involvement,

poverty, and health management systems which impede the demand for utilization of reproductive health care. The

following table shows the number of women recommending antenatal care since 1993 to 2008/9 Kenya Demographic

and Health Survey (KDHS).

0

20

40

60

80

100

Recommended number of antenatal care

visits


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The graph above shows the number of women receiving skilled care during delivery, which declined from 51% in 1989

to 45% in 1993 and 1998 to 42% in 2003 and 92% in 2008/9.

Neonatal Mortality Rate per 1000 live births


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The Contraceptive Prevalence Rate (CPR) among married women for all methods rose from 27 to 39 percent between

1989 and 1998 and stalled thereafter.

The unmet need for family planning has stagnated at about 24 per cent with the poorer women more disadvantaged.

This has been largely due to inadequate service provision and poor access to family planning commodities and lack of

support for contraceptive security. The unmet need for RH services translates into unacceptably high maternalmortality ratio of about 414 per 100,000 live births since 1998, and high morbidity levels. The lack of access to rapid

means of referral in case of emergency compounds the situation. According to Kenya Aids Indicator Survey (KAIS),

2007 preliminary results about 83.6 per cent of HIV infected persons do not know their HIV status, while 26 per cent


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Whereas the scenario captured above is an assessment of the government, the other stakeholders in the sector do

believe that the position could be much more deplorable. The situation has indeed been compounded by the recent postelection violence, which caused the displacement of some 300,000 people, disrupted delivery of basic services in the

most affected areas, displaced health workers and closed or rendered partially functional health facilities, and

contributed to the pending food crisis.

The health sector has been faced with inadequate funding, weak management systems, and shortages in qualified

health staff. The allocation for health remains at about 8 per cent, far below the Abuja target of 15 per cent. MOH and

development partners have responded to the human resource crisis brought about by the freeze on employment in the

late 1990s and continuous to the present times. The low allocation for health and the high poverty prevalence in the

country means that the majority of the Kenyan populace, and mainly the women, continues to lack proper health

treatment.

This study aims to clearly chart out the landscape of the international treaties that Kenya has subscribed to, the laws

instituted and the strategies adopted by the government. In addition it provides an analysis of the effectiveness in its

implementation as lifted from various reports submitted by the government and other key stakeholders. Finally the

gaps are identified and the factors contributing to the shortcomings in achieving internationally accepted health

standards outlined.

2.2 The Operationalization of Dignified Child Birth; Kenyan Context

Kenyas health gains of the 1980s and 1990s have begun to reverse, with the country experiencing a general

deterioration in health status, with large inequalities existing geographically and by wealth quintiles. The health sectorhas been faced with inadequate funding, weak management systems, and shortages in qualified health staff. The

allocation for health remains at about 8 percent, far below the Abuja target of 15 per cent. MOH and development

partners have begun to respond to the human resource crisis brought about by the freeze on employment in the late


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In 2007, Kenya recognized the need to scale up investments in child health and maternal health to achieve Kenyas

long-term goal, as stated in its National Health Sector Strategic Plan, to reduce U5MR to the MDG target of 33 by

2015 and the MMR to 170 by 2010. From the KDHS 2003, the U5MR was at 115 per 1,000 live births, and the IMRwas at 77 per 1,000 live births. UNICEF estimates U5MR to have risen to 121/1,000 in 2006. Kenya has one of the

highest numbers of neonatal deaths in the African region, with 43,600 neonatal deaths per year. Other major causes of

child deaths include acute respiratory infections (ARI), diarrhea, malaria, and HIV/AIDS. Malnutrition is an

underlying factor in about 70 per cent of illnesses that cause death among the 5 year-olds and younger. From the

KDHS 2003, 30 per cent of children under 5 are stunted, while 11 per cent are severely stunted. Care-seeking and

treatment for major childhood illness remain poor, with only 46 per cent of children with reported ARIs having been

taken to a health professional, and 51 per cent of children with diarrhea receiving ORT. Although malaria is a major

cause of morbidity and mortality, the successful increase in ITN coverage (52 per cent in 2006) and the use of ACT has

reduced child deaths by 44 per cent in four sentinel malaria-endemic districts. From 2003 DHS data, immunization

coverage stands at 49 per cent but is being affected by critical vaccine shortages. HIV/AIDS prevalence has risen to an

estimated 7 per cent, and there are an estimated 102,000 HIV-positive children in Kenya.

Maternal mortality remains a serious concern, with WHO estimating MMR to have risen to 560 per 100,000 live births

in 2005. Studies suggest that the majority of these deaths are due to obstetric complications, including hemorrhage,

sepsis, eclampsia, obstructed labor, and unsafe abortion. Only 42 percent of births are attended by a skilled provider

(KDHS 2003). Fertility appears to have stalled at an average of 4.9 children per woman. Contraceptive prevalence has

also stagnated at 39 per00 cent, although knowledge of FP methods in Kenya is almost universal. The MOHs national

reproductive health policy outlines priority actions for the safe motherhood program in Kenya to improve the health of

women. They include ensuring access to RH information, skilled care, basic and comprehensive emergency obstetric

care, and strengthening the capacity of CORPS (community own resource persons) to support birth preparedness,

referrals, postnatal care, and registration of births, among other priorities.

2.3Key Provisions


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The Kenyan Constitution 2010, directly or indirectly provides for the right to maternal health. Article 2 (subsection (5)

and (6)) states that the general rules of international law as well as any treaty or convention ratified by Kenya form part

of its domestic laws, this implies that international and regional instruments ratified, acceded to or signed by Kenya hasthe same legal obligations than Kenyan laws. Article 27 advocates for equality and prohibits all forms of

discrimination, while Article 43 guarantees each persons economic and social rights, in particular the right to the

highest attainable standard of health, which includes the right to health services including reproductive health rights.

Articles 26 and 28 provide for right to life and human dignity respectively.

2.4 Policy and Governance Landscape: A Review of Its Gaps and Contradictions The wider protection of health equity would come from including the provisions outlined above in domestic law. It is

thus important to draw attention to the deficits in their application. Particular attention should be given to ensuring

national laws cover the relevant provisions in Article 12 of the International Covenant on Economic, Social and

Cultural Rights (1966); the relevant provisions of the African Banjul Charter on Human and Peoples Rights and

relevant provisions of the Protocol to the African Charter on Human and Peoples Rights on the Rights of Women in

Africa (2003/5). The right to enjoy the highest attainable standard of physical and mental health as outlined in Article

12 of the ICESR, for example, is generally expressed in a more limited manner in national laws.

2.4.1 Review of the Legal Framework for Health Standards

This section explores the legal frameworks for equity and public health within major themes. Constitutional provisions

for these areas of legal rights are explicitly separated, as they signal a hierarchy of protection of health rights in all

areas of economic and social activity. Where public health is given explicit protection in areas of economic and social

activity in law this is noted in the analysis.

Right to Life


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Legal protection of the right to life in Kenya

The Constitution is the supreme law of Kenya and any law inconsistent with it is null and void. Chapter

Four (4) of the Constitution contains the Bill of Rights, which offers protection for the safeguards of the

individual rights and freedoms for every Kenyan.

The Constitutionprovides that no person can be deprived of his/her life intentionally, expect for theextents authorized by the constitution or other written law. The Constitution states that life begins at

conception.

The Children Act 8 of 2001provides the inherent right to life to children (Section 4) and puts

responsibility on government and family to ensure children survival right from the time of birth.

The Penal Code, Chapter 63,provides that anyone who: unlawfully or negligently does any act which

is, and which he knows or can reasonably believe to be, likely to spread the infection of any disease

dangerous to life (Section 186); commits unlawful acts or omits to act and causes the death of another

person (Section 202); of malice aforethought causes death of another person by an unlawful act or

omission is guilty of murder (Section 206); prevent a child from being born alive by any act or omission(Section 228); and administers poison to another which endangers or causes grievous harm (Section 236)

is guilty of an offence.


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should be done by female medical practitioner (Section 52). Advertising or sale of medicines, appliances

or articles to alleviate or cure venereal disease, disease affecting generative organs or sexual impotence

is prohibited.

The Children Act of 2001provides that children should be protected from sexual exploitation and use inprostitution, inducement or coercion to engage in any sexual activity, and exposure to obscene materials

(Section 15). Contravention of these provisions would predispose a child to risk of early pregnancy with

all the potential risks that it brings.

The Employment Act, 2006prohibits sexual harassment in employment. Thus employees working with

delivering mothers must not subject them to harassment.

The Sexual Offences Act 3 of 2006 makes provision for sexual offences, their definition, prevention and

the protection of all persons from harm from unlawful sexual acts (Preamble). It is also an offence for

any person to rape

(Section 3); to defile (Section 8); or sexually harass (Section 23) a child; and for any person with actual

knowledge that s/he infected with HIV or any other life threatening sexually transmitted disease

intentionally, knowingly and willfully infects another person (Section 26). These provisions applyequally to those working with delivering mothers


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2.4.2 Financing of Health Services

Funding for health facilities is key to improve health standards and to the population health and well-being. However,the level of funding in Kenya is still insufficient to ensure equitable access to basic and essential health services and

interventions, making adequacy and equity of resource mobilization and allocation for health important the principle of

financial protection, fundamental to equitable health financing, states that no one in need of health services should be

denied access due to inability to pay and that households livelihoods should not be threatened by the costs of health

care. According to EQUINET, progressive health care financing implies that contributions should be distributed

according to ability-to-pay and those with greater ability-to-pay should contribute a higher proportionof their income

than those with lower incomes. This cross-subsidies system (from the healthy to the ill and from the wealthy to the

poor) should be promoted in the overall health system. Fragmentation between and within individual financing

mechanisms should be reduced and mechanisms put in place to allow cross-subsidies across all financing mechanisms.

Individuals should not be prejudiced in their access to essential health care due to the location of their residence,

income or other factors. Government allocations are a critical way of offsetting disparities arising from other factors,

and should take these disparities into account when allocating resources across areas and levels of the health system

(EQUINET SC, 2007). National policies pay some attention to these issues. In Kenya, under Vision 2030

government pledges to provide resources to those who are excluded from health care because of financial reasons. It

further aims to implement a financing plan that involves the government, donors and other stakeholders.

In Kenya, various acts provide for funding of services, for example:

o The Public Health Act provides that expenses incurred by the municipal council in maintaining a person in ahospital or in a temporary place for the reception of the sick can be recovered from him/her after discharge from

the hospital (Section 3).

o The Children Act 8 of 2001 requires government to use the maximum available resources to achieve progressivelyfull realisation of the rights of the child (Section 3)


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Food Safety and Security: the right to food refers to rights for regular access to sufficient, nutritionally, adequateand culturally acceptable food for an active, healthy life (FAO, 2007). Articles 11(1) and (2) of the International

Covenant on Economic, Social and Cultural Rights recognize the fundamental right of every-one to be free fromhunger, and links this to achieving the right to health. The Convention on the Rights of the Child , Article 24(2)

(c), obliges states to combat disease and malnutrition, including within the framework of primary health care.

The government through the Ministry of Agriculture has a strategic Paper on food security whose primary

objective is to ensure that there is food security for all. The realisation of this objective has not been achieved as

has been clearly evident in recent times with the national famine that has gripped the country recently.

The lack of food or adequate nutrition is a direct negative factor to adequate health standards and needs to be addressed

by the Government. Expectant and delivering mothers as well as new mothers need special dietary concerns.

Promotion of Healthy Environment; Healthy environments include access to health promoting shelter, water,sanitation, working conditions and community environments. Socio-economic differentials in access to healthy

environments in Kenya are a determinant of inequalities in health, with particular disadvantage for poor

communities (EQUINET SC, 2007).

Housing: whereas the constitution has addressed the need for proper housing under article 43.1(c), the realization isyet to be achieved as demonstrated by the many slums located throughout the country and other poor housing

schemes nearby the towns and in semi arid regions whose residents live in deplorable shelters. A number of

legislations namely the Public Health Act (1-prevent erection or occupation of unhealthy buildings or unhealthy

sites, 2-prohibits causation of nuisance by persons on land or premises injurious or dangerous to health.

The Environment and Management act 8 of 1999 (right to clean environment), Protection of the right to health education. Not much in legislation apart from the HIV and Aids Prevention Act of

2006 which requires government to promote public awareness about causes modes of transmission consequences

f i d l f d h h h i i id d i l d


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2.5.1 Kenyan Practice

Maternal health remains a big challenge in much of sub-Saharan Africa, with maternal deaths estimates still as high as1000 deaths in 100,000 live births in some countries. In Kenya, maternal deaths are currently estimated at an average

of 488 per 100,000 live births (DHS 2008/9). In urban Kenya, one would expect the number of maternal deaths to be

lower given the existence of many well-equipped health facilities, but this is not necessarily the case. Research by

APHRC in informal settlements (slums) in Nairobi, Kenyas capital has shown that these areas have a maternal

mortality of 706 deaths per 100,000 live births, which is higher than the countrys average. That research further

revealed that nearly half of expectant women in slums deliver either at home, with the assistance of traditional birth

attendants or in unlicensed and unregulated health facilities that lack capacity to handle even minor obstetric

complications.

Government statistics on the status of maternal health care present a narrower picture of the entirety. The data on

antenatal care from the 2008-09 Kenya Demographic and Health Survey (KDHS) provide details on the type of service

provider, the number of antenatal visits made, the stage of pregnancy at the time of the first and last visits, and the

services and information provided during antenatal care, including whether tetanus toxoid was received. The results

indicate that 92 per cent of women in Kenya receive antenatal care from a medical professional, either from doctors(29 per cent), or nurses and midwives (63 per cent). A very small fraction, (less than one per cent) receives antenatal

care from traditional birth attendants, and 7 per cent do not receive any antenatal care at all. The 2008-09 data indicate

a rise since 2003 in medical antenatal care coverage. Trends in use of antenatal care show that the proportion of women

who had antenatal care from a trained medical provider for their most recent birth in the five years before the survey

rose slightly, from 88 per cent in 2003 to 92 per cent in the current survey. Moreover, there has been a shift away from

use of nurses and midwives (70 per cent in 2003 down to 63 per cent in 2008-09) towards doctors (18 per cent in 2003

and up to 29 per cent in 2008-09). In Kenya, less than half (47 per cent) of pregnant women make four or moreantenatal visits. Sixty per cent of urban women make four or more antenatal care visits, compared with less than half of

rural women (44 per cent). Moreover, most women do not receive antenatal care early in the pregnancy. Only 15 per

cent of women obtain antenatal care in the first trimester of pregnancy and only about half (52 per cent) receives care


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more likely than rural women to receive all the specified components of antenatal care. Similarly, women with more

education and those higher on the wealth index are more likely to receive more components of antenatal care than are

less educated and poorer women.

Forty-three per cent of births in Kenya are delivered in a health facility. Births to older women and births of higher

order are more likely to occur at home. Similarly, mothers in rural areas are more than twice as likely to deliver at

home compared with those in urban areas. The proportion of children born at home decreases as level of education and

wealth quintile of the mother are on the rise for example, 84 per cent of children whose mothers have no education are

born at home, compared with 27 per cent of those whose mothers have some secondary education. Similarly, children

whose mothers had more antenatal care visits during the pregnancy are less likely to deliver at home.

By comparison, a number of studies conducted by various organizations indicate that in nearly all informal settlements

in urban areas in Kenya no public facilities, such as health care facilities, have been established. This void has resulted

in many private providers setting up poor quality health care facilities lacking qualified personnel, equipment and

supplies to offer adequate services to people living in these settlements. APHRCs research in two slums in Nairobi

also demonstrates that most of those facilities, , lack the capacity in terms of qualified personnel, equipment and

supplies to handle even minor obstetric complications. Subsequently, private healthcare providers located within the

slums are not regulated by the government and many are illegal as they are not licensed.

While eclampsia (pregnancy-induced hypertension) is a life-threatening condition, a mere 14.3 per cent of the health

facilities were equipped to manage this complication at the time of the study. Hence, a functioning referral system,

which is vital to save lives in time of emergencies, is lacking in most facilities. Moreover, APHRC research shows that

about 10 per cent of births in slums are handled by traditional birth attendants (TBAs). These attendants lack skills to

handle delivery and Kenyas National Reproductive Health Policy has made it illegal for them to practice obstetrics.

The TBAs however feel that they are offering useful services especially to poor women who are unable to afford highhospital charges. The TBAs also argue that many women prefer them to nurses in public health facilities because the

nurses can have bad attitudes and be abusive towards the women. The mere fact that TBAs continue to receive clients

means that access to quality public health care especially by the poor is still a challenge


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3.0 TARGETED APPROACHES TO ACCELERATION PROGRESS AND MINIMIZEOPPORTUNITIES

Another driver category, for which there are important gaps, concerns the effect of a lack of accountability

interventions, such as legal redress and patient charters on the incidence of disrespect in childbirth. An in-depth review

of the literature on accountability mechanisms in middle and high income countries, such as patient charters and

provider professional regulatory mechanisms (e.g. licensure maintenance protocols) might yield useful insights,

although the generalizability of such mechanisms might be constrained by context specific health care, legal and

political factors. In 2006, the government through the Ministry of Health institutionalized the Charter of Patients

Rights, a policy measure to improve patient satisfaction.

3.1 Policy Level

Harmonize and Strengthen policies and lawsfor improving sexual and reproductive health delivery Develop a national action plan immediately to accelerate progress towards achievement of MDG Target 5B

(improve maternal heath care) within five years

Engage government sectors and civil society to mobilize and promote political will for development of supportivepolicy and legislation

Clarify the aspects within policy that require translation into law Disseminate information on the status of policies and laws pertaining to sexual and reproductive health, with a

view to accelerating progress

Introduce and implement targeted approaches to achieve universal access Ensure adequate financingof sexual and reproductive health care


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Review guidelines for integration into the curriculum Develop special programmes for managers to be trained in issues of supportive supervision Give attention to health workforce motivation Promote task shifting or task sharing according to available evidence Improve service deliveryby managing and integrating services Develop and implement innovative community outreach programmes Innovate (communicate, adapt, implement new technologies), for example through introduction of new practices

such as m-health (use of mobile phones for health) and new products for family planning including emergency

contraception

Monitor for successful implementation


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Disrespect and Abuse in Child Birth:

Non-Consented Care

Physical Abuse

Non-Dignified Care

Discrimination

Abandonment of Care

Detention in Facilities

Non-Confidential Care

Individual and CommunityNormalization of disrespect and abuse

during childbirth; lack of communityengagement and oversight; financialbarriers; lack of autonomy andempowerment

National Laws & Policies, HumanRights and EthicsLack of human rights, ethics principles innational policies; lack of enforcement ofnational laws & policies; lack of legalredress mechanisms

Service DeliveryLack of standards andleadership/supervision for respect andnon-abuse in childbirth; lack of

accountability mechanisms at care site

ProvidersProvider prejudice; provider distancingas a result of training; providerdemoralization related to weak healthsystems, shortages of humanresources & poor professionaldevelopment opportunities; providerstatus and respect.

Under utilization of

Skilled Birth Care

Cultural Birth

Preferences

Governance & LeadershipLack of leadership & governance forrespect and non-abuse inchildbirth

APPENDIX 1: POTENTIAL CONTRIBUTORS TO AND IMPACT OF DISRESPECT AND ABUSE IN CHILDBIRTH ON SKILLED CAREUTILIZATION

Lack of Financial

Success

Lack of Geographic

Access


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APPENDIX 2:INTERNATIONAL AND REGIONAL INSTRUMENTS AND THEIR RATIFICATION AND INCLUSION IN

DOMESTIC LAW

Instrument Health Related Clauses Kenya ratification and inclusion indomestic law

Implication to disrespect andabuse

InternationalCovenant onEconomic, Socialand Cultural Rights(1966)

Article 12: Recognises the right of everyone to enjoy thehighest attainable standard of physical and mental health. Itrequires states to: provide for the reduction of the stillbirth-rateand of infant mortality; and for the healthy development of thechild; improve all aspects of environmental and industrialhygiene; prevent, treat and control epidemic, endemic,occupational and other diseases; and create conditions whichwould assure access to all medical service and medicalattention in the event of sickness.

Ratified May 1972The Children Act 2001 gives every child aright to health and medical care, which isthe responsibility of parents andgovernment (Section 9).Environmental Management and Co-ordination Act 1999 gives every Kenyanthe right to a clean and healthy environmentand a duty to safeguard and enhance theenvironment (Section 3).

The Public Health Act Cap 242 empowersthe minister to regulate to prevent spread ofinfectious diseases, by medicalexamination, detention, vaccination,isolation and medical surveillance (Section71).

Socio-economic differentials inaccess to healthy environments inKenya are a determinant ofinequalities in health, with particulardisadvantages for poor communities.Constrained by poverty (inability toaccess medical services and poornutrition) exacerbates accessibility tomedical services in the face ofexposure to unhygienic situations.

Convention on theElimination of AllForms ofDiscriminationagainst Women1979

States shall take all appropriate measures to eliminatediscrimination against women in the field of health care inorder to ensure, on a basis of equality of men and women,access to health care services, including those related tofamily planning. Also states shall ensure to women appropriateservices in connection with pregnancy, confinement and the

post-natal period, granting free services where necessary aswell as adequate nutrition during pregnancy and lactation .

Ratified March 1984The Constitution prohibits discrimination ofany nature (Art. 27).

Public authorities and institutions areexpressly prohibited from treating anyperson in a discriminatory manner.The Kenya National Commission onHuman Rights has been at theforefront in addressing subtle cases

of discrimination reported to it throughits human rights complaints. Humanrights violations including physicaland verbal abuse and detention inhealth facilities for inability to pay stillexist.


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InternationalConvention on theElimination of allforms of RacialDiscrimination

1969

State parties undertake to prohibit and eliminate racial discrimination in allforms in the enjoyment of the right to public health, medical care, socialsecurity /services (Article 5).

Ratified 1972The Constitution prohibitsdiscrimination of any nature(Art. 27)and further specifically

provides under economic

and social rights (Art.43 (1),

the right to health care

services, including

reproductive health care.

Public authorities and institutions areexpressly prohibited from treating anyperson in a discriminatory manner.The Kenya National Commission onHuman Rights has been at theforefront in addressing subtle cases

of discrimination reported to it throughits human rights complaints. Humanrights violations including physicaland verbal abuse and detention inhealth facilities (increasing thealready high cost of health) forinability to pay still exist. Womencontinue to hold second class statusparticularly in as far as economicempowerment is concerned and as aresult continue to be unable to obtainaccess to social support and health.

The Convention onthe Rights of theChild -1989

Recognises the right of the child to enjoy the highest attainable standard ofhealth and to facilities for the treatment of illness and rehabilitation of health(Article 24.1). It requires state parties to: strive to ensure that no child isdeprived of his or her right to access to such health care services (Article24.1); and take measures to combat disease and malnutrition, throughprovision of adequately nutritious foods and clean drinking-water (Article24.2.c).Guarantees the right to the best attainable state of physical and mental health(Article 16) and requires state parties to take necessary measures to protectthe health of their people and ensure they receive medical attention when theyare sick (Article 16).Places restrictions on the enjoyment of certain rights in the interest of public

health (Article 11 and Article 12(2)).

Ratified July 1986The Children Act 2001provides that every childhas a right to health andmedical care, which is theresponsibility of bothparents and government(Section 9). It imposes aresponsibility ongovernment and the familyto ensure the survival anddevelopment of the child

(Section 4),Art. 53 of the Constitution

outlines almost all the rights

relating to children.

Insufficient funding for health hasmeant inadequate staffing and supplyof equipment and medical suppliesthereby adversely affectingservice delivery and henceattainment of the rights under theconvention and as a result high childmortality. Children below the age of 5continue to remain at high risk. InKenya child under one year mortalityrate is 52:29 death/1000 lives birthsmale, 55:03 deaths /1000 lives births,

female 49:49 deaths/1000 live birthsby 2011 January estimates - CIAWorld Factbook.


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African BanjulCharter on Humanand Peoples Rights

1986

Requires state parties to enact and implement laws to prohibit discriminationand harmful practices that endanger womens health (Article 2); respectwomens right to health (Article 14(1)); provide adequate, affordable andaccessible health services to women (Article 14 (2)); establish and strengthenpre-natal, delivery and post-natal health and nutrition services for pregnantand breast-feeding women (Article 66).

Programs have beenimplemented by thegovernment that aims toimprove the number ofhealth facilities and thusmake them more

accessible.

Access to health facilities, particularlyin rural areas remains limited at best.Even where the physical facilitiesmay be in place they are far drawnand poorly equipped. As a resultmaternal mortality rates remain high.

Protocol to theAfrican Charter onHuman and PeoplesRights on the rightsof Women in Africa1985 .Adopted on11th July 2003)

Requires member states to: protect womens reproductive rights by authorizingmedical abortion in cases of sexual assault, rape and incest (Article 14(2));take measures designed to protect human health against pollutants and water-borne diseases (Article 7); co-ordinate and harmonize general policies onhealth, sanitation and nutritional co-operation (Article 2(2) (e)); and work withinternational partners to eradicate preventable diseases and promote goodhealth on the continent (Article 3). The Executive Council must also co-ordinate and take decisions on policies in areas of common interest to themember states, including health.

Art. 26 (4) of theConstitution provides thescope within which abortionis allowed.

The ambiguity in the area as to whenabortion can occur subsists. As aresult specialized access to theservice where and when neededremains skewed and deaths resultingfrom botched and unprofessionalabortions continue with the numbersreaching alarming levels.

MillenniumDevelopment Goals(2000)

Adopt by world leaders in 2000 this goals are committed to reducing extremepoverty and setting out a series of time-bound targets amongst them- childHealth(MDG4) and Maternal Health (MDG5) with a deadline of 2015.

Goal 5 of the Millennium Development Goal targets to reduce by threequarters the maternal mortality rate between 1990 and 2015,MDG4 includes neonatal mortality aims at reducing the rate of infantmortality by 2/3 between 1995 and 2005.

Kenyas Vision 2030goals is to reduce the infantand mortality rate

In Kenya, Vision 2030 requiresgovernment to lower infant andmaternal mortality howeverrecent health trends indicate thatmaternal mortality is still highespecially in the rural areas whereaccess to health services are still achallenge.The factors causing high mortalityrates in Kenya include poverty, poor

policy implementation, resourceavailability and service deliverychallenges.

International

Conference on

Population and

DevelopmentCairo

Egypt 1994)

About 179 countries agreed inter alia that empowering women and meeting

people's needs for education and health, including reproductive health, are

necessary for both individual advancement and balanced development. The

conference adopted a 20-year Program of Action, which focused on providing

universal education; reducing infant, child and maternal mortality; and ensuring


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universal access to reproductive health care including family planning by 2015,

assisted childbirth and prevention of sexually transmitted infections including

HIV/AIDS. The fundamentals for population and development policies were

identified as advancing gender equality, eliminating violence against women

and ensuring women's ability to control their own fertility.

Maputo Plan of

Action (2004) (Plan

of Action on

Reproductive and

Sexual Health

Rights)

The framework on sexual and Reproductive Health Rights addresses the

reproductive health and rights challenges faced by Africa and calls for

strengthening the health sector by increasing resource allocation for health,

and to improve access to services. The framework advocates for

mainstreaming of gender issues into socio economic development programs

and SHR commodity in Kenya.

They Include the following objectives:

1. HIV/STI, Malaria and SHR services integrated into primary healthcare.

2. Strengthened community-based STI/HIV and SRHR services.3. FP repositioned as key strategy for attainment of MDGs.4. Youth friendly SRHR services positioned as a key strategy for youth

empowerment development and wellbeing.

5. Increased effort to reduce unsafe abortion6. Increased access to quality maternal and child services.7.

Resources for SRHR increased

8. SRH commodity security strategies for all SRH componentsenhanced

9. A monitoring, evaluation and coordination mechanism for the Plan ofthe Plan of Action established


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Abuja declaration

(2000)

Based on an earlier commitment The Harare Declaration on malariaPrevention and control, the Abuja declaration:

Is committed towards halving the malaria mortality for Africas people by 2010through implementing the strategies and actions.

Initiates actions at regional level to ensure implementation, monitoring andmanagement of Roll Back Malaria.

Initiates actions at the national level to provide resources to facilitaterealization of Roll Back Malaria Objectives.

Promotes working with partners in malaria affected countries towards statedtargets, ensuring the allocation of necessary resources from private and publicsectors and from non-governmental organizations.

Creates an enabling environment in our countries which will permit increasedparticipation of international partners in our malaria control actions.

The Children Act 2001gives every child a right tohealth and medical care,which is the responsibility ofparents and government(Section 9).

EnvironmentalManagement and Co-ordination Act 1999 givesevery Kenyan the right to aclean and healthyenvironment and a duty tosafeguard and enhance theenvironment (Section 3).The Public Health Act Cap

242 empowers the minister

to regulate, prevent spread

of infectious diseases, bymedical examination,

detention, vaccination,

isolation and medical

surveillance (Section 71).

Kenyas Vision 2030

sets goals to reduce the

infant and mortality rate.

Road map for

reduction ofmaternal and

neonatal mortality

2004 ratified by AU.

Ratified by AU Adoption of the National

Maternal and NewbornHealth (MNH) towards

implementation of the Road

map adopted by the Au.


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policy and governance landscape -maternal health

Documents