Literature Review: Assessing the major health disparities in Kenya and the gap for its health system to reach health equality

Name: Yile Xu

Word Count: 2380

Introduction

The issue of health inequality and low coverage of public health services constantly torments people in developing countries including Kenya. Despite of the considerable improvement on public health conditions over the last decades, geographical and socio-economic inequalities in health are persisted in almost all sub-Saharan African countries. People in poverty not only have worse health condition but also suffer from lacking access to needed care services compared to wealthier population groups (Ilinca, et al. 2019). According to Amartya Sen’s definition of human development, having sufficient access to high quality public health care is an important aspect of social freedom for every human, which is part of the overall freedom we are seeking to improve. Therefore, besides economic growth or increase in GDP, almost all the countries in the world have treated achieving health equality as one of their most important development goals. This literature review will mainly analyze the major burdens on Kenya’s health system with their determinants and the different aspects of health inequality in context in order to provide insights for proposing improvement solutions.

Major public health issues in Kenya and their determinants

Both under-5 mortality rate and maternal mortality rate remain high in Kenya with significant variations among different regions because of the regional unequal accessibility to health care. Although the under-5 mortality rate in Kenya decreased significantly for about a half, it failed to meet the Millennium Development Goal of a two-thirds reduction in under-5 mortality rate between 1990 and 2015. In 2019, Kenya’s Under-5 mortality rate reached 51.3 per 1000, but estimated by its current annual rate of reduction, it is unlikely for Kenya to reach the 2030 Sustainable Development Goal (SDG) target of 25 deaths/1000 live births (Marshall, et al. 2016). Maternal mortality fell from 315 deaths per 100000 in 1990 to 257 deaths per 100 000 in 2016, but the level of improvement is heterogeneous at subnational level (Achoki, et al. 2019). Using data from nationally representative Demographic and Health Surveys, Emily C Keats and her colleagues conducted multivariable spatial analysis to investigate the determinants of under-five mortality rate. It is shown that variations of under-5 mortality rate in different region can be attributed to several main determinant factors including maternal literacy, household wealth, childhood immunization, maternity services, and maternal and infant nutrition.

Communicable or infectious diseases such as HIV, tuberculosis, and malaria constantly cause the major burden on Kenya’s public health system. Moreover, urbanization and concentration of settlements in rural areas lead to even higher burden of these communicable diseases although the mortality rate declined since 2000s (Iyer HS, et al. 2020). Kenya is among countries with highest rates of HIV/AIDS in the world. The overall mortality trends increased between 1990 and 2006, but decreased between 2006 and 2016. However, HIV/AIDS-specific mortality rates in young men have continued to increase since 2006. Low levels of knowledge about sexual behaviors, disempowerment of young women to make decisions about sexual behavior, and use of alcohol and drugs together contribute to higher rates of HIV/AIDS mortality in younger age groups (Achoki, et al. 2019). People in Kenya still stay vulnerable in disposition of malaria as malaria treatment and prevention interventions are distributed unevenly for different regions. The poorest population in Kenya still suffer from the least accessibility to malaria treatment. According to a study conducted in the poorest areas of four malaria endemic districts, about 40 percent of individuals self-treated using shop-bought drugs and 42 percent who visited a formal health facility reported not having enough money to pay for treatment, and having to adopt coping strategies including borrowing money and getting treatment on credit in order to access care. Drug and staff shortages are also commonly existing problems in local area (Chuma et al. 2010).

Although compared to communicable diseases, noncommunicable diseases or chronicle diseases such as cancers, cardiovascular disease, and cerebrovascular disease take up a relatively smaller proportion of burden on public health system, the burden from noncommunicable diseases in recent years increased because of urbanization and change in people’s lifestyle. Based on The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) conducted across the 47 counties of Kenya, population’s accessibility to health care stays limited. Take preventive care services like blood pressure checks and hypertensive diagnoses and treatment for example, more than half the population (56%) had never checked their blood pressure. In addition, within those who had been diagnosed previously as hypertensive, only 22% were on treatment (Achoki, et al. 2019).

Examine health inequality from three perspectives: affordability, availability, and geographical accessibility

The above health issue analysis shows that health inequality, the variation of health care services received by population with different socioeconomical state, is the major hindrance for Kenya to alleviate its overall health burdens and improve health state, so it is extremely important for Kenya to improve its health equality. Health equality is accompanied by increase in equitable access to health services and equitable access can be defined in 3 components: affordability, availability, and geographical accessibility (Iyer HS, et al. 2020). There are three major types of health services including outpatient care, inpatient care, and preventive and promotive care. The overall accessibility to these three types of health care services varies significantly among different populations or regions in Kenya. Therefore, to get a systematic view of the unequal access to health care services characterized by lacking affordability, availability, and geographical accessibility, we should separately study and analyze the gap for Kenya to fulfill each important perspective.

The variation in affordability of health care for Kenyans is the major determinant of the overall disparities in health care utilization. In a study conducted by Ilinca S, concentration curves and corrected concentration indexes are used to measure socio-economic inequality in care use, while the horizontal inequity indexes are used as measure of inequity in care utilization for three types of care services: outpatient care, inpatient care and preventive and promotive care. The results proved that significant inequality and inequity in access of all types of care services which primarily favor richer population group are driven by differences in living standards and educational achievements. Affordability of medicine for people in low-income settlements is estimated based on the retailing price and the lowest average wage per day. Assuming a 100% disposable income, it takes 0.03 to 1.33 days’ wages for a lowest paid government employee to pay for selected single generic medicines. However, innovator brands are 13.8 times more expensive than generic brands. In addition, caused by loose regulations and low availability, retail medicine prices in the low-income settlements are found to be generally higher than the corresponding international reference prices and the prices for selected medicines vary among different regions. The lowest priced generics and innovator brands are, on average, sold at 2.9 and 32.6 times the median international reference prices of corresponding medicines. These inconsistencies negatively impact the affordability of healthcare (Ongarora, et al. 2019). Besides unreasonable high medicine prices, health facility user fees also place burden on the affordability of health care. Although the 10/20 policy in 2004 replaced user fees for different health facilities by a flat registration fee of 10 and 20 KES, the Public Expenditure Tracking Survey of 2012 still found that only 45% of facilities complied with this policy and user fees continued to take up the majority of facilities’ operating budgets (Ilinca, et al. 2019).

Besides affordability, the regional availability of health care services including drug and vaccination storage, health care workforce, and life-saving commodities varies significantly in Kenya. Based on an the availability study on a basket of 15 medicines and 45 public facilities, none of the 45 facilities stocked captopril and the average availability for the basket of medicines was 43%, which is considered as quite low. Because of the low availability of medicines in the public health facilities, low-income populations in Kenya have to travel further to more expensive private health facilities where they pay out-of-pocket for health care (Ongarora, et al. 2019). Moreover, Kenya’s health workforce has been constantly inadequate to meet population needs since 1990. According to a geospatial analysis that mapped health workforce density in different counties in Kenya, significant regional disparities are revealed that only 10 of 47 counties meet the WHO minimum density threshold of 22.8 workers per 10000. Since overall the availability of health work force measured by work-force density is highly correlated with the service delivery and health outcomes, the disparities of insufficient health care negatively impact Kenyon’s health system (Emily, et al. 2018). The availability of important commodities for preventive care like sexual and reproductive health commodities, essential for child and maternal mortality decline is also found quite low in Kenya. The overall availability of SRHC in Kenyan public facilities is less than 50% and stock-outs commonly exist in all facilities (Ooms, et al. 2018).

The impact of variations in geographical accessibility to health care facilities has been actively examined by different geospatial models. In order to quantify the impact of geographical accessibility on the uptake of preventive healthcare, some researchers developed a geospatial model based on mobile phone data. A measure called radius of gyrations for travel patterns or mobility was created based on two spatial scales: the county level and the individual cell tower level, and travel time to the nearest health facility was calculated using a cost–distance algorithm. The result shows that long travel times to health facilities are strongly correlated with increased mobility in geographically isolated areas, and in areas with equal physical access to healthcare, high mobility predicts which regions are lacking preventive care (Wesolowski, et al. 2015). Another geocoded inventory examined the geographical access of emergency hospital services for population in 48 sub-Saharan Africa countries. Geographical coordinates of each facilities were obtained from Google Earth while population mappings at 1 km2 spatial resolution were derived from the WorldPop database for 2015. Researchers also assembled road network data from Google Map Maker Project and OpenStreetMap using ArcMap. The proportion of population located less than 2 hour travel time to the nearest hospital was estimated based on a cost distance algorithm which incorporated both location of public hospitals and the travel impedance surface. The result shows 29% population are located more than 2 hour travel time from the nearest emergency hospital services (Paul, et al. 2018). Both studies emphasize that the variations in travel time to facilities is a key driver for unequal health uptake and improvement in geographical accessibility to health care facility is essential for health equality.

However, there is a tradeoff between health system’s efficiency and geographical equity, which has to be balanced when making policy decisions regarding health facility allocations. Allocating health facilities in urban areas with more concentrated population will improve health system’s efficiency because of the economies of scale. However, preferential deployment of services in urban area will exacerbate urban rural disparities and health inequality. In order to achieve more equitable geographical accessibility for the whole country, some efficiency has to be sacrificed. For the policy makers to balance health equity and efficiency, a Geo-PSA model using Access Mod 5 algorithm was developed based on both descriptive characteristics data and geospatial data including the location of care facilities and geographical feature maps which are collected from administrative government databases and satellite imagery. Travel time to the nearest health facility was chosen as a measure of equity while population density became a measure of efficiency. This model can be constantly applied overtime to evaluate the trade-offs between equity and efficiency and monitor progress towards equitable access of services, which can assist the optimization of public facilities allocation. This analytical model also enables policy-makers to identify locations with inefficient resource allocation (e.g. with low population density but short travel times) and respond to these inefficiencies based on their resources (Emily, et al. 2018).

Conclusion

This literature review mainly analyzes the current burden on Kenya’s public health system, and the disparities and inequalities of accessibility to health services from its three major perspective: affordability, availability, and geographical accessibility. The current burdens on Kenya are consisted of the relative high under-5 mortality rate, high maternal mortality rate, and high mortality caused by both communicable and noncommunicable diseases. Moreover, disparities of all these health issues and corresponding care services in different regions of Kenya place challenges on the alleviation policy. Therefore, in order to improve Kenya’s public health coverage, it is essential to address these health disparities by optimizing the allocation of healthcare resources and promoting the equitable access to health services. So I then mainly analyzed Kenya’s gap for achieving equitable access from three perspectives: affordability, availability, and geographical accessibility.

Public health system can be considered as a complex adaptive system because there are many social, economic or environmental features associated with its smooth operation, like people’s income level, the availability and affordability of essential health care, and the geographical accessibility to health facilities. Disparities of these features will lead to health issues in corresponding regions and undermine the whole health system. In addition, after new policy is formulated to improve the whole system, it’s nearly impossible to predict or measure the increasing healthcare received by each individual in the country. But it’s feasible to predict some broader system properties——those metrics for assessing health care level like the under-5 mortality rate. In the development process for greater health equality, new methods or technologies will be adopted, so the health system will restructure inherently and become more complex, moving away from equilibrium.

All the sources provide insightful analysis for Kenya’s health system disparities based on various data science methods including the geospatial analysis using mobile phone data and satellite images, and propose relevant solutions for public health care improvement. Nevertheless, most researchers never had a chance to implement their proposed actions on local and assess whether that makes a change for alleviating health issues, which is considered as a gap that need to be addressed in further research. Another issue needs to be considered is that some geospatial analysis for people in poverty only relied on mobile phones to collect data. Although it is cost-effective to collect mobile phone data and develop model based on that, people in real low-income settlement may not have a mobile phone, which will lead to unrepresentative samples. The central research question for my investigation into a human development process is how to improve the people’s equitable access to Kenya’s public health services in order to address the major health disparities and inequalities in Kenya.

Reference

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