As we commemorate a decade of county governments at the devolution conference this year, our focus will be on how counties have implemented last-mile primary interventions that have significantly enhanced population health.
To demonstrate this, we take a dive into Kenya's journey in drastically lowering maternal mortality, eliminating malaria, cholera, and measles as public health problems by 2030, flattening the non-communicable diseases (NCDs) curve, and addressing neglected tropical diseases through four proven levers of change.
These four are political commitment and action, people-centered models of care, addressing social determinants of health, and precision public health premised on data science.
According to health survey and analysis data, the maternal mortality rate in Kenya has improved only marginally from 362 to 355 deaths per 100,000 live births from 2014 to 2019. While the country has seemingly stagnated, the story is different in some counties.
Turkana, for example, has reduced the maternal mortality rate by more than four times from 1,594 to 381 deaths per 100,000 live births. The county has achieved this remarkable fete through our first lever -political commitment, and action.
The county enacted the Community Health Service Act, which has led to the remuneration of community health promoters enabling them to provide basic health services right at home. Further, the enactment of the County Health Services and Administration Act 2021, will ring-fence health resources and enhance service delivery.
According to the Chief Officer for Health, Dr Gilchrist Lokoel, the county has doubled the health budget from Sh600 million to Sh1.2 billion, increased health facilities from 72 to 282, and health workers from 273 to 2,000, including increasing the number of doctors and specialists.
"The average distance from a health facility, while still not below the recommended 5km, has dropped significantly from 50km in 2013 to 15km today," he says.
The proportion of women delivering with skilled assistance has more than doubled from 22.8 per cent in 2014 to 52.6 per cent in 2022.
Moreover, Turkana, in partnership with Amref, has implemented the second lever of change, people-centered models of care. One such model, Kimormor (Turkana word for 'all together'), is a community outreach programme that connects the largely pastoralist communities to basic health and animal services.
This model has thus contributed to the county's effort to improve access to maternal health. The percentage of mothers attending at least four antenatal care visits in the last pregnancy has increased from 44 per cent to 57.7 per cent between 2014 and 2022.
This is, however, still below the national average of 66 per cent and therefore requires more effort to reduce. The county is now planning to fund this largely donor-dependent model with county resources.
A look at how to deal with malaria also demonstrates how people-centered approaches work. About 70 per cent of the population is at risk for malaria, including 13 million in endemic areas. Eradicating malaria is further complicated by global warming, which is changing current endemicity patterns and increasing the risk of transmissibility of the malaria parasite.
In view of this, Amref has worked with a number of counties in the endemic region to train and equip community health promoters to visit households where they screen and test people for malaria.
In fact, they treat non-severe cases of malaria at home and subsequently follow up with the people to ensure they are treated. So far, more than 1.1 million people have been treated. Homa Bay County is one such county that has seen notable improvement with 78 per cent of children suspected to have malaria seeking medical advice while 97.7 per cent of children with malaria being treated in 2022 up from 67 per cent and 89 per cent in 2014.
The third lever, which is addressing social determinants of health can be elucidated by Kenya's fight to flatten the rising burden of NCDs as they are likely to overwhelm the health systems and the economy if not addressed. According to health reports, NCDs are responsible for more than 50 per cent of in-patient hospital admissions and 39 per cent of all deaths annually.
Further, NCDs place a continuous social and economic strain on households, in view of their long-term management. Despite this, the management of NCDs is not adequately resourced. As such, we have to explore efficient models of care to flatten the NCDs curve. In addition to integrating NCDs management in primary health care, counties should enhance and leverage improved levels of education and livelihoods as they directly influence lifestyle, diets, and health-seeking practices.
Meru County, in collaboration with Amref, has integrated screening of cancer, hypertension, diabetes, and palliative care into primary health care delivered through trained and equipped community health promoters. This way, 156,965 people were screened for hypertension and diabetes, with 9,731 referrals. Further, the county has seen a 319 per cent increase in the uptake of palliative care services from 2019.
Lastly, and not by design, let us look at Neglected Tropical Diseases (NTDs). An estimated 25 million people in Kenya suffer from NTDs. The presence of NTDs is the hallmark of neglect and inequality in the health system. For counties to change the narrative, we prescribe the fourth pillar, precision public health, whereby, they must build robust systems to collect and use data to determine the most appropriate and impactful interventions to invest in limited resources - and more so on access, quality, and equity.
Vihiga County, with support from Amref, has utilised detailed granular mapping surveys and GIS data to target specific populations in endemic regions to address soil-transmitted intestinal worms and bilharzia. Through this initiative, over 630,000 people have been reached. Preliminary reports indicate a decline in the prevalence of both diseases signalling progress toward interrupting the transmission of these diseases.
We urge counties to adapt and scale up these levers of change as we aim to achieve Universal Health Coverage through primary health care. By applying these levers, counties will be able to deliver devolution's promise of delivering accessible, affordable, inclusive, and transformative health care to all Kenyans as an instrumental pillar for economic development.
As a country, we can apply such levers of change to deliver on big bets that will transform Kenya's population health by 2030, to achieve maternal deaths to below 100 deaths per 100,000 life births. Flatten and begin to reverse the NCDs curve (diabetes, high blood pressure, and mental ill health) and eradicate selected NTDs such as intestinal worms, bilharzia, and elephantiasis.
Dr Ndirangu is the Country Director, Amref Health Africa in Kenya
