Efforts have been made to increase awareness and availability of family planning services, with public facilities offering subsidized or free family planning commodities. Despite gaps in program efficiencies, there has been an emphasis on the importance of including family planning services under Kenya’s universal health coverage (UHC) program to address health disparities, reduce unintended pregnancies, and enhance women’s agency over their reproductive health.
Kenyan women and teenage girls across the country have, over the years, had a reduction in the unmet need for family planning. But it still remains relatively high due to limited knowledge of and access to family planning services and commodities, social norms, and commodity and service costs. According to the Kenya National Bureau of Statistics (KNBS) 2022 Kenya Demographic and Health Survey (KDHS), the national unmet need for family planning is 14%, which is down from the former rate of 35% in 1993. In regional comparison, Uganda’s need for family planning is at about 11%, and Rwanda is at 9%.
For Kenya, this is compounded in settings with a deep-set culture of early teenage marriages, gender-based violence, and polygamy, particularly in Narok, Samburu, Pokot, Kajiado, Homabay, Marsabit, Mandera, and Isiolo counties. These communities are mostly rural and each share similarities such as higher levels of teenage pregnancy, poverty, low levels of education, and the consistent climate-related disruptions of essential family services health services due to drought, floods, and conflict.
In essence, the initial idea of having many children was to address the higher risk of losing children to diseases and natural disasters such as droughts, famines, wars, to sustain parents in their old age, and for the retention of family wealth maintaining land, livestock, and farming crops. With the modern strain on resources and relatively improved living conditions, family sizes have gradually become reduced, planned, and healthier across the country. The total fertility ratenow stands at about 3.2 children per household. This may be attributed to modern medicine through family planning options that have increased the overall contraceptive prevalence, disease prevention, better practices of midwifery, and areduction in child mortality through immunization and regular clinical care.
In parts of the country like Wajir, where polygamy is still practiced, girls who marry often do not have accurate family planning information and may be unable to access family planning services even when they want them. Many of these teens are exposed to pregnancies early in their lives, increasing the risk to seek for emergency contraceptive methods. In relatively urban centers, sexually active young girls who cannot conveniently access family planning services and commodities may get pregnant and seek abortion services, which are illegal countrywide except in circumstances where the mother’s life is at risk.
Through advocacy and joint efforts by the Kenyan Ministries of Health and Education, development partners, and community/faith-based organizations, the awareness and availability of family planning have been comparativelyimproved nationwide. A number of public facilities offer subsidized and/or free family planning commodities including male and female condoms, IUDs, coils, emergency and daily birth control pills, injectables, implants, pregnancy testing, and counseling services. The male partner’s involvement gap in matters of family planning is still quite wide, but the Ministry of Health has developed innovative ways of reducing it. For example, couples that attend clinical visits together are prioritized, and they can be advised together on collective family planning choices.
Alongside this, other innovative methods that have increased the uptake of family planning have reduced adverse results that come from the absence of family planning. There are existing occasional interruptions in the supply chain that often make family planning commodities and services scarce, which often leads to increased prices. Amidst a very strained economy and a large unemployed youth population, the instinct to survive may overshadow the need for family planning services. A number of reported cases indicates that teenage girls and women regularly miss scheduled sessions for family planning services and counseling. Studies express that, given the economy, individuals would rather spend the little cash they make on family sustenance for the moment than worry about visiting medical centers. This is a general feeling across the country, and in 2017, the Cabinet Secretary for Health corroborated a World Bank report that recently estimated that approximately 1.5 million Kenyans are driven into poverty annually due to out-of-pocket health expenditures.
Under the ‘Big 4 Agenda’ to achieve universal healthcare (UHC), in December 2018, Kenyan President Uhuru Kenyatta launched the Afya Care UHC program as a pilot phase covering 4 out of 47 counties (Kisumu, Nyeri, Isiolo, and Machakos) incited by high incidences of maternal mortality and morbidity, (with Kisumu and Isiolo being 2 of 15 counties that account for about 98.7% of the country’s total maternal mortality), among other reasons. This excluded counties like the capital, Nairobi, which hosts a large unemployed youthful population, especially in informal settlements like Kibera, Korogocho, Mukuru, and Mathare, also contributing to a significant percentage of service seekers for family planning services and commodities, unsafe abortions, and post-abortion care. Amongst Nairobi’s 5.5 million estimated population according to the World Population Review, about 70% are hosted in informal settlements characterized by acute shortages of critical health services like family planning. This leads to a ballooning population with reduced health indices.
The pilot phase of the UHC program ‘Afya Care’ was met with excitement and anticipation. Kenyans of all walks were expected to be able to save their stretched incomes for sustenance while at the same time, be able to access affordable, accessible, and quality health services, including access to family planning services and commodities upon demand. The prospects of the program delivered a glimmer of hope for those who sought convenient access to free and/or subsidized options of the services and commodities available in public health facilities when needed. Some experts argued that financing the adopted UHC model would be a steep hill to climb and as a country we needed to further benchmark methods from other countries with relatively better health-for-all models (e.g., Rwanda) to ensure systems are in order for ‘Afya Care’ first.
For the UHC pilot phase, the government added funds and health commodities from the national government authorities, which involved the Kenya Medical Supplies Authority, (KEMSA). This phase was envisioned to ensure, foremost, inclusion in access to healthcare, quality, equitable, and affordable access to health care, and to later implement informed best practices on learning and program design for the planned national rollout after a year. With an initial plan to cover 100% of the Kenyan citizenry by 2022, covering the scope of essential health services, critical services that are indispensable for the health and social well-being of citizens. Family planning services fall under essential health services identified by the Ministry of Health in Kenya, which also include antenatal care, delivery care, postnatal care, immunization, water, sanitation, hygiene, prevention and treatment of HIV/AIDS, and malaria prevention and treatment.
The program’s policy structure held a principal person per covered household who were able to present their national identification cards, and after registration, were entitled to a health card that enabled them, their spouse, and their dependents to access free services in public facilities. The program purposefully barred residents of other counties from accessing these same health privileges. Adolescents and teenage girls and boys were recognized as dependents, and anyone over the age of 18 was treated as an independent legible cardholder.
As some experts had projected, the outcomes of the pilot phase reported a number of gaps that still needed to be filled, from the rushed startup process that also turned out to be flawed, favored corruption practices (discussed at a 2018 official conference on Kenya’s UHC program), and missed opportunities capturing demographic data on inclusion, disability-friendly services, and health inequalities.
The program also seemed to overlap in service delivery with other programs such as the Linda Mama program, which was tailored exclusively for expectant and new mothers since 2013. Additionally, the two programs had differences in eligibility needs and benefits, for example, the Linda Mama program was only available to pregnant women, while the UHC pilot program was for all residents of the four piloted counties.
The Linda Mama program also covered a wider range of maternity services than the UHC pilot program, but there was some duplication of services and resources. This led to several newly expectant women receiving antenatal care services from both programs, making it hard to report outcomes on either initiative. Essentially, the public did not have a pre-understanding of how the UHC program was to work, that Linda Mama was to be a path to UHC. What they understood it as was ‘free healthcare services’. As such, any other country and program interventions that look to pick up similar health models like the Kenyan UHC in their context should be able to have a starting point by benchmarking from the reported loopholes in ‘Afya Care’, and explaining the details in a language that the public would understand.
Given the financing design of the program , the quarterly disbursement of funds from the national government was often delayed and insufficient. Often, the supply of essential commodities and services was compromised. One of the most notable gaps was the constant absence of essential contraceptives and family planning commodities and services across the pilot counties due to these delays. The supply shortages included male and female condoms, birth control pills and injectables, IUDs, coils, pregnancy testing, and STI and HIV testing and counseling. With the absence of the services and commodities, the few that were available were distributed with bias, and sometimes corruption delivered them to private pharmacies.
Despite these gaps, the short-term recorded benefits of pooling family planning services and commodities under the ‘Afya Care’package cannot be ignored. Even though the implementation period was short, records show that from the baseline survey in 2017, notable improvements were captured including the expansion and operationalization of maternity, oncology, and Intensive Care Unit centers in Kisumu and Nyeri, procurement and installation of critical medical equipment, ambulances, and employment of personnel, and the collective aversion of loss of lives through focused specialized services.
The United Nations, WHO, shared the standard doctor-to-patient ratio of 1:1000 is actually at 1:16000, and the suggested nurse-to-patient ratio of 1:50 stands at about 1:1000. By inferring these statistics, a number of family planning service seekers will miss out on critical services and commodities. Limited funding has bedeviled the health sector for a long time, despite commitments including the Abuja Declaration and the African Charter for Human and People’s Rights.
As UHC is pegged on the provision of quality and accessible services to all while concurrently offering financial protection, governments that seek to achieve UHC must maximize the utilization of resources to deliver the health for all mandate. Health budgets should be able to address the minimum percentage of the total budget, for example, according to the Abuja declaration that suggests 15% of the overall budget should address health. Additionally, it is important to lobby for specific budget vote heads, for example, family planning can have a dedicated budget instead of generally lumping allocations under reproductive health. The budgets can also be further sub-divided into activities, interventions, and sub-programs. Finally, for the success of UHC, accountability is key. Each sub-program should be subjected to a systematic reporting structure that allows straightforward accountability and auditing by the relevant bodies, as well as citizens in their civic duties. This citizenry can only be sustained effectively if family planning is regarded as a human right, and made accessible, affordable, and quality under the UHC umbrella.
By enabling inclusive, equal, affordable, quality, and accessible family planning services within the UHC umbrella, the Ministry of Health will not only achieve the vision of the Alma Ata Declaration for primary healthcare, but will also enable citizens to access these services without economic burden. This will eventually lead to a reduction in the burden of unintended pregnancy, maternal mortality, and increased agency for women and girls to take charge of their bodily autonomy.