With gag rule and suspension of funding, future remains bleak for urban poor woman

Esther Achieng with a client. Dwindling funding to affect Kenyan health sector. Picture:Kevin Ouma
Esther Achieng with a client. Dwindling funding to affect Kenyan health sector. Picture:Kevin Ouma

When it comes to accessing sexual and reproductive health services one of the biggest misconceptions is that urban poor women are closer to hospitals and many other institutions that offer such services.

“This is a misnomer, the reality is that the urban poor do not necessarily have better access to services based on the mere fact that they are close to them,” explains Dr Gikama Kinyanjui, a leading gynaecologist and obstetrician in Nakuru County.

Kinyanjui notes that statistics continue to show the “urban advantage” does not exist and urban poor women are worse off than their rural counterparts who have to travel for many kilometres to access the nearest clinic.

This comes within a context of the US government cutting back KSh2 billion over graft claims at the Ministry of Health in Afya House.

“This is likely to affect health service delivery to Kenyans seeking services at public facilities in the long term,” says Evelyn Samba, Kenya Country Director, Deutsche Stiftung Weltbevölkerung (DSW).

She adds: “Owing to the fact that most frontline public health service provision is executed by county governments, the effect of this suspension is not likely to be very severe and immediate.”

Samba further explains that the suspension, if it goes on for an extended period, is likely to slow down the implementation of policy which will directly delay the execution of emerging and current interventions.

“Service delivery at national referral facilities such as Kenyatta National Hospital, managed by the national government, may suffer,” she expounds.

According to DSW, activities that directly strengthen county health systems, surveillance and service delivery are exempt from the suspension.

“Having said that, we call on President Uhuru Kenyatta to move with speed to discuss and resolve all issues raised by The United States Ambassador to Kenya to ensure swift return to full US government support for healthcare service delivery in Kenya,” Samba urges.

She notes: “The longer this suspension stays in place, the more likely that Kenyans seeking healthcare services at public health facilities will feel the effects of the suspension.”

This suspension comes in the heels of the recent reinstatement of the global gag rule by the Donald Trump administration which is feared will have far reaching consequences for the urban poor woman, worsening an already bad situation.

By reinstating the gag rule, Trump has essentially returned a ban on the United States funding of any international agency that provides any kind of abortion services including counselling or advice to women on abortion.

Affected organizations include the United Nations Population Fund (UNFPA) which promotes family planning in many developing countries.

Family planning is crucial to improving maternal health in general and in reducing maternal deaths specifically.

Reproductive health experts such as Samba have extensively documented the impact of the 2001-2009 gag rule in Kenya whereby in just four years, at least 9,000 Kenyans had lost access to crucial health services.

This was as a result of the closure of eight reproductive health services facilities operated by non-profit organizations due to lack of funding.

Within this context, the urban advantage will only exist in theory. Despite urban poor women being close to services, this has not necessarily led to urban inclusion.

As a matter of fact, reports among women working in the four major flower farms in Naivasha show that this is a highly marginalized cohort where massive exclusion exists.

These reports further show that there has been too much focus on the urban poor in Nairobi slums and little focus on the urban poor in satellite towns such as Naivasha, Thika and Narok where reproductive health services are needed in equal measure.

Trends on maternal mortality nationally have been on a steady decline. According to the Kenya Demographic and Health Survey (KDHS) of 2014, maternal deaths now stand at an estimated 360 deaths in every 100,000 live births.

This is down from the 2008-2009 KDHS report which showed that maternal mortality stood at 488 deaths for every 100,000 live births.

However, for the urban poor such as those working in Naivasha flower farms, the numbers remain alarmingly high.

Kinyanjui confirms that the burden of maternal mortality is heaviest among the urban poor where maternal deaths are estimated to be as high as 700 deaths in every 100,000 live births.

With dwindling funding for family planning and other reproductive health services, the situation is dire for these women.

There are two issues at play. First, if Kenya is unable to close the gap for unmet need for contraceptives there will be consequences of unwanted and unplanned for pregnancies as well as abortions that will be majorly unsafe.

Unmet need for family planning had dropped from 25 percent in 2008-2009 to 18 percent. These are women who would like to use family planning methods but do not have access to them.

“The percentages are much higher among urban poor who, for various reasons, still lack access to quality health care,” says Kinyanjui.

He adds: “In the absence of sufficient family planning for all women who need them, this will consequently lead to unwanted pregnancies which will also lead to unsafe abortions.”

When structures that hold sexual and reproductive health services together begin to collapse, it is the urban poor who feel the impact the most.

In 2007, at the height of the 2001-2009 gag rule an estimated 360,000 abortions were induced in that year alone.

In that same year, a group of non-governmental organizations working in reproductive health and rights released a report which revealed that at least 40 percent of maternal deaths were a direct consequence of unsafe abortion.

Needless to say, a majority of them were urban poor women who are constantly in close proximity to backstreet clinics and quacks who offer abortion services using life threatening methods.

According to KDHS 2014 nearly a quarter of Kenyan women will have started child bearing by age 20 and the urban poor woman who is more likely to have started child bearing by age 20.

However, among the urban poor women, be it those in the slums of Nairobi or the neighbouring Nakuru County, the number of women who will have had a child by the age of 20 will be twice that of the national level.

This goes to confirm that half of the urban poor women start child bearing by the age of 20 years.

The younger a woman is when she starts to have children, the higher are risks and complications she is likely to encounter during child birth. Young urban poor women are highly vulnerable especially in light of statistics that show at least 60 percent of maternal deaths occur in women aged 20 to 29 years.

This backdrop and dwindling donor funding is a wakeup call to both national and county governments to prioritise sexual and reproductive health services.

In the absence of increased domestic funding, urban poor women are facing even tougher times ahead.

Domestic driven interventions should focus on both the demand as well as the supply side.

The demand side interventions should remove barriers that hamper utilization of available services such as the attitude of health providers as well as the quality of services and products on offer.

The supply side should address the entire system and infrastructures around the health system. Such challenges could be in relation to human resources where frequent labour unrest can lead to a continued disruption of crucial services.

This can be achieved through partnerships between the government, private sector as well as non-governmental organizations.

These engagements will not only address existing challenges that continue to solidify the exclusion of the urban poor woman, but will lead to solutions that are not only practical, but sustainable.

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