The Commission on Smart Global Health Policy

In Mombassa, Kenya HIV prevalence for female sex workers is 31 % and condom use remains extremely low among women in Coast province. Commissioners visited a commercial sex worker drop-in center to learn about the most HIV-at-risk populations in Kenya and hear their stories. Commissioners heard from peer educators who use their knowledge of HIV prevention and family planning to counsel sex workers and others to encourage healthier behaviors.

 “The strategic location of the port city of Mombasa, which serves as the gateway to commerce in East and Central Africa, also contributes to HIV transmission. Major transport routes in Kenya and neighbouring countries are dotted with FSWs while the tourism industry, which is the backbone of the province’s economy, attracts motleys of small business operators such as curio sellers, beach boys, tuk-tuk and taxi drivers, matatu crews and boda-boda cyclists – all of whom have disposable incomes. The thriving tourism industry, which attracts local, regional and international visitors and the presence of trucker drivers provide a perfect environment for commercial sex work.” – APHIA II Baseline Behavioral Monitoring Survey Report, 2007 (download PDF).

Listen to Daughtie, Anne and Fuad tell their stories of empowerment, leadership, and the change they are having on their communities.

For more information, please read Janet Fleischman’s recent blog post on Women’s Health and HIV/AIDS in Kenya: http://www.smartglobalhealth.org/blog/entry/family-planning-and-hiv-aids-in-kenya/

This blog marks the first installation of a six part series that will go behind the scenes into the CSIS Commission on Smart Global Health Policy’s August trip to Kenya, and the short documentary filmed there.  This first segment is an introduction to the trip and its objectives, narrated by Jennifer Cooke, director of the CSIS Africa Program. The main objectives of the trip were:

• To understand the impact of U.S. assistance
• To explore opportunities for better integration of U.S. programs
• To see how maternal and child health is improving in some parts of Kenya and to evaluate prospects for scaling up programs
• To study how Kenya and the United States can work together to create sustainable and effective programs

Before leaving for Kenya, we had the chance to interview Representative Keith Ellison [D-MN] on his thoughts and his plans to use Twitter to describe his experiences firsthand. Dr. Helene Gayle and Admiral William Fallon wrote a welcome letter to the delegation as part of the briefing materials for the trip. Later, Dr. Gayle wrote detailed personal accounts from Kenya on the CARE travel blog. We also produced a trip FAQ, and Katherine Bliss, Senior Fellow with the Global Health Policy Center, wrote a detailed article titled, “Kenya: The Big Picture on Health” that provides further background on the history of the Kenyan health system, financing, donor issues, and challenges.

As we move through the six parts of the trip documentary we hope you will enjoy these blogs and the experience of the Commission’s tour.

To watch the complete documentary and submit feedback, visit:  http://www.smartglobalhealth.org/documentary

With all the troubling political news coming out of Kenya these days, it’s important to highlight some promising initiatives that are under way in the arena of women’s health, often driven by civil society groups or international NGOs in collaboration with the government.  One area where such initiatives are getting some traction involves the bi-directional integration of family planning/reproductive health with HIV/AIDS services.  Indeed, the new approaches toward broader integration hold the promise of helping to address both the country’s HIV/AIDS crisis and women’s reproductive health needs, including addressing the huge unmet need for family planning.

The importance of this approach is starkly revealed in the recently published Kenya AIDS Indicator Survey (KAIS), produced by the Kenyan government with technical and financial support from the U.S. government.  The report found that women were more likely to be HIV-infected (8.4%) than men (5.4%), and that young women were 4 times more likely to be infected than boys their age. Among women of reproductive age (15-49), the report found that 70.5% wanted to delay pregnancy for at least two years or did not want a child, but less than half reported using modern contraception. The situation is particularly critical among HIV-infected women – 66.8% reported wanting to delay pregnancy for at least two years, yet just over 40% of these women used modern contraception.  On top of all this, the percentage of Kenyans who know their HIV status remains low throughout the country.

On a recent trip to Kenya, I visited a number of health clinics in Coast Province, many supported by the AIDS Population and Health Integrated Assistance program (APHIA II), funded by USAID and PEPFAR, where Family Health International leads a consortium. These clinics are working to expand the entry points for access to ensure that wherever women enter the health system, they are able to receive the broader services they need.  This means, for example, that a woman entering a Comprehensive Care Center (CCC) at Malindi District Hospital for her HIV/AIDS treatment services, will also have access to information about family planning and access to a range of contraceptive methods, as well as screening for cervical cancer –- a critical problem for HIV-infected women – post rape care, and treatment for sexually transmitted infections.  At the same time, women seeking services at the family planning or antenatal clinics will be given information about HIV testing and prevention of mother-to-child transmission (PMTCT), and offered on-site tests.  Similarly, young women visiting the youth friendly clinic at the hospital, or the youth clinic in Mombasa run by Family Health Options Kenya, are offered information about the range of HIV and reproductive health services.

These kinds of integrated programs represent critical ways to expand women’s access to both HIV and reproductive health information and services.  Yet expanding these services and increasing the numbers of Kenyans who know their HIV status is only part of what needs to be done. In addition to addressing the significant human and financial resources required to roll out and sustain these services, there is also a need to go beyond the numbers and identify the barriers that women and girls face in accessing services in the first place.  In a context where women are often marginalized economically, find themselves married or pregnant as teenagers, and face risks of gender-based violence, HIV programs must be encouraged to develop innovative ways to address these issues in a more comprehensive and integrated environment.

This report marks the culmination of nine months of deliberation by the Commission — a group formed to develop actionable recommendations for a long-term U.S. strategic approach to global health.

We have not answered all the questions that emerged, nor have we devised perfect solutions. But we believe we have put forward a compelling, concrete, and pragmatic plan of action.

Watch the video from this event

Download the Commission Report.

The video below provides a snapshot of our visit.  Through the shouts of children, navigation of drainage ditches and interviews with commissioners, you get a sense of challenges in the overcrowded slum and its many possibilities:

The CSIS/CARE delegation started its trip to Kenya with a trip to Carolina for Kibera (CFK), an international non-governmental organization based in one of the world’s largest slums. In addition to the program’s community-based medical clinic and youth leadership programs, the Tabitha Clinic serves as a major data collection point for CDC surveillance. Twice a month community health workers visit resident’s homes to collect routine health data on mobile devices. The CDC’s International Emerging Infections Program provides key reporting information for emerging infectious diseases and offers technical support to Kenya’s public health infrastructure. This data is essential to efficiently link available services and resources to the biggest burdens on the community.  Kibera residents suffer disproportionately from HIV/AIDS, malaria, tuberculosis, diarrheal diseases, respiratory infections and unintentional injuries.

The CSIS Commission on Smart Global Health seeks fresh, new approaches to global health policy. Realizing that a wealth of expertise resides in front-line global health professionals, volunteers, and students, the Commission has launched a contest to attract innovative ideas that work.

Authors of the best responses are eligible for $1,000 in scholarships or prizes and publication in the Commission's final report.

Entrants need only answer one question:

What is the most important thing the U.S. can do to improve global health over the next 15 years?

Enter the contest now and tell your friends and colleagues about this opportunity to shape the future of global health.

Keith Ellison, Smart Global Health commissioner and representative of Minnesota’s fifth district, came to CSIS Thursday morning to provide reflections on the Commission’s trip to Kenya. While covering issues from governance to maternal health to the state of the Dadaab refugee camps, Ellison called Kenya a great case study for smart global health policy as an arrow in the quiver to reach out to the rest of the world.
Ellison praised the tremendous U.S. effort in Kenya and called for a move from the idea of a world power donor and its patron to the idea of an equal partnership. He highlighted the very productive cooperation between the Centers for Disease Control and the Kenyan government on malaria, as well as the positive impact of the President’s Emergency Plan for AIDS Relief.

The sharpest challenge going forward is governance for a country in which the two major political parties, who have ruled in uneasy compromise since the 2007 election, duplicate state functions. Progress is difficult with one minister for hospitals and another for public health, said Ellison, describing the irrational portfolios that result from political stalemate.
Parliamentary politics are also interfering with the passage of appropriate gender-based violence legislation, Ellison said.

He reported great progress in reducing mother-to-child transmission of HIV but then told of a town of AIDS orphans and the women struggling to care for them.
Ellison visited the Ifo refugee camp at Dadaab, which is filled far past capacity by Somalis and others from Kenya’s north. He found many incredible people in Dadaab, working to reduce HIV transmission, improve nutrition, and train midwives.

Ellison repeatedly emphasized the need for sound global health policy. “It spreads good will,” he said. “It builds communities. It provides opportunities for partnership. It’s the right thing to do.”

Special Thanks to Seth Gannon for authoring this summary.

Nyanza Visit, August 11

On Day 2 of its three day visit to Kenya the CARE/CSIS delegation divided in two, with one group led by Helene Gayle and including Congressman Keith Ellison, heading north to Nyanza Province in northwestern Kenya. Nyanza is one of Kenya’s poorest areas with 63% of the population living on less than $1 a day. The province has the highest HIV prevalence rate in Kenya (14%), a significant burden of malarial disease and among the lowest life expectancies in the country – according to the director of the district hospital, age 43 for women and 37 for men. Household economies are largely supported by subsistence farming and fishing along the shores of Lake Victoria. However, Nyanza has been hard-hit by Kenya’s current drought, with both maize and sorghum harvests considerably constrained, posing further nutritional challenges at the household level.

After a pre-dawn departure from Nairobi, the delegation arrived in Kisumu City (Nyanza’s regional hub) by air and immediately headed 90 minutes north by road to Siaya District, one of Nyanza’s most impoverished areas and the home of President Obama’s father’s family. As the roads became increasingly narrow, rugged and pot-marked, eventually turning into dusty dirt tracks, the delegation came face to face with the reality of rural poverty and the challenges of providing accessible, basic health services in a region where electricity and clean water are luxuries.

First stop – the Tiwani Health. The group is greeted by the “Obama Nannies” a union of women roughly ages 40 to 60 caring for their orphaned grandchildren as well as other kids whose parent(s) have died of AIDS. The women, almost all illiterate, speak with dignity and conviction about their challenges in raising a generation of kids without parents, the struggle to secure some small source of external income to cover school fees and other expenses and the fact that people in the village are still dying of AIDS. CARE supports a group savings and loan program that has provided the women with both financial and psycho-social support and President Obama is also said to have made a donation to the program following his visit to the region as senator in 2005. Indeed, when the delegation arrives, it is granted by a chorus of women signing “Obama is great” in the local Dholuo dialect.

The group moves on to visit the local clinic which receives direct support from PEPFAR through CDC for HIV care and treatment. Both clinic staff and patients say ARVs are readily available (PEPFAR supported and at no-cost) and the clinic’s doctor makes a real effort to integrate family planning, VCT and PMTCT services. However, despite a strong effort to improve HIV programming, services for malaria treatment, the most acute cause of illness in the province, lag and there are frequent stock-outs of the anti-malarial drug, Coartem. More fundamentally, the clinic has no source of clean running water and no means to easily refer a pregnant woman with complications to more advanced care.

The delegation takes a walk through the village and stops to see two families in their homes – one a grandmother caring for five kids ages four to thirteen . The grandmother is in her forties, but looks much older. She supports herself through money earned via participation in the CARE group savings and loan program which has also replaced her thatched roof dwelling with a more substantial structure. A small patch of maize grows in an adjoining plot and chickens roam among the visitors. Despite the fact that this household lives less than a 10 minute walk from the local clinic, the thirteen year-old grand-daughter, born HIV positive, has already developed drug resistance to her first line ARVs. Her access to second line drugs seems uncertain.

Next stop – the Bar Olengo Dispensary, a further 20 minute drive down a dirt track. This is a “front line” facility in the Kenyan medical system, operating at a more rudimentary level than the just-visited Tiwani Clinic. For example, HIV testing is offered once a week instead of everyday. The dispensary is run by inspiring, dedicated Kenyan staff with a clear commitment to patient service. Painted on the wall of the clinic waiting room is a patient bill of rights and fee schedule detailing the clinic’s commitment to serving the community.

Karen Meacham, Deputy Director of the CSIS Global Health Policy Center, shares her photos from the recent Commission Delegation to Kenya.

As a Commissioner on the CSIS Commission on Smart Global Health Policy, I participated in last month's visit to Kenya. Our purpose was to observe how US investments in health are being implemented and to gather ideas to improve program integration and maximize impact in Kenya, a key US development assistance partner.

During our three-day visit, we met with officials from USAID, CDC, PEPFAR, the Kenyan Ministry of Health, and nongovernmental and community-based organizations. Most importantly, we met with the beneficiaries of US Government assistance. It's impossible to comprehensively assess the effectiveness of US assistance to Kenya based on such a short visit, so this is only a "snapshot" of my thoughts, but it draws upon my 25 years of work in HIV in Africa.

Key Successes

Since the 1980s, the United States has provided financial, technical, and research support to Kenya that has contributed to the reduction in HIV incidence and prevalence in the country. Current PEPFAR assistance of about $500 million annually makes Kenya one of the largest beneficiaries of US foreign aid.

PEPFAR supports the provision of antiretroviral therapy to 190,000 people, nearly two-thirds of those who are known to need treatment. One successful program in Eldoret, a collaboration between US and local institutions, has placed 90,000 on treatment. However, US funding supports much more than antiretroviral therapy. It also contributes wrap-around services, purchases commodities, strengthens technical cooperation, and rehabilitates health infrastructure.

US support for Kenya's response to HIV and AIDS is increasingly integrated. With sustainability a key objective, many programs are addressing the broader health and life needs of communities. The CSIS delegation visited the USAID-funded AIDS, Population, and Health Integrated Assistance (APHIA II) program in Coast Province, an excellent example of service integration. APHIA II, managed by Family Health International, provides integrated services for HIV/AIDS, sexually transmitted infections, maternal and child health, family planning, TB, and malaria. The program also coordinates provision of food supplements to disadvantaged people in HIV-affected communities. An additional striking element of this program is its extensive and highly engaged network of community-based peer educators who are reaching out to populations most at risk of HIV infection. The ROADS project, also supported by USAID, is another example of an integrated health development program. ROADS partners with both the private sector and communities to develop sustainable income-generating activities.

Challenges to Kenya's response to HIV

Many Kenyan stakeholders we spoke to listed important challenges Kenya faces in making its HIV/AIDS as effective as possible. For example, the country's two health ministries (Public Health and Sanitation and Medical Services), whose creation resulted from a power-sharing agreement between the country's president and prime minister, are seen by stakeholders at all levels as costly and dysfunctional. Critics also say the procurement system is broken, corrupt, and ineffective, and that it contributes to commodity shortages and an underspent government health allocation. Further, politically motivated expansion of district boundaries has made decentralized planning and health service delivery unwieldy.

Another impediment is stigma, one that we in the HIV world have been combating since the beginning of the epidemic. Kenyan national policies hinder implementation of programs to reach injecting drug users, sex workers, men who have sex with men, and victims of gender-based violence. Kenyan policies prohibit needle exchange and methadone treatment, despite the known effectiveness of these harm-reduction programs and their global acceptance. Gender-based violence continues to be a major public health problem, and the 2008 post-election violence escalated the issue.

Enhancing Kenya's HIV Response

My view is we must scale up the response to the epidemic in Kenya even further. Prevention is still the best medicine, so we must make more effort to engage key populations who are at greatest risk of contracting HIV, including individuals whose participation in the healthcare system may be impeded by stigma. Currently, an estimated 110,000 people living with HIV need antiretroviral therapy, and this number will grow without a more robust prevention effort. Increasing demand for antiretroviral therapy, a pervasive treatment-prevention gap, costly yet necessary second-line therapies, and recent research that indicates HIV-positive individuals should start treatment earlier in their disease progression, all contribute to Kenya's "HIV treatment mortgage." Because antiretroviral therapy is a lifetime commitment, the treatment mortgage is certain to become more costly.

Increased integration of health services with other development interventions is another crucial component of a heightened response. After all, what good is antiretroviral therapy to a person if she is unable to feed herself and her family? US-supported programs that integrate services and strengthen health systems need to be evaluated and scaled up to ensure that the health and development needs of Kenyans are approached comprehensively.

The United States has developed a partnership framework with Kenya to guide future HIV/AIDS assistance. Because of Kenya's remarkable technical capacity and leadership potential, I am optimistic that this partnership will succeed. With heightened commitment from both the international community and the Kenyan government, continued strong funding support, and soundly designed and implemented evidence-based programs and policies, Kenya's response to the epidemic can become a model for other countries.

Jennifer Cooke, Director, CSIS Africa Program, shares her first set of photos from Dadaab, Kenya traveling with Representative Keith Ellison [D-MN].

Over the past few days we’ve learned a lot, visited various sites, dividing into three groups going to communities and through urban areas.
When reflecting on visits to countries like Kenya I’m always impressed and encouraged by the enthusiasm of the people I’ve met along the way. In the case of the recent Kenya Learning Tours trip, it gave me great hope to witness health workers, mothers, people with HIV and youth express their commitment to solve health problems and work to overcome extreme poverty. Their names, faces and powerful stories will always be with me to drive my work.

As co-chair of the CSIS Commission on Smart Global Health Policy with Admiral Bill Fallon, we hosted this trip to Kenya to learn and bring back messages to U.S. policy makers on global health solutions. Much can be drawn from Kenya to be applied more broadly as we look to enhance awareness and commitment to health issues around the world. We are seeing improvements but we aren’t where we should be. Clearly, there’s no quick nor easy fix to get there.

The good news is we know the kinds of things that make health systems work – from procurement of medicines to training health workers to good policies that make efforts sustainable. And, as more evidence-based data is collected and analyzed, it will help drive priorities. Moving forward, as we look to solve health problems and increase access to health services, it’s important to not solely think about the technical interventions. Donor integration and coordination is also extremely critical. Increased flexibility of investments will be a major driver of success. Ultimately, our goal is to allow governments and communities to use this platform to take on more of an ownership role and make it sustainable. The bottom line is that we need to get this strategy right and efforts should not be about political advantage but rather on the health and well-being of the people, like the one’s I’ve met in Kenya and in so many other developing countries I’ve visited over the years.

To read more please visit CARE’s blog with additional “notes from the field.”

There were a couple visits that really left a strong impression on me and others in the delegation. One was to a CARE program once visited by President Obama when he was a senator. The program is called Tego Od Dayo or Strengthening the House of Nanny. It supports more than 1,000 women to help care for some 3,191 AIDS orphans and children orphaned by other circumstances. One woman, Anastasia Akinyi Otieno, said her son was killed during post-election violence in Nairobi last year and she took in his twin daughters as a result. The project helps support this grandmother's small cereal and vegetable business through access to credit. Using modest earnings from her hard work, she provides for her family. Anastasia named her two dogs Obama and Michelle, evidence of how much she appreciates the support.

AMPATH is widely recognized as one of the largest and most effective responses to the HIV pandemic in Sub-Saharan Africa. Which is why Commissioner Mike Merson and Karen Meachem were quite surprised to learn that "AMPATH doesn't actually exist." Contrary to popular opinion, AMPATH is not an NGO. There are no AMPATH employees. Rather, AMPATH is a name that symbolizes a partnership between Moi Teaching and Referral Hospital (Kenyan Ministry of Health), Moi University School of Medicine (Kenyan Ministry of Education), and a consortium of North American Institutions led by Indiana University. 

What form will the US-Kenyan partnership on health take in the coming years? Will it be one in which the U.S. stays very deeply engaged over many years, while the Kenyan government takes on greater ownership of health programs, ensuring long-term sustainability? That is a macro question we will be pondering during and after this trip. There is no immediate answer, and much hope, but there are several important issues to consider, including the state of the overall bilateral relationship.

The United States has made a very big play the past several years in regard to health in Kenya. The major driver is the President's Emergency Plan for AIDS Relief (PEPFAR). Of the 300,000 people on life-sustaining therapy today in Kenya, the U.S. supports 190,000 of them. Expenditure this year on HIV/AIDS programs is vast, $534 million. Kenya joins with South Africa and Nigeria as among the three top countries for U.S. health investments in the past five years. It is a global priority where much is at stake for the United States and Kenya.

The CSIS Commission’s August 10-12 visit to Kenya has been a valuable experience, by introducing -- in real time and concrete detail -- many of the major issues surrounding the promotion of health in a developing country. We were able to engage with U.S. and Kenyan government officials at different levels, along with several U.S. implementing organizations and independent Kenyan groups.  We could see U.S. funds at work in both urban and rural settings, in Nairobi, on the Mombasa coast, in western Nyanza, and in Eldoret in the Rift Valley.  As co-chair of the CSIS Commission on Smart Global Health Policy, I am deeply grateful to the many individuals who generously gave of their time to make the visit a success. The trip will certainly help inform the Commission’s aim to formulate recommendations on a long-term U.S. strategic approach to global health.

Who would have thought that the biggest slum in Africa is also the crucible for some of the best health metrics studies on the planet?

The slum is a section of Nairobi called Kibera, compassionately called an "informal settlement" that defies population enumeration and has somewhere between 600,000 and 2 million people compressed in less than 60 hectares of land. It is an oppressively dense amalgam of rusting corrugated metal, tattered cardboard, rivulets of raw sewage, and mountains of randomly strewn garbage. If it were only a huge compost heap anywhere else it would be condemned. The major qualifier is that this heap is not inanimate. It crawls with hundreds of thousands of people, traversing ant-farm like narrow corridors carved by human steps through ages of uncontained refuse and decay.

International humanitarian organization CARE helped organize the CSIS Commission on Smart Global Health Policy's visit to Kenya. Check out some of the great pictures they took on the trip.

Images copyright © 2009 CARE/Evelyn Hockstein or CARE/Allen Clinton. Used with permission.

Question: Kenya was the site for early family planning successes in sub-Saharan Africa.  A once steep fertility decline has stalled at still-high levels (about 5 children per woman).  Without progress in this realm, the fight for child survival, education, women’s health, economic growth, and political stability remains overly daunting.  How does Kenya get back on track and how can the US help? – Rich Cincotta

Response: Rich, thank you for your feedback. You are right: In previous decades, the U.S. government invested quite successfully in family planning programs in Kenya and saw significant results. Fertility declines have leveled out, however, and there is renewed concern that not enough has been done in family planning. While on the ground this week, we saw much evidence of new activity on this front.

Family planning will need to be a strong part of an integrated health strategy. There are many capable Kenyan partners who are already working on integrated programs. We saw in the Coast Province’s APHIA II (AIDS, Population, and Health Integrated Assistance Program) increased efforts by Family Health International and partners to introduce family planning programs in combination with HIV/AIDS programs.

An important Demographic and Health Survey for Kenya, completed in 2008, is due to be released at the end of September or early October. The survey will contain critical new data and will become a significant point of reference, particularly for the Commission.  

Please tell us more about your family planning work in Kenya and why you think progress has stalled.

Dr. Michael Merson and I left Nairobi yesterday to visit the AMPATH (Academic Model for Prevention and Treatment of HIV/AIDS) program in Eldoret. It's an impressive program and we had a great time!

Inspired by Dr. Joe Mamlin and launched with support from Indiana University (IU), AMPATH is driven by a unique partnership between the Moi Teaching and Referral Hospital, Moi University School of Medicine, and the Kenya Ministry of Health. Though it has tremendous outside support, the work program is Kenyan owned and Kenyan run.

AMPATH leads an aggressive approach to HIV treatment with Kenyan health workers going door to door, village to village collecting data on hand held devices. The aim is comprehensive testing and counseling to reduce total viral load in the region; they serve 90,000 people in their catchment area and aim to reach all 2 million. This decentralized work is complimented by the significant 'central nervous system' that is the referral hospital and Moi University working together. These institutions hold clinics, a pharmacy, a mother and baby facility, and serve as a hub for an exceptional electronic case management system that holds field data from their 90,000 patients scattered across the Rift Valley Province.

Care and treatment is the fundamental starting point for AMPATH, and they will receive a $60M USAID grant to prevent and treat HIV/AIDS between 2007 and 2012.