CHWs, Community health worker, Contraceptives, Development, Family planning, Fertility rate, Gag rule, IPPF, KMET, Maternal health, MDGs, Millicent Odhiambo, Monica Ogutu, MSK, Obama, President Obama, Public Private Partnership, Reproductive health, USAID, Western Kenya, Wish list
For Willikista Ongere, a neighborly visit means more than just catching up on the latest gossip. Recently, as the 30-year-old resident of Kisumu’s Manyatta slum area chatted with her neighbor Millicent Odhiambo, the talk turned to things medical.
As Odhiambo extended her hand, Ongere bent over to peer at her upper arm where two thin rods were inserted just under her skin. The rods contain a hormonal contraception called Jadelle, which prevents pregnancy. Odhiambo, a 31-year-old widowed mother of 4, had the Jadelle inserted free of charge at a Kisumu Medical and Educational Trust (KMET) clinic three days earlier.
Willikista was there to see if Odhiambo’s insertion site was healing well. She is a community health worker (CHW) with KMET, an NGO that promotes reproductive health among the rural poor in Western Kenya. Ongere is also at the leading edge of a national trend to increase access to family planning information and resources in Kenya, due in part to a healthy policy decision made thousands of miles away.
On January 23, 2009, just 3 days after his inauguration, US President Barack Obama rescinded the Mexico City Policy, also called the Global Gag Rule (GGR). And Kenya’s Reproductive health community heaved a sigh of relief. For more than three decades, USAID had been the biggest family planning donor to Kenya. But in 1984, then President Ronald Reagan enacted the GGR, which stipulated that to qualify for US government funding, foreign NGOs had to certify that they would not perform or promote abortion, or even mention the word.
President Clinton dropped the policy in 1993, but it was reinstated by President George Bush in 2001. Marie Stopes Kenya (MSK) and Family Health Options Kenya (FHOK) the country’s leading reproductive health care providers, refused to comply with its terms. The International Planned Parenthood Federation (IPPF), affiliated with FHOK, disagreed with its terms too. As a result, FHOK lost 58 percent of its budget through direct cuts from the US government and indirect cuts from IPPF. MSK lost 40 percent of its operating budget.
When he rescinded the Gag Rule, President Obama condemned what he called a “stale and fruitless debate” about the government’s role in facilitating abortions. Rather, he said governments should “work together to reduce the number of women seeking abortions by reducing unintended pregnancies, and providing care and support for women who do carry their child to term.” Kenyan reproductive health services say that’s exactly what they were trying to do. They joined a worldwide chorus of service providers who claimed the gag rule was a clear case of US foreign aid policy getting needlessly entangled in abortion politics.
“We do not offer abortion services. But we lost the funding nevertheless because we offer post-abortion care” said Mr Muraguri Muchira from FHOK. But President Obama’s move unblocked the flow of family planning aid money, which will help restart programs in Kenya. Overnight, administrators and doctors in Kenyan family planning circles launched plans to double their efforts, following nearly a decade of reduced funding. “Immediately after the announcement by President Obama, I got 40 phone calls from reproductive health service providers,” says Monica Ogutu, KMET’s executive director. Ogutu describes a sense of excitement and high hopes among those providers.
“The lifting of the GGR means there will be higher access to family planning supplies. It will also push policy in Kenya; the service providers on the ground can now fearlessly share the data they have collected over the years with the Government,” explained Ogutu. Reproductive health care and access to family planning have been critical concerns for Kenya. Millennium Development Goals 1, 4 and 5 are on: poverty and child mortality reduction and the improvement of maternal health respectively. These goals are directly tied to proper population growth management.
At the core of a larger strategy for reproductive health care provision is an aggressive community-based family planning approach. In communities plagued with high HIV/AIDS prevalence, extreme poverty, illiteracy, unemployment, high birth rates and contraceptive prevalence rates of as low as 14%, neighborhood-based family planning service providers like Willikista are considered a godsend.
Apart from Millicent Odhiambo, Willikista visits nine other women weekly, who all live in her neighborhood. Of these, six are married, and three more are widowed like Odhiambo. Four of her clients use either oral contraceptive pills or condoms. Apart from needing contraceptives, the other five women are also HIV-positive. Of those HIV positive women, one had a tubal ligation performed at the New Nyanza General Provincial Hospital. She also uses condoms. The other four use condoms exclusively.
KMET supplies Ongere with cartons of condoms and oral contraceptives which she distributes to her clients. The women can drop by her house or send her a text message for new supplies. CHWs like Ongere can greatly increase access to family planning within their communities, and ease the load at local clinics. “Most health facilities are referral hospitals. The queues are extremely long. They cannot prioritize family planning provision because the medical cases are more urgent.”
“We found that most people seeking these services would turn back and go home after waiting endlessly at a health facility for a simple family planning procedure. The next thing they know, they are pregnant,” offers Mr. George Ogumu from MSK. KMET has 180 CHWs while MSK has 300 CHWs. This figure includes their Community Based Distributors who distribute contraceptives to private practitioners but do not do home visits.
FHOK has 507 CHWs, but they only offer HIV care. Clients must come to the FHOK clinics to receive contraceptives. “The GGR stripped us off our source of contraceptives so there were none for the CHWs to distribute anyway”, explains FHOK’s Muchira.
During a recent visit to the Marie Stopes head office in Nairobi on May 18th, staffers revealed that USAID officials had visited them just days earlier, to assess what they called their ‘family planning wish list’. They said this visit was the clearest indication, since the announcement by President Obama, that the ‘funds tide’ was turning in their favor.
MSK’s “wish list” includes scaling up of outreach programs that offer long term family planning in rural areas, increasing ties with traditional mid-wives providing them with support and supplies to expand their scope of reach, and aggressive contraceptive social marketing to make contraceptives more readily available to clients.
“Another dynamic that will be impacted by the bigger cash flow is the Public Private Partnership Program PPP,” says Ogutu. “During the GGR, a lot of organizations were sidelined. With its lifting, this opens up possibilities for collaborations. When we have a lot of the team players working together, we will accelerate government’s efforts to reach that rural woman.”
“Today, when there is a van going in some direction to deliver contraceptives, no one cares whether the van belongs to GoK, KMET or MSK. We just fill the fan with whatever supplies we have and we indiscriminately distribute these supplies to both public and private health facilities,” Ogutu said.
This bigger cash flow in family planning could not have come at a better time for Kenya. The period between 1984 and 1998 saw a major uptake of contraceptives. That led to a substantial decline in the total fertility rate-TFR-from 8.1 to 4.7 in 1988. Data from the 2003 KDHS however, showed a slight increase in TFR to 4.9.
The contraceptive prevalence rate (CPR) leveled off in 2003, at 39%. Meanwhile, 20% of all births in Kenya are unwanted while 25% of the births are mistimed. Among adolescents 47% births are unintended. Finally, the survey found that 24% of people who wanted to access contraceptives could not get them.
Family planning advocates insist that the government needs to ensure contraceptive security. The National Contraceptive Commodities Security Strategy 2007-2012 defines this as the, “uninterrupted and affordable supply of quality contraceptives to all people that need them, whenever and wherever they need them”.
“We need to think of long-term sustainability of family planning commodities. What happens if the GGR is reinstituted again?” asks Ogutu. Meanwhile, CHWs like Willikista Ongere will continue to knock on doors to ask their neighbors if they need information or supplies to help them manage their family size. “Most women here are desperate for family planning services. The men say it is up to them to prevent a pregnancy; others oppose contraceptives outright. A lot of women then opt to take contraceptives secretly. KMET’s course was not too time consuming but I have seen it make a big difference,” said Ongere.
Note: This article was published on July 11, 2009 by the Daily Nation as a News Feature. The article is sadly not available online so I cannot link to it. However, I will try and acquire the pdf document and link it.
Also, I once again extend my gratitude to Ms. Rachel Jones my extremely supportive editor whom I’ve previously mentioned in a different post. She’s a rock, oh, and a rockstar!