reaching the poor in kenya: are there effective implementable strategies frederick mugisha, phd...

Reaching the poor in Kenya: are there effective implementable strategies

Frederick Mugisha, PhDAfrican Population & Health Research Center

Tuberculosis and Poverty: Are we doing enough? Bellagio Workshop 6th-8th December 2005

Clarification

Reaching the poor means at least 2 things;– Geographical targeting global resource distribution– Individual/household targeting delivery of

intervention to the patient The poor are in at least two categories

– Extremely poor people don’t even have a voice,– vulnerable people risk falling into extreme poverty– ?? For TB, do we need to focus on both groups or the

majority and easier to reach??


What are the issues here?In

terv

en

tion

s

Poor

&

Vu

lnera

ble

Effectively Delivery

Effectively identify them

Effectively reach them

Effectively Deliver?

?


How then do we define the poor & vulnerable

Money-metric, e.g. household income or expenditure to get a threshold – static concept & problems of applicability

Asset-based measures – may not capture the ability to pay

Vulnerability & livelihood measures – dynamic concept & focuses on ability for households to cope with shocks; offers the best choice


Examples from Kenya

Bursary scheme for secondary school Waivers at health facilities (hospital and

lower levels of health provision) Food for insure households affected by

HIV/AIDS


Bursary scheme for secondary schools

Has been in operation for over 15 years & underwent modification in 2005

Major target is the poor and the vulnerable, and the girl-child as an affirmative action

Government used to channel bursaries directly to schools, which was expected to be distributed according to financial need,


Bursary allocation procedure

Bursaries were allocated to schools in districts proportionately based on student enrollment only – whether the district was the richest or the school was boarding or day

No guidelines for identifying those in financial need, was left to the discretion of the head teacher – subjecting the system to abuse

Bursary was based in school & only meant for children enrolled in school – leaving transiting children from primary to secondary


Bursary improvements

Is now based at a constituency level – a much smaller area (at most 2 divisions) & linked to electoral process,

Established a constituency bursary committee of max 16 people with area MP (patron), Assistant education officer (secretary), councilor, NGO etc

Committee issues & receives applications, vets the applicants and ensures cheques are dispatched to schools


New Bursary Criteria

Orphan hood – max 50 scores Affirmative action (girl-10, boy-8, slum/

marginalized-5,special needs like handicapped-5) – max 20 scores

Displine/conduct in current or previous school, including primary – Max 10 scores

Academic performance within the school – max 20 scores


Waivers at health facilities

Like in many countries, waivers and exemptions established with cost-sharing in government health facilities

Waivers and exemption are for:-– under fives, readmitted patients, patients from

destitute homes, prisoners & unemployed persons; – Out-patient services of family planning, antenatal &

postnatal, & STDs;– All investigations, out-&in-patient services for

antenatal complications of pregnancy, tuberculosis (TB) and leprosy, and AIDS;


Implementing waiver & exemptions at Government health facilities in Kenya

Automatic exceptions (according to patient age or service) are applied uniformly, waivers for the poor are applied infrequently and inconsistently – subject to abuse

The screening occurs at the health facility, & the would be beneficiary are not aware of such waivers & exemptions – even at public meetings, the very poor are systematically unrepresented

Limited waivers are granted - health staff are reluctant to offer and publicize waivers due to the associated loss of revenue; and reimbursements from government are not that forthcoming


What do examples tell us in respect to tuberculosis control among the poor?

There are implementable strategies that work, but we are not doing enough, we can do more;

Many poor and vulnerable people are excluded, either they are not aware (systematically excluded from communication channels) or the screening process excludes them or the system is not objective enough and renders itself to manipulation and abuse


Can we reach the poor or it is a foregone conclusion?

Yes we can, let us recognize that there are poor, very poor and extremely poor in poor communities,

The biggest challenge will be to have a criteria that objectively identifies them so we can reach to them,

I bring to your attention an approach that uses what we know and what people perceive how the poor look like


Developing a simple tool to identify the poor for hospital waivers

The aim is to develop a simple tool with 5-10 objectively measurable attributes that would identify and classify the poor into “poor”, “very poor” and “extremely poor” households

In addition to identify 5-10 attributes common to children and women in these households,

Ultimately to apply the tool in screening both in the community and at health facility level


Method for developing the tool

Did 12 focus group discussions, 15 indepth interviews and 1072 household interviews in Busia district, western Kenya – the pilot district

These were distributed across urban, rural and semi-urban; male and female; and age groups

Question: Thinking of households in village X, are there household that you would consider extremely poor? What are characteristics are common to them?


Contrast of poor and extremely poor households

A poor household has a house, an extremely poor household has a grass thatched-leaking house

A poor household can afford to take children to a day school, an extremely poor household cannot

A poor household can expect to have at least a meal, an extremely poor household does not hope to eat even once

Children in a poor household have cloth, children in extremely poor households wear torn & dirty cloths


Final look of the tool

[A]ATTRIBUTE

[B]WEIGHT

[C]=[A] X [B]

Attribute 1

Attribute 2

Attribute 3

Attribute 4

Attribute 5

Attribute 6

TOTAL


Thoughts on tuberculosis control

Screening to be done in the community among those identified as poor – syndromic screening may suffice

Provision of vouchers to those identified may act as an incentive to the health workers, & will empower the poor to choose and demand for their rights

reaching the poor in kenya: are there effective implementable strategies frederick mugisha, phd...

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