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YOURFREECOPY

Friday 1st August 2014

Health of the nation

II BUSINESS DAILY | Friday August 1, 2014

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Chief Executive Officer Linus Gitahi Acting Editorial Director Tom Mshindi

Managing Editor Ochieng’ Rapuro Consulting Editor Jenny Luesby

Production Editor Bobby Kiama

Senior Graphic Designer Gennevieve Nahinga

Graphic Designers Chrispus Bargorett, Millicent Wachira

Photo Editor Joan Pereruan Illustrations Joseph Barasa

Invest in healthca≥e to ≥eap f≥uits of devolution Health is always the first casualty in times of change and disorganisation. With this edition of The Edge, we have sought to gauge the health of our nation, digging into is-sues of devolution, commercial development, best prac-tice, and systemic weaknesses.We have looked at the country’s health profile, the gains and the areas where health is actually deteriorating.What has emerged are three recurrent themes. The first is the need for better general understanding of health is-sues, with poor eating choices now driving the majority of deaths in Kenya, not through lack of quantity, but through individual decisions to eat one food over another.Government and private sector moves to fortify the foods we love - maize flour, sugar and cooking oil - are an effort to replace the vital nutrients we aren’t eating, but for all our frustrations with the inadequacy of health resources, the single biggest health revolution that can occur in Kenya would be a shift in eating habits - taking us off the spot of being one of the most malnourished nations in the world.A second recurrent theme is our shortage of medical staff, afflicting the management of every function within our health facilities and giving pause for thought on ways and means of driving the growth of our medical personnel even harder and faster.Finally, our investigation into the scope and challenges for Kenyan health care has highlighted the often poor use of the health care resources we have, revealing areas where reforms have led to more health for the same spend, and also the very many areas where we are getting less than we should be, because we lack the systems and records to deliver efficiently.Overall, globally, as in Kenya, healthcare resources are finite. But Kenya has tighter budgetary constraints than many nations over the globe. What is clear from this report is that despite the underfunding, large strides have been taken in alleviating child hospital admissions, extending life expectancy, and caring for the terminally ill, in all those areas where resources are focused tightly on the most pro-ductive ways of getting the furthest.Our challenge, in health, is one of spending what we can raise to deliver the most impact, for the most Kenyans.

OCHIENG’ RAPURO JENNY LUESBYMANAGING EDITOR CONSULTING EDITOR

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innovations

AFRICA 5 TOP

Ea≥ly to bed and ea≥ly to ≥ise, makes a man healthy, wealthy

and wise” Benjamin F≥anklin

Physical fitness is not only one of the most impo≥tant keys to

a healthy body, it is the basis of dynamic and c≥eative intellectual

activity.” John F. Kennedy

The g≥eatest wealth is Health.” Unknown

Just because you’≥e not sick doesn’t mean you’≥e healthy”

~Autho≥ Unknown

Those who think they have no time fo≥ exe≥cise will soone≥ o≥ late≥ have to find time fo≥

illness.” ~Edwa≥d Stanley

Life expectancy would g≥ow by

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the edge: Health of the nation

CONTENTS In this issue4 Quality care for all: A nation’s dream remains

elusive and complex An acute shortage of qualified health workers, rising cost of treatment

and poor quality drugs leaves millions in poor and failing health 8 Malnutrition: Kenya’s silent killer Micronutrient deficiency mainly linked to poor diet has become Kenya’s

biggest killer standing way above most other developing nations 10 Take up of insurance grows but profits still remain

elusive While the number of Kenyans with medical cover has more than doubled

in the past five years, profitability remains rare among the underwriters 12 Short on resources, long on needs: Healthcare

faces hurdle of impact investing Getting the most benefit for the cost is particularly vital in Kenya, where

total expenditure on healthcare has been on the decline 14 Quality and access unattained 15 months into

devolved healthcare Fifteen months into devolution, much of Kenya’s health sector operations

remain in shambles thanks to the unending power games between na-tional and county governments on the description of devolved services, negligible budgetary allocation, and understaffing.

IIIFriday August 1, 2014 | BUSINESS DAILY

Distribution of total health expenditure in Kenyan private sector (2005/2006)

Private clinics

NFP hospitals

Private for profit hospitals

Private pharmacies

NFP health centres and dispensaries

Community health workers

4.35Bn

3.73Bn

9.73Bn

1.86Bn

621Mn

414Mn

Source :NHA 2005/

45.8bn 85bn 31.6bn 47.4bn

2011/2012 2012/2013 2013/2014 2014/2015

Health budget: Allocation in health budget (Sh)

Rural-urban comparison on family planning, maternal and child health

Women ages 15-49 who report their most recent birth was unplanned pregnancy (%)

Births attended by a skilled provider (%)

Households with an improved toilet facility (%)

Deaths among children under five per 1,000 live births

Married women ages 15-49 using contraception

Rural 50.3 34.9 36.8 74.8 20.1 29.8 86 74 45.5 43.1Urban

SOURCE : KENYA POPULATION DATA SHEET (2011)

Birth spacing can reduce child mortalityDeath of children under age 5 (per 1,000 live births)

Less than 2 years

2 years

3 years

130

Health of a nationWHAT THE NUMBERS SAY ABOUT KENYA’S HEALTHCARE

Mortality rate under 5 (per 1,000 live births)

SOURCE: WORLD BANK

8379

7673

2009

2010

2011

2012

COMPILED BY ISABELLA MUKUMU

GRAPHICS BY CHRISPUS BARGORETT

Probability of dying among under fives (per 1 ,000 live births, 2012)

73% $1,730 Gross national income

per capita (PPP international $, 2012)

Life expectancy at birth m/f (years, 2012)

59/62

Probability of dying between 15 and 60 years m/f (per 1 000 population, 2012)

307/261

Total population (2012)

43,178,000

7353


IV BUSINESS DAILY | Friday August 1, 2014

Kenya’s health industry is beset by chal-lenges in meeting the promise of quality healthcare for all. But it is now braced for

a new assault, with an increased health budget, and a new wave of medical recruitment.

The shortage of health workers has long been acute in Kenya, and has been getting worse. The Kenya Medical Practitioners and Dentists Board (KMPDB) has registered around 9,000 medi-cal doctors and 1,000 dentists over the past 32 years, but only 75 per cent of these are currently considered “active”, having renewed their medi-cal licences within the past five years, and 11 per cent of the active medical doctors are 61 years of age or older, while an additional 17 per cent are 51-60 years old: although many will continue

working after retirement age. The shortages are not just of doctors: Kenya has just 1.03 health workers (doctors, nurses, midwives, and clinical officers) per 1,000 population, compared with the WHO recommendation of 2.30 per 1,000 population.

Government and other stakeholders have put in place various strategies to address the issue. In 2008, the country launched an Emergency Hire Plan (EHP) and a computer-based distance education programme.

The EHP saw the hiring of an additional 1,836 nurses, increasing the public sector nursing workforce by 12 per cent and functional health facilities by 9 per cent. While the computer-based distance education programme, developed in a government partnership with the African Medi-cal and Research Foundation, saw a 31 per cent increase in the number of registered nurses, as 5,887 upgraded from enrolled to registered.

Other efforts to scale up of the number of medical workers have included the opening of additional medical training facilities. There are over 70 institutions accredited by the Nursing Council of Kenya (NCK) to train nurses, of which 68 are actively training three classes of nurses.

But up to 2010, The University of Nairobi trained 90 per cent of Kenyan-trained medical doctors, while Moi University trained the other 10 per cent. Now, medical programmes have also been introduced at Kenyatta and Egerton universities.

But it’s a slow and expensive climb. On aver-age, the cost of training a doctor in Kenya, from primary to university, is about Sh5.7 million and after training the government faces an immedi-ate challenge of retention of medical workers in

the public health service. Medics cite poor pay packages as the reason for their exodus from the public sector to private, local or even interna-tional organizations.

According to the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU), in the private sector, doctors earn a gross monthly salary of between Sh120,000 and Sh150,000. Even consultants in Kenya are paid about Sh250,000, which is less than in neighbouring countries, with Tanzania paying similar professionals about Sh450,000.

As a result, Kenya is among the top six coun-tries in Africa for doctors migrating to greener pastures. According to statistics from Internews Agency, the number of Kenyan born doctors that work abroad is twice the number working in national referral hospitals and for the Ministry of Health.

Dr. Victor Ng’ani, the chair of KMPDU, says 80 per cent of doctors leave the public sector by the third year of their career to go abroad or join private practice.

This flight is even accelerating, with COTU reporting that the 3,300 doctors in public health centres are resigning at speed due to poor work-ing conditions, and warning that if government does not set up mitigating measures, by the end of the year public health may remain with only 2,000 doctors - expected to serve 40 million Kenyans.

The exit comes after a decade of dwindling health budgets, despite the fact that Kenya was a signatory to the Abuja Declaration of 2001 com-mitting countries to spending 15 per cent of their national government budget on health.

The aim is an ambitious one, for while high

Quality ca≥e fo≥ all: A nation’s d≥eam ≥emains elusive, complexThe combination of a rapidly growing population, an acute shortage of qualified health workers, rising cost of treatment and poor quality drugs leaves millions in poor and failing health

80 pe≥ cent of docto≥s leave the public secto≥ by the thi≥d yea≥ of thei≥ ca≥ee≥ to go ab≥oad o≥ join p≥ivate p≥actice.

DR. VICTOR NG’ANI, THE CHAIR OF KMPDU

NATIONAL GOALBY JULIUS OMONDI & VICTOR AMADALA


VFriday August 1, 2014 | BUSINESS DAILY

income countries typically spend an average of 7 per cent of GDP on health, low income countries spend an average of only 4.2 per cent. But in Kenya, health spending as proportion of GDP has been falling over recent years, until the country’s most recent budget.

However, with quality health care enshrined in the Bill of Rights of the country’s 2010 Constitu-tion, the government has now formulated a plat-form of health policies that it claims will deliver consolidated progress in health outcomes.

It builds on a platform of some gains. For al-though Kenya’s life expectancy is still four years short of the global average of 68 years, government measures, which have included compulsory na-tional health cover for everyone in formal employ-ment and low national insurance rates of Sh160 a month for the unemployed and informal sector workers, have played a pivotal role in minimiz-ing mortality rates and increasing life expectancy from 55 to 64 years.

The National Health Insurance Fund (NHIF) has lowered health costs and guarantees subscrib-er the convenience of medical attention in most health facilities.

PolicyIn a bid to tackle maternal fatalities, in the face of glaring statistics from the World Health Organiza-tion reporting that 488 in every 10,000 mothers die while giving birth, the government last year introduced free primary maternity care in all pub-lic health facilities too.

The policy is aimed at encouraging expectant mothers to seek medical assistance from profes-sional midwives, with a report by the Ministry of Public Health and Sanitation last year showing that 56 per cent of women give birth at home cit-ing inadequate health facilities and overstretched human resources.

Critics have argued that implementation of this policy is too ambitious given that the country’s crude birth rate, which currently stands at 28.27 per 1000 population, is on an ascending scale, while others see it as a calculated political stunt to appease the majority poor.

But the government is optimistic that the cur-rent devolved system of governance will bring health services closer to the people and include free maternal services.

The country is also burdened with other severe conditions. In 2008, The World Health Organisa-tion ranked Kenya 15th among 22 high burden countries that collectively contribute about 80 per cent of the world’s tuberculosis cases.

To combat this menace, the government adopt-ed the WHO STOP-TB Strategy offering free tuber-culosis tests, prevention and treatment, which together with a directly observed treatment pro-gramme, has seen the TB and HIV/Aids co-infec-tion rates reduced by 39 per cent since 2005.

The government also rolled out a TB sensitisa-tion programme in mid-2012 where Community Health Workers (CHW) reach people at the grass-roots. In March this year, the Global Fund granted the Kenyan government Sh42.4 billion to support malaria, HIV and tuberculosis programmes for a three-year period.

However, HIV/Aids remains the leading cause of death in Kenya with a Joint United Nation re-port on HIV/Aids of 2012 indicating that its claims at least 130,000 lives yearly. Since it was declared a national disaster in 1999, the formation of the National Aids Control Council (NACC) has seen enactment of three Kenya National HIV and Aids Strategic Plans whose objective is to reduce trans-mission.

Currently, there is free HIV/Aids testing and counseling in all public health centres, prevention of mother to child infections, a sex abstinence cam-

paign amongst underage children and promotion of the use of contraceptives. Together these have reduced the HIV/Aids prevalence rate to 5.6 per cent in 2013, from 7.2 percent between 2007 and 2012. Free ARV medications for infected people has meanwhile helped to increase victims’ life span and reduced stigmatisation.

Critics like Peter Churotich of the National Aids and Sexually Transmitted Infections Control Pro-gramme (NASCOP) observes that 80 per cent of the HIV/Aids programmes in the country depend on external funding hence are not sustainable. But the gains are real enough.

MilestoneThe country’s free immunisation policy, especially for children below the age of five years, has also helped to avert diseases such as polio. This coupled with the recent announcement by the health ministry of free Rotavirus vaccines in all public health facilities is a milestone in preventative health care.

Other initiatives include free mosquito nets for expectant mothers and households in malaria prone areas and cancer screening campaigns.

But the gains being made in the health sector are probably best illustrated by the emerging in-flow of medical tourists, which the National Treas-ury estimates to be growing at 15 per cent a year.

According to Dr Amit Thakker, Avenue Health-care founder and chief executive of Kenya Health care Federation, a multi-faceted approach has been put in place to ensure Kenya becomes a medical tourism hub drawing 2,000 patients a month from Burundi, Rwanda, Tanzania, Uganda and Zambia and reducing the increasing number of

Kenyans who have been going out of the country to get specialized treatment in India, South Africa, America and Europe.

In East and Central Africa, Kenya has assumed a leadership role in offering quality medical care in cardiology, dentistry, dermatology, endoscopic, general and spinal surgery, obstetrics and gynae-cology.

In recent years, Kenya’s largest medical referral facility, Kenyatta National Hospital and private in-stitutions such as Nairobi and Aga Khan Hospitals, have served high profile patients from Uganda, Tanzania, Rwanda, Burundi and the Democratic Republic of Congo (DRC), among others.

Karen, Nairobi, Aga Khan, MP Shah and Mater hospitals are also renowned for their sophisticated medical equipment and qualified personnel who undertake delicate operations such as heart and brain surgery, and kidney transplants.

The private sector’s positioning for this unique form of tourism has also seen Kenyan hospitals invest heavily in diagnostic and treatment facili-ties, equipment, and professionals.

The 320-bed ward Nairobi Hospital has been expanded and a Doctor’s Plaza with 70 suites for medical consultants built. It has also invested Sh23 million ($287,500) in a modern oxygen plant and now produces and supplies its own oxygen.

Starting for behind, and forever underfunded and strapped for resources, Kenya’s health indus-try is nonetheless making concrete strides, and now stands at a crossroads in improving health care working conditions in pursuit of universal quality in health delivery.-AFRICAN LAUGHTER

1.03The number of health workers (doctors, nurses, midwives, and clinical officers) per 1,000 popula-tion that Kenya has, compared with the WHO recommen-dation of 2.30 per 1,000 population.

3,300The number of doc-tors in the public health sector in Kenya

Sh5.7mthe cost of training a doctor in Kenya, from primary school to uni-versity,

64 Kenya’s average life expect-

ancy, which is four years short of the global expect-

ancy rate of 68 years

Last year, 56 per cent of women gave birth at home citing inad-equate health facilities and over-stretched human resources, ac-cording to a report by Health min-istry

56%

THE NUMBERS


VI BUSINESS DAILY | Friday August 1, 2014

Pascalia Omonga, now in her late 40s, has lived with HIV for the past 20 years. But due to the anti-retroviral drugs she takes

daily, she appears healthy, strong and full of life. “I thank God for bringing me this far,” she says.

Indeed, Ms Omonga has a reason to be grate-ful. Living with the disease during the 1990’s was a struggle for infected Kenyans. The majority could not afford the required drugs, nor get the much needed social support, due to the im-mense stigma and low awareness that shrouded the disease.

Thus, Kenya lost thousands of her citizens, and at an alarming rate. Many helpless orphans were left behind, even as the country was drained of human resources. This culminated in HIV being declared a national disaster in 1999.

It was a catastrophic script that was not unique to Kenya; it was being replicated across sub-Saharan Africa and other developing nations, eventually prompting the global community to move in to salvage the situation and channel re-sources towards the worst hit nations.

A major stream for those finances is The Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria.

Even though Tuberculosis existed way be-fore HIV, the disease is now a global concern as it can easily affect patients like Ms Omonga. This is because HIV tends to lower the immu-nity of those infected, making them vulnerable to other diseases.

Indeed, the World Health Organisation (WHO) estimates that the risk of developing TB is12-20 times greater in people living with HIV than among those not infected. The WHO sta-tistics further note that in 2012, there were 8.6m new cases of TB, of which 1.1m were among peo-ple living with HIV.

Moreover, the disease is also a potential public health threat due to the emergence of multi-drug resistance TB, which does not readily respond to treatment.

Malaria on the other hand, is endemic to Kenya and severely affects pregnant women, contributing immensely to the country’s high child mortality. The 2014 Kenya Economic Survey lists it as a leading cause of death in the country, claiming about 24,000 lives yearly.

In a country where the proportion of govern-ment finances allocated to the health sector falls way below the Abuja Declaration minimal rec-ommendation of 15 per cent, the external funds from the Global Fund are extremely important for improving public health and have delivered real strides.

Global Fund statistics indicate that there are now 620,000 people on Anti-Retroviral

Therapy (ART), aimed at forestalling the pro-gression of HIV.

Similarly, it shows that close to 11m insecti-cides treated bed nets have been distributed. Evi-dence shows that sleeping under bed nets reduces malaria transmission by 50 per cent.

By spearheading these major interventions, health experts note that the Global Fund has had a considerable impact on its target diseases. Indeed, the 2012 Kenya Aids Indicator Survey showed that HIV prevalence among adults aged 15 to 64 years decreased from 7.2 per cent in 2007 to 5.6 per cent in 2012.

In addition, the Ministry of Health reports that the country has diagnosed close to 1.2m cases of TB and all the patients were put on treatment at no cost – thanks to the Global Fund. Over a million of them successfully completed their full course of treatment, hence their lives were saved.

Kenya has also reported a decline of up to 44 per cent in under-five mortality (deaths) in Global Fund targeted districts, due to the use of insecticide treated bed nets.

But the progress that Kenya is celebrating now did not come easily. For most of the 2000s, Kenya’s Global Fund performance was deemed poor, due to claims of unaccountability and mismanage-ment of finances. This saw the country’s rating running somewhere between B1 (adequate) and B2 (inadequate). Worse still, Kenya at one point scored a C (poor) and the finances were discon-tinued by the Global Fund.

This dealt the country’s health system a severe blow and left the lives of patients like Ms Omonga and children in high malaria zones in western and costal Kenya hanging in the balance.

Margaret Onyimbo, Global Fund Co-ordina-tor at Kenya’s National Treasury, notes that this unfortunate experience provided the government with an opportunity to reflect and initiate reforms key to the management of the Global Fund.

She notes the National Treasury, which re-ceives the Global Fund on behalf of the govern-ment, initially lacked an institutional structure for the management of the funds.

“So upon receiving the funds - through the World Bank - we would just channel it to the Ministry of Health, but there were no mecha-nisms to monitor their use,” she says.

To rectify this challenge, they established a Global Fund Management Unit at the National Treasury, which is charged with the responsibil-ity of tracking the funds to ensure they are used effectively to achieve set objectives.

Ms Onyimbo says the unit then built the ca-pacity of the Ministry of Health – specifically the Division of Malaria Control Programme, and the National Aids and STI Control Pro-

Battle against Aids gets new lease of life with ≥enewal of Global Fund

Sarah Ooko tells the story of a lifeline that nearly got blocked but has now put more than 620,000 people on Anti-Retroviral Therapy, forestalling progression of HIV

gramme (NASCOP) - to effectively manage funds channeled to their areas. The training involved effective writing of progress reports to ensure fi-nancial accountability.

Whereas funds were initially sent to the Minis-try of Health (MOH) Headquarters, the National Treasury began channeling funds directly to specif-ic departments within MOH dealing with diseases targeted by the global fund (NASCOP and Malaria programmes). The respective programme manag-ers were made signatories of this account.

This new model promoted efficiency by avert-ing long bureaucratic processes that departments previously had to go through before getting mon-ey from MOH headquarters to implement Global Fund projects.

The government went further to create the position of Global Fund Focal Person in each of the departments, charged with responsibility for tracking Global Fund performance in their respec-tive departments.

Under the Global Fund structure a body known as the Country Co-ordinating Mechanism (CCM) – comprising of all stakeholders dealing with the three targeted diseases - is supposed to manage all matters pertaining to the fund. But Ms Onyimbo notes that even though the CCM existed before, it was not proactive and was thus unable to perform

A health offic-er takes blood sample for HIV testing. Many Kenyan are voluntar-ily taking the test to know their status.

HIV prevalence among persons aged 15-64 years by residence, KAIS 2007 and 2012

HIV prevalence among persons aged 15-64 years by sex, KAIS 2007 and 2012

Self-Reported HIV Status among HIV- infected persons aged 15-64 years, KAIS 2012


VIIFriday August 1, 2014 | BUSINESS DAILY

its role effectively. The body was thus reformed and branded the Kenya Co-ordinating Mecha-nism (KCM). In it, two levels were created: The National Oversight Committee (NOC), which provides the overall leadership for the co-ordi-nation of the Global Fund grants in Kenya; and the Inter-agency Co-ordinating Committee (ICC), which co-ordinates each of the disease compo-nents (TB, Malaria, HIV/AIDS) targeted by the Global Fund.

Within each of those committees are stake-holders – from civil society, UN bodies and af-fected patients - that share ideas on how to best address the challenges.

Other reforms initiated by the government involved putting in place a committed Global Fund leadership that was transparent and keen on performance. This greatly reduced corruption and mismanagement of finances.

All this hard work eventually paid off. In 2011, Kenya’s grant performance broke with the previ-ous record of poor performance and was rated A1 (exceeds expectations). Consequently, the Glo-bal Fund awarded Kenya with one of the largest single grants it had ever extended to a country to finance its response to HIV. The $318m five-year grant was as much as the five previous Global Fund awards combined.

Through this grant, the Global Fund was ac-knowledging that Kenya was developing high-impact strategies, investing funds appropriately, and using effective systems to monitor targeted programmes so as to benefit people most in need - like Ms Omonga.

Despite this success, the previous ordeal brought to light a major weakness in the coun-try’s health system, in its over-reliance on donor funding, which puts the country’s health spending at risk whenever external funding is reduced or withheld. To address this challenge, the govern-ment began putting in place structures for a more sustainable investment approach.

Thus, between 2008 and 2010, the Govern-ment doubled domestic HIV spending.

Moreover, in December 2012, the Cabinet agreed to establish a trust fund for HIV and pri-ority non-communicable diseases, with the aim of ensuring that at least 70 per cent of the cost targeting their interventions are covered with domestic funds.

Following Kenya’s success story, the nation’s President Uhuru Kenyatta was in 2014 made a Global Fund Champion. In this capacity, he ad-vocates for the fund’s significance and mobilises resources to the cause.

[email protected]

BY SARAH OOKO

The Global Fund to fight Aids, Tuberculosis (TB) and Malaria is present in more than 100 countries. It spe-cifically targets those nations with a high burden of the three diseases.

Abshiro Halake, deputy secretary-general and Global Fund manager at Red Cross, notes that to maximise performance, the fund uses a multi-stake holder approach.

All finances initially went to the government, but this changed in 2009, when the dual-track funding mechanism was introduced.

Through it, the Global Fund monies are chan-nelled to two parties: the government (through the National Treasury) and civil society (through con-tracted representatives who are currently the Red Cross and Amref).

The two work in partnership, drawing from each other’s strength, to meet set targets.

Since the government has health facilities all over the country, it is charged with services that take place there, such as conducting diagnostic tests, offering treatment and prescribing medication.

The civil society works with communities, espe-cially those that are marginalised or hard to reach. They are charged with sensitising communities on health issues and mobilising them to seek services at

health facilities such as anti-natal care visits and HIV tests. They also make follow-ups to ensure patients adhere to the treatment given.

“For instance, we encourage those with TB to com-plete recommended drug doses,” said Ms Halake. In countries where the Global Fund operates, a body known as the Country Co-ordinating Mechanism is formed to oversee the smooth implementation of the fund. Representatives of patients afflicted by these diseases are also members of the co-ordina-tion mechanism.

“This ensures that the impact of the fund is felt by the targeted beneficiaries,” says Ms Halake.

For accountability purposes, money allocated to countries is not disbursed all at once by the Global Fund. It is released in phases, depending on how a country performs based on progress reports and im-pact on the ground.

The Global Fund also employs a local fund agent (currently PricewaterhouseCoopers) that audits the funds to ensure they are used and managed accord-ingly.

The performance is ranked as: A1 (exceeds ex-pectations), A2 (meets expectations), B1 (adequate), B2 (inadequate but potential demonstrated) and C (poor). If a country gets a C rating, the funds are dis-continued.

T≥anspa≥ency c≥itical in financing wa≥ on diseases


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VIII BUSINESS DAILY | Friday August 1, 2014

Malnutrition isn’t always caused by starvation. The reality is that up to 90 per cent of Ken-yans are suffering from some form of malnu-

trition - because they are eating the wrong foods. The result is micronutrient deficiencies that are stunting growth and intelligence, suppressing immune systems, and causing multiple diseases and deaths.

In fact, micronutrient deficiency is Kenya’s biggest killer, at levels that are way higher than most other de-veloping nations: because the Kenyan diet is worse. With children the most studied and the worst affected, some 35.2 per cent of under 5 year old Kenyans are malnourished, according to the World Bank. But the overall figure hides a more severe mix of micronutri-ent deficiencies.

“Most child deaths are caused by malnutrition,” said Maanan Mumma, a nutritionist. Moreover, the country’s levels of malnutrition are rising, not falling, driven by the near absence of fruit and vegetables in many Kenyan diets. Says Huyen Tran, Action Against Hunger’s country programme co-ordinator in Kenya, the cause is “the consumption of foods low in fibre and high in fats and sugars”. Specifically, the emphasis on staple foods, such as Ugali, with almost zero nutritional content, and the heavy loading of sugar into drinks, is making for a disease cocktail.

At base, Kenya is suffering some of the highest levels in the world of Vitamin A Deficiency (VAD), which is affecting 85 per cent of Kenyan children under 5 years, according to a recent World Bank report. VAD is the leading cause of preventable blindness in children, causes child and maternal deaths, and night blindness among pregnant women. UNICEF reports that VAD is causing tens of thousands of deaths a year in Kenya, and affecting the vast majority of Kenyan children.

A direct consequence of VAD and associated nu-trient deficiencies is stunting, which is defined as low

height for age and is caused by insufficient nutrients over a long period of time, coupled with frequent in-fections.

A stunted child is usually inches shorter than a well nourished child. They also have a weaker im-mune system and are therefore more vulnerable to disease. According to UNICEF, a stunted child is five times more likely to die from diarrhoea. Other effects include delayed motor development, impaired cogni-tive function, and poor school performance.

The fact that nutrient deficiency can permanently reduce intelligence, as well as growth and immunity, has drawn little attention in public debate, but the problem is both severe and widespread across Kenya.

Globally, stunting affects about 180m under the age of five years. In Kenya, as of 2009, 35 per cent of Kenyan children under five years were stunted, with the then Eastern province reigning supreme at 42 per cent. Stunting is more common in rural areas, at 37 per cent, than in urban areas, where the prevalence is 26 per cent. Altogether, Kenya accounts for almost one twelfth of the world’s stunted children.

Iron Deficiency Anaemia (IDA) is also a severe prob-lem in Kenya. According to the World Health Organisa-tion, in developing countries, every second woman and 40 per cent of pre-school children are anaemic. But a 1999 survey in Kenya, conducted by UNICEF and the government, found that 89 per cent of children under six years, 56 per cent of women of child-bearing age, and 46 per cent of men were anaemic in Kenya.

Anaemia causes impaired physical and cognitive development, increased levels of disease in children, a reduction of work productivity among adults, and contributes to 20 per cent of all maternal deaths.

The overall scale of malnutrition is now driving a raft of initiatives, including campaigns to encourage the consumption of orange-fleshed sweet potatoes, which contain high levels of vitamin A and beta caro-tene, both of which help reduce child blindness and child mortality.

According to a Nutrition Action Health Letter’s study of 58 vegetables in which the percentages of six nutrients including vitamin A and C, folate, iron, cop-per and calcium and fibre were analysed, sweet pota-toes topped the list with 582 points, with raw carrots following with 434 points.

Food fortification has been another way of curbing micronutrient deficiencies, with the 2012 launch of a

food fortification programme in Kenya set to benefit some 27m people. The aim is to nutritionally fortify wheat flour, vegetable oil and maize meal thereby reduc-ing the widespread prevalence of vitamin and mineral deficiencies by inserting Vitamin A.

And other fortification into the foods that Kenyans do eat. Large scale maize meal, wheat flour and veg-etable oil producers are now committed to fortifying their food products.

But obesity and poor diet are also driving other conditions, with diabetes one of the most devastating. Type 1 diabetes is hereditary, but Type 2 can be brought on as the insulin produced by the body becomes insuf-ficient or the body is unable to respond to sugar intake, leading to a build-up of glucose in the body. It used to be a condition that generally struck in old age, but is now becoming more prevalent in children and young adults, and once developed, is permanent.

As it is, obesity is twice as high in urban areas than in rural areas, and increases with age, education and wealth. As of 2009, 41 per cent of Nairobi women were found to be overweight or obese. This is especially trou-bling for pregnant overweight women with impaired glucose tolerance, a category of higher than normal blood glucose that is normally below the threshold for diagnosing diabetes.

To stabilize glucose levels, which can cause high blood pressure, kidney failure, foot ulcers and many other conditions, a typical diabetes food program rec-ommends small portions of meat, meat substitutes and other proteins. With meat not easily affordable for everyone, protein maize also can provide an al-ternative.

The maize, known as Quality Protein Maize (QPM), is biofortified and non-transgenic, made from a natu-rally occurring mutant maize gene that increases the amount of two amino acids, lysine and tryptophan, necessary for the synthesis of proteins in humans.

QPM does not increase the total amount of protein but rather contains enhanced protein which is more beneficial to humans on consumption. Having 90 per cent the nutritional value of milk, this type of maize is also great for malnourished children.

While much remains to be done to stop the explo-sion in Kenya’s diet-related diseases, measures are be-ing taken to improve, which can only signify a step in the right direction.-AFRICAN LAUGHTER

Malnut≥ition: Kenya’s silent kille≥Micronutrient deficiency mainly linked to poor diet has become Kenya’s biggest killer standing way above most other developing nations

A vegetable platter. The country’s levels of malnutrition are rising, not falling, driven by the near absence of fruit and vegetables in many Kenyan diets. FILE

MALNUTRITIONBY SILVIA MWENDIA

35.2% The percentage of under five years Kenyan children that are malnourished, according to the World Bank.

85% The percentage of under five years Kenyan children that are vitamin- A deficient

THE NUMBERS


IXFriday August 1, 2014 | BUSINESS DAILY

Tabotha Muthoni, 27, has had health chal-lenges that few others have. She is O-nega-tive, a rare blood group shared by very few

people. While expecting her first child, she had to be

admitted to Kijabe hospital because of the need for blood. Fortunately, volunteer blood donors, through Kenya National Blood Transfusion Serv-ices (KNBTS), came to her rescue. Her baby was born at seven months.

When she was expecting her second child, she faced the same challenge of having low he-moglobin levels. As a result, she could not carry her pregnancy to full term and at five months of pregnancy she had to have an emergency caesar-ean with her son weighing only 800gms.

“This time I was transfused with 25 units of blood, even as my son was transfused to keep him

alive. I thank God for having saved our lives,” she said. Overall, she has been the beneficiary of more than 100 units of blood, thanks to the efforts of KNBTS. She also has to receive 3-4 units of blood every 2-3 months.

“I have been a great beneficiary of these ef-forts, thanks to Dr Margaret Oduor, the director of KNBTS, and her team, who, through the Na-kuru office, have come to my rescue over time, she said.

She is aware that not all mothers are lucky enough to access donated blood while giving birth, and even newborns lose their lives due to hemor-rhages or lack of blood.

Ms Muthoni is one of the few Kenyans who have understood the critical role that KNBS – one of the most silent agencies – plays in the big picture of healthcare provision and appeals to the authori-ties to provide more resources to the effort. “With-out blood there would be no life,” she said.

The reality is that many are not as lucky as Tabitha, particularly if they live in rural areas,

or give birth away from a health facility. Thou-sands lose their lives, that of their babies, or both. Kenya is known to lose between 6,000 and 8,000 women every year to pregnancy and childbirth complications.

East Africa’s largest economy remains among the sub-Saharan African countries that contrib-ute up to 62 per cent of all global maternal deaths -- a death toll that has not improved much over the past two decades. The most common cause of maternal death is excessive bleeding during or soon after birth, which accounts for 27 per cent of all deaths.

The World Health Organisation recommends that pregnant women attend antenatal care (ANC) and are seen by skilled healthcare personnel at least four times in the course of the pregnancy.

Most crucial is to have the first contact and ex-amination by the skilled healthcare worker during the first three months of pregnancy. Currently, less than a quarter of the almost two million women who become pregnant in Kenya every year visit health facilities early enough for ANC.

Ms Muthoni, who had a medical complica-tion related to her negative rhesus blood group, benefited from ANC because of early diagnosis of her condition.

She was able to get blood transfusions as soon as her anaemia was detected, and her ba-bies were delivered before the rhesus complica-tion endangered their lives. Early antenatal care and delivery in a health facility is also necessary to detect, prevent and manage other diseases such as HIV, syphilis, tuberculosis, diabetes and hypertension. This not only reduces the chances of death of the mother, but also of the unborn and newborn baby.

Almost one-third of all maternal deaths are caused by the worsening of a pre-existing medi-cal condition during pregnancy.

Most recently, the Ministry of Health has insti-tuted a process countrywide of surveillance of and response to all maternal and newborn deaths in the country. This monitors the direct and indirect causes and contributors to the deaths, both in the community and health facilities, with a view to taking necessary corrective measures.

What is clear is that reducing maternal deaths is not a problem of the health sector alone. A mul-ti-sectoral response is mandatory to make any headway in addressing this issue, which has a profound effect on the overall development of the country.

TRANSFUSIONBY BD CORRESPONDENT

Blood t≥ansfusion makes its ma≥k on health of mothe≥s

Blood Donation: The most common cause of ma-ternal death is excessive bleeding during or soon after birth, which accounts for 27 per cent of all deaths.


X BUSINESS DAILY | Friday August 1, 2014

The number of Kenyans with medical cover has more than doubled in the last five years, while the health insurance

premiums collected by insurance com-panies has more than tripled, making medical insurance the fastest grow-ing insurance segment and now the largest insured risk class, having over-taken statutory commercial motor ve-hicle insurance.

But profits remain elusive.The FinAccess National

Survey reports 1.5m people with private insurance cover in 2013, up from 700,000 in 2009, while those with access to the National Insurance Health Fund (NHIF) rose to 15.6m, from 4.3m.

More employers have been offering their staff private medical cover schemes as part of the remu-neration package. Those in the informal market are also taking medical cover following aggressive pitches by insurers in social meeting points, such as churches, supermarkets and open markets.

As a result, the Insurance Regulatory Authority reports insurers collected medical premiums worth Sh21bn last year, compared with commercial motor vehicle premiums of Sh19.6bn and those paid by pri-vate owners of Sh14.1bn.

But rising medical treatment costs continue to press on the sector. In a bid to cover costs, the NHIF has pushed to increase its mandatory contributions sixfold from the current Sh320 a month, although the rise has been challenged in court by workers’ body COTU.

“The cost of healthcare has gone up drastically and out of pocket payments are expensive, creating a need to mitigate that risk when it comes up,” said Mr Tom Gichuhi, chief executive of the Association of Kenya Insurers (AKI).

Medical related claims reached Sh9bn last year, up from Sh6.8bn a year earlier. But despite the wide margin between premiums collected and claims raised, insurers are still reporting losses in the busi-ness, which they attribute to fraud, undercutting and misuse of the cover by the insured.

“We are compiling the 2013 numbers, but because there was nothing drastic that happened to address the fundamental areas which have made it not return profits, I am not sure this year it will be any different,” said Mr Gichuhi.

Insurance companies contend that hospitals tend

to overcharge insured clients and take them through unnecessary cash sapping procedures.

CIC Insurance has even hired medical personnel to investigate suspected fraudulent claims, which the firm blames for a steep increase in customer bills. CIC collected premiums worth Sh2.35bn, but incurred claims of Sh1.6bn, according to the regulator.

In the United States, concerns at excessive costs billed to insurance have seen insurance companies construct their own hospitals and hire their own medi-

cal staff in order to contain the cost of operations. But with none of Kenya’s medical insurers yet having sufficient muscle to execute such a project, the insurance companies are currently undercutting each other to gain more business and thus critical mass, further driving the losses.

An account manager in one insurance firm said some companies, especially the smaller ones looking to grow their market share, were waiting for insurers to submit their bids before approaching the manage-ment of corporate institutions with cheaper offers.

Insurance companies have also pointed the finger at the insured for pushing them to losses by making excessive demands.

Insurance firms have been forced to put caps on spectacle prices as some people misused the window to get expensive, trendy lenses and frames. Dental operations have also been capped.

However, the market potential is considerable. A recent survey in Mombasa County found that only 11 per cent of respondents had medical insurance, but 26.6 per cent desired cover, underlining the potential for lowly priced medical covers.

This untapped demand has seen insurers home in on consumers at the bottom of the pyramid, with the high profile launch by Britam in January of a mobile product dubbed Linda Jamii in partnership with Safaricom.

The cover, which costs Sh1,000 a month, had been signed up for by 5,000 consumers by March.

[email protected]

Take up of insu≥ance g≥ows but p≥ofits still ≥emain elusive While the number of Kenyans with medical cover has more than doubled in the past five years, profitability remains rare among the underwriters

The cost of healthca≥e has gone up d≥astically and out of pocket payments a≥e expensive, c≥eating a need to mitigate that ≥isk when it comes up.”

MR TOM GICHUHI, CEO, ASSOCIATION OF KENYA INSURERS

1.5 millionThe number of people with private insurance cover in 2013

15.6 million

The number of people with access to National Health Insurance Fund (NHIF)

ACCORDING TO THE FINACCESS NATIONAL SURVEY

THE NUMBERS

INSURANCEBY GEORGE NGIGI


XIFriday August 1, 2014 | BUSINESS DAILY


For Kenyans attending regional meetings in Arusha, the short distance to Meru Pri-mary School comes in handy when the

strains and stresses of the day call for medical attention. For, on the way, sits a forlorn sign-post proclaiming the Aga Khan Medical Serv-ices brand.

In Tanzania, the Aga Khan Hospital has out-reach centres in Arusha, Dodoma and Dar es Salaam, which it has set up in its quest to take services closer to patients across East Africa.

Players in the health sector say the satellite clinics have radically changed the face of health-care services, ending an era when financially able East Africans had to come to Nairobi for special-ised services at the hospital’s facilities.

“The Kenyan hospitals with units in member states have taken with them quality medicine, expertise, and equipment that used to force pa-tients to travel long distances to Nairobi,” said Dr Kamamia Murichu, chairperson of Kenya

Pharmaceutical Manufacturers and Distribu-tors Association. “The health sector is far from its potential, but I can say this is one area in which the regional integration has played an important part in boosting access to medicine and healthcare,” said Dr Kamamia, who is also the Secretary of the East African Health Platform in an earlier interview.

In reality, however, the drive by major Kenyan hospitals to brand and chain small clinics has less to do with regional integration than with positioning in the market.

Whether the clinics are set within the coun-try, or outside the national borders, the model is similar across the hospitals, the institutions’ bosses say.

To start a satellite clinic, all a hospital needs is a laboratory, physiotherapy unit, imaging facility, and other equipment that enables it to provide comprehensive service to patients, said Betty Gikonyo, CEO of Karen Hospital. These are the internal resources that are likely to drive any hospital into expansion.

Hospitals executives also talk of a desire to

address time constraints that limit their clients by taking services closer to them. However, Dr John Muriithi, CEO of Mater Hospital, said hos-pitals set up outreach centres in smaller towns only if assured of manpower that will guarantee the same business model and service level as is available in the main hospitals.

“It’s just like opening a bank branch. You start from the scratch, but with responsibility for giv-ing patients the same standard of service they’d get at the main hospital,” said Dr Muriithi.

In terms of external resources, the hospitals tend to follow the distribution of public health facilities to enable them to share manpower. This, he said, is a reality that the health sector, which has been grappling with shortages of specialised skills since independence, has to deal with.

At the satellite clinics, patients are mainly served by general practitioners, but special-ists, including paediatricians and oncologists, have to be sent at regular intervals to attend to specific cases. Similarly, satellite clinics tend to encourage the use of generic medicine, which is equally effective, but cheaper than the branded drugs offered at the main hospitals.

With the cost of medical care largely dictated by doctor’s fees and prescriptions, the executives say satellite hospitals end up charging less for their services than the main hospitals.

At the Mater Hospital, Dr Muriithi said delib-erate effort is also made to discount consultation fees for clinics located in small towns to reflect the lower level of economic activities.

The Mater Hospital based in South B first opened its satellite clinic in Nairobi’s Develop-ment House in 2009. “With devolution, this (opening satellite clinics) is the way to go.

In fact, I expect more hospitals to expand presence through such outreach centres, as coun-ties address the manpower shortage,” he said.

Dr rGikonyo agrees, saying the satellite clin-ics are more of a strategy to expand brand and increase access to healthcare, rather than about taking “convenience” to patients.

“Through these clinics, somebody who has never visited main hospital gets to learn of

some of the specialised services on offer,” Dr Gikonyo said.

The Karen Hospital, which only took up the concept just recently, says it has been able to reduce consultation fees at some of its facilities to only 60 per cent of what the main hospital charges.

Every month, the hospital sends specialists to its satellite clinics to attend to patients as part of reducing crowding at main hospital.

“I believe that most of our outreach clinics will develop into fully fledged hospitals with time,” she said, adding that the hospital admin-istration is currently gathering important data on the feasibility such facilities.

The Business Daily discovered that the dream of satellite facilities growing into fully fledged hospitals in future is a dream shared by almost all of the hospitals.

ClientsApart from its main hospital and regional units, the Aga Khan Hospital, which together with AAR and Gertrude’s are credited with pioneering in setting up the satellite centres, has fully fledged hospitals in Kisumu and Mombasa. It also now has satellite clinics in most towns.

An urban centre as small as Ongata Rongai on the southern fringes of Nairobi, has, for in-stance, seen an aggressive foray of major hos-pitals, each of them citing internally compiled data to argue that a sizeable number of clients reside in the area.

Today, the centre has Gertrude’s Children Hospital and Nairobi Women Hospital, which set up operations there two years ago, joining Aga Khan and Meridian hospitals which were already established in the area.

On May 21, Gertrude’s Hospital management announced that the Sh30 million facility that it completed building in Mombasa this year will be converted into a fully-fledged children’s hospi-tal, making its initial foray into counties outside Nairobi. The hospital said similar units will soon come up in Kisumu, Eldoret and Nakuru.

[email protected]

CLINICSBY GEORGE OMONDI

Satellite clinics take quality healthca≥e to consume≥s’ doo≥steps

Mater Hospital in Nairobi. It is among the hos-pitals that have opened satel-lite centres in the country. FILE

Outposts change the face of medicare with slices of top of the range service providers for consumers at the grassroots

XII BUSINESS DAILY | Friday August 1, 2014

Health is a $3.5 trillion industry, accounting for eight per cent of the world’s gross domestic product (GDP).

The growth in health spending has exceeded eco-nomic growth in almost all Organisation for Economic Co-operation and Development (OECD) countries over the past 15 years, and the world’s population is also growing, adding 200,000 people a day, according to the World Bank.

The universal challenge for all health systems globally is how to allocate finite resources across almost unlim-ited demand - and get the most impact for spend.

But getting the most benefit for the cost is particularly vital in Kenya, where total expenditure on health has been on the decline, from 4.7 per cent of GDP in 2004 to 4.4 per cent in 2010, even as demand grows, with the population, estimated at 42 million in 2010, set to reach 60 million by 2030.

Kenya currently has 7,608 health facilities, up from 6,190 health in 2008, with 55 per cent of them owned and operated by the public sector, according to the Master Facility List.

Together, these facilities shared the Sh10.6 billion al-located to health care by government in the 2013/2014 budget, augmented by funds from donors.

However, Sh47.4 billion has been set aside for qual-ity and accessible health care services for all Kenyans in 2014/ 2015 budget.

In this, the government’s decisions on what health care to spend on will have a profound impact on the country’s disease profile.

Overall, investing in preventive health care, as op-posed to curative health, has been shown to save more lives for less money.

This saw Kenya, in 2011, emerge as the first African country to roll-out the pneumococcal conjugate vac-cine, which protects against different pneumococcal diseases, including pneumococcal pneumonia, bacter-emia, meningitis, and middle ear infection.

At the time, pneumococcal infections were one of the leading killers of children in the country, claiming some 30,000 lives a year, and a large proportion of the 124,000 under-5 child deaths.

The infections kill approximately one million chil-

dren worldwide, according to 2009 data from the WHO, and in Kenya are leading causes of hospital admissions among children under five years.

GAVI, a public-private partnership focused on in-creasing access to immunization in poor countries, com-mitted approximately $40m for the roll out in 2011, and $35m for the following years, with the government giv-ing some $900,000 (Sh79.1m) a year.

The initiative is already reaping results. Since the in-troduction of Pneumococcal Conjugate Vaccine (PCV), a group of investigators have found a 69 per cent drop in the rate of invasive pneumococcal disease in children less than one year old.

Globally, such spending choices in health care are the basis on which countries’ health care success is judged.

This saw Britain’s National Health Service (NHS) in May 2014 judged the “world’s best health-care system” by the Washington-based Commonwealth Fund in its latest ranking of 11 rich countries’ health provision. The UK ranked first overall, scoring highest on quality, ac-cess and efficiency.

In this, efficiency is key to maximizing both quality and access, and depends on medical staff being able to function effectively, with workforce the public hospital system’s biggest cost. Wages account for nearly 70 per cent of recurrent hospital spending.

Kenya has an acute shortage of health care workers, with currently 16,371 public sector nurses, and an av-erage of 16 doctors and 153 nurses per 100,000 people, compared to the WHO recommended minimum of 36 doctors and 356 nurses per 100,000 of population.

The government now has plans to hire 42,000 health workers in 2014, and an additional 5000 every year after.

The challenge for hospital administrators is there-fore to ensure its nursing labour force skills are fully utilised.

Currently, many nursing professionals work well be-low their skill level, with statistics indicating that about 15 per cent of nurse time is spent on personal care tasks that nursing assistants could do without compromising the quality of health care.

One 2006 study found that at least two thirds of patient call lights were to ask nurses to get or do some-thing, like closing curtains or getting tissues, assisting with toileting, questions about care like “when will the doctor be here?”, food requests, or repositioning, like

Sho≥t on ≥esou≥ces, long on needs: Healthca≥e faces hu≥dle of impact investing

Getting the most benefit for the cost is particularly vital in Kenya, where total expenditure on healthcare has been on the decline

Kenya - Life expectancy at birth

1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Life expectancy - Men

Life expectancy- Women

Life expectancy

Year

46.36 47.01 47.65 48.27 48.86 49.43 49.98 50.53 51.09 51.66 52.23 52.81 53.38 53.94 54.48 55.02 55.57 56.13 56.7 57.27 57.82 58.33 58.76 59.12 59.38 59.55 59.62 59.61 59.53 59.37 59.12 58.72 58.19 57.53 56.77 55.96 55.13 54.35 53.67 53.15 52.84 52.78 52.95 53.35 53.93 54.7 55.6 56.59 57.61 58.62 59.55 60.37 61.12

44.48 45.07 45.66 46.24 46.81 47.36 47.91 48.46 49.02 49.6 50.17 50.76 51.33 51.9 52.46 53.02 53.6 54.18 54.78 55.38 55.95 56.47 56.92 57.28 57.54 57.7 57.76 57.75 57.67 57.51 57.27 56.91 56.42 55.81 55.12 54.39 53.67 53 52.44 52.03 51.83 51.84 52.07 52.48 53.06 53.77 54.59 55.47 56.36 57.22 58.01 58.71 59.31

48.34 49.05 49.74 50.4 51.02 51.6 52.16 52.71 53.26 53.83 54.4 54.97 55.53 56.07 56.6 57.12 57.64 58.18 58.72 59.26 59.79 60.27 60.7 61.05 61.31 61.48 61.56 61.56 61.48 61.32 61.05 60.63 60.06 59.34 58.5 57.6 56.66 55.76 54.97 54.33 53.91 53.76 53.88 54.25 54.85 55.67 56.66 57.78 58.93 60.08 61.16 62.12 62.95

The Pumwani Mater-nity hospitalKenya has an acute shortage of health care workers, with currently 16,371 pub-lic sector nurses, and an average of 16 doctors and 153 nurses per 100,000 people, compared to the WHO recom-mended minimum of 36 doctors and 356 nurses per 100,000 of population.FILE

7,608The current number of health facilities in Kenya up from 6,190 in 2008

55% Percentage of hospitals owned and operated by the public sector

HEALTH SPENDINGBY EVELYNE KOPAR


XIIIFriday August 1, 2014 | BUSINESS DAILY

turning over, or moving an arm or leg. Responding to call lights was found to be the most frequently de-layed task by nurses.

But, in Australia, nursing assistants have been shown to lead to a decline in patient-initiated calls for assistance, enabling nurses to focus on their core duties.

Technology has also pushed up costs, while not always being used efficiently. According to an analy-sis by the Kaiser Family Foundation, technology has accounted for as much as 75 per cent of the recent in-creases in US health care expenditures, with the US having some 54 per cent more CT scanners and 40 per cent more MRI machines per million of popula-tion than other developed nations.

But at a cost of some $112,038, an MRI machine is a hefty spend for Kenyan hospitals, seeing the number of Magnetic Resonance units, across both public and private sectors, running at 0.16 MRI units per 1,000,000 population, according to the WHO.

However, a shift to equipment leasing is now open-ing the way to more availability, allowing immediate access to equipment at ‘rental’ type payments.

On this basis, the 2014/2015 budget has allocated Sh3bn for the leasing of health care equipment, such as ultrasound, x-ray, ventilators, physical rehab, and intra-oral cameras.

For hospitals that have such equipment, the prior-ity will now be to use it efficiently. Reports indicate an estimated 50 per cent of medical equipment in

developing countries is not used because of a lack of spare parts or maintenance, or because health work-ers do not know how to use it.

But even where equipment is operational, it is often only used for only a few hours each day. Keny-atta Hospital, East Africa’s largest referral hospital, serves an average of 6,500 patients a month through its radiology department.

But it only runs MRI scans, for which it charges Sh16,000 a scan, from 8.00am to 5.00pm, perform-ing an average 5 scans a day.

Operating theaters, likewise, are costly, although they typically deliver of 40 per cent of a hospital’s rev-enue, according to the Health Care Financial Man-agement Association.

“The most efficient way of utilising an operating theatre is to have 24 hour operations for both emer-gency and elective cases. That way theatre space is maximally utilised,” said Dr. Thomas Ngwiri, Head of Clinical Services, Gertrude’s Hospital, Nairobi.

“Efficient procurement processes for surgical supplies, batching of cases to be done by the same surgeon and anaesthetist team, proper pre-operative procedures to reduce theatre time and risk of adverse events, as well as package pricing where total cost of surgery is agreed in advance and is fixed are some of the methods used in hospitals” to increase efficiency, said Dr. Ngwiri.

QualityOn the quality side, “following protocols for most services, adopting quality improvement programs, including an audit of performance and outcomes as well as quality certification and accreditation – for example ISO 9000 and Joint Commission Interna-tional accreditation - are ways to ensure quality of services,” he said.

The chase for maximum health gains on mini-mum spend has even seen doctors move to count-ing sutures.

Cleveland Clinic in Ohio, US, realized that to lower healthcare costs, it helped for doctors to know what medical services and supplies cost, so it asked its physicians to record the price of sutures, count how many instruments were on the table, tag the devices on the shelf, and record how long patients spent in post-anaesthesia care.

The savings were considerable. For example, ni-tric oxide, a drug commonly used in heart, lung and chest surgeries to keep tissues well-supplied with oxygen during the operation, can be very effective, but it doesn’t help all patients.

On realizing it was spending $2m a year on the drug, the hospital drilled down to see, who was us-ing it and why.

They found that doctors and staff did not have a standard protocol to guide them on when and how much to rely on nitric oxide; they had to educate them that if the drug didn’t work within a half hour of being administered, it won’t work at all, so repeated doses were wasteful. The result: nitric oxide use dropped by half, saving $1m without any adverse effect on patient care.

Only by counting costs in, measuring them against health gains, and ensuring equipment is fully utilized, can Kenya now begin to deliver on its long-term prom-ise of quality health care for all.

-AFRICAN LAUGHTER

1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

46.36 47.01 47.65 48.27 48.86 49.43 49.98 50.53 51.09 51.66 52.23 52.81 53.38 53.94 54.48 55.02 55.57 56.13 56.7 57.27 57.82 58.33 58.76 59.12 59.38 59.55 59.62 59.61 59.53 59.37 59.12 58.72 58.19 57.53 56.77 55.96 55.13 54.35 53.67 53.15 52.84 52.78 52.95 53.35 53.93 54.7 55.6 56.59 57.61 58.62 59.55 60.37 61.12

44.48 45.07 45.66 46.24 46.81 47.36 47.91 48.46 49.02 49.6 50.17 50.76 51.33 51.9 52.46 53.02 53.6 54.18 54.78 55.38 55.95 56.47 56.92 57.28 57.54 57.7 57.76 57.75 57.67 57.51 57.27 56.91 56.42 55.81 55.12 54.39 53.67 53 52.44 52.03 51.83 51.84 52.07 52.48 53.06 53.77 54.59 55.47 56.36 57.22 58.01 58.71 59.31

48.34 49.05 49.74 50.4 51.02 51.6 52.16 52.71 53.26 53.83 54.4 54.97 55.53 56.07 56.6 57.12 57.64 58.18 58.72 59.26 59.79 60.27 60.7 61.05 61.31 61.48 61.56 61.56 61.48 61.32 61.05 60.63 60.06 59.34 58.5 57.6 56.66 55.76 54.97 54.33 53.91 53.76 53.88 54.25 54.85 55.67 56.66 57.78 58.93 60.08 61.16 62.12 62.95

SOURCE: COUNTRY ECONOMY | COMPILED BY ISABELLA MUKUMU | GRAPHICS BY CHRISPUS BARGORETT

SOURCE :MINISTRY OF HEALTH KENYA 2011

37% Percentage of population with high blood pressure

THE NUMBERS

12.7% Percentage of people with heart disease

10% Percentage of population

with diabetes

28,500Number of Kenyans

diagnosed with cancer

77.5% Percentage of people

who die due to high cost of treatment

55% Percentage of hospitals owned and operated by the public sector

16,371The number of nurses in the public sector

Doctors at the Kenyatta Na-tional Hospital theatre carry out a kidney transplant FILE


XIV BUSINESS DAILY | Friday August 1, 2014

Fifteen months into devolution, much of Kenya’s health sector operations re-main in shambles thanks to the unend-

ing power games between national and county governments on the description of devolved services, negligible budgetary allocation, and understaffing.

Under the Kenyan constitution, the Transi-tional Authority was given a three-year window to devolve health services.

But even essential services that are sup-posed to have been devolved by now, like the upgrading of major hospitals remain far be-hind schedule.

The extent of health service decentraliza-tion has been clearly demarcated, the national government having been tasked with the for-mulation of health policies, financing, taking care of national referral hospitals, quality as-surance and standards, among other respon-sibilities.

County governments have the bulk of dea-conry tasks, including the promotion of pri-mary health care, disease surveillance and re-sponse, veterinary services, and the licensing and control of agencies that sell food to the public, among others.

The push by county governments to take over all the roles assigned it under the consti-tution at once has sparked major supremacy battles that have lasted more than one year with no end in sight.

Key battle points include management of level five hospital (formerly known as provin-cial general hospitals) and the thorny issue of hiring of medical personnel.

Last year, doctors and nurses went on a go slow after it emerged that they would be de-ployed to the county governments. Their argu-ment has been that the decentralized govern-ments don’t have the necessary resources to accommodate them.

MismanagementSince September last year 201 doctors are re-ported to have resigned from public service in protest over devolution of health services to county governments that are fraught with mismanagement, nepotism, frozen promotions, and reduced or delayed salaries.

According to the doctors, only the manage-ment of non-medical staff was supposed to be transferred to the county governments over the first two years, whereas the management of technical staff - including doctors, nurses and pharmacists - was to await the second phase of devolution.

County governments, on the other hand, insist that doctors are not being sincere since devolving health services affords county gov-ernments the opportunity to closely supervise the health workers – a task the national gov-ernment has been unable to perform. Doctors, the county governments say, are merely afraid of close supervision.

Caught between the battle are Kenyans who had expected devolving government closer to

them as a way of addressing the biting short-age of health officials that has over the years taken a toll on service delivery.

The shortage of healthcare workers is not unique to Kenya. The country has been identi-fied by the WHO as having a “critical shortage” of healthcare workers.

The WHO has set a minimum threshold of 23 doctors, nurses and midwives per popula-tion of 10,000 as necessary for the delivery of essential child and maternal health services. Kenya’s most recent ratio, in 2012, stands at 13 per 10,000.

This shortage is markedly worse in the ru-ral areas, where, as noted in a recent study by Transparency International, under-staffing levels are running at between 50 and 80 per in provincial and rural health facilities.

Devolution has done nothing to help. Ac-cording to International Budget Partnership (IBP), an organisation that analyses public budgets around the world, none of Kenya’s 47 counties meets the target for doctor-popula-tion ratios, which the government has set at 36 doctors for every 100,000 people.

Indeed, budgetary allocation to health by virtually all county governments has been dis-mally low, with 30 counties having spent less on health in the 2013 financial year than the na-tional government spent on citizens in 2012.

In their rush to beat the June 30, 2013, dead-

line set by the Public Finance Management Act, many counties ended up under-budgeting for health, drastically affecting service delivery and creating a national health crisis.

Tharaka Nithi, Nyeri, Homa Bay, Kitui and Kericho top the list of counties that slashed their budgets by more than half, compared to the Ministry of Health’s previous spend in the areas. Other counties have invested as little as Sh24 per person in health.

The consequences are now becoming mani-fest. An acute shortage of essential drugs and medical supplies in most health facilities is creating a trail of misery for patients.

“Malarial drugs, rehydration salts, ARVs, and antibiotics are some of the drugs that are in short supply at the institutions and patients are suffering,” said Dr. P. Nyaga, the Thika Level Five Hospital Assistant Medical Superintend-ent in an earlier interview.

Health workers in other county facilities complain of poor equipped hospitals. In Bu-sia, a report by the county Health and Sanita-tion committee says that some health centres have inadequate wards and male and female patients share the same wards.

The report says patients at Malanga dispen-sary in Bukhayo Central ward answer the call of nature in a nearby bush because there are no toilets. Kericho’s Kapkatet District Hospital medical superintendent Kenneth Sigilai said

Quality and access unattained 15 months into devolved healthca≥e

devolution was done in a hurry without proper systems in place. He said that while previously hospitals received drugs every two months they now get it twice a year.

“Before devolution, we had drawing rights with the Kenya Medical Supplies Agency (KEM-SA), where hospitals placed orders for the drugs they required and the National Treasury made payments directly to them,” Dr Sigilai said. Now that we directly transact with KEMSA, hospitals have to wait for county governments to raise money before we can get supplies,” he said.

Kemsa is the government institution tasked with supplying drugs and other medical sup-plies to public health institutions in the country. But in the wake of devolution and the various allegations of corruption, bureaucracy and in-efficiencies in procurement and distribution of drugs, its fate hangs in the balance.

Nyeri Governor Nderitu Gachagua has been cited repeatedly as expressing interest in invit-ing tenders from medical supply companies, after residents complained that Kemsa was taking advantage of its monopoly to charge ex-orbitant prices.

The Senate is trying to come to Kemsas res-cue with the Kenya Medical Supplies Authority (Amendment) Bill sponsored by Majority Leader Kithure Kindiki – which seeks to grant Kemsa exclusive rights to procure drugs and medical supplies for the 47 county governments.

CartelsOpposition senators are, however, up in arms ar-guing that Prof Kindiki’s is an attempt by the na-tional government to claw back some of the func-tions devolved to the counties. Others say that it has been sponsored by cartels that have controlled the medical drugs trade for years.

In the meantime, the county government works directly with Kemsa, but supplies rest on the county raising money for the purchase of the drugs: and the new Public Finance Management Act makes withdrawal of any money from county government coffers very bureaucratic.

“We don’t have emergency funds left. Hospi-tals are going for months without drugs,” said Dr. Jeremy Mutangi from Nakuru County.

But it’s not all doom and gloom. Already, devolution has enabled counties to put more focus and resources on diseases affecting their areas, which were traditionally ignored by the national government.

For example, poor sanitation and a lack of clean water has been blamed on the rising cases of trachoma, a painful scarring of the inside of the eyelid which causes blindness. In Pokot county. West Pokot is one of the trachoma en-demic districts surveyed in 2014 by the govern-ment of Kenya. It was found to have a preva-lence of active trachoma of 26.6 per cent for children aged one through nine, of whom nearly six per cent had developed blinding trichiasis. The WHO defines trachoma as a district-wide public health problem when active disease and trichiasis prevalence are equal or above 10 per cent and one per cent respectively.

This makes West Pokot’s position extreme. But, for the first time, the county government has scaled up commitment to eradicating tra-choma through specific budgetary allocations of over 10 per cent of the health budget allocation, which is the highest allocation ever.

Such regional tuning is the aim in serving Kenyans, and the grail, as public service grapples with divisions of responsibilities and procedures to enable more regionalised health care.

-AFRICAN LAUGHTER

DEVOLUTIONBY BOB KOIGI

Kenyatta National Hospital in Nairobi.


XVFriday August 1, 2014 | BUSINESS DAILY

VaccinesFor a long time in Africa, the three main causes of child deaths for those below 5 years have been malaria, pneumonia and diarrhoea. Through R&D, development of vaccines and partnership with global funding groups, GSK has assisted in reducing the impact that these illnesses cause.

In Kenya, two GSK vaccines are in current use in government-led universal mass vaccination programs to tackle pneumococcal illnesses and rotavirus caused diahorrea. The company, together with other partners, is a pioneer in malaria vaccine research and recently submitted a regulatory application to the European Medicines Agency (EMA) for its malaria vaccine candidate, RTS,S, under the Article 58 evaluation1 procedure to be conducted by the EMA in collaboration with the World Health Organisation.

1. The European Medicines Agency’s Article 58 evaluation procedure allows the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) to give scientific opinions, in co-operation with the World Health Organization, on certain medicinal products for human use intended exclusively for markets outside of

the European Union.

GSK donates drugs to fight killer disease

Lymphatic Filiarisis (elephantiasis) Programme GSK has donated over 4 billion tablets of Albendazole to help fight lymphatic filariasis (LF) and intestinal worm infections. Our albendazole, which kills the parasitic worms that cause the infections, has reached over 600 million people -- nearly 200 million of whom are children -- since the start of our donations in 2000.

Since 2001, Kenya has received 12 million free Albendazole tablets. With leadership from the World Health Organization (WHO), we aim to donate as much Albendazole as needed to treat the 1.3 billion people who are at risk from this mosquito-borne disease.

children globally who live in countries where intestinal worms are endemic.

In 2013, Kenya received the first shipment of 10,918,040 tablets and has dewormed 5.9m children against a target of 5m children. This donation is managed by the Ministry of Health and Ministry of Education.

Trust in ScienceSince 2012 GSK has funded the Trust in Science initiative designed to help build and support sustainable, long-term independent scientific research based in East African economies. The first grants through this programme in 2013 were awarded to three scientists, two from KEMRI and one from Egerton University. Their area of research awarded was on neonatology, nutrition and HIV. The winners for 2014 will be announced soon.

Save the Children –‘Boresha’ Programme in BugomaIn 2013, GSK globally committed to a 5 year strategic programme with Save the Children where we combine our expertise, resource and influence in the

GSK is a global pharmaceutical company. Whose mission is to improve the quality of human life

by enabling people to do more, feel better and live longer. We serve our mission by delivering quality medicines and vaccines and also via community partnership programmes and collaborations with like minded organisations.

area of health to make a difference in maternal and neonatal health. Kshs 600 million will fund Save the Children’s policy, advocacy and operational research work as well as supporting direct interventions in Bungoma for a 5-years period. The flagship programme known as Boresha was formally launched on 4th July in Bungoma at Bumula Health Centre.

Employees contribute to this via our Orange United fund raising activities.

Kombewa District HospitalGSK has partnered with the County Government of Kisumu to put up a maternity unit. The new upgraded facility will have a capacity of carrying out 4,000 operations a year, 2 theatres for caesarian section and other operations, a 40 bed pre and post natal ward, 3 delivery units with potential to increase the delivery capacity 10 fold, room for 8 incubators, doctors rooms, nurse stations, offices and stores. The cost of upgrading this facility and the equipment will cost shs 78m and this is to be cost shared at 50/50 basis. The facility is expected to deliver its first baby in December 2014.

HE. Mwai Kibaki and Hon. Beth Mugo, then Minister of Health during the Pneumococcal vaccine launch in Kenya on 14th February 2011.

John Musunga, MD, GSK

School De-worming Programme Soil-transmitted Helminth (STH) infections (intestinal worms) can stunt growth and cause anaemia and malnutrition. They can impact a child’s ability to learn and affect their performance at school.

According to the World Health Organisation (WHO), de-worming can result in immediate improvements in child health, leading to increased growth rates, better school attendance and performance, improved iron status, and a decline in anaemia. WHO recommends treatment of all children in endemic areas with anthelminthic drugs to reduce and control intestinal worm infection and illness.

In 2011, GSK made a commitment to contribute to the school children deworming programme for a five year period with the aim of donating two billion more Albendazole tablets by 2020 to treat intestinal worms. This will help achieve the WHO’s target of reaching 75% of school

In Kenya, two GSK vaccines are in current use in government-led universal mass vaccination programs to tackle pneumococcal illnesses and rotavirus caused diahorrea.

XVI BUSINESS DAILY | Friday August 1, 2014

As the huge scale of county government un-derspend on health emerges, Kisii stands out as having prioritised health, allocating

10 per cent of its 2013-2014 budget to improving health access for its people. It has emerged among the top three counties with high health budget al-location, according to a Commission on Revenue Allocation report.

The Sh1.9 billion budgetary allocation means the county will spend Sh2,555 on each of its residents to improve their health infrastructure compared to other counties that have allocated health budgets as low as Sh24 per person. Kisii’s spend represents 10 times more than the combined total of the bottom five counties. The health master plan for the county tar-gets reducing the most prevalent diseases in the area, bridging doctor patient ratio, and investing in mod-ern medicine to cater for its 1.2 million citizens.

Currently, Kisii is served by 32 community health units, 84 dispensaries, 28 health centres and 14 hos-pitals. The county has 41 doctors and 504 nurses, among other health workers.

The biggest medical headaches for the county are malaria, diarrhoea, skin and respiratory diseases, which account for the largest percentage of deaths.

A rising rate of new HIV infections, currently stand-ing at 8.9 per cent, way above the national average of 5.6 per cent, has also caught the county government’s attention. Through public private partnerships, Kisii Level Five Hospital, set up in 1916, has been receiving a complete make over.

In collaboration with Kenya Commercial Bank, the county government set up a Renal Unit for kidney patients. Chase Bank has also renovated and equipped the Orthopaedic ward at the hospital, while Care Kenya has provided Orthopaedic diagnostic equip-ment. Kisii Level Five is one of the major hospitals in Nyanza region, serving Kisii, Nyamira, Migori, Homa Bay counties and parts of South Rift.

Another flagship project, now in its final stages, is turning Kisii Level Five Hospital into a teaching and referral facility, which has received approval from the Kisii County Assembly. A memorandum of understanding has been signed between the county government and Kisii University and teach-ing protocols, including finalising of a curriculum, are now underway.

According to Kisii University vice chancellor Prof. John Akama, upgrading the hospital will reduce the cost of travelling to seek specialised medical treat-ment in Nairobi, Eldoret and India. With investment in modern technology the hospital can now attend to patients with more ailments. The University’s Medical School will use Kisii Level Five Hospital as its Teaching Hospital when it admits the first medi-

cal students by September 2014.Another initiative funded by the county govern-

ment has seen Kisii County enter into a Memorandum of Understanding with Kenya Red Cross Society to provide advanced pre-hospital emergency medical services in all the nine sub-county hospitals within Kisii County. This includes the roll out of nine state of the art 4x4 Toyota LandCruiser ambulances, which are manned by nine paramedics and nine EMT’s, trained and qualified in pre-hospital critical care management. The fleet is now stationed across the nine constituencies.

“My government has placed high priority on im-proving the health sector. This sector has for long faced challenges, including inadequate financing, dilapidated physical facilities, unreliable supply of drugs, absence of adequate medical equipment and shortage of qualified medical staff,” said Kisii Gover-nor James Ongwae during the launch.

The county government has also signed an MoU with investors to set up the new health care facilities in the county, including a state-of-the art diagnostic laboratory, an endoscopic unit in Kisii and theatres in all nine sub-county hospitals.

The county government has also advertised to employ more than 15 medical specialists to add to the 81 already working in various health centres in the County. More than 30 clinical officers will also be employed and posted to all sub-county health cen-tres. In partnership with Care International Kenya, all sub-county health facilities have also received a number of medical equipment and machines.

The county’s next focus is developing an aggres-sive health campaign against communicable and non communicable diseases and an efficient and responsive patient referral system. The county hopes to have halved endemic diseases in the next two years in a resolve guided by the mantra of keeping diseases at bay for a productive workforce.-AFRICAN LAUGHTER

Kisii p≥io≥itises healthca≥e as it combats p≥evalent diseasesIt has been ranked among top three counties that have allocated higher health budgets. Its spend is 10 times more than the combined total of the bottom five county governments

COUNTY FOCUSBY BOB KOIGI

Patients wait for services at a county hospital. FILE


XVIIFriday August 1, 2014 | BUSINESS DAILY

than a Caesarean birth. A vaginal birth is also better for future fertility. “A lot of women come to the clinic with their minds set on Caesarean delivery as opposed to vaginal birth. As a policy, we sit them down and advise them not to go through with it by giving them both merits and demerits and circumstances sur-rounding Caesarean and vaginal births. Most of the times we manage to convince them in favour of vaginal delivery,” adds Dr. Ong’ech.

The risks of Caesarean deliveries include complications such as endometritis - an infection of the uterus - bladder damage, blood clots surrounding the uterus, haemorrhaging and the most common of them, sepsis, which invades the bloodstream when the Caesarean wound remains open. Sepsis is frequently fatal.

About half of all women who have Caesarean also suffer ad-hesions, which are bands of scar tissue that can make organs in the tummy stick to each other, or to the inside of the tummy wall. Adhesions can be painful because they limit the movement of internal organs.

It additionally takes many weeks for the wall of stomach mus-cles to reknit after a C-section, with women advised not to drive or lift heavy objects, and initially having difficulty walking.

To engender such risks and consequences perhaps speaks to misinformation. It is even questionable whether sexual function and vaginal contraction are diminished after vaginal delivery. There are few studies into this and those that have done report a weak correlation. “Sex is all in the mind. Pleasure after delivery should remain the same,” says Dr. Ong’ech.

BY RITA NJOROGE

For the families left behind when a mother dies from an elective Caesarean-section, the rise of the C-section as a medical fashion holds a terrible aftermath.

Yet despite the greater risks, longer time in recovery and per-manent physical damage, C-sections have become a seeming ‘must-have’ for Kenya’s urban elite.

For example, Jennifer decided to undergo elective surgery instead of vaginal birth four months into her pregnancy without any clear medical reason. “I think I am too posh to push. I cannot imagine myself going through labour for more than 15 hours. I have heard lots of scary stories as far as labour is concerned. Why go through all that while there is another option?” she says.

Victoria, a lawyer in Nairobi who also opted for a C-section, is another in a generation of women that is choosing surgery because they claim natural birth comes with complications like tearing, long hours in labour, incontinence, the psychological and physical pain of pushing, and resultant changes in the origi-nal size of the vagina.

Some reported cases of poor treatment by health workers in some hospitals does not help the situation either. As a result, working class women are using their medical insurance to cover the high cost of C-sections. But there is a growing concern that unnecessary C-sections are causing deaths and long term damage by putting women through a procedure meant for emergency use only. When correctly administered, C-sections can prevent fatal obstetric outcomes. Moreover, C-section delivery rates are generally low in sub-Saharan Africa, according to a World Health Organisation study. Ten study countries in sub-Saharan Africa had national rates of less than 2 per cent and only five countries – Ghana, Kenya, Lesotho, Rwanda and Uganda – had national rates of more than five per cent. These figures, however, only reveal the average percentage rate of total live births for the whole population.

C-section delivery is more common within the urban popula-tion, and much more common among the rich. The WHO data collected from 2003 to 2011 reveals that, in Kenya, C-section deliv-ery among the rural poor was 3.21 per cent of total live deliveries compared to 9.41 per cent among the rural rich. In urban areas, C-section delivery was 2.69 per cent among the urban poor and 11.16 per cent among the urban rich. Such high rates have never been necessary, historically, to achieve lower maternal mortalities. In the Netherlands, for example, maternal mortality had fallen below 20 deaths per 100,000 live births by 1950, when C-sections were associated with less than 2 per cent of live births.

“Generally the high increase in Caesarean section deliver-ies is being advanced by the development of fetus monitoring and pregnancy throughout the country. However, we cannot rule out the few conspicuous private institutions that are push-ing pregnant mothers towards Caesarean delivery for personal benefits,” said Dr. John Ong’ech, Assistant Director and Head of Department Obstetrics and Gynaecology at Kenyatta National Hospital. As Dr.Ong’ech explains, the bottom line is that if there are no complications with your pregnancy, a vaginal birth is safer

Women igno≥e ≥isks, choose C-section ove≥ natu≥al bi≥th

C-section de-livery is more common within the urban popu-lation and much more common among the rich.

Some urban women now think they are ‘‘too posh to push’’ turning an emergency procedure into a ‘‘must-have’’ in the labour wards

“A lot of women come to the clinic with thei≥ minds set on Caesa≥ean delive≥y as opposed to vaginal bi≥th. As a policy, we sit them down and advise them not to go th≥ough with it by giving them both me≥its and deme≥its and ci≥cumstances su≥≥ounding Caesa≥ean and vaginal bi≥ths. DR. JOHN ONG’ECH, ASSISTANT DIRECTOR AND HEAD OF DEPARTMENT OBSTETRICS AND GYNAECOLOGY AT KENYATTA NATIONAL HOSPITAL.


XVIII BUSINESS DAILY | Friday August 1, 2014

BY BOB KOIGI

One in every five Kenyans walking into a hospital dies due to wrong diagnosis or procedures that go wrong, according to

medical practitioners.Even more startling is the admission by patholo-

gists that up to half of the deaths are not recorded because proper post-mortems are not conducted on people who die during medical care.

This paints a grim picture on the reality in Ken-yan hospitals, where no hospital is required to keep and submit records of the number of deaths by ac-cident, misdiagnosis, procedures that go wrong, or post-operative complications such as sepsis.

Those who actually keep the records remain stuck in manual systems that are subject to files disappearing or being manipulated. The entire process from registration, triage, diagnostics and therapy are all paper-based, leading to the poor and inefficient use of health records. At one private hospital in Thika, doctors admitted that the patient filing system is just a formality, with the doctors not keen on referring to the files when attending patients. According to some of the hospital doc-tors, they have never visited a patient’s file, even if a patient has been there before. This explains why the hospital that handles on average 100 patients a day has recorded one of the highest cases of wrong-ful diagnosis, which has even lead to death. It was among hospitals that were put under probe by the Ministry of Health. Yet the mayhem reverberates across the country, with the medical provisions on

patient data remaining vague and fanning medical negligence at the expense of patients’ survival.

Having a patient’s records means that the doctor can quickly access the patient’s medical history in a timely and accurate manner. If a patient arrives un-conscious at the emergency room, the doctor would still be able to know their blood group, allergies, cur-rent ailments, and medication, among other details that can be critical to the patient’s survival.

Indeed, pilot projects digitising medical records have returned positive results in saving lives, while

minimising the time it takes for doctors to track the medical history of patients. A study conducted in clinics in Eldoret, Kenya, evaluating the impact on quality of using electronic medical records, in 2011 reported that computer-generated reminders about overdue tests yielded nearly a 50 per cent increase in the appropriate ordering of CD4 blood tests. CD4 counts are critical to monitoring the health of pa-tients with HIV and guiding treatment decisions. In reality, many HIV-positive patients are taken care of by people whose training is similar to that of nurse practitioners, and who are overworked and only getting busier. “Finding innovative ways to improve care within these constraints is critical. This study shows how electronic medical record systems with clinical decision support capabilities can help fill this need,” said Dr. Were assistant pro-fessor of medicine at the Indiana University School of Medicine, which was behind the project.

The system used in the study is called OpenMRS, an open source electronic medical record system widely used in the developing world. The clinics are part of the Academic Model Providing Access to Healthcare (AMPATH) programme, which cares for more than 120,000 HIV-infected adults and children at 25 main clinical sites in Western Kenya.

A digital health care management system that links clinics across the country under the Kenya Medical Women’s Association project is also assist-ing doctors attend to as many patients as possible within the shortest time. Partnering with Dactari Health, the programme has allowed its 400 mem-bers to incorporate the Afya Digital Doctor (ADD) software to digitise outpatient services, freeing up doctors to attend to patients. The software enables doctors to send automated reminders to patients via text messages about appointments and results of medical tests. The system can also interlink the member clinics for the health specialists to share knowledge.

Errors“A patient with a gynaecological problem in Kis-umu can get real time feedback from a specialist in Nairobi without having to travel, saving costs and time,” said Kemwa chairperson Dr. Praxedes Oku-toyi. It is this positive feedback from the pilots that has also seen the government through the Minis-try of Health embark on creating Information and Communication Technology (ICT) Standards and Guidelines for the Health Sector.

The guidelines focus particularly on electronic medical records (EMR) to address the medical may-hem in the country, with the government rolling out the EMR system to over 600 medical facilities coun-trywide. The superior quality of EMR compared to the manual filing system that currently exists is that the EMR will allow physicians and staff to document interactions with patients, view medical histories and insurance information, make referrals, order laboratory tests and view test results, and send elec-tronic prescription requests to pharmacies, which reduces the risk that hard-to-read handwriting will lead to medical errors, and cause potentially harm-ful drug interactions. The guidelines will also make it possible to access doctors’ professional resumes and achievements such as specialisation, research, number of surgeries done, and how many of their patients have died.

Digital medical records have also been hailed as key to providing the statistics necessary to show disease trends and prevalence rates and thus help forecast potential outbreaks. The health records according to the Ministry of Health will be stored at a national data centre, providing medical research-ers with an opportunity to consult with doctors in other countries and share best practices as well as new knowledge in the health profession.-AFRICAN LAUGHTER

Digitised hospital ≥eco≥ds keep docto≥s on the ale≥tWrong diagnosis and failure to keep or update patients’ medical files has been blamed for one in every five deaths at Kenyan hospitals

A patient with a gynaecological p≥oblem in Kisumu can get ≥eal time feedback f≥om a specialist in Nai≥obi without having to t≥avel, saving costs and time.”

DR. PRAXEDES OKUTOYI, KEMWA CHAIRPERSON

Manual records of patients are prone to disappear-ing or being manipulated.


XIXFriday August 1, 2014 | BUSINESS DAILY


Access to healthcare is more limited in Africa than anywhere else in the world, seeing the continent bowed down with health issues, but new research and innovations are opening the way to accelerated progress in health are.

The vinegar swab provides a cheaper alternative to the

pap smear test, which requires laboratories with expensive equipment to test the samples.

innovations

Giant African pouched rats can evaluate more samples in ten minutes than a lab technician can in one day

Transgenic mosquitoesGenetically Modified mosquitoes can reduce global Malaria disease burden

WinsengaThe application uses a sound logarithm to monitor the feotal heart rate

Cervical cancer vinegar swab testWhite vinegar used in home testing to slash killer cancer

deaths

Portable eye examination kitA smartphone

is used to diagnose Cataract

Glaucoma and Trachoma to

prevent blindness

Compiled by Sandra Chao/ Infographic by Millie Wachira

30% According to the World

Bank, 30 per cent of the nine million new cases of TB reported globally are in Africa. While the disease is preventable and curable, many people continue to suffer and die without treatment. Others who default on the medication develop more complex forms of multi-drug resistant and extensively drug resistant TB.Apopo, a Belgian non-

governmental organisation based

in Tanzania with operations in Mozambique, Thailand, Angola and Cambodia, has developed a technology that enables rats to detect tuberculosis.

The company, which also trains rats to detect mines, relies on the fact that they have an exceptional sense

of smell and are easily trainable.According to Apopo, one of their

rats can evaluate more samples in ten

minutes than a lab technician can in one day. So far, the company has trained 54 TB detection rats at their Morogoro research centre and is collaborating with 21 TB clinics in Dar es Salaam, screening over 200,000 sputum samples since 2007. The rats have, since January, also been used in eight health units in Maputo to help with faster disease detection.

2.7m of new cases of TB reported globally are in Africa.

Three Ugandan computer science students have also taken up the technology challenge, to create a mobile phone aide for pregnancy and childbirth.

2 in 5 pregnant mothers in Africa attend the minimum 4 recommended antenatal visits. This is according

to the World Health Organisation.

800 women a day die, globally, from preventable causes related to pregnancy and childbirth, half

of them in subSaharan Africa.

8m children a year die before delivery, or in the first week of life, mostly as a result of preterm birth, birth asphyxia

and infections.

But the student trio has developed a mobile application based on the Pinard horn - developed by a French doctor two centuries ago to listen to the vital signs

of a baby. The Winsenga kit is made up of a plastic trumpet similar to the Pinard horn, but attached with a microphone to a Windows phone loaded with the application.

Using a sound logarithm, the kit can monitor the feotal heart rate and indications of the baby’s overall health, without electricity, and advise the midwife

appropriately.

Another innovation that could transform the continent’s fight against malaria is transgenic (genetically modified) mosquitoes.

2010 year researchers

at the John Hopkins Malaria Research

Institute found that the anopheles mosquito could be engineered to block the transmission of malaria causing parasites to humans.

2012 year researchers

from the University of California succeeded

in injecting the male anopheles mosquito with a killer gene.

Since then, several companies have come up with genetically modified mosquitoes. Oxford-based biotech company, Oxitech, which has successfully developed GM mosquitoes that are resistant to dengue fever, is conducting research to develop a sterile male anopheles in order to reduce the wild population.

In March this year, Oxitech received approvals for commercialization of their dengue resistant transgenic mosquitoes in Brazil.

However, scientists in Nigeria have called for further investigations into the possible impact of releasing the modified mosquitoes before releasing them in Africa. According to a study in the April edition of the Malaria Journal: “The main concerns expressed by the scientists were that Genetically Modified Mosquitoes (GMMs) can spread in an uncontrolled way beyond their release sites and will mate with other mosquito species to produce hybrids with unknown consequences.

Most participants agreed that it was important that before approving the release of GMMs in Nigeria, there had to be evidence of contingency measures available to remove the GMMs should a hazard become evident during the course of the release.”

White vinegar, which has for years been used in cooking, is now proving to be an essential within the medical field in Sub-Saharan Africa helping to prevent one of the most common killer cancers among women.

250,000 women a year succumb to cervical cancer, with

nearly 80 per cent of them living in low income areas, according to WHO estimates. With the vinegar swap test, it is estimated that 73,000 deaths a year can be prevented. Cervical cancer is easily

treatable if caught early, and the cheap and easy detection test approved for use by the World Health

Organisation in 2010, is gaining

popularity quickly.While the organisation has been

running trials of its Visual Inspection with Acetic acid (VIA) program in Malawi, Madagascar, Nigeria, Uganda, Tanzania and Zambia, the technique is also catching on in Burkina Faso and the rest of Africa.

White vinegar is diluted with distilled water, before the mixture is swabbed

on the cervix, after which the cells are observed for change. If the cells in the cervix turn white, they signal a positive response and a biopsy can be done to confirm the presence of cancerous cells. If they remain pink, it indicates a negative result.

The uptake of mobile technologies and penetration of the internet within sub-

Saharan Africa has opened the door to numerous mobile

technologies.

Led by ophthalmologist Andrew Bastawrous, a team from the

London School of Hygiene and Tropical Medicine has developed attachable hardware and a mobile application to create a Portable Eye Examination Kit (PEEK) on a smart phone.

295m people are

blind or visually impaired globally, with 90 per cent living in

poor countries. Yet, according to the WHO, four out of five cases of blindness can be avoided, with Africa accounting for 16 per cent of avoidable blindness cases, as a result of cataracts, glaucoma, corneal opacities, trachoma, childhood blindness and river blindness.

For most of these conditions, the blindness is due to the lack of access to affordable healthcare, particularly in rural areas.

But the smart phone now offers a cheap, portable diagnostic

kit. The smart phone’s lens scans the patient’s eye and the camera’s flash light checks the retina for any ailments.

The application also has a shrinking letter that offers a

basic eye test. The patient’s data can be keyed into the phone and their information and the pictures taken emailed to eye specialists anywhere in the world.

Peek is currently undergoing trials in parts of the Rift Valley in Kenya. The trials, which began late last year, are seeking to diagnose and treat 5,000 people and at the same time compare the data collected with the smart phone to other conventional eye testing equipment.

90% of people

who are blind or visually impaired globally are living in poor countries.

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AFRICA 5 TOP

TB sniffing rats

XX BUSINESS DAILY | Friday August 1, 2014

Two white trucks queue at the Kenya Medical Sup-plies Authority (Kemsa) warehouse in Embakasi, Nairobi, waiting for medical supplies.

Carefully, staff inside the warehouse verify the orders, before loading them into the waiting trucks.

The routine is repeated for all the four requests received from Ololung’a sub-district hospital in Narok South.

The supervisor cross checks the delivery note and veri-fies the batch number of the products, the quantity, box numbers and expiry dates, before releasing the truck.

The same note is also signed by the security office at the warehouse, and the truck driver, before he is issued with two copies, which the clinics will also check to approve the quantity and type of drugs delivered.

“Drugs with a shelf life of less than six months can’t pass through the system (an Enterprise Resource Plan-ning-ERP system),” said Joshua Obell, operations director, Kemsa Embakasi warehouse. The ERP is part of Kemsa’s changing face.

Seven years ago, Kemsa was an institution whose name was stained, with Kenyan trust lost to alleged corruption and inefficiencies.

To clean it up, the government constituted a task force,

in 2005, which reported that the authority had failed to perform its role owing to its dependency on funds from the ministry, parallel funding from the government and aid agencies, divergent medical commodity procurement con-ducted by the Ministry of Health, and mismanagement.

The ‘spaghetti’ way of funding, as Kisumu senator Ayang’ Nyong’o (the then minister) termed it in a parlia-mentary debate, had complicated Kemsa’s operations.

It was, therefore, resolved that all the funds be fun-nelled into one basket. The ministry was also relieved of drug procurement and the role left solely to Kemsa. The Kemsa Act, 2013 saw it change its name from an agency to authority, redefined its mandate to be a commercial outfit, and saw the government, in 2013, gave the authority its assets, including stocks.

Under the new law, the authority now procures ware-houses and distributes drugs and medical supplies for public health programmes, the national strategic stock reserve, prescribed essential health packages, and national referral hospitals. It also provides consumption data to county and national government, which is critical in pro-jecting future consumption.

The law also stipulates that Kemsa ‘establish a network of storage, packaging and distribution facilities’.

“We are also required to work with county government in strengthening supply chain systems and structure. It’s not for Kemsa to load on counties but a collaborative ef-fort,” said Dr John Munyu, the Kemsa CEO. To this end, the authority is currently in discussion with Marsabit on logistics. “We engage them separately, because each county has wants that are unique and different and therefore we serve them as such.”

Since July 2013, Kemsa has managed to sign memo-randa of association with all 47 counties. Murang’a and Mombasa were the last to be roped in.

“We are operating a ‘commercial model’, in quotes. We have stock, counties buy, and we replenish our stock using

Medical agency goes comme≥cial to att≥act county gove≥nmentsKemsa changes tack, polishes systems to attract devolved units that are now in charge of basic healthcare facilities

Dr John Munyu, Kenya Medical Supplies Authority CEO, at the North Rift Warehouse in Eldoret town during a fact finding mission.JARED NYATAYA

the money we get from counties, and therefore the funda-mentals of marketing should apply,” Dr Munyu said.

In fact, some 70 per cent of money that runs Kemsa doesn’t come from the Exchequer. The government only contributes minimally towards Malaria and HIV/Aids drugs and test kits and commodities for referral hos-pitals.

Kemsa has various partnerships with aid agencies, including the World Bank, Global Fund, USAid and the Danish government, on system strengthening and gov-ernance. The US government procures through Kemsa and pays for the services.

“This is how we make the 70 per cent,” said Dr Munyu. But Kemsa’s main clientele is now the county govern-ments. The Transition Authority, in a gazette notice this year, requested counties to consider the authority as the first point of call. “That, for me, makes sense because there is no need to leave commodities lying in govern-ment warehouse,” said Dr Munyu.

“We work like a supermarket. Counties give us the list of needs, we issue a pro forma invoice and they prepare an invoice as we prepare the order. Most counties give us instructions to deliver to the facilities,” he said.

In the former model, Kemsa worked on directions from the ministry. This delayed supply of medical com-modities leading to stock outs.

However, nothing stops the counties from sourcing for specific items elsewhere. “Because of unique needs, we may lack an item. It’s not practically viable for us to stock everything. In this case, the Act doesn’t force them to source from us. But if certain items are repeated, our marketing team will alert us to stock needs.”

FacilitiesKemsa has an upper hand in medical logistics, across in-frastructure, commodity stocks, and a map of all health-care facilities in the country. This saw the Medicine Price Survey conducted by USAid in 2006 and 2010 rate it the best amongst similar procuring entities. But the Mission for Essential Drugs and Supplies (MEds) founded 28 years ago is among the institutions that coexist beside Kemsa. Meds serves faith based organisation. This year, it was also contracted by 22 counties to supply medical com-modities worth Sh300 million.

But where Meds supplies 3,900 types of drugs and medical supplies to 2,000 health facilities in the country, Kemsa serves 6,000 county health facilities and 5,047 HIV/Aids testing sites.

It still grapples, however, with the old problem of ex-pired drugs. Three months ago, the dailies run a story on expired supplies in government clinics. But Kemsa points the blame to health facilities that don’t apply proper drug handling procedures.

“The rule is: first in, first out. But some health facilities don’t do it. They use recent stock, thus piling up old stock, which ends up expired,” said Dr Munyu.

According to a report conducted in 2012 by the minis-try dubbed ‘Towards Universal Access to Essential Health Products & Technology in Kenya’, untrained pharmacists at public clinics are the source of this problem.

“The number of pharmaceutical personnel deployed to public facilities in 2010 was 684, 25 per cent of the norms and standards for the provision of the essential health package. This understaffing puts at risk patient safety and contributes to other shortcomings of the health sys-tem- stock-outs, inadequate stock records, inadequate labelling and poor medicines’ storage and handling,” reads the report.

“Kemsa and Meds maintain adequate records, but public facilities have only about 77 per cent adequacy of stock records, compared with 83 per cent in faith-based health services facilities,” said the ministry’s report.

Kemsa and the other drugs and medical procurement agencies are also actively engaged in quality control.

As a result, Meds last month reported that cases of counterfeit drugs have dropped significantly in the last 16 years. According to Paschal Manyuru Meds Manag-ing Director, the failure rate of drugs tested at its labo-ratory had declined from 13.2 per cent in 1997 to 1 per cent in 2013.

HEALTHBY EVELYN SITUMA


XXIFriday August 1, 2014 | BUSINESS DAILY

BD Reporter unearths

The problem?

The solution?

How it works?

Companies and/or

scientists producing

them?

and facts about the

latest cutting

edge health

inventions globally.

GLOBAL

innovations5

Ingestible Sensors ‘Smart pills’Grain size sensors are embedded on pills and taken orally along with other medication to monitor the effect of a drug on a patient and how their particular organ respond.

Breast tomosynthesisA technique that uses 3D technology to screen for breast cancer to determine the exact size of the tumor and appropriate treatment

Bionic eyeThe Bionic eye, which is also referred, to as a visual prosthesis is designed to restore functional vision for those with sight problems.

OptogeneticsThe use of light to manipulate

the brain. Currently in trials with mice. technology has since proved successful in

trials where mice whose sensitised neurons were

targeted with light did not react to pain stimuli

3D bio-printingWhere human

cells are printed using modified 3D

printers.

Compiled by Sandra Chao/ Infographic Millie Wachira

Lack of a way to monitor and measure exactly how patients react to particular medication or treatment therapies given over time creates a challenge within the healthcare system. There is also no way of monitoring strict adherence to taking medication as per the dosage and times indicated.

The smart pill offers medical professionals with

a more accurate way to better monitor and treat chronic conditions without the need to have physical checkups. They also reduce the innovation time for pharmaceutical companies as patient’s reactions during trials can easily be detected.

The sensor is embedded on a

pill and taken along with other medication. Once it is swallowed it captures the actual

time of ingestion and begins to monitor various health indicators like respiration, health rate and mapping the path taken until medication is absorbed.

The sensor, which is powered by body fluids, transmits data of the physiologic responses to a battery powered transdermal patch.

The patch then transmits the information to a Bluetooth enabled device which has an application to interpret the

collected data.The ingestible sensors are

currently being produced by California based drug company Proteus Digital Health in collaboration with global pharmaceuticals Novartis and Ostuka Pharmaceuticals.Europe approved the use of the smart pill in 2011 and the American Food and Drug Administration (FDA) approved use of the drug in 2012.

285m people are visually impaired worldwide, according to the World Health Organisation

estimated and of these, 39 million are completely blind. 90 per cent of the 282 million liveg in developing countries and this contributes to their mobility as well as their ability to be financially independent.

The camera captures and processes images in real time while the implant converts the images into electrical impulses that are transferred by the optic nerves to the brain.

The device is currently undergoing human trials and the trials which began last year have begun showing signs of success.The first retinal prosthesis received approval for clinical and commercial use in Europe in 2011 after more than two decades of research and development.

At the moment visual prosthetics have attracted attention of several companies and researchers including the Bionic Vision of Australia, a consortium of Australian researchers,

the Second sight company which is marketing their Argus retinal prosethesis as well as the retinal implant fronted by MIT and Harvard researchers.

80% of all visual impairment can be avoided or cured. WHO

>0.5m women die annually

from breast cancer. Breast cancer is the top cancer in women both in the developed and the developing world. The main problem, especially in developing countries, is lack of early detection so many women end up going for treatment when it is almost too late.

At the same time in 2 dimensional breast cancer screening, some of the tissues appear layered and it becomes difficult to tell the exact location and size of a lump.

Tomosynthesis offers better sensitivity and sharper x-rays making detection

of breast cancer faster and more precise.It also eliminates the layering problem brought about by 2d mammography meaning fewer women a recalled to have another screening.

The technology uses is similar to that used in 2d

breast mammography only that

the images of the compressed breast are taken from a multiple angle.

The data collected is then reconstructed to generate images that take into account the height dimension enabling the radiologists to view each layer of tissue during screening so that they can pinpoint the size, shape and location of any abnormalities.

It also enables earlier detection of a small lump within the tissue and which can be confirmed as cancerous through a biopsy.

One of the main manufacturers of breast tomosynthesis equipment is medical imaging

systems manufacturer Hologic. The 3d screening system was first approved for use in America in 2011 and is now widely used in Europe as well.

50% of breast cancer

cases and 58% of deaths occur in less developed

countries. WHO

There is still little knowledge on precisely

how neurons operate an this discovery could help in understanding diseases like Parkinson’s and epilepsy better.

The use of light to manipulate brain cells to act

in a particular way. combination of genetics and optics to control well defined events in a specific cell/cells in a living tissue.

2005 Year

Optogenetics was first discovered, by two scientists Karl Deisseroth and Ed Boyden who inserted a light sensitive gene from green algae to specifically cultured neurons

Light sensitive proteins are inserted into cells

allowing scientists to turn off or on neurological activity more accurately.

Also has potential of providing better treatments for depression and other neurological disordersTrials done in mice have shown that altering the motor neurons with light exposure can make them start running as well as able to control pain and fear.

Francis Crick in during a lecture at the university of California

in 1999 hinted at the possibility of using light to selectively control neural activity

With increasing need for body transplants and properly fitting

prosthetics scientists are looking and having moulds made from a patient’s own biomaterial in order to make them a better fit.At the same time drug testing takes a long time because several trials but with bioprinted cells it is easy for drugs to be tested without actually affecting an individual.

Cells are extracted from a patient through a

biopsy, cultured and allowed to multiply in Petri dishes. When an adequate amount is collected it is fed into the modified three dimensional printers to be used as bio-ink.The ink is programmed to arrange different cell types that are printed in layers, with a layer of hydro gel in between and molded into a precise 3dimensional shape. The gel is removed once the cells fuse and the 3d mould is then placed into a bioreactor where the cells grow into their final form.

At the moment US startup Organovo is the only one

that is involved in aggressive commercial bio-printing. Last year, Hangzhou Dianzi

University in China announced that it had created a biomaterial 3D printer Regenovo but it is yet to be established if they will pursue the actual printing with the new bioprinter.

Progress made so farIn 2008 Japanese scientist Makoto Nakamura modified the inkjet technology by creating a bio-printer that printed bio tubing similar to blood vessels.Since then the industry has grown driven mainly by the development of more sophisticated printers, refined software and advances in regenerative medicine.

2010 Year Commercial bio-printing begun.

In 2013, Researchers from Princeton University printed a ’bionic ear’ using a modified ink-jet printer onto a petri dish which was cultivated for 10 weeks and was demonstrated to be able to “listen” to music.

2013 Year a two-year-old child in the US

received a windpipe built with her own stem cells.

2014 In May, Chemical engineering

students at the University of Connecticut used 3D printing to develop two prototypes for an

artificial kidney.

In April, Chemistry professor Hagan Bayley and his team from the University of Oxford designed a customised 3D printer that can churn out thousands of fake-flesh cells at a time.

Researchers in Japan have also been able to create a 3D bio-printer that is able to print bones.Researchers at the Cardiovascular Innovation Institute have already bioengineered a coronary artery and printed the smallest blood vessels in the heart used in microcirculation using bespoke 3D

The move by a Virginia foundation to announce award of $1 million prize for the first organization to print a fully functioning liver has spurred a lot of interest in liver bio-printing with Organovo making headway by having successfully printed a few layers of liver tissue.

The small 3D bioprinted kidney printed by Hangzhou

DianZi University researchers last year was able to last for four months

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XXII BUSINESS DAILY | Friday August 1, 2014

Chakrajmal village, in the Bijnor district in the North Indian state of Uttar Pradesh, got its first doctor in 2008. He was not based in

the village, though.The villagers had access to the doctor via a

telemedicine project launched by World Health Partners (WHP) to provide health care services to 1,000 villages in Uttar Pradesh’s Bijnor, Meerut and Muzaffarnagar districts.

Set up in 2008, WHP, a US-headquartered inter-national nonprofit, provides basic health care and reproductive health services by harnessing local market forces to work for the poor.

According to Gopi Gopalakrishnan, founder-president of WHP, the organisation’s model is to draw on private sector capacity through social franchising, innovations in labour management, and low-cost technologies to develop a scalable and sustainable health care service delivery model.

WHP’s Uttar Pradesh telemedicine network now comprises around 1,200 local individuals called Sky Care Providers and 120 entrepreneur-run centres branded as Sky Health Centres. The Sky Care Pro-viders are given training and low-cost mobile so-lutions by WHP to perform diagnostics, symptom based treatments, tele-consultations and, wherever needed, referrals to the Sky Health Centres.

These centres use remote diagnostic devices for measurement of basic parameters such as blood pressure, heart rate, electrical activity of the heart and pulse rate. The patients are connected to doctors

at WHP’s central medical facility in New Delhi via computers and webcams. The entrepreneurs have the option of leasing the equipment from WHP. For the patients, consultation charges vary from 20 US cents for below poverty line households to $1 (at the exchange rate of 50 rupees to a US dollar).

Patients who require surgery, inpatient care or specialised procedures that cannot be delivered via telemedicine are referred to the nearest WHP fran-chised health care clinic. Currently WHP has 16 such clinics in Uttar Pradesh. Since 2008, WHP has provided villagers in Uttar Pradesh with around 35,000 tele-consultations for common ailments such as fever, indigestion and gynaeco-logical problems.

Gopalakrishnan is now replicating this model in Bihar. Currently there are 104 telemedicine centres up and running in 13 districts of the state. He hopes to expand to 400 centres across 25 districts (cover-ing a population of 70 million) by end of 2012 and 1,250 centres over the next three years. Apart from treating basic ailments, Gopalakrishnan now also wants to focus on detection and treatment of tuber-

culosis, visceral leishmaniasis, childhood pneumo-nia and diarrhoea. “There’s a huge, unmet health care need in our rural hinterlands. The challenge is to make health care affordable for the masses and attractive to the providers at the same time,” says Gopalakrishnan. “Telemedicine is a good strategy to strengthen the existing human resources available

in health care. The scale, however, will come only through effective govern-ment intervention.”

According to Rana Mehta, execu-tive director and leader of health care practice at PricewaterhouseCoopers (PwC), access to health care in India “gets limited by the affordability factor and hence telemedicine — or the remote diagnosis, monitoring and treatment of patients via videocon-ferencing or the Internet — has a very important role to play. It is at a fairly nascent stage right now having started only about a decade back, but it is undoubtedly a fast-emerging trend, led by growth in the country’s information and communications technology sector.” K. Ganapathy, president of the Apollo Telemedicine Networking Foundation, past president of the Telemedicine Society of India and

adjunct professor at the Indian Institute of Tech-nology, Chennai, is categorical that telemedicine is the way ahead. “We can’t go far with conventional brick-and-mortal hospitals,’ he says.

Vijay Govindarajan, professor of international business at the Tuck School of Business at Dart-mouth College, not only sees India as one of the early adopters of telemedicine, he also notes that the country has the potential to develop innovations that can be adopted in other parts of the world, including developed nations like the US “In the United States, we are thinking of IT [information technology] as just electronic medical records,” Govindarajan says. “This shortchanges IT’s full potential. Driven by extreme need, India is inventing new ways to use information technology to improve health care.”

Potential Govindarajan lists the reasons why telemedicine will take off first in India: A severe shortage of doctors, especially in rural areas; very high patient volumes; widespread availability of mobile networks; rapid growth in the availability of low-power, hand-held medical monitoring devices, and the shift away from the proprietary, local area network-based medical image archiving and communications systems to a networked tele-enabled system.

“Innovations in telemedicine will accelerate in India, where access and cost are critical issues. These telemedicine innovations will be adopted in the US, where cost and access are becoming increasingly talked about. This is a classic reverse innovation story,” he adds.

A January 2012 report titled, “Global Tele-medicine Market Analysis,” by RNCOS Industry Research Solutions, an India-based market re-search and information analysis company, projects that the global telemedicine market will grow at a compound annual growth rate (CAGR) of around 19% from 2010 to 2015. An earlier report in 2009, titled “Global Telemedicine Market: 2008-2012Åç published by Infiniti Research, a London-based market intelligence firm, pegged the size of the global telemedicine market in 2008 at $9 billion. According to this report, Asia is the fastest grow-

Telemedicine to the ≥escue: How technology is tackling wo≥ld’s healthca≥e p≥oblems

Patients in remote villages are connected to doctors in cities through videoconferencing or the Internet where diagnosis, monitoring and treatment is done

KNOWLEDGE @

WHARTON

A video conference of the first telemedicine surgery conducted in Kenya.ORRESPONDENT


XXIIIFriday August 1, 2014 | BUSINESS DAILY

ing region for the telemedicine market with India and China leading the growth.

There are no clear numbers, though, on the current size of the telemedicine market in India.Murali Rao, associate vice president for health care at the New Delhi–based research and consultancy firm Technopak Advisors, es-timates the current size of the Indian telemedi-cine market to be around $7.5 million. “This is expected to grow at a [compound annual growth rate] of 20 per cent over the next five years,” he says. That would take it to around $18.7 million by 2017. Mehta of PwC on the other hand notes: “Studies indicate that the size of India’s telemedicine market is expected to be $500 million by 2015.” (This is a nascent area and estimates vary widely.)

Ganapathy of Apollo points out that 80% of India’s population has no direct, physical access to specialist health care and gives some back-of-the-envelope calculations: “Estimates suggest that the telemedicine market is at least for 800 million Indians. Even if half of these 800 million need to consult a specialist once a year, [that still amounts to] 400 million special-ist consultations per year. Even if 10 per cent of these are enabled through telemedicine we are talking about 40 million consultations per year from rural India alone…. The market potential for telemedicine is obviously enormous.”

PotentialWhile the numbers may vary, what is undis-puted is the potential that telemedicine holds. A major driver of telemedicine in India is the dismal state of health care in the country. India’s government spending on health as a proportion of the GDP – currently at around one per cent of the GDP – is among the lowest in the world. Even in other Asian countries, it is higher.

The corresponding amount is 1.8 per cent in Sri Lanka, 2.3 per cent in China and 3.3 per cent in Thailand. Despite the launch of the National Rural Health Mission in 2005, In-dia continues to grapple with a 33 per cent shortage of rural hospitals, which are called Community Health Centres (CHCs). Even in the ones present, there is an acute shortage of staff. According to the Ministry of Health and Family Welfare, there is a shortage of 50-70 per cent of physicians, specialists, lab technicians and radiographers at the CHCs. And around 10-15 per cent of them lack even basic ameni-ties such as water supply and electricity.

Experts have time and again suggested that if the vision of “Health for All” is to be achieved by 2020, India will have to pump in six per cent of its GDP in the health care sector. At the same time, technology-enabled health care networks can play a huge role by bridg-ing the distance between doctors and patients through Internet and other telecommunica-tion technologies.

Some of the major players in telemedicine in India at present include Narayana Hrudaya-laya, Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute and Aravind Eye Care. Devi Prasad Shetty, a leading cardiac surgeon based in Banga-lore and founder of Narayana Hrudayalaya Hospitals, predicts that it is only a matter of time before we see a huge spurt in the use of telemedicine.

“In the early days, satellite was the only means of managing the telemedicine pro-gram and keeping satellite connectivity was not very easy,” he notes.” However, now with Skype and other ways of videoconferencing there are many options available. With the

stabilizing of technology platforms, technical problems are extremely rare.”

Shetty is at the helm of one of India’s ear-liest and largest telemedicine programmes. Launched around 10 years ago, the initia-tive is managed through satellite connectiv-ity provided free of cost by the Indian Space Research Organisation (ISRO). Presently, the Narayana Hrudayalaya telemedicine network is connected with about 100 telemedicine cent-ers across India.

Outside India, as part of the PAN African satellite network, it is connected to 55 cities in Africa. The connectivity also extends to some other places like Iraq, Malaysia and Mauri-tius. Since its launch, it has conducted around 53,000 tele-consultations in the areas of cardi-ology, neurology, urology and cancer.

Narayana Hrudayalaya also has an electro-cardiogram (ECG) network wherein general practitioners in remote locations are given a trans-telephonic ECG machine that helps transmit ECGs. Narayana Hrudayalaya gets about 200-300 ECGs daily. These are interpret-ed by its doctors and then communicated to the local doctors at the remote locations.

Shetty points out that telemedicine is not just about connecting remote locations. Six years ago, when Narayana Hrudayalaya start-ed performing liver transplants on babies, its cardiac anaesthetists did not have adequate experience for this procedure. So Shetty turned to telemedicine. Narayana Hrudayalaya’s op-erating room in Bangalore was connected to the Children’s Hospital of Philadelphia and the anaesthetists there.

“After hand-holding for about five to seven liver transplants, our anaesthetists acquired the knowledge,” says Shetty. He goes on to add: “In the coming years, most of the medical treat-ment will be through telemedicine either in the same city or in other countries. There will be enough gadgets available at home to check blood pressure, blood sugar, ECG, oxygen satu-ration, even ultrasound. Patients will consult the doctors through mobile phones or vide-oconference through cellphones.”

Some of this is already happening. Re-cently, leading telecom player Airtel tied-up with Healthfore (a division of Religare Tech-nologies) and Fortis Healthcare (a Religare

group company) as the knowledge partner to offer Mediphone services to its customers. This service allows subscribers to access basic medical guidance on non-emergency health problems over the phone. The service is avail-able around-the-clock at less than $1 for each consultation.

TractionOther telecom players like Aircel and Idea have launched similar services in collaboration with HealthNet Global, a Hyderabad-based emer-gency and health care management services firm. The subscribers who call to seek health advice are visited by paramedics who come with a laptop and medical diagnostic equipment and conduct consultations via video conferencing. This is also gaining traction among insurance companies.

“We have already conducted 1,000 sessions since our launch in September 2011. We are currently present in Chennai, Mumbai, Delhi and Hyderabad. We plan to expand our services to all the metros,” notes Rahul Thapan, global head of marketing & sales for HealthNet Glo-bal. In December of last year, microfinance firm Equitas also launched tele-health care delivery centers in association with HealthNet Global. The project is funded by Fem Sustainable So-cial Solutions (FemS3), a nonprofit company operating in the social business space.

Equitas’ Consult 4 Health and Call 4 Health products, developed exclusively for the firm by the Centre for Insurance and Risk Management at the Chennai-based Institute for Financial Management and Research, allow its mem-bers to consult physicians from Apollo Hospi-tal over video for a charge of $1 a consultation. The patient’s data is also stored for any further diagnosis and treatment in the future.

“It is our endeavour to improve the quality of lives of our members and their families,” says P.N. Vasudevan, managing director of Equitas. “Health care is a source of significant finan-cial stress for this segment. The initiative with HealthNet Global using physicians from Apollo Hospital will bring a revolution by providing health care to the doorstep of our members and the best medical care anytime, anywhere. We will roll out our services from Chennai and gradually go pan-India.” Currently, Equitas has

three tele-health care centers operational in Chennai. Other new models are also emerg-ing. Take Mumbai-based MeraDoctor (My Doctor) founded in 2010 by Gautam Ivatury, who was earlier working in the area of mobile phone-based services, and Ajay Nair, a medical doctor with a master’s degree in public health management from Harvard. A phone-based medical advice service, MeraDoctor works on a membership model. The company offers family membership plans for three months and six months; during this period, members are entitled to unlimited phone consultations with MeraDoctor’s team of doctors. Members can also avail of discounts at select diagnostic centres that MeraDoctor has tied up with.

There are new products, too. Dartmouth’s Govindarajan points to General Electric’s in-novative low-cost ECG machines, which were developed in India and can take digital images that can be emailed to cardiologists in the U.S. “[This gives] poor patients in remote rural areas access to world-class care,” he says.

Another example is 3nethra from Banga-lore-based Forus Health. Developed with the aim of enabling mass pre-screening outside the hospital environment, 3nethra is a port-able, non-invasive device that helps in early detection of eye diseases like cataract, diabetic retina, glaucoma and cornea related issues. The digital information taken by 3nethra can be easily transmitted electronically. The device won the Samsung Innovation Quotient award in 2011. “At 3nethra, we wanted to work with the system and its limitations,” notes K. Chan-drasekhar, founder and CEO of Forus Health. “Even a minimally trained technician can operate it. The idea was to develop a solution that was cost effective. The device that we have developed is available for one-sixth the cost of present diagnostic devices. Also, it uses only 10 watts of power. It can run for four hours on a UPS, making it ideal for rural areas [which face enormous shortage of power].”

But even as the telemedicine scenario in India is seeing significant developments, chal-lenges still remain. According to Narayana Hru-dayalaya‘s Shetty: “The greatest challenge is get-ting enough medical specialists to see patients in remote locations and also to get the patients to trust the opinion by the doctors, virtually.”

Doctor Asfaw Atnafu, head of telemedi-cine at Black Lion hospital in Addis Ababa, uses a high-speed Internet connection to communicate with doctors at Care Hospital Hyderabad in India.REUTERS


XXIV BUSINESS DAILY | Friday August 1, 2014


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