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The Unwinnable War: How the Myth of an ‘Institutional’ Solution Has Hobbled the Fight Against Graft and Wasted Time and Resources

The political vernacular of corruption has lost its lustre, especially with the millennial generation, who today perceive corruption not as the abuse of public office for private gain but the abuse itself lays in the existence of the public office.

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The Unwinnable War: How the Myth of an ‘Institutional’ Solution Has Hobbled the Fight Against Graft and Wasted Time and Resources
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What is clear is that in Kenya’s case, the public policy reform/technocratic approach to fighting corruption has become utterly irrelevant in the current political context. The Presidential ‘Summit’ on Governance and Corruption in November 2016 as former anti-graft Czar John Githongo opined was the final nail in the coffin of the ‘technical fix’ to corruption when President Uhuru Kenyatta expressed his helplessness, ripped into his anti-corruption officials and their approach, and basically reduced the event to a public relations exercise. Kenyans have done all the anti-corruption benchmarking, created all the anti-graft institutions, committees, working groups, task forces, units; drafted all the frameworks and policy papers; taken all the advice possible from multilaterals, bilaterals, NGOs, the private sector and others including churches; enacted all the laws and their subsidiaries; held all the conferences, summits, workshops and get-togethers possible. Fundamentally, what started in 1956 with a series of legal and institutional reforms aimed at improving governance and fighting corruption was a phase that ended with Presidential Summit on Governance and Corruption in November 2016. But the history of corruption didn’t begin here.

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In 1888, the Imperial British East Africa Company (IBEACo) claimed Kenya as one of its territories. That arrangement continued until 1895 when the territory reverted to the British as the East African Protectorate encompassing areas deemed “waste and unoccupied” that did not have a settled form of government. In the early 1900s, Europeans began to stream into the country at the invitation of the colonial government and were allocated the most fertile land upcountry in areas where for generations Africans had farmed, grazed animals, and practised their customs freely. The consequence was that the indigenous people were driven to low-density areas unsuitable for agriculture with low rainfall, poor soil, and absence of pasture. Those who didn’t find a place to settle became squatters in white farms or worked as labourers for Asian merchants. The expropriation of African land by Europeans was done fraudulently and represented one of the first acts of land grabbing and looting by the colonial regime in Kenya. They just grabbed African farms without much effort to hide their activities. Until then, the African lands were secured by the Protectorate.

Regulations of 1897 forbade any alienation of land regularly used by Africans unless the colonial administration was satisfied the land was no longer regularly used and that Africans would not be adversely affected. That changed with the Crown Lands Ordinance of 1902 which gave the government jurisdiction over all lands subject to the right of occupation by Africans. From that time, African ownership of land was not recognized; only occupation and use of it were permitted.

The Unwinnable War: How the Myth of an 'Institutional' Solution Has Hobbled the Fight Against Graft and Wasted Time and Resources

Dawa ya Ufisadi

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In 1915, another Crown Land Ordinance was passed giving whites 999- year leases. It also transferred all lands formerly occupied by Africans to the control of the governor, and barred European landowners from employing non-white managers or supervisors to be in-charge of their holdings. The Ordinance also created African reserves to be located away from white settlements. As the whites entrenched themselves, more land laws were passed to govern different parts of the country making the Land Law in Kenya one of the most complicated land systems in the world. After World War II, the British government heightened the process of settling former servicemen by grabbing more land. Overall, 1% of the white population occupied 16,500 square miles of land.

At that time, crown or public land comprised 76.97% of Kenya. It included everything from forests to lakes and rivers. However, 70% of it was in the dry Northern Frontier Province, inhabited mainly by Somali ethnic groups. Of the total land area, only 1.9% was put to agricultural use at the time and almost all of it by white settlers. Thus, while each of the majority Africans occupied one or two acres on average, whites were sitting on 160 acres each per person.

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In 1935, Archdeacon Eric Burns, a British member of the Kenya Legislative Council (LegCo), complained that chiefs were forcing widows exempted from taxes into paying them a bribe so that the widows could retain their exemptions; and that animals sold in distress for non-payment of tax were undervalued and purchased by the chiefs and their henchmen. The evil of corruption and bribery got worse when colonialists enacted the Chief’s Act in 1937 giving the officials a wider latitude of powers, including maintaining law and order, collecting taxes to help sustain the luxurious lifestyles of whites, overseeing agricultural activities in their areas, and mediating disputes. To meet their financial needs, chiefs habitually confiscated livestock from tax defaulters to swell their herds, and accumulated land that really belonged to other people.” It was routine for chiefs to raid a village and demand surrender of personal property under threats of arrest. They collected hut and poll taxes and retained part of the money. The more levy they collected the more money went into the Exchequer and into their pockets. During colonial times, chiefs commanded respect and trepidation from locals in equal measures. Chiefs exerted themselves to please the authorities, often taking actions that turned out to be abuse of peoples’ rights. They sometimes beat and tortured innocent villagers to demonstrate their commitment to duty and loyalty to their masters. As the government’s “eyes” on the ground, chiefs frequently held barazas to explain colonial plans and policies, and were spokespeople and translators for white administration officials.

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The biggest known case of public corruption in Colonial Kenya involved the construction of the Mbotela and Ofafa housing estates on the east part of Nairobi in the 1950s. According to Joe Khamisi in his seminal work Kenya: Looters and Grabbers: 54 Years of Corruption and Plunder by the Elite, the project was intended to ease accommodation problems created by mass movements of people from the rural areas in search of jobs in the city, as well as the return of African soldiers from World War II. Thirteen thousand bed spaces per year were scheduled to be built over a period of five years at a cost of GBP.2 million (KES.273 million), which was to come as a grant from the Colonial Development Corporation (CDC). In those years, construction work was dominated by big European and Asian owned firms though many small “one-job-at-a-time operations” also existed. Those nondescript companies were prepared to take any job even though they didn’t have proper equipment and relied on cheap unskilled labor. Soon after tendering for the housing project was done and contracts awarded, news went around alleging corrupt practices in the selection process. The Criminal Investigation Department (CID) was called in to investigate. When news reached London, the British government appointed Sir Alan Rose a well-known lawyer to head a three-man commission with a brief to “examine accusations of corruption and malpractices in every aspect of the affairs of the Nairobi City Council.

A long list of contraventions of building specifications was provided, including “shallow excavation of footings, under-strength concreting in floors and lintels, substandard joinery, the use of cheaper, weaker materials throughout, and generally poor standards of workmanship” – all of which had apparently been approved by council officers in exchange for kickbacks. One of several officials implicated in the debacle was the city engineer Harold Whipp. Before the council made the decision to sack him, Whipp committed suicide and his body was found on a railway line. The Commission also unearthed several other cases of misconduct in the council including some in the fire brigade and the city market. The Mayor, Israel Somen, and his deputy, Dobbs Johnson, were cited for corrupt practices. The two survived the scandal and Somen was, after independence, appointed by Tel Aviv as the Israel ambassador to Kenya. The Rose Commission concluded that bribery and corruption were “by no means uncommon” among city office holders at ‘all levels and in all departments’; that the scale of cash inducements involved to secure services or preference from the council was often significant; and that such behavior was accepted as the norm and widely tolerated. So, it wasn’t just African home guards and chiefs who engaged in bribery and extortion in colonial Kenya.

Europeans were as guilty of corruption and malpractice in colonial Nairobi as anyone else, and Africans at the bottom of the colonial racial hierarchy were most often its victim. To stymie the growing trend of corruption in government, the LegCo (Legislative Council) enacted the Prevention of Corruption Act (Cap 65) in 1956, setting out jail terms for any public servant who solicited, accepted or obtained money unlawfully in exchange for service. It also provided for forfeiture of awards of gifts offered in a corrupt manner.” It was the Roe vs.Wade legislation as pertaining to fighting corruption in Kenya.

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On 12 December 1963, the Union Jack was lowered for the last time on Kenya soil, Kenya obtained ‘independence’ from the British. Under its first president, Jomo Kenyatta promulgated its first constitution which laid bare the hopes, dreams and promises of the Kenyan people. The government promised every part of the country will be controlled by the indigenous people of the area. Too, it promised it would eradicate poverty, disease and ignorance and also fight corruption.

However, that arrangement lasted for less than a year as Kenyatta abolished the region-based independence constitution in 1964 and introduced a unitary system of government which gave the presidency executive powers. Corruption took centre stage. An estimated 25,000 people were settled in the month of January 1964 alone. The pace in which the process was implemented implied there was no intention to vet and accord deserving cases their rights, but rather persons had already been predetermined or identified by the authorities.” The bottom line was: corruption was at play. One of the first things Kenyatta did after becoming Prime Minister, was to order a Rolls Royce car from the London’s Motor Show, for his use without any state budgetary provisions or (even) personal intent to pay. In doing so, Kenyatta became the first Kenyan official to violate procurement procedures which required that the Central Tender Board (CTB) call for multiple quotations from suppliers. It was a colonial process which did not change until the 1970s. Kenyatta also ignored the advice of Finance Minister James Gichuru who told him Kenya was short of capital and therefore bankrupt and could not afford the expensive vehicle.

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Having heard the complaints of senior officials in his administration about their inability to do private business because of government restrictions, Kenyatta 1 regime decided to do something. In 1971, Kenyatta appointed a body called the “Public Service Structure and Remuneration Commission” to recommend reforms in the public service on a system established by the colonial government. Known as the Ndegwa Commission, after its Chairman Duncan Ndegwa, the Commission recommended sweeping changes in moral and professional conduct of civil servants. It suggested increases in civil service salaries; the appointment of an ombudsman to oversee integrity in government; and slashing the number of parastatals. Furthermore, it permitted civil servants to engage in private businesses.

The Ndegwa report broke the colonial rule which was observed up to around 1970 that public workers should not engage in businesses. In the meantime, civil servants began immediately to engage in businesses. Soon, the civil service was submerged in corruption from top to bottom. Officers demanded bribes and sold tips and confidential government information to the highest bidders. Service delivery was impacted as many civil servants were often away tending to their private businesses. The Ndegwa allowed people to use their public offices to loot public resources with very little or no accountability.

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When Moi came to power many Kenyans hoped corruption would end. Because Kenya’s second president was a staunch Christian; and as a man with a strong rural upbringing, he was less entangled in the twisted urban lifestyles of intrigues, corruption, and conspiracy. He demonstrated that commitment by lashing at corruption and those involved in it wherever he went in the country, even as his family and cronies were amassing wealth. At one time, he showed up in Parliament to personally lead a debate on a legislation intended to deal with the menace. In 1982, Moi formed a working committee to draft a national code of conduct to deal with various issues including inequitable distribution of resources, misappropriation of public funds, and corruption. In announcing its formation, he accused some of his officials of greed and selfishness and promised tough action. He said his government would no longer tolerate graft and those caught would be punished severely. The working committee, chaired by a prominent businessman, B. M. Gecaga, submitted its report in October 1983, but that was the last time anyone heard of it. The whole charade appeared to be a public relations stint to hoodwink Kenyans into believing he was serious about corruption. It was a show of empty bravado.

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In 1993, the Government established the Police Anti-Corruption Squad in the police force to spearhead the fight against corruption in the Criminal Investigation Department. It was abandoned in 1995. The Prevention of Corruption Act (Cap 65) was amended in 1997 and would lead to the creation of the Kenya Anti-Corruption Authority (KACA), the first government anti-corruption organ established by law to fight corruption. The first Director of the Kenya Anti-Corruption Authority, John Harun Mwau, was appointed in December, 1997. KACA was disbanded in the year 2000 after it was declared unconstitutional by the High Court. This decision was on the basis, among others, that the powers of KACA to prosecute went against Section 26 of the then Constitution which had then preserved powers of prosecution on the Attorney General. After the disbandment of KACA, the Anti-Corruption Police Unit was formed as an administrative organ to continue the fight against corruption.

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In July 1998, Parliament appointed a Select Committee on anti-corruption under the Chairmanship of MP Musikari Kombo and gave it the mandate to study and investigate the causes, nature, extent and impact of corruption in Kenya; identify the key perpetrators and beneficiaries of corruption; recommend immediate and effective measures to be taken against such individuals involved in corruption, recover public property corruptly appropriated by them; and enact a Bill to provide stiff penalties for corruption related offences. The motion led to the enactment of the Anti Corruption and Economic Crimes Bill (2000) which established the Kenya Anti-Corruption Commission (KACC) with responsibilities to investigate corrupt cases and institute civil proceedings for recovery of corruptly obtained assets; and the formation of the Kenya anti-corruption advisory board to be responsible for appointing commissioners, and advise the commission on the performance of its functions. Nothing came out of those efforts until Moi handed over the government to Kibaki in December 2002.

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Kibaki’s victory in the 2002 general elections came as a big sigh of relief that four decades of KANU’s misrule had come to an end. Kenyans dreamed of a new beginning away from corruption, misadministration, and human injustices. Kibaki vowed to deal firmly with corruption which Moi had failed to clamp down. Kibaki said that corruption would cease to be a way of life in Kenya. Soon after being sworn-in, Kibaki moved to create institutions to deal with the challenge. He established the Kenya Anti-Corruption Commission (KACC) and appointed John Githongo as PS in his office to deal with matters of ethics in the public sector. Within a few months, he got Parliament to enact the public officer ethics legislation to compel all public servants to declare their wealth. The legislation tightened protocols to discourage favoritism, nepotism and administrative malpractices in government. From all initial indications, Kenyans were convinced Kibaki was the man to steer the country away from rampant sleaze which had dominated the two previous administrations. KACC was born out of the Anti-Corruption and Economic Crimes Act (ACECA) and the Public Officers Ethics Act of 2003 which became fully operational on 2 May 2003. The Act also established the Kenya Anti- Corruption Advisory Board (KACAB), a body which recommends to Parliament persons to be appointed as director and assistant directors, and advises the commission on the exercise of its powers and performance of its functions. However, while the anti-corruption push, led from the front by President Mwai Kibaki, started with a bang it faltered within eight months. Through a series of circulars, directives, committees, commissions and endless meetings, the fight against corruption was bureaucratised, effectively reduced to an annual laundry list by the anti-corruption authority of what they mostly hadn’t achieved, and the odd court appearance by suspects wearing broad smiles and expensive suits.

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In August 2010, a new constitution was promulgated in Kenya, which made far-reaching changes on governance, leadership, integrity in the anti-corruption regime. Article 79 of the Constitution required Parliament to enact legislation to establish an independent body to ensure compliance with and enforcement of Chapter Six of the Constitution. Pursuant to this Article, Parliament enacted the Ethics and Anti Corruption Commission Act, No. 22 of 2011 which came into effect on 5th September 2011. The Act amended the Anti-Corruption and Economic Crimes Act (ACECA) by repealing the provisions establishing Kenya Anti Corruption Commission and its Advisory Board, while retaining all other provisions relating to corruption offences and economic crimes, their investigation and prosecution.

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After billions of dollars have been spent in the war on graft, today, corruption is undergoing a moral and political paralysis. Largely due to the politicization of corruption by the Kenyan political class in their battles for 2022, and more fundamentally because the standard post-colonial logic that “all would be fine” if it were not for the corruption of some persons and their ability to mobilise their own ethnic groups in pursuit of the public purse has been falsified. The political vernacular of corruption has lost its luster, especially with the millennial generation, who today perceive corruption not as the abuse of public office for private gain but the abuse itself lays in the existence of the public office. Indeed, the very idea and roots of the Kenyan state is that of “corruption” and of the continuous abuse of its citizens.

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The author is an analyst based in Nairobi, Kenya.

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Train Traditional Birth Attendants, Don’t Ban Them

Traditional birth attendants (TBAs) remain the main providers of delivery services, especially in rural and remote areas. Rather than banning them, governments should support them to reduce maternal and child mortality, and ensure that they get adequate training.

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Throughout African history, traditional birth attendants (TBAs) have provided maternity care for women despite having no formal training.

Poverty, cultural practices, and a shortage of primary healthcare services are forcing women to seek the help of untrained traditional birth attendants, despite the serious risks involved.

Last year Kenya recorded a maternal death rate of about 362 per 100,000 live births and an under-five death rate of 52 per 1,000 live births, while in Tanzania, one in every 126 women die due to maternity complications. The story is the same in Uganda and Ghana as well. According to the World Health Organisation (WHO)’s figures for 2016 on maternal mortality, 560 women die per 100,000 births in Nigeria.

Despite these shocking figures, women, even learned ones, are still flocking to unskilled birth attendants’ homes to give birth, putting their lives at risk. Why is this so? Is it is because governments are failing them?

For some women, traditions prevent them from attending hospital. For others, long distances to medical facilities prevent them from reaching a health facility in time to give birth. Some are put off by health workers’ attitudes.

TBAs can provide them with all the care they need, both during and after pregnancy and childbirth, and there is no doubt they are a much-needed resource.

In 2013, the Kenyan government introduced free maternal healthcare. The goal was to encourage more women to give birth in health facilities. However, according to data from the Kenya National Bureau of Statistics (KNBS) released this year, more women are still flocking to TBAs.

It is evident that pregnant women are not satisfied with the quality of care they are given at the hospitals. With the high number of women taking advantage of the free services, combined with the few health care workers to attend to them, some women are giving birth on their own even when they are in hospitals.

In 2013, Kenya had one of the highest maternal mortality rates in the world: 488 maternal deaths per 100,000 live births, according to the Ministry of Health.

In 2013, the Kenyan government introduced free maternal healthcare. The goal was to encourage more women to give birth in health facilities. However, according to data from the Kenya National Bureau of Statistics (KNBS) released this year, more women are still flocking to TBAs.

According to KNBS data for 2015/2016, the findings reveal that three out of ten children were delivered at home in 2018 in Kenya; this is an estimated 31.3 per cent improvement from 53.9 per cent recorded in 2005/06.

The survey showed that in rural areas the proportion of children born at home was 40.7 per cent compared to 13.3 per cent in urban areas.

Childbirth statistics in Kenya
“The county with the lowest proportion of children born at home was Kirinyaga, at 3.8 per cent, while Wajir, Mandera, Samburu and Marsabit had over 70 per cent of children born at home. Kirinyaga, Nyeri and Kisii counties recorded over 90 per cent of children born in a health facility,” KNBS stated.

The proportion of children delivered with the assistance of a traditional birth attendant in rural areas was 25.6 per cent compared to 7.8 per cent in urban areas. Wajir, Mandera and Samburu had over 60 per cent of the births assisted by a traditional birth attendant. Turkana County had the highest proportion of self-assisted births, at 34.5 per cent.

The low hospital births among pastoral communities may be partly linked to inadequate health facilities and personnel in the regions they live in. Families in pastoral counties also tend to be polygamous, which puts a strain on resources such as healthcare.

Nairobi, Kisii, Kiambu, Kirinyaga and Nyeri counties top in childbirths in hospitals, an indication of the success of the safety campaigns. These five counties are the only counties that recorded over 74 per cent of children born in hospitals.

Statistics further show that more deliveries are now handled by trained medical personnel, which is a plus in attaining safer childbirths. However, women in rural areas still prefer to be attended by TBAs, friends, and relatives during delivery.

According to WHO, with the exception of sub-Saharan Africa, where most births in rural areas are conducted by TBAs, rates of births assisted by a medically trained attendant have shown impressive increases over the past 15 to 20 years, Current data indicate that 59 per cent of births in the developing world are assisted by a medically trained professional.

Nairobi, Kisii, Kiambu, Kirinyaga and Nyeri counties top in childbirths in hospitals, an indication of the success of the safety campaigns. These five counties are the only counties that recorded over 74 per cent of children born in hospitals.

Uganda banned TBAs) in 2010 but they have continued to practise. Eighty per cent of rural women prefer TBAs to skilled attendants, according to officials at the Ministry of Health; 10 per cent of them delivered with the assistance of TBAs.

With TBAs playing such an important role in maternal and newborn healthcare, especially in rural areas, should governments abolish them completely or look for ways of incorporating them into the system as referral agents to hospitals?

One midwife’s experience

The Telegraph, through an informal survey in Kisumu’s Nyalenda Estate in Kenya, established that some mothers delivering in hospitals still relied on traditional birth companions during pregnancy and after giving birth.

Pictures of newborn babies adorn the walls of Margret Owino’s house. They are a treasured decor in the improvised maternity ward in her two-roomed corrugated iron-walled house. Hundreds of women have trekked the dusty and curvy road to Ms Owino’s Kisumu home, judging from the many pictures.

It is at 6 am when we got to her house. Dressed in a blue nylon apron, she is busy attending to a pregnant woman. In a busy month, she delivers over 60 children, according to her well-kept records.

Her small house acts as a labour and delivery room. She is among traditional midwives who assist women at childbirth, mostly in areas that lack infrastructure and trained health personnel.

Even though there are several health facilities in the area, some pregnant women prefer traditional birth attendants. They say they are more comfortable with them than obstetricians and trained midwives.

Ms Owino learned the midwife’s skills at a tender age. When she was 15 her late grandmother, who was a midwife, placed herbs in her right hand and some coins in the left — the traditional way of transferring the skills to her. This has since been her job. She is among Kenya’s 35 registered traditional birth attendants who work with hospitals to ensure safe deliveries.

She has had women who are bleeding profusely brought to her in the middle of the night. She does not attend to them but sends them immediately to the nearby hospital. Some clinics contact her to attend to mothers with breech births and at times they are brought to her “clinic”.

She also refers HIV-positive women to the hospital, but says she knows not all women disclose their status to her. She says it is a constant risk.

Her maternity services are similar to those in health facilities. She records clients’ details in a book and weighs infants on a weighing machine given to her as a token.

One of her clients said that harassment in public hospitals is one of the reasons they still troop to traditional birth attendants’ clinics.

Even though there are several health facilities in the area, some pregnant women prefer traditional birth attendants. They say they are more comfortable with them than obstetricians and trained midwives.

‘‘The midwives harass us, calling us names while we are often left in the hands of inexperienced trainees. The midwife can detect when a woman has the strength to push the baby or not, or if the baby is in the right position,” she says.

She says community midwives pamper and take care of women during and after delivery. She says this helps them give birth with dignity. That is why a lot of women come back to her when they are having another baby

Initially, the government was threatening the TBAs while others were being harassed and their tools were being confiscated. However, this has since changed; they are now being registered and undergo training to ensure safe deliveries.

The Ugandan government has also lifted the ban on TBAs and the focus now is training them. As a result, there has been a shift towards skilled birth attendants capable of averting and managing childbirth complications.

Ms Owino only attends to women who know their HIV status. She ensures that HIV positive clients have antiretroviral (ARVs) drugs given by a doctor, which she gives to the child immediately after tying the umbilical cord.

Benefits of supporting and training TBAs

Rather than educate against the use of TBAs, the United Nations Population Fund (UNFPA) believes that working with them is the best solution. It did a a study on the benefits of supporting and training TBAs across the world. The study was done in the Upper East Region in Ghana, and tracked antenatal visits and deliveries conducted by trained TBAs from 1990 to 1993.

“Antenatal visits increased from 20,000 to 180,000. Deliveries reported by TBAs increased from less than 10,000 to 50,000. Nationally, the percentage of TBA deliveries as a percentage of supervised deliveries increased from 16.4 percent to 22.2 percent between 1992 and 1993. Policymakers and program managers state that TBAs have contributed to: improve prenatal care, increase contraceptive acceptance rate, and decrease neonatal tetanus admissions”.

“The role of traditional birth attendants in the provision of healthcare in resource-poor countries is still important because of the current inadequacy of human resources for health. In developing countries for years to come, TBAs will remain the main providers of child deliveries in rural areas,” it states.

Dr Elizabeth Ogaja, a health analyst, says that midwives are an integral part of the healthcare system, adding that the reduction of maternal and newborn mortality in developing countries requires rigorous efforts that involve governments and non-governmental organisations in identifying TBAs who are known by the community to be experts.

“Recruitment and training of TBAs using adult learning techniques is important. The programmes should focus on basic primary healthcare, especially on symptoms of risky cases that need to be referred to formal health services and on hygiene to prevent mother and child from infections,” she says.

“Creation of dialogue, trustworthiness, patient, tolerance, willingness to collaborate, transparent and familiarity during training are key when working with TBAs as partners in health care and when sharing experiences,” says Dr Ogaja.

Training, she says, should be followed up by frequent meetings to share feedback and problems TBAs experience.

“We have realised that they are very important. Mothers trust them and we want to integrate them as much as we can. We advise that they bring pregnant mothers to hospitals so that we can take it from there,” she says.

Dr Lawrence Koteng’, the Homa Bay health executive, acknowledges the role played by traditional midwives but encourages expectant women to deliver in health facilities.

He says the county health department is training community health workers to discourage unsafe home deliveries.

“We do not support expectant women to deliver at home or anywhere except at health facilities where there are experts who can help whenever there is a complication,” says Dr Koteng’.

However, Allan Mayi, the deputy project director at Elizabeth Glaser Paediatric Aids Foundation, says the birth attendants should not attend to expectant mothers because they lack the skills needed to offer safe deliveries.

The organisation encourages women to deliver in hospitals and even offers incentives to birth attendants to take them to health facilities.

“Most mother-to-child HIV transmissions are recorded at midwives’ homes,” says Mr Mayi.

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Preeclampsia: The “Silent Killer” Stalking Expectant Mothers

Ten million women develop preeclampsia each year around the world. Worldwide about 76,000 pregnant women die each year from preeclampsia and related hypertensive disorders. And, the number of babies who die from these disorders is thought to be on the order of 500,000 per annum, according to the World Health Organisation.

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Preeclampsia: The “Silent Killer” Stalking Expectant Mothers
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A recent study has revealed that expectant mothers in African countries, especially Uganda are more likely to die with preeclampsia condition compared to their counterparts in other East African countries.

Preeclampsia is a pregnancy disorder characterised by hypertension especially after 20 weeks of pregnancy. It can be dangerous to both the mother and the unborn baby. Gestational pregnancy may increase the risk of premature birth of the baby, increased birth weight of the baby, cesarean delivery, and preeclampsia.

Bulk of government health facilities in the country are struggling to manage the condition since most of the critical drugs needed to manage the condition are not stocked, simply because the government has not prioritised the condition.

The condition is the second cause of maternal deaths worldwide.

Preeclampsia: The “Silent Killer” Stalking Expectant Mothers

The study done by the Health Action on the situation on reproductive health commodities revealed that only 25 per cent of health facilities in Uganda stock Magnesium Sulphate as compared to 71 per cent in Kenya.

Magnesium sulphate is a mineral that reduces seizure risks in women with preeclampsia. A healthcare provider will give the medication intravenously.

The study conducted in four countries (Kenya, Uganda, Tanzania and Zambia) revealed that facilities in Tanzania and Zambia were not any better as far as the stocking of the commodity is concerned with 45 and 40 per cent respectively.

During the commemoration of world Preeclampsia Day on May 22 in Uganda, health facilities in Lira – a city in the Northern Region of Uganda – called for support from the government to enable them to handle mothers with the condition.

About 10 million pregnant women around the world develop preeclampsia each year. Out of the total 76,000 women die from preeclampsia and related hypertensive disorders. Additionally, the World Health Organisation (WHO) estimates the number of babies who die from these disorders every year to be on the order of 500,000.

In developing countries, a woman is seven times as likely to develop preeclampsia than a woman in a developed country. From 10-25 per cent of these cases will result in maternal death.

Preeclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications.

Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.

In developed countries like the US, pregnant women are commonly followed by a healthcare specialist (doctor, midwife or nurse) with frequent prenatal evaluations. In other areas of the world with little access to care and lower social status of women for instance in Africa, traditional health practices are usually inadequate to detect preeclampsia early.

Hypertensive disorders of pregnancy commonly advance to more complicated stages of the disease, and many births and deaths occur at home unreported.

Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia.

Although levels of prenatal care have increased in many parts of the world during the past decade, the WHO reports that only 46 per cent of women in low-income countries benefit from skilled care during childbirth. This means that millions of births are not assisted by a midwife, a doctor or a trained nurse.

But why are women in Africa dying of this condition yet it can be prevented?

Dr Annettee Nakimuli, an obstetrician-gynecologist at Mulago Hospital in Kampala and lecturer at Makerere University did research to answer that question.

She says although the condition affects women worldwide, in African women, it is more common and particularly severe. It also occurs earlier in pregnancy and can recur in subsequent pregnancies.

Dr Nakimuli reported that at Mulago Hospital where she works, 15 per cent of pregnancies develop life-threatening complications such as preeclampsia, hemorrhage, obstructed labour and sepsis.

She describes herself and her colleagues as being “on the front line” in the battle against death in pregnancy and childbirth. She did a study in 2017 in collaboration with Cambridge’s Department of Pathology and Centre for Trophoblast Research to unravel why a complex disease is so much worse in Africa.

But why would women of African descent suffer so much more from preeclampsia than other women? “There was an assumption in Africa that there was a socioeconomic reason, like poverty,” says Nakimuli. “I was convinced that there was something biological.”

She recruited 750 mothers at Mulago Hospital to what is the largest genetic study of pre-eclampsia conducted in Africa. She collected blood and umbilical cord samples and, in Cambridge, ‘typed’ the DNA to look at all the genetic variation.

“It was kind of a high-risk project, but my determination kept my hope alive. I wanted to find big things.” She says

The findings of the study revealed that killer-cell immunoglobulin receptors (KIRs), genes that protect African women against pre-eclampsia are different from those that protect European women.

KIRs recognises proteins called MHC on the invading fetal cells. Certain combinations of maternal KIR genes and fetal MHC genes are associated with pre-eclampsia, whereas other KIR genes appear to protect against the disease.

Moreover, the risky combination of maternal KIR and fetal MHC proteins occurs at a much higher frequency in sub-Saharan Africa than anywhere else in the world.

From the study, Dr Nakimuli together with other researchers will be researching to understand the biology of preeclampsia.

“We think that women of African ancestry may have these risk genes because of certain beneficial selective pressures, otherwise why would genes that kill mothers and babies be so common in the population? People with the gene that causes sickle-cell anaemia can fend off malaria – perhaps something similar is happening for KIR genes? And so now we are starting work to see whether the genes are protecting against infections such as measles, HIV and malaria.” She says

She also pointed out a lack of awareness and understanding of the condition as a barrier to treatment.

“There’s a general lack of awareness and understanding,” explains Nakimuli. “There isn’t even a Ugandan word for preeclampsia. The closest people get to describing the condition is ‘having hypertension which is different from other hypertension when you’re not pregnant’. It becomes a mouthful.”

Together with other researchers, they developed a format of awareness messages in which a radio presenter would play a real-life testimonial – such as a woman relaying the complications of her pregnancy – and then invite listeners to reply to a related question by sending a text to a toll-free number. Each respondent would subsequently receive an SMS socio demographic survey to complete.

“What makes preeclampsia such a challenge is that it has been impossible to predict or prevent,” explains Professor Ashley Moffett, from Cambridge’s Department of Pathology and Centre for Trophoblast Research, who is an expert on the disease.

“It’s been called the ‘silent killer’ because many women cannot feel the danger signs that their blood pressure is rising until it’s too late. Even when it is detected the only course of action is constant monitoring, and ultimately the only cure is delivery sometimes at too early a stage for the baby to survive,” adds Moffett.

However, during the release of the research study in the four countries in Zambia, Mr Denis Kibira, Executive Director, Coalition for Health Promotion and Social Development (HEPS) who conducted the study cited lack of enough blood pressure (BP) machines, designated preeclampsia ward, a postnatal ward, and inexperienced health workers to handle women with the condition as some of the challenges.

For instance, Lira Regional Referral Hospital in Uganda which receives about 100 expectant mothers daily for antenatal care, has only one blood pressure machine yet it serves nine districts in the region.

Mr Jino Okot, the in-charge of Ogur Health Centre IV, most health workers do not have the necessary skills to administer magnesium Sulphate and the government should do something to improve the situation of the mothers.

“Most of the health workers do not have the skills to diagnose preeclampsia. Some of them do not even know how to mix and administer. The Ministry of Health should understand that health workers need training if we are to ably manage the condition,” Mr Okot said.

Mr Edmond Acaka, Lira District assistant health officer-in-charge of maternal and child health, appealed to the Ministry of Health to come to the rescue of the district by increasing its budget to accommodate more of the commodities.

While Ms Beatrice Nyangoma, communications officer for HEPS-Uganda, asked the Ugandan government to consider regulating prices for magnesium sulphate to improve affordability and availability.

Mr Kibira while releasing the data to health journalists in Zambia in September said different levels of facilities were picked in each country. The methodology used consisted of a questionnaire and a qualitative survey component. Data collectors were trained in June 2018 (Tanzania), July 2018 (Kenya and Uganda), and August 2018 (Zambia).

The levels of health facilities visited in Kenya were level 3 and 5, in Tanzania: ‘Dispensary’ and above (country level 1-3), in Uganda: ‘Health Centre III’ and above (country level 3-7), and in Zambia: ‘Health post’ and above (country level 1-4).

The study conducted across sectors (public, private and mission) hospitals in urban and rural areas in 169 facilities in Kenya, 126 in Tanzania, 145 in Uganda and 237 in Zambia also revealed there was a large variability of supplements per type and country.

The mean availability of these commodities was 36 per cent in Kenyan health facilities, 29 per cent in Tanzanian, 37 per cent in Ugandan and 34 per cent in Zambian health facilities.

The data collection tool assessed the availability of 55 SRH commodities at the moment of data collection in each of the 677 study facilities.

Only in Zambia were all these supplements such as calcium gluconate, ferrous salt, folic acid, zinc, and oral rehydration salts commonly available (70-84 per cent overall) except calcium gluconate, which had an overall availability of just six per cent.

Calcium gluconate was also poorly stocked in other countries, with availabilities of 28 per cent in Kenya, 17 per cent (Uganda) and two per cent (Tanzania).

Oxytocin, used to induce labour and for the prevention and treatment of postpartum hemorrhage, was stocked relatively commonly (47-91 per cent), except the private sector in Kenya (27 per cent) and Zambia (20 per cent).

Zambia was leading with oxytocin stocks in facilities at 94 per cent followed by Kenya at 84 per cent. Tanzania third at 78 per cent while Uganda was the least with 64 per cent.

Gentamicin, used to treat pneumonia and neonatal and maternal sepsis,was moderately available in all countries (overall, 60-81 per cent), except for in Tanzania (23 per cent).

While the availability of dexamethasone, used in the management of pre-term labour to improve foetal lung maturity, was considerably lower, ranging from 11 per cent (overall, Tanzania) to 50 per cent in Uganda.

According to the World Health Organisation, the full intravenous magnesium sulphate regimens are recommended for the prevention and treatment of eclampsia.

“Magnesium sulfate is a lifesaving drug and should be available in all health-care facilities throughout the health system. The guideline development group believed that capacity for clinical surveillance of women and administration of calcium gluconate were essential components of the package of services for the delivery of magnesium sulfate,” says the WHO.

The international health agency states that in settings where there are resource constraints to manage the administration of magnesium sulfate safely in all women with pre-eclampsia, there may be a need to accord greater priority to the more severe cases.

The availability of medical devices from the study was inconsistent across the countries.

Speculums (metal or plastic device that is used to open the vagina enough to see inside were available at 85 per cent of the public facilities of Kenya, 84 per cent of Tanzania’s, 89 per cent of Uganda’s and 64 per cent of Zambia’s public facilities.

The private sector showed lower availabilities at 45 per cent of Tanzanian, 82 per cent of Uganda, 72 per cent of Kenya and 15 per cent of Zambian facilities.

Ultrasound scans had availability levels below 50 per cent in all sectors (public and private hospitals) of all countries, except the mission sector of Uganda (57 per cent).

Foetal scopes were commonly available in the public sector of Tanzania (97 per cent), Uganda (96 per cent) and Zambia (80 per cent), but not in Kenya (35 per cent).

Availability in the private and mission sectors showed a more mixed picture, with availabilities ranging from 16 per cent (private, Zambia) to 96 per cent (mission, Uganda).

Safe delivery kits were not at all available in Kenya and Uganda, and only 16 per cent of Zambian facilities. Tanzania had a much more elaborate availability at 82 per cent of public, 32 per cent of private and 33 per cent of mission facilities.

The availability of antiseptic was similar in Tanzania (65 per cent), Uganda (61 per cent) and Zambia (63 per cent), but lower in Kenya (24 per cent).

Vasectomy and tubal ligation kits were mostly unavailable in the four countries, with all overall availabilities below 10 per cent

Mr Kibira said most of the sexual reproductive health commodities were unavailable in most facilities because the governments were not budgeting enough for them.

“These are essentials that each country should have in place but most countries are not considering them as a priority hence the stock-outs,” he said

In the recommendation, Kenya was asked to adopt a multi-sectoral approach in the

provision of health services and commodities, especially in the rural and hard to reach areas, by integrating and bringing services closer to the population.

“County governments should include all the drugs as essential medicines by making budget available for their purchase,” recommends the study.

For Uganda, the government has been asked to actively seek out strategies to reduce the cost of high-cost SRHC such as magnesium sulphate, for instance through offering subsidies.

“Strategies to improve the SRHC supply chain must be actively sought to ensure that commodities are delivered on time and in the quantities ordered. Healthcare providers to receive additional training on SRHCs, especially in the private and mission sector facilities,” states the study.

The Zambian government has been urged to increase the number of trained staff, and improve the knowledge of existing staff and also improve the supply chain of the commodities.

For Tanzania, inadequate availability of SRH commodities, frequent stock-outs, poor logistic management, and limited community knowledge constituted major factors contributing to the problems experienced with accessing SRH commodities in the country

The government was, therefore, asked to ensure all the commodities on the international Essential Medicines Lists (EMLs) are also included in the Tanzania EML and sensitise communities about SRH services and commodities.

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Food Trends in Kenya (2007- 2017)

Rising food prices in Kenya have an adverse effect on the country’s development as a whole.

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Food Trends in Kenya (2007- 2017)
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The right to food as stipulated in Article 43 of the Constitution of Kenya recognises that all Kenyans have the right to be free from hunger and to have adequate food of acceptable quality. But we are still hungry.

Kenya has had several droughts that have affected its productivity yields in agriculture over the past few years. This, in tandem with corruption, inefficiency and demographic bulge has put pressure on our current food systems. Food prices have therefore increased to the detriment of the consumer whose income has barely increased. 

Because of this, it is estimated that about 16 million Kenyan’s are poor, 7.5million people live in extreme poverty, and over 10 million people suffer from chronic food insecurity and poor nutrition. During periods of drought, heavy rains and/or floods, the number of people in need could double if this trend continues. 

Since 2007, the cost and volatility of many staple food commodities (maize flour, beans, carrot and milk) have increased tremendously. Adverse weather conditions and climate change, prolonged or recurrent droughts, shifts in local production, disease and consumption shocks, inflation and changing informal trading patterns, are rapidly redefining food affordability and transforming food consumption, production and market dynamics.  

The Consumer Price Index  – a measure of prices of a basket of goods over time –  has also increased since 2007 due to a steady increase in prices of food and non-alcoholic drinks. While the annual average of non-food Consumer Price Index (CPI) which includes alcoholic beverages, tobacco, narcotics, clothing, footwear, housing, water, electricity, gas and other fuels, furnishings, household equipment and routine household maintenance, health, transport, communication, recreation & culture, education, restaurant and hotels and miscellaneous  goods and services, has increased by 53.9 per cent.

Retail prices of food products have gone up by 83.3 per cent in the last ten years. During this time, 30 per cent of food commodities have tripled in prices. The prices of kerosene and petrol rose by only 15.73 and 28.23 per cent respectively over the same period. The slow rise in the fuel prices was mainly due to the decline in international oil prices that started in 2014 through to 2018. Government revenue and expenditure increased over the past years though expenditure grew at a faster pace resulting in the increase of fiscal deficit. 

Household spending

Data from Basic Report Based on 2015/16 Kenya Integrated Household Budget Survey, shows the majority of households spend  44.6 per cent of their budget on education. Food closely follows at 33.5 per cent. In male-headed households, expenditure on education accounted for more than half of the cash transfers while female-headed households spend a higher proportion on food. Nationally, 54.7 per cent of cash transfers received from government programmes was spent on education while 32 per cent was spent on food. In rural areas, 43.8 per cent of cash received was spent on education compared with 73.4 per cent in urban areas.

Shocks to Household Welfare

A shock is an event that may trigger a decline in the well-being of an individual, a community, a region, or even a nation. According to the economic survey (2017) the shocks which occurred during the five-year period preceding the survey and had a negative impact on households’ economic status/welfare. 

Three in every five households reported having experienced at least one shock within the five years preceding the survey. A sharp rise in food prices was reported by the highest proportion (30.15%) of households as the first severe shock. Most households reported that they used their savings to cope with the shock(s).

The severity of a shock is assessed to define the impact on the household’s economic or social welfare. This is a simple ranking mechanism from the respondent’s perception to assist in determining the effect of the shock. A severe shock has debilitating effect on the household economic or welfare status. 

Nationally, a steep rise in food prices was reported as a severe shock by the highest proportion of households (30.1%). Other shocks reported by households as severe were droughts/floods (27.3%), death of other members of the family (21.5%) and death of livestock (20.1%).

In urban areas, high proportions of households reported that they struggled with high food prices (18.6%) and the death of other family members (14.9%). Death of other family members was ranked as the first severe shock, by about the same proportion of households in rural and urban areas. Households that lost livestock through death or theft mainly resorted to selling animals, while those affected by high food prices reduced food consumption at the household level.

According to the derived poverty lines, households whose adult equivalent food consumption expenditure per person per month fell below Ksh 1,954 in rural areas and Ksh 2,551 in urban areas were deemed to be food poor. Similarly, households whose overall consumption expenditure fell below Ksh 3,252 and Ksh 5,995 in rural and urban areas, respectively, per person per month were considered to be overall poor. Further, all those households that could not afford to meet their basic food requirements with all their total expenditure (food and non-food) were deemed to be hard-core/ extreme poor.

Rising food prices in Kenya have an adverse effect on the country’s development as a whole. Key contributors, partners and relevant authorities in the food sector should continue to analyse food prices and related issues, put in place mechanisms to respond to early warning of disasters such as droughts, floods and other disasters and come up with strategies to avert the negative effects of high food prices in the future. 


Written and published with the support of the Route to Food Initiative (RTFI) (www.routetofood.org). Views expressed in the article are not necessarily those of the RTFI.

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