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China In Africa: It’s a Numbers Game

8 min read. Over the past two decades, China has grown into the undisputed champion of Africa’s infrastructure financing needs but as the popular adage goes, there is no such thing as a free lunch.

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China In Africa: It’s a Numbers Game
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China’s growing global dominance got a publicity boost this April 2019 with the latest Forum on Belt and Road International ( BRI) Cooperation. The annual event brought world leaders from 37 countries, 5000 delegates from 150 nations and representatives of 90 international organisations to Beijing for the BRI conference that culminated in a resolution to continue strengthening ties and promoting global growth and economy through policy coordination among participating economies, infrastructure connectivity, trade investment and industrial cooperation

To Africa in particular, China has become a significant economic partner. China has catapulted from being a relatively small investor in the continent to becoming Africa’s largest economic partner, providing infrastructure and investment loans that have helped the continent record massive expansion of roads, rail and other utilities. Obviously, the forum is crucial in strengthening existing relationships and opening new opportunities for cooperation.


To date, it is difficult to understand the full extent of China’s blueprint in Africa due to the data knowledge gap that exists. This vacuum has fueled urban legends and sensational stories, everything from charges of neocolonialism, persistent yet unfounded rumor that Chinese firms use convict labor en masse, to even a Chinese settler colony in Africa. However, to dispel or confirm these narratives Africa must take a critical review, audit and examination of its principal relationship with China and what it portends for Chinese influence and footprint in the continent.

Trade

Since the turn of the 21st century, China has catapulted from being a relatively small investor in the continent to becoming Africa’s biggest economic partner. Africa-China trade increased from $13 billion in 2001 to $188 billion in 2015—an average annual growth rate of 21 percent. China has far surpassed Africa’s longstanding trade partners such as France, Germany, India, and the United States. According to a McKinsey and Company report dubbed Lions and Dragons in 2015, total goods trade between China and Africa amounted to $188 billion—more than triple that of India.


Statistics from the General Administration of Customs of China, in 2018, indicate that China’s total import and export volume with Africa was US$204.19 billion, a year-on-year increase of 19.7%, exceeding the overall growth rate of foreign trade in the same period by 7.1 percentage points. Among these, China’s exports to Africa were US$104.91 billion, up 10.8% and China’s imports from Africa were US$99.28 billion, up 30.8%; the surplus was US$5.63 billion, down 70.0% year on year. In December last year, China’s total imports and exports with Africa were US$18.27 billion, up 15.5% year on year and 2.1% month on month. Among these, China’s exports to Africa were US$9.55 billion, up 3.9% year on year and 3.0% month on month; China’s imports from Africa were US$8.72 billion, up 33.7% year on year and 2.2% month on month; the trade surplus was US$840 million, down 68.7% year on year and up 13.5% month on month. In 2018, the growth rate of China’s trade with Africa was the highest in the world.

China and Infrastructure

China has a long history of infrastructure investment in Africa, and this remains the country’s most visible legacy to this day. In the 1970s, China constructed the 1,710 km Tanzania-Zambia railway (Tan-Zam Railway completed in 1976), which linked landlocked, mineral-rich Zambia to the Indian Ocean. China’s aid for the project consisted of a nearly one billion interest-free loan, over one million tons of machinery and materials, and 50 thousand laborers to undertake construction efforts. Zambia’s first president, Kenneth Kaunda, hailed China’s support, and claimed the railway served as “a model for south-south cooperation.”


However, one of the megatrends of our times has been the growing presence of China in Africa’s infrastructure sector. Over the past two decades, China has helped to meet some of Africa’s infrastructure financing needs and is now the single largest financier of African infrastructure,financing one in five projects and constructing one in three mega projects.

Most funded projects are in the Transport, Shipping and Ports sectors (52.7 per cent), followed by Energy and Power (17.6 per cent), Real Estate (15 per cent, including industrial, commercial and residential real estate) and Energy and Power (13.1 per cent)

To date China has participated in over 200 African infrastructure projects. Chinese enterprises have completed and are building projects that are designed to upgrade about 30,000km of highways, 2,000km of railways, 85 million tonnes per year of port output capacity, more than nine million tonnes per day of clean water treatment capacity, about 20,000MW of power generation capacity, and more than 30,000km of transmission and transformation lines.

Foreign Direct Investment

China is poised to become Africa’s largest source of Foreign Direct investment. At the current growth rates, China will be Africa’s largest source of FDI stock within the next decade. China’s financial flows to Africa are around 15 percent larger than previous estimates. This discrepancy is found because official figures, which rely on banking-system data, do not cover informal money-transfer methods often used by smaller businesses. These methods include “mirror transfers,” in which a local payment is made into the Chinese account of an associate or family member, who in turn makes a local equivalent payment in Africa to the beneficiary’s bank account.

Aid

China is the second- or third-largest country donor to Africa Chinese official development assistance (ODA) and other official flows (OOF) to Africa together amounted to $6 billion in 2012. Chinese foreign aid expenditures increased steadily from 2003 to 2015, growing from USD 631 million in 2003 to nearly USD 3 billion in 2015. The United States promised somewhat more—$90 billion in the same period—but Chinese aid is more sought after. Unlike Western assistance, which comes mainly in the form of outright transfers of cash and material, Chinese assistance consists mostly of export credits and loans for infrastructure (often with little or no interest) that are fast, flexible, and largely without conditions. Thanks to such loans, the International Monetary Fund estimates that, as of 2012, China owned about 15 percent of sub-Saharan Africa’s total external debt, up from only 2 percent in 2005. And McKinsey & Co. reckons that, as of 2015, Chinese loans accounted for about a third of new debt being taken on by African governments. 

Debt

Most of China’s loans to Africa go into infrastructure projects such as roads, railways and ports. China’s loan issuance to Africa has tripled since 2012. New debt issuance by Chinese institutions to African governments increased dramatically in the past five years, rising to some $5 billion to $6 billion of new loan issuances each year in the 2013–15 period. The McKinsey report suggests that in 2015, these loans accounted for approximately one-third of new sub-Saharan African government debt. Most of these loans are linked to infrastructure projects, such as China EXIM Bank’s $3.6 billion loan to finance the Mombasa-Nairobi Standard Gauge Railway in Kenya. From 2000 to 2017, the Chinese government, banks and contractors extended US $143 billion in loans to African governments and their state-owned enterprises (SOEs).


In 2015, the China-Africa Research Initiative (CARI) at John Hopkins University identified 17 African countries with risky debt exposure to China, potentially unable to repay their loans. It says three of these – Djibouti, Republic of Congo ( Congo-Brazzaville) and Zambia – remain at risk of debt distress derived from these Chinese loans. In 2017, Zambia’s debt amounted to $8.7bn (£6.6bn) – $6.4bn (£4.9bn) of which is owed to China. For Djibouti, 77% of its debt is from Chinese lenders. Figures for the Republic of Congo are unclear, but CARI estimates debts to China to be in the region of $7bn (£5.3bn). Angola is the top recipient of Chinese loans, with $42.8 billion disbursed over 17 years. Yet, Chinese loans are currently not a major contributor to the debt burden in Africa; much of that is still owed to traditional lenders like the World Bank.

Business

According to the McKinsey report , there are about 10,000 Chinese-owned firms operating in Africa today. Around 90 percent of these firms are privately owned. State-owned enterprises (SOEs) tend to be particularly in specific sectors such as energy and infrastructure, the sheer multitude of private Chinese firms working toward their own profit motives make Chinese investment in Africa a more market-driven phenomenon than is commonly understood. Chinese firms operate across many sectors of the African economy. Nearly a third are involved in manufacturing, a quarter in services, and around a fifth in trade and in construction and real estate. In manufacturing, an estimated 12 percent of Africa’s industrial production—valued at some $500 billion a year in total—is already handled by Chinese firms. In infrastructure, Chinese firms’ dominance is even more pronounced, and they claim nearly 50 percent of Africa’s internationally contracted construction market.

One-third of Chinese firms based in Africa reported profit margins of more than 20 percent in 2015. They are also agile and quick to adapt to new opportunities and they are primarily focused on serving the needs of Africa’s fast-growing markets rather than on exports.

Agriculture

According to CARI China has acquired 252,901 hectares of land in Africa. Cameroon alone accounts for 41% of all lands actually acquired: driven by two large purchases of existing rubber plantations (over 40,000 hectares each) in 2008 and 2010.China has also established 14 agricultural centres across Africa.

China has also taken an increasingly hands-on role in its work and investment related to African agriculture, leasing and developing land and in many instances being accused of “grabbing” large swathes of it. But as Deborah Brautigam’s reports the assumptions about China’s role in Africa are often not borne out in reality and the areas of land “grabbed” for investment are small compared to the vast areas identified by some.

Security

Over the past decade China’s role in peace and security has also grown rapidly through arms sales, military cooperation and peacekeeping deployments in Africa. Today, China is making a growing effort to take a systematic, pan-African approach to security on the continent.

China is now the second-largest contributor to the peacekeeping budget. Chinese personnel have served on missions in Africa for decades, but until 2013 they were small contingents in unarmed roles such as medical and engineering support. China now provides more personnel than any other permanent member of the Security Council – they numbered 2,506 as of September. Chinese peacekeepers now serve in infantry, policing and other roles in Africa.

In 2017, China established a 36 hectare Djibouti military facility.with a ten-year lease at $20 million annually. It has been described as a support base for naval anti-piracy operations in the Gulf of Aden, peacekeeping in South Sudan and humanitarian and other cooperation in the Horn of Africa, but has also been used to conduct live-fire military exercises.

Labour and Population

The number of Chinese immigrants in Africa has risen sevenfold in under two decades, The Annual Report on Overseas Chinese Study said the African continent was home to more than 1.1 million Chinese immigrants in 2012, compared with less than 160,000 in 1996, adding that 90 percent of the current total arrived after 1970. Initially, most labourers coming to Africa were from retail industry but today with the closer relationships with Africa, Chinese intellectuals and skilled professionals have settled in Africa.

The number of chinese workers by the end of 2017 was 202,689. In 2017, the top 5 countries with Chinese workers are Algeria, Angola, Nigeria, Ethiopia, and Zambia. These 5 countries accounted for 57% of all Chinese workers in Africa at the end of 2017; Algeria alone accounts for 30% of the numbers. These figures include Chinese workers sent to work on Chinese companies’ construction contracts in Africa (“workers on contracted projects”) and Chinese workers sent to work for non-Chinese companies in Africa (“workers doing labor services”); they are reported by Chinese contractors and do not include informal migrants such as traders and shopkeepers.

Media

There has been a significant increase of Chinese media on the African continent in recent years. This has taken place across various levels, including infrastructure development, training of journalists, production and distribution of media content, and investing directly in African media houses and platforms. The increased media footprint is widely seen as a way for China to extend its ‘soft power’ on the continent. But this is not the first time that China has established a media presence on the continent. As far back as the 1960s and 1970s, Chinese media was active in Africa.

However, since 2012, state-run media outlets have also pitched up in the continent, among them the Africa bureau of China Global Television Network (CGTN based in Nairobi) and China Daily Africa newspaper. China also takes African journalists to Beijing for training, while state-linked firms have made investments in local media outlets including buying a 20% stake in South Africa’s Independent News and Media firm (INMSA). The Beijing-based StarTimes Group has also become one of Africa’s most important media companies, increasingly influential in the booming pay-TV market. As it spread its foothold in Africa, the company has embarked on a project to provide solar-powered satellite television sets to 10,000 villages across Africa.

*****

China has not “taken over Africa”; she has merely joined with earlier groups of imperialists in grabbing a part of the African bounty. As a newcomer, her presence is more visible, but not yet as substantially deep-rooted as the long-standing European imprint.

She comes with two key differences: first, China does not yet have the military and diplomatic capacity to replace any of those Western powers in physically securing and enforcing the various trade routes and treaties needed to keep the global trade machine, upon which they all depend, running. Second, therefore, this venture cannot be implemented remotely, but by human displacement. Even a settler-overlord project may not work. What could work is one where millions of Chinese people are steadily shipped over to “yellow” Africa as a continuation of the anti-black ethnic cleansing and encroachment the Asians began centuries ago in South Asia.

The Africa of the ordinary people must therefore assert itself and force its concerns on to all public agendas. The struggle now is to hold a public conversation independent of these various imperialists and their allies.

Sources: McKinsey and Company report. Compiled by Mdogo.

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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

7 min read. 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

9 min read. 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)

4 min read. 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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