World Health Day meant more to me this year than it ever has. Having just returned to the States after spending six months in Kenya as a Pfizer Global Health Fellow, it was a reminder, among other things, of how little I knew, before I left for Nairobi in August 2005, about the public health challenges the developing world faces.
I went to Kenya to assist the Ministry of Health with their organizational restructuring plans. In order to do that, I had to learn a fair amount. I spent my first month in Nairobi reading everything about the country's public healthcare system I could get my hands on, including the National Health Sector Strategic Plans I and II, Economic Recovery Strategy for Wealth and Employment Creation, the Ministry of Health's Annual Operating Plan, the new Kenyan constitution that had come out of a November 2005 referendum but had not yet been passed, and the Millennium Development Goals (MDG) charter and 2005 progress report.
Each of those documents articulates in different but fascinating ways the current state of Kenya's public health system and, more importantly, what it could and should be in the future. Each offers impressive amounts of data and supporting evidence that clearly lay out the rationale for change. The vision is reasonable and compelling: An efficient, high-quality healthcare system that is accessible, equitable, and affordable for every Kenyan. But I soon discovered that while healthcare leaders in Kenya know what needs to be done, the country's crumbling infrastructure and corruption in the political culture undermine their efforts and aspirations at virtually every turn.
The facts are stark: Kenya's population of 34 million is about the same size as California's. Life expectancy is 48 years for women and 47 for men. Roughly 40 percent of rural households and almost 30 percent of urban households survive on less than $1 a day. Fifty percent of all Kenyans do not have access to safe drinking water or proper sanitation, which explains why diarrhea, skin diseases, and intestinal worms are among the country's leading causes of morbidity and mortality.
The public healthcare system delivers fully half of all the healthcare services received by Kenyans through some 2,100 facilities, ranging from teaching hospitals, which handle the most difficult patient cases, to dispensaries designed to handle scrapes and cuts and hand out medication. (Services delivered by the private sector are managed by a combination of non-governmental organizations, faith-based organizations, and private facilities.) Health centers and dispensaries deliver the bulk of the services in the arid and semi-arid parts of the country where 80 percent of the population lives. Most of these are staffed by a single nurse who may see as many as three hundred patients a day. A doctor will visit once or twice a week, or will be on site more regularly but with a limited schedule. It's common for these facilities to run out of the drugs needed to treat diseases such as malaria or HIV/AIDS, not to mention non-pharmaceutical supplies like gloves and gauges. In addition, delivery of critical supplies can be disrupted or delayed by bandits and road conditions that strand trucks on their way to and from clinics.
I spent most of October doing site visits and talking to staff about their working conditions, conducting eighteen sets of interviews with leadership teams in hospitals, health centers, and dispensaries in three of the country's eight provinces. What I learned in terms of how much needs to be done for the Kenyan government to deliver on its promises was depressing, surprising, and inspirational.
Inspiration is found in the patience and perseverance of the people who use and staff these facilities. In Kenya, a public health facility cannot close until the last patient has been seen. Then most likely the staff will board a matatu (the ubiquitous mini-vans that provide most of the public transportation in the country) to begin their journey home. Perhaps they were paid on time this month for their efforts, but more likely not, as the public health sector's payroll system doesn't function any better than its drug supply system. Somehow they figure out a way to make ends meet. And the next morning they get up and, with second-rate tools and too few resources, go to work in an effort to improve the quality of life for their friends and neighbors.
Based on my field visits, I returned to Nairobi and produced a report that outlined four issues that, in my opinion, put the Ministry of Health's plans at risk: 1) the recent cost-sharing policy introduced by the government that reduced/eliminated the ability of health centers and facilities to set fees based on their location and patient population; 2) staffing, especially figuring out ways to recruit, and retain, qualified people from urban areas to work in remote backcountry villages; 3) the vulnerability of the drug supply system; and 4) healthcare worker education.
My report provided a diagnosis of the problems, some root-cause analysis, and several organizational-model options for the Permanent Secretary, the chief operating office of the Ministry of Health, and his leadership team to review and consider. I also reviewed more than thirty department-level planning documents and provided feedback on the degree to which they were aligned with the ministry's own strategic plan for the health sector, as well as the MDG charter. The resulting revisions will be rolled into the ministry's strategic plan over the next five years.
I was one of four Pfizer Fellows on assignment in Nairobi (my three colleagues all worked for NGOs), and returning home was a bittersweet experience. I had hoped to make a difference in Kenya by using my professional strengths and experience to help create a new public health infrastructure to support the delivery of critically needed services and education. But while I was there famine in the northeast part of the country tightened its grip, and corruption within the government seemed to worsen, making it harder for committed individuals to move the changed agenda forward. I now realize it will take a lot more than four people working over six months to even make a dent in the problems we had hoped to address. Still, the four of us were determined, as Teddy Roosevelt urged, to do what we could, with what we had, where we were. And each of us, in our own way, made a contribution.
I wish I could tell you how much resolve the average Kenyan must muster to overcome the hunger, poverty, and illiteracy that is the lot of too many Kenyans. I wish I knew what it takes to ignite transformation in an individual or a nation. I do know, based on my experience in Kenya, that real transformation cannot happen without leaders who identify with the average person and are willing to put their own self-interest aside.
Kenya is a beautiful country with a multi-ethnic population that shares a common dream to rid the country of the preventable plagues, medical and otherwise, that are draining the life from it. I have every hope that Kenyans will find the resolve to move forward together and demand what they need from those who can provide it. In the meantime, Pfizer's Global Health Fellows program has given me something that no amount of money can buy: A connection to Kenya and its people that I will always cherish.
Dannette Hill, Senior Director of Worldwide Development Operations in Pfizer's New London, Connecticut facility, spent six months in Kenya working with the USAID ~ President's Emergency Plan For AIDS Relief (PEPFAR), where she applied her human resources and management expertise to assist with an organizational restructuring at the Ministry of Health and helped implement new human resources policies designed to create incentives for staff.