Globally, Kenya ranks top 30 in terms of its population size (Worldometers, 2019), with more than 70% of the population situated in rural areas. The 2019 census (conducted every 10 years) revealed a total population of 47,564,296 (males: 23,548,056; females: 24,014,716 and intersex population: 1,524), 12,143, 913 households, with an average household size of 3.9. Kenya covers a land area of 580,876.3 km² and a population density of 82 per km²(Kenya National Bureau of Statistics (KNBS), 2019).

References:

Kenya National Bureau of Statistics (KNBS). (2019). 2019 Kenya Population and Housing Census Volume I : Population By County and Sub-County (Vol. I). Nairobi, Kenya.http://housingfinanceafrica.org/app/uploads/VOLUME-I-KPHC-2019.pdf

Worldometers. (2019). Kenya Population (LIVE). https://www.worldometers.info/world-population/kenya-population/

Geographically and administratively, the country is divided into 47 counties. Since 2013, each county is responsible for county legislation and executive functions transferred from the national government.

There are two official languages (English and Swahili) and one national language (Swahili) but most residents in rural areas only speak their native languages, which are about 70.  Kikuyu, Luo, Luhya, Kamba and Kalenjin ethnic groups account for 70% of the nation’s total population (University of Pennsylvania, 2019). The majority of the residents in cities and town centers speak the national language (Swahili) which is spoken in several other countries such as Tanzania, Burundi, Uganda, and Zaire.

References:

University of Pennsylvania. (2019). Kenya Ethnic Groups. https://www.africa.upenn.edu/NEH/kethnic.htm

Since the mid-20^th century, there has been increasing population growth due to high birth rates and decreasing mortality rates. However, after the introduction of family planning programs in 1967 (Kenya was the first Sub-Saharan African country to introduce a national family program), there has been a substantial decrease in birth rates from about 8 children per woman in the late 1970s to an average of 4 children today (Index Mundi, 2019b; Kenya National Bureau of Statistics (KNBS), 2019) and this is likely to drop down to 2.4 children by 2050 (Fengler, 2010). Despite the intercensal growth rate declining from 2.9% in 2009 to 2.2% in 2019 (Kenya National Bureau of Statistics (KNBS), 2019), UN projections indicate that Kenya’s population will grow by around 1 million per year and are therefore expected to reach about 85 million by 2050 (Fengler, 2010).

References:

Fengler, W. (2010). Demographic Transition and Growth in Kenya. https://www.worldbank.org/en/news/opinion/2010/04/28/demographic-transition-growth-kenya

IndexMundi. (2019b). Kenya Demographics Profile 2018. https://www.indexmundi.com/kenya/demographics_profile.html

Kenya National Bureau of Statistics (KNBS). (2019). 2019 Kenya Population and Housing Census Volume I : Population By County and Sub-County (Vol. I). Nairobi, Kenya.

Age distribution

3.07% of the population is above 65 years while the majority (38.71%) is below 15 years. Those aged between 15 to 24 years, 25 to 54 years and 55 to 64 years constitute 20.45%, 33.75% and 4.01% of the population respectively (Central Intelligence Agency, 2019).

Median age

The median age in Kenya is about 18 years (World Health Rankings, 2018).

Life expectancy at birth

Life expectancy at birth is 66.7 years  (64.4 years for males and 68.9 years for females) (World Health Rankings, 2018).

Total fertility rate

Fertility rate of 2.98 (World Health Rankings, 2018) due to high fertility, early marriages and still a continuing high unmet need for family planning.

References:

Central Intelligence Agency. (2019). The World Factbook: Africa – Kenya. https://www.cia.gov/the-world-factbook/countries/kenya/

World Health Rankings. (2018). Health Profile: Kenya. https://www.worldlifeexpectancy.com/country-health-profile/kenya

Kenya is the second biggest refugee-hosting country in Africa with 259,100 (54.5% of registered refugees) originating from Somalia (UNHCR, 2019) and others from the East and the Horn of Africa due to continued conflict and displacement. The key drivers for Kenyan emigrants appear to be access to employment, education and other opportunities with top destinations being the United Kingdom, the United States of America, and other African countries, particularly the United Republic of Tanzania and Uganda (International Organization for Migration (IOM), 2015).

References:

International Organization for Migration (IOM). (2015). Migration in Kenya: A country profile 2015. Nairobi, Kenya. https://publications.iom.int/books/migration-kenya-country-profile-2015

UNHCR. (2019). Kenya: Registered refugees and asylum-seekers. https://www.unhcr.org/ke/wp-content/uploads/sites/2/2019/04/Kenya-Infographics_March-2019.pdf

Kenya still experiences epidemiological and demographic challenges which affect the health of its population thus increasing mortality rates.

Non-communicable diseases (NCDs) account for more than 50 to 70% of hospital admissions and 55% of hospital deaths in Kenya (MoH-Kenya, KNBS, & WHO, 2015). The greatest burden on the healthcare system is attributable to four major NCDs: cardiovascular diseases, diabetes mellitus, cancer, and chronic respiratory illnesses. According to the 2015 NCDs surveillance using the STEPS (STEPwise approach to surveillance), a standardized protocol involving three levels of gathering data on demographics and risk factors from nationally representative populations, articles revealed the following rates (Wamai, Kengne, & Levitt, 2018):

Hypertension: The age-standardized prevalence for hypertension in Kenya was 24.5% with 15.6% of them being aware of their elevated blood pressure of which 26.9% were on treatment and only half were able to achieve their blood pressure control.

Diabetes: The age-standardized prevalence for pre-diabetes and diabetes mellitus was 3.1% and 2.4% respectively, with 43.7% being aware of having pre-diabetes or diabetes of whom 20% were on treatment and only 7% were able to achieve glycaemic control.

Cervical cancer: Out of 1180 women who were interviewed, 16.4% had screened for cervical cancer despite high awareness.

NCDs common risk factors: Three-quarters of individuals who had participated in the STEPS study had four to six risk factors for NCDs while 10% were exposed to more than six risk factors. The most universal risk factor was inadequate fruit intake (99.8%), and majority had high dietary salt consumption (89.5%) and insufficient physical activity (80.3%). Other modifiable risk factors associated with these four NCDs are tobacco use, excessive alcohol consumption, air pollution, environmental degradation, climate change and psychological stress. Additional significant contributors to the burden of disease are violence, injuries, haemoglobinopathies, mental disorders, oral, eye and dental diseases.

References:

MoH-Kenya, KNBS, & WHO. (2015). Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report. MoH-Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Executive-summary-6-2.pdf

Wamai, R. G., Kengne, A. P., & Levitt, N. (2018). Non-communicable diseases surveillance: Overview of magnitude and determinants in Kenya from STEPwise approach survey of 2015. BMC Public Health, 18(Suppl 3), 1–8. http://doi.org/10.1186/s12889-018-6051-z

HIV/AIDS, neonatal disorders, diarrheal diseases, lower respiratory infections, congenital defects, tuberculosis, stroke, ischemic heart disease, meningitis, cirrhosis were the top 10 causes of death and disability-adjusted life years (DALYs) combined in 2017 in Kenya (all ages and sexes combined) (Institute for Health Metrics and Evaluation, 2017)

Although HIV prevalence in Kenya reduced from 7.2% (excluding North-Eastern region) in 2007 to 5.6% and an incidence of 0.5% in 2012 with similar decline across males and females, it continues to be a public health concern due to the annual transmission rate of 8.9 per 100 HIV-infected persons. In 2012, HIV prevalence peaked (9.8%)  among those aged 45-49 while in 2007 the highest prevalence (11.9%) was seen among those aged 30-34 (Kimanga et al., 2016).

Kenya was also hit by the global pandemic of corona virus disease (COVID-19) which was first detected in China on 31^st December 2019. In March 2020, the first case was confirmed. Older people have experienced a double blow during the pandemic as they are at a higher risk of developing dementia and are vulnerable to frailty and comorbid conditions. By 12^th April 2020, 7% of COVID-19 cases (out of 197) were aged 60 years. In addition, most deaths across the globe were older adults with underlying health issues (Lloyd-Sherlock et al., 2020).  Unfortunately, non-governmental organizations (NGOs) offering support to persons with dementia and their caregivers remain scarce in  Kenya, yet that is the only face-to-face and practical option for the increasing cases of dementia (Comas-Herrera et al., 2020).

The World Health Organization (WHO) and the government of Kenya has continuously put in strict safety measures to reduce further infection of COVID-19 such as physical distancing, wearing masks, hand washing and other sanitization procedures. In some countries like Kenya, measures to reduce public gatherings and crowds included government curfew and minimal movement outside major counties affected by COVID-19. Some of the measures may pose difficulties for persons with dementia such as remembering these instructions since decline in memory is a key presentation for dementia. As a result, persons with dementia may be predisposed to infection (Wang et al., 2020) or experience legal consequences because there have not been exceptions or guidelines that have been put in place for persons with disability such as dementia.

References:

Comas-Herrera, A., Lorenz-Dant, K., Ferri, C., Govia, I., Sani, T., Jacobs, R., … The STRiDE Team. (2020). Supporting people living with dementia and their carers in low- and middle-income countries during COVID-19. LTCcovid.Org, International Long-Term Care Policy Network, CPEC-LSE, April, 7–10. https://ltccovid.org/2020/04/10/supporting-people-living-with-dementia-and-their-carers-in-low-and-middle-income-countries-during-covid-19/

Institute for Health Metrics and Evaluation. (2017). Country profiles: Kenya – What causes the most death and disability combined? https://www.healthdata.org/kenya

Kimanga, D., Ogola, S., & Umuro, M. (2016). Prevalence and Incidence of HIV Infection, Trends, and Risk Factors Among Persons Aged 15–64 Years in Kenya: Results From a Nationally Representative Study. Journal of Acquired Immune Deficiency Syndromes, 1999(66(Suppl 1)), 13–26. https://doi.org/10.1097/QAI.0000000000000124

Lloyd-Sherlock, P., Ebrahim, S., Geffen, L., & McKee, M. (2020). Bearing the brunt of covid-19: older people in low and middle income countries. BMJ, 368, 1–2. https://doi.org/10.1136/bmj.m1052

Wang, H., Li, T., Barbarino, P., Gauthier, S., Brodaty, H., Molinuevo, J. L., … Tang, Y. (2020). Dementia care during COVID-19. Lancet (London, England), 395(10231), 1190. https://doi.org/10.1016/S0140-6736(20)30755-8

In Kenya, the leading causes of injury include assault (42%), road traffic accidents (28%), unspecified soft tissue injury (11%), and less than 10% for cut-wounds and dog-bites, falls and burn and poisoning each (MoH-Kenya et al., 2015). According to the Kenya Health and Demographic survey 2008/9, 39% and 20.6% of women have experienced physical and sexual violence, respectively (Kenya National Bureau of Statistics (KNBS); ORC Macro, 2010). There has been an increase in transport injuries with pedestrians comprising 43% of fatalities (Kenya National Bureau of Statistics (KNBS); ORC Macro, 2010). Other vulnerable road users include motorcyclists and cyclists. More than 75% of deaths on the roads are males and about 50% of the total deaths are children or young adults. The major killer has been consistently identified as speed and lack of use of safety equipment such as helmets, seat-belts and child-restraints (World Health Organization (WHO), 2010).

References:

Kenya National Bureau of Statistics (KNBS); ORC Macro. (2010). Kenya Demographic and Health Survey 2008-09. Health (San Francisco), 1–314. https://dhsprogram.com/pubs/pdf/fr229/fr229.pdf

MoH-Kenya, KNBS, & WHO. (2015). Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report. MoH-Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Executive-summary-6-2.pdf

World Health Organization (WHO). (2010). Road Safety in Ten Countries: Kenya. Nairobi, Kenya. https://www.who.int/violence_injury_prevention/road_traffic/countrywork/rs10_kenya_en.pdf

Key developmental challenges affecting access to health care and economic growth include political instability and climate change. Real Gross Domestic Product (GDP) was estimated to be 5.9% in 2018 with mainly services accounting for 52.5% of the growth since 2017, agriculture (the backbone of the Kenyan economy) for 23.7%, and industry for 23.8% on the supply side and private consumption as the key driver of growth on the demand side (African Development Bank Group, 2019). Real GDP was projected to grow by 6.0% in 2019 and 6.1% in 2020. The public debt–to-GDP ratio was 57% at the end of June 2018 (African Development Bank Group, 2019) reflecting a volatile economy.

References:

African Development Bank Group. (2019). Kenya Economic Outlook. https://www.afdb.org/en/countries-east-africa-kenya/kenya-economic-outlook

In spite of the political instability in Kenya, tourism accounted for 20% of the economy, demonstrating the significance of this sector in the country’s economy (Central Intelligence Agency, 2019). The agriculture, service, industry, and private consumption sector are also quite significant as mentioned in 01.03.01.

References:

Central Intelligence Agency. (2019). The World Factbook: Africa – Kenya. https://www.cia.gov/the-world-factbook/countries/kenya/

National debt has been increasing since 2014 (25.65 billion dollars). In 2018, it amounted to 52.37 billion dollars and was projected to be 109.9 billion dollars in 2024 (Plecher, 2019). This is because Kenya has been relying heavily on public debt, aid and grants as a source of financing thus increasing the public debt stock and affecting private investment (Ngugi, 2016).

References:

Ngugi, W. N. (2016). Effect of Public Debt on Economic Growth in Kenya. Kenyatta University.http://erepository.uonbi.ac.ke/bitstream/handle/11295/98782/Kobey_Effect+Of+Public+Debt+On+Economic+Growth+In+Kenya.pdf?sequence=1

Plecher, H. (2019). Kenya: National debt from 2014 to 2024 (in billion U.S. dollars).

Even though Kenya is recognized as a lower-middle income country, most of its residents continue to live below the poverty line in rural areas. Poverty levels vary across different cities and towns in Kenya with a lower incidence of multidimensional poverty in Nairobi (capital city of Kenya) and satellite towns such as Ruiru (22%) and Thika (27%). This figure is higher in other cities such as Mombasa (44%) and Kisumu (46%). Additionally, location-based horizontal inequality estimates are higher in the capital city and Thika town. Although these urban centers show relatively lower overall poverty levels compared to other urban centers, they register higher inequalities in deprivation scores between their different sub-locations (Shifa & Leibbrandt, 2017).

Nevertheless, Kenya’s level of inequality is moderate in comparison to Tanzania, Uganda, and Ghana as the Gini index dropped from 0.45 in 2005/06 to 0.39 in 2015/16 while in rural areas it fell from 0.37 to 0.33, demonstrating a remarkable positive change for an indicator that seldom changes over time (International Bank for Reconstruction and Development/The World Bank, 2018). The current monetary and non-monetary poverty indicators in Kenya are better than most countries in Sub-Saharan Africa. Specifically, Kenya’s adult literacy level is among the highest in Africa and performs better in access to improved sanitation compared to countries with a similar poverty headcount (World Bank Group, 2018).

There is very low financial protection from catastrophic health expenditure under the current health insurance system in Kenya. The absence of Universal Health Coverage (UHC) and the considerable costs associated with accessing health care often drain household resources. This has predisposed an estimated 1 to 1.1 million individuals (not only from lower income groups but also those with middle and higher income) to a high risk of being pushed or trapped into poverty (Salari et al., 2019).

References:

International Bank for Reconstruction and Development/The World Bank. (2018). Fiscal Incidence Analysis for Kenya: Using the Kenya Integrated Household Budget Survey 2015/16. Washington, DC. https://openknowledge.worldbank.org/bitstream/handle/10986/30263/Kenya-Fiscal-Incidence-Analysis.pdf?sequence=1&isAllowed=y

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

Shifa, M., & Leibbrandt, M. (2017). Urban Poverty and Inequality in Kenya. Urban Forum, 28(4), 363–385. http://doi.org/10.1007/s12132-017-9317-0

World Bank Group. (2018). 17th Edition of the Kenya Economic Update: Policy Options to Advance the Big 4 – Unleashing Kenya’s Private Sector to Drive Inclusive Growth and Accelerate Poverty Reduction. Nairobi, Kenya. https://openknowledge.worldbank.org/handle/10986/29676

Kenya experiences: (i) natural hazards such as recurring droughts, landslides, lightening and thunderstorms, flooding during rainy seasons but limited volcanic activities; and (ii) environmental pollution including water pollution from urban and industrial waste, water shortage and degraded water quality resulting from use of pesticides and fertilisers, deforestation, soil erosion, desertification, and poaching. The level of destruction is increasing leading to more deaths, loss of livelihoods and infrastructure destruction (Central Intelligence Agency, 2019; United Nations Development Programme, 2007).

Another aspect hampering Kenya’s effort to improve its annual growth is inadequate infrastructure. The current efforts through multisectoral collaboration with international financial institutions and donors have raised capital in the global market by investing in infrastructure. One of the most recent projects is the construction of the Chinese financed standard gauge railway between Nairobi and Mombasa (Central Intelligence Agency, 2019).

References:

Central Intelligence Agency. (2019). The World Factbook: Africa – Kenya. https://www.cia.gov/the-world-factbook/countries/kenya/

United Nations Development Programme. (2007). Kenya Natural Disaster Profile. Enhanced security Unit. https://meteorology.uonbi.ac.ke/sites/default/files/cbps/sps/meteorology/Project%20on%20Disasters.pdf

Employment (status, sector, and hours), conditions of work (wages, compensation costs, working poverty) and characteristics of job seekers (education, labour productivity) form some of the key indicators of labour market. Kenya’s bulging youth unemployment rate is more than 20%, primarily due to reduced education opportunities. This is also reflected in the general population where unemployment and under-employment are extremely high (about 40% of the population) with a higher rate of unemployment among women (2.9%) compared to men (2.6%) (Central Intelligence Agency, 2019; International Labour Organization (ILO), 2016). A third of those employed (with 83% of all employment opportunities provided by the informal sector) in Kenya work for more than 48 hours per week.

References:

Central Intelligence Agency. (2019). The World Factbook: Africa – Kenya. . https://www.cia.gov/the-world-factbook/countries/kenya/

International Labour Organization (ILO). (2016). Country profile. https://www.ilo.org/dyn/normlex/en/f?p=1000:11110:0::NO:11110:P11110_COUNTRY_ID:103315

The informal sector consists of both professionals and non-professionals engaging in small-scale commercial activities such as selling second-hand items, shoe-shining, street vendors, carpentry, vegetable selling, repair and construction work. These activities are not formally established, regulated or protected by the government and often times, simple skills are used to generate income and profits (Institute of Economic Affairs, 2012). There is a higher labour force participation rate among men (77.5%) compared to women (71.5%) (International Labour Organization (ILO), 2016). The considerable part of the population that is unemployed or in the informal work is severely under-insured, which limits their access to health care significantly.

References:

Institute of Economic Affairs. (2012). Informal sector and taxation in Kenya. https://s3-eu-west-1.amazonaws.com/s3.sourceafrica.net/documents/118220/The-informal-sector-and-taxation-in-Kenya-IEA.pdf

International Labour Organization (ILO). (2016). Country profile. https://www.ilo.org/dyn/normlex/en/f?p=1000:11110:0::NO:11110:P11110_COUNTRY_ID:103315

In the recent past, Kenya’s enrollment numbers for primary education was 100% due to free primary education (Hall, 2017). In 2012, the gross enrolment ratio (total enrolment in secondary education, regardless of age, expressed as a percentage of the population of official secondary education age) in secondary schools was 67.6% which increased at an average annual rate of 4.67% since 1981 (29.3%) (Knoema, 2019b). However, only 3.3% of women and 4.7% of men enrolled in tertiary education but sometimes the education obtained does not provide the necessary skillsets for the job market  (Samuel Hall, 2017), contributing to an average of 10.48% unemployment rate (CEIC, 2019). It is worthy to note that the literacy rate in Kenya increased by 5.57% between 2007 and 2014. By 2014, the adult literacy rate was 78.73% (83.78% for females and 74.01% for males). The literacy rate for those aged 15 to 24 was 86.53% (86.14 for females and 86.94% for males) (Country Economy, 2019). In 2018, the adult literacy rate increased to 81.5% (Knoema, 2019a).

A major barrier to achieving higher levels of education are the high levels of poverty. Despite the fact that the government provides free secondary school education, most are boarding schools and parents still bear the cost of paying for meals in schools, boarding fees, buying uniform and examination fees. This results in children dropping out of school in cases where parents cannot afford these costs (James, Simiyu, & Riechi, 2016; Khamati & Nyongesa, 2013). Another contributing factor is the delay in disbursement of funds or treasury underfunding for secondary school fees and inconsistency in increasing the government’s contribution despite inflation, which makes the actual cost of secondary school education higher (Republic of Kenya, 2016a; Shiundu, 2017).

Other factors contributing to reduced school retention include peer pressure related to minimal interest in schooling, early marriages, pregnancies, domestic duties and negligence by parents (James et al., 2016). The few students who are able to withstand such pressures and stay in school are affected by (Khamati & Nyongesa, 2013):

1. Delay in successful implementation of free secondary schools due to factors such as poor management (accountability, preparing budgets and general management of resources).
2. Initial increase in enrollment in secondary schools leading to overstretching of the available resources including laboratories hence compromising the quality of education. This affects enrollment in tertiary education and results in more than 60% of the youth (aged 18 to 35) working in the informal sector, contributing to a high degree of income inequality.

References:

CEIC. (2019). Kenya Unemployment Rate. https://www.ceicdata.com/en/indicator/kenya/unemployment-rate

Country Economy. (2019). Kenya – Literacy rate. https://countryeconomy.com/demography/literacy-rate/kenya

Hall, S. (2017). Youth Employment in Kenya Literature Review. Nairobi. https://static1.squarespace.com/static/5cfe2c8927234e0001688343/t/5d42d9d220ada4000196692f/1564662260539/Samuel-Hall-Youth-Employment-in-Kenya-2017-for-the-British-Council.pdf

James, A. M., Simiyu, A. M., & Riechi, A. (2016). Factors Affecting Subsidized Free Day Secondary Education in Enhancing Learners Retention in Secondary Schools in Kenya. Journal of Education and Practice, 7(20), 49–55. https://files.eric.ed.gov/fulltext/EJ1109168.pdf

Khamati, M. J., & Nyongesa, W. J. (2013). Factors Influencing the Implementation of Free Secondary Education in Mumias District, Kenya. Journal of Social Science for Policy Implications, 1(1), 32–47. http://jsspi.com/journals/jsspi/Vol_1_No_1_June_2013/4.pdf

Knoema. (2019a). Kenya – Adult (15+) literacy rate. https://knoema.com/atlas/Kenya/topics/Education/Literacy/Adult-literacy-rate

Knoema. (2019b). Kenya – Gross enrolment ratio in secondary education. https://knoema.com/atlas/Kenya/topics/Education/Secondary-Education/Gross-enrolment-ratio-in-secondary-education

Republic of Kenya. (2016a). Education Sector Report, 2017/18 – 2019/20. https://planipolis.iiep.unesco.org/sites/default/files/ressources/kenya_education_sector_report.pdf

Shiundu, A. (2017). FACTSHEET: Cost of providing ‘truly’ free secondary education in Kenya. https://africacheck.org/fact-checks/factsheets/factsheet-cost-providing-truly-free-secondary-education-kenya

Several countries have adopted social protection strategies to reduce poverty levels and inequalities. In Kenya, social protection has been implemented using non-contributory and contributory schemes in the areas of social assistance (cash transfer and school-feeding programmes), social security and health insurance.

Cash transfer programmes

(National Gender and Equality Commission, 2014) – to support access to health care, food, school retention for children, social support networks, self-esteem and dignity. In 2016, the total coverage was 519,878 households (table 1), accounting for only 3.8% of the total expenditure among the bottom 20% of the population (cash transfer for orphans and vulnerable children (CT-OVC), the older persons cash transfer (OPCT), cash transfer for persons with severe disability (CT-PwSD); and Hunger Safety Net Program (HSNP) for chronically poor people (International Bank for Reconstruction and Development/The World Bank, 2018). The OP-CT program, which received the highest allocation (3 billion) among the above listed cash transfer programmes during the 2018/19 financial year only covered about 3% of all households in Kenya in 2015/16 (International Bank for Reconstruction and Development/The World Bank, 2018). Other programs such as the CT-OVC, HSNP and CT-PwSD received Sh7.95 billion, Sh4.5 billion and Sh1.2 billion, respectively (Business Daily, 2018). This shows an increase in budgetary allocation for all direct cash transfer programmes from 8 billion shillings in 2013 to over 30 billion shillings in 2017 (The World Bank, 2019). Together, all four direct transfer programs account for close to 1.5% of household expenditure across the entire population (International Bank for Reconstruction and Development/The World Bank, 2018). In April 2020, the government allocated 33 billion Kenyan shillings during the COVID-19 pandemic to enable older persons and the vulnerable population to buy food. This funding has increased by 7 billion since end of 2019 (Okoth, 2020).

Table 1: Summary of the four main cash transfer programs in Kenya

Source: (Kenya Institute for Public Policy Research and Analysis (KIPPRA), 2019; Ministry of Labour and East African Affairs (MLEAA), 2016)

Social protection coverage in Kenya is relatively low compared to other African countries such as Uganda and South Africa. This is due to inadequate budget allocation that has resulted in low coverage and impact on poverty reduction. It is therefore essential to expand these programmes in order to reduce the poverty head count rate (Kenya Institute for Public Policy Research and Analysis (KIPPRA), 2019). It is however important to note that the current trend on increasing budget allocation to social protection schemes is promising and would improve the economy of the country if synergistic investment measures could be put in place to tackle gaps in other sectors. The government of Kenya has either solely come up with and funded these programs or partnered with other organizations at national and international levels.

Another safety net programme in Kenya is food distribution including school feeding and emergency relief food programmes. Relief food is mainly distributed in arid and semi-arid areas during drought and famine seasons while school feeding programmes are intended to keep children in school during food shortages (Republic of Kenya, 2011). Below are specific examples of these programmes (HGSM, 2019):

• The Njaa Marufuku Kenya Programme (NMKP) (Swahili word translated as eradicate hunger) led by the Ministry of Agriculture targets regions that have high to medium potential to grow food and reaches over 44, 000 children in 66 schools. The programme also provides fertilizers to local small holder farms and trains and farmers to enable them to produce excess and sell to schools. NMKP runs for a maximum of three years after which the communities manage the programme or seek the support of Home Grown School Meals Programme (HGSM).
• The Home Grown School Meals Programme (HGSM) is led by the Ministry of Education and feeds 600, 000 school children in 1800 schools located in 66 semi-arid districts with midday meal (cereals, pulses, oil and salt). The government transfers funds to this programme so that food is purchased locally.
• The kazi kwa vijana (jobs for youth) safety net programme established in 2008 to absorb young people into the job market faced management and logistical shortcomings (Republic of Kenya, 2011) and was cancelled by the World Bank.

National Social Security Fund (NSSF)

(National Social Security Fund, 2019) – provides social security protection in the form of lump sum payments upon retirement for formal and informal workers (members and their dependents). At the end of 2016/17, the total number of members was 6.8 million (Mugo et al., 2018) out of a total of approximately 24 million eligible people (falling under the category of early to mature working age i.e. (15 to 64 years)). To become a member, individuals (regardless of the cadre, permanent or casual employees, employed or self-employed etc) and businesses are required to register with NSSF and pay contributions before 15^th of each month to avoid attracting interests on a monthly basis.

National Health Insurance Fund (NHIF)

– This is the main health insurer in Kenya covering 19% of the population, with other private insurers covering 1% of the population (Kazungu & Barasa, 2017). Free inpatient health care services are available to formal and informal sector employees remitting monthly contributions to NHIF, but outpatient services are only available to civil servants. Contribution for formal sector employees is mandatory while for informal sector is voluntary. It is therefore possible that the 11% of the population covered within this scheme is comprised of mainly formal sector employees. The informal sector employees are not able to afford the monthly contributions (USD 5) because their income is unpredictable and they are not organized into sizeable groups which makes it difficult to register and collect contributions effectively (Barasa, et al., 2018).

The social protection programmes outlined above face five challenges, which need to be addressed to improve the efficiency of the interventions. These include: (i) lack of effective coordination of the programmes due to implementation by different ministries and in different departments. This complex organizational structure reduces the efficiency of service delivery and strain on the inadequate administrative resources (Oxford policy Management, 2019); (ii) lack of universalism across programmes leading to enrolment of ineligible people and exclusion of eligible people; (iii) inadequate structures to facilitate timely exit, graduation and sustainability mechanisms. For instance, the structures necessary for removing those who no longer qualify for support e.g., social protection assistance are inadequate; (iv) lack of funding to finance social protection programmes and (v) lack of comprehensive legislation on social protection. However, there is a high degree of policy interest in social protection interventions, evidenced by an increase in funding for cash transfers to support the vulnerable populations in Kenya. The continued interest can bridge the gap between social protection research, programming and policy (PASGR and AIHD, 2017). The UHC pilot that was launched in 2018 will also increase health care access to all populations and protect vulnerable populations from financial consequences of accessing and receiving health care.

The government also introduced the National Identify Management System (NIMS) to register all Kenyans (through a unique identifier locally referred to as “Huduma Namba” (huduma means “service” in Kiswahili)). This was done by collating biometric details, identity documents and physical addresses. The purpose of the unique number was to improve service delivery to all citizens including health care without necessarily using the actual health insurance cards since the information is integrated within the NHIS. The uptake of registration was slow by Kenyans due to concerns over privacy and data security or protest to the government’s threats such as being locked out of government services or imprisonment of one to five years or fine of between $10,000 and $50,000, for transacting without the Huduma Number (Mungai, 2019; Nyabola, 2019).

References:

Barasa, E., Rogo, K., Mwaura, N., & Chuma, J. (2018). Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage. Health Systems & Reform, 4(4), 346–361. https://doi.org/10.1080/23288604.2018.1513267

Business Daily. (2018). World Bank asks Kenya to expand cash transfer plan for poor. 18 July. https://www.businessdailyafrica.com/bd/economy/world-bank-asks-kenya-to-expand-cash-transfer-plan-for-poor-2211492

HGSM. (2019). The Home Grown School Meals programme (HGSM) in Kenya. World Food Programme, Novermber 2018. https://docs.wfp.org/api/documents/WFP-0000105578/download/

International Bank for Reconstruction and Development/The World Bank. (2018). Fiscal Incidence Analysis for Kenya: Using the Kenya Integrated Household Budget Survey 2015/16. Washington, DC. https://openknowledge.worldbank.org/bitstream/handle/10986/30263/Kenya-Fiscal-Incidence-Analysis.pdf?sequence=1&isAllowed=y

Kazungu, J. S., & Barasa, E. W. (2017). Examining levels, distribution and correlates of health insurance coverage in Kenya. Tropical Medicine & International Health, 22(9), 1175–1185. https://doi.org/10.1111/tmi.12912

Kenya Institute for Public Policy Research and Analysis (KIPPRA). (2019). Social Protection Budget Brief (No. 67/2018-2019). Nairobi, Kenya. https://repository.kippra.or.ke/bitstream/handle/123456789/2278/social-protection-budget-brief-pb67.pdf?sequence=1&isAllowed=y

Ministry of Labour and East African Affairs (MLEAA). (2016). Inua Jamii – Towards a more effective National Safety Net for Kenya Progress Report. https://www.socialprotection.or.ke/images/downloads/NSNP-Progress-Report_March_2016.pdf

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya. https://repository.kippra.or.ke/bitstream/handle/123456789/2095/an-assessment-of-healthcare-delivery-in-kenya-under-the-devolved-system-sp19.pdf?sequence=1&isAllowed=y

Mungai, C. (2019). Kenya’s Huduma: Data commodification and government tyranny. https://www.aljazeera.com/opinions/2019/8/6/kenyas-huduma-data-commodification-and-government-tyranny

National Gender and Equality Commission. (2014). Participation of vulnerable populations in their own programmes.The cash transfers in Kenya. https://www.ngeckenya.org/Downloads/cash-transfer-programme-vulnerable-groups-kenya.pdf

National Social Security Fund. (2019). National Social Security Fund website. https://www.nssfug.org

Nyabola, N. (2019). If you are a Kenyan citizen, your private data is not safe. https://www.aljazeera.com/opinions/2019/2/24/if-you-are-a-kenyan-citizen-your-private-data-is-not-safe

Okoth, J. (2020, April). Cash Transfers to Vulnerable Kenyans. The Kenyan Mall STreet. Nairobi, Kenya. https://kenyanwallstreet.com/cash-transfers-to-vulnerable-kenyans/

Oxford Policy Management. (2019). Social protection in Kenya: improving cash transfer programmes. https://www.opml.co.uk/projects/social-protection-kenya-improving-cash-transfer-programmes

PASGR and AIHD. (2017). Strengthening Kenya’s social protection agenda through research, prgramming and policy (Vol. 2). http://www.pasgr.org/wp-content/uploads/2017/11/Strengthening-Kenyas-Social-Protection-Agenda-through-Research-Programming-and-Policy-Policy-Brief-1.pdf

Republic of Kenya. (2011). Kenya National Social Protection Policy. Nairobi, Kenya. https://www.socialprotection.or.ke/images/downloads/kenya-national-social-protection-policy.pdf

The World Bank. (2019). In Kenya, Uplifting the Poor and Vulnerable Through a Harmonized National Safety Net System. https://www.worldbank.org/en/results/2019/04/18/in-kenya-uplifting-the-poor-and-vulnerable-through-a-harmonized-national-safety-net-system

Between 1920 and 1963, Kenya was a British colony. Following its independence in 1963 the country became a republic in 1964.

Since 2013, Kenya operates under a devolved system of government consisting of 47 counties to enhance better governance. The devolved system ensures effective policy implementation at grassroots levels while enabling development of policy instruments at the national level (Kenya Law Reports, 2013).

References:

Kenya Law Reports. (2013). The Constitution of Kenya, 2010. Nairobi, Kenya. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

There has been a noticeable change in governance and a reduction in ethnic tensions since the 2007 post-election violence and political instability in Kenya producing a political stability index of -1.08 in 2017 from -1.3 in 2007, compared to a range of -2.4 (weak) and 2.56 (strong) (The Global Economy, 2019). This measure indicates perceptions of the likelihood that the government will be destabilized or overthrown by unconstitutional or violent means, including politically motivated violence and terrorism. The index is an average of several other indexes from the Economist Intelligence Unit, the World Economic Forum, and the Political Risk Services, among others (The Global Economy, 2019). The governance score (measured on a scale of -2.5 to +2.5 with higher values corresponding to better governance) also increased since 2008 (-1.39) to -1.17 in 2013 and -1.16 in 2018 (Kaufmann & Kraay, 2019).

References:

Kaufmann, D. & Kraay, A. (2019). Worldwide governance indicators.

The Global Economy. (2019). The Kenya Economic Indicators. https://www.theglobaleconomy.com/Kenya/

According to the constitution of Kenya, general election of members of parliament should take place every five years on the second Tuesday in August. The next major elections will take place on 9^th August 2022. Executive authority continues to lie within the mandate of the president who is elected to a five-year term through universal adult suffrage of more than 50% of the votes and at least 25% of the votes cast in each of 24 out of the 47 counties (Kenya Law Reports, 2013).

References:

Kenya Law Reports. (2013). The Constitution of Kenya, 2010. Nairobi, Kenya. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

As of 2020, Kenya ranked 124/180 and had a score of 31/100 in the corruption perception index.

The Health System in Kenya is divided into the public sector (largest in terms of number of health facilities), a private for-profit sector and a private not for profit sector. In the private not for profit sector, services are being provided by voluntary organizations, such as faith based organizations (Mugo et al., 2018). According to the 2013 Kenya Household Health Expenditure and Utilization Survey, rural versus urban (66.7% vs 44.1%), (23.5% vs 43.0%), (8.5% vs 8.8%) and (1.3% vs 4.1%) visit public, private, faith based and others facilities (traditional and faith healers and community health workers) respectively to receive outpatient services (Ministry of Health, 2014a).

References:

Ministry of Health. (2014a). 2013 Kenya Household Health Expenditure and Utilization Survey. Nairobi, Kenya. https://www.healthpolicyproject.com/pubs/745_KHHUESReportJanuary.pdf

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.https://repository.kippra.or.ke/bitstream/handle/123456789/2095/an-assessment-of-healthcare-delivery-in-kenya-under-the-devolved-system-sp19.pdf?sequence=1&isAllowed=y

63% of the Kenyan population access public health services within a distance of 1 hour walk on foot (Mugo et al., 2018). The public sector in Kenya is composed of the national government, county government, development partners and public corporations. Their main mandate is to strengthen performance and management systems including the capability of public service leadership and to enhance quality and efficiency of public service delivery while transforming the culture and attitude of its employees (Fortune of Africa, 2019).

The public health system is overseen by the Ministry of Health and parastatal organizations. It includes a total of 4,616 health facilities, and consists of different levels of care, including national referral hospitals (level 6 – highest level of care – only four in Kenya (Kenyatta National Hospital, Moi Referral and Teaching Hospital, Mathari Hospital and National Spinal Injury Hospital), county hospitals (level 5), sub-county hospitals (level 4), health centres (level 3), dispensaries (level 2) and communities (level 1). Any higher level facility acts as a referral centre for the lower level facility (see table 2 below). The different levels of care are outlined below (Noor et al., 2006).

Approximately 63% of Kenyans access public health facilities. The facilities are unequally distributed across the 47 counties, with a national average facility density of 22 health facilities per 100,000 populations. The average distance between places of residence and nearest low level health facilities is about 3 kilometers (an average time of one hour by foot), which becomes a hindrance to uptake of health services (Mugo et al., 2018). Considerable distance to the nearest formal health provider acts as an important barrier to access for Kenyans from rural communities, who are therefore more likely to rely on traditional healers rather than seek care services in health facilities.

Nearly a third of the population in Kenya access levels 1-3 levels of care (further described in table 2) which form 80% of public health facilities as they are focused on primary health care services, while the hospitals (rest of the facilities) provide specialized services (Mugo et al., 2018). The national health sector referral strategy aims to improve client access to services and provides clear guidelines on referral processes through (Ministry of Health, 2014d):

• Realization of the capacity of health care providers to make appropriate referrals
• Development of protocols that will lead to referral system efficiency and effectiveness
• Promotion of information use and communication technology (ICT) to manage referral processes
• Promotion of research and innovation for referrals

Another initiative by the national government to increase access to health care services includes implementation of the Universal Health coverage (UHC), called “Afya Care” which is part of the Big Four Agenda. The Big Four Agenda has been implemented by the Kenyan government to ensure (i) the Expansion of the Manufacturing Sector, (ii) Affordable Housing, (iii) Affordable Healthcare and (iv) Food Security.

The pilot phase of the UHC (launched in 2018 with a national roll-out out expected in 2022) is covering 4 out of 47 counties with a high disease burden, (Kisumu, Machakos, Nyeri and Isiolo – which represent about 5% of the Kenyan population) and involves the removal of user fees at all public health facilities (including levels 4 and 5). It also ensures ‘commodity security’ that is, uninterrupted supply of quality and affordable medicines through KEMSA. This pilot phase encourages uptake and utilization of community Health Volunteer (CHVs) services and strengthening health systems in the other 43 counties by ensuring efficient and appropriate use of health funds in preparation for scale-up (Kariuki, 2019). Provision of health services will cover emergency, community, outpatient, and inpatient services for both communicable and no-communicable illnesses including mental health and maternity care. Furthermore, there is a focus on improving access to quality primary health care services by supporting operation and maintenance costs. There is only one out of the 43 non-pilot UHC counties (Makueni County), that has introduced some component of universal health care (Makueni Care), where a family (household) pays an annual fee of Kshs. 500 ($5 US dollars) to cover both preventive and curative services as well as free access to health care services (without payment) for individuals above 70 years. However, most hospitals are located far from people’s homes and only a small percentage of the population is able to access extensive services at higher levels of care (table 2). For instance, the risk of developing multiple illnesses and requiring long-term support is higher among older people, yet some of these services and medications can only be accessed at higher levels of care (levels 4-5) and are therefore inaccessible to a large population. In other non-pilot UHC counties, access to health care is limited. Out-of-pocket costs for registration upon first visit to the health facility and limited supply of medication at the public facilities create barriers to access and quality of care.

References:

Kariuki, S. (2019). World Health Day: Universal Health Coverage – Everyone, Everywhere – Celebrating Kenya’s journey towards universal health coverage. https://www.health.go.ke/wp-content/uploads/2019/04/WORLD-HEALTH-DAY-SUPPORT-07-04-2019.pdf

Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House. https://www.measureevaluation.org/pima/referral-systems/referral-strategy

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.https://repository.kippra.or.ke/bitstream/handle/123456789/2095/an-assessment-of-healthcare-delivery-in-kenya-under-the-devolved-system-sp19.pdf?sequence=1&isAllowed=y

Yes. The health service delivery system in Kenya is organized across six levels of care, with the first level at the community level and continuing through primary care services, which include dispensaries (level 2) and health centres (level 3), and county referral health services (level 4 & 5) all the way to the national referral health services (level 6). Higher health care facilities act as referral centres for lower-level facilities. For instance, level 1 is the foundation of health care service delivery and referral to a higher level of care is performed to seek additional services such as diagnosis, treatment, admission or to seek expert opinion (Ministry of Health, 2014d). However, sometimes patients bypass the low-level facilities depending on proximity and go directly to higher levels of care resulting to high caseloads. In some circumstances, referral by a health worker from higher to lower levels of care (except level 1) is made, particularly if the higher health facility is far from the client’s home and the client has been prescribed medicines that are available at a nearby lower health facility.

In terms of private health care, the referral chain is not structured as access to health services is based on proximity and the ability to pay for the services. Some community members access the services of community health providers (residing within their communities) while others visit nearby private clinics where referral to a specialist is made if necessary. However, patients can go directly to a specialist without a referral.

References:

Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House. https://www.measureevaluation.org/pima/referral-systems/referral-strategy

The introduction of UHC, named “Afya Care” described above supports only 5% of the population (4 counties) during its pilot phase. In 2022, the World Bank funded programme will be rolled-out across all counties (Kariuki, 2019). In addition to the four counties covered by ‘Afya Care’, one county that is not among the trial counties has implemented‘Makueni care’ which covers access to public health services. This leaves 42 counties to rely on NHIF.  In those counties, members (formal and informal workers) have to either make monthly contributions in order to access either public or private health care or pay at the hospital similar to other community members. NHIF has contracted hospitals under three categories (A, B and C) for contributors. Under category A (government hospitals), members enjoy full and comprehensive cover (maternity and medical diseases including surgery). Category B (some private and mission hospitals), members receive a comprehensive cover but in case of a surgery, the member would co-pay.  Category C (private), members pay specified daily benefits (NHIF, 2020). If the fee in a particular hospital exceeds the insurance limit, patients are required to pay the balance. Patients are therefore encouraged to visit hospitals that are within the NHIF cover.

To become members, those working in the informal sector can opt to pay a monthly premium of 500 Kenya Shillings (about $5.00 US dollars) per household to access both outpatient and inpatient services or directly pay for the services at the point of care. The formal sector contributions are based on salary scales (representing 2.4% of the gross salary) (Okungu, Chuma, & McIntyre, 2017). In addition to issues around health care inaccessibility due to distance to health care providers (geographical characteristics)  and inability to pay for the health services (individual characteristics), quality of care is also impaired in many counties as several facilities cannot supply sufficient amounts of drugs for non-communicable diseases and also experience inadequate staffing levels (Barker, Mulaki, Mwai, & Dutta, 2014; Turin, 2010). Data collected in 2010 from a nationally representative sample of public health centers and dispensaries across all 8 provinces (before devolution) in Kenya revealed evidence of pro-rich inequalities for electricity and laboratory services, and for availability of drugs and qualified staff. Less than 20% facilities had all drugs on the tracer list in stock. These resources provide salient inputs into the quality of care provided at health facilities (Toda et al., 2012). Societal (social and cultural) factors can also influence health seeking behavior, for instance, past interactions with a favorable view of services may result in continuing visit to the same provider. Similarly, stigma around certain conditions is a contributor to where and how people seek or avoid seeking care (Turin, 2010). Provider characteristics also provide a range of actions that a person can take when in need of care (Awiti, 2014).

References:

Awiti, J. O. (2014). Poverty and health care demand in Kenya. BMC Health Services Research, 14(1), Pp. 560. https://doi.org/10.1186/s12913-014-0560-y

Barker, C., Mulaki, A., Mwai, D., & Dutta, A. (2014). Devolution of healthcare in Kenya assessing county health system readiness in Kenya: a review of selected health inputs. Washington, D.C. https://doi.org/10.13140/RG.2.2.36622.87363

Kariuki, S. (2019). World Health Day: Universal Health Coverage – Everyone, Everywhere – Celebrating Kenya’s journey towards universal health coverage. https://www.health.go.ke/wp-content/uploads/2019/04/WORLD-HEALTH-DAY-SUPPORT-07-04-2019.pdf

NHIF. (2020). Inpatient services.

Okungu, V., Chuma, J., & McIntyre, D. (2017). The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms. International Journal for Equity in Health, 16(1), 39. JOUR. https://doi.org/10.1186/s12939-017-0535-9

Toda, M., Opwora, A., Waweru, E., Noor, A., Edwards, T., Fegan, G., … Goodman, C. (2012). Analyzing the equity of public primary care provision in Kenya: variation in facility characteristics by local poverty level. International Journal for Equity in Health, 11(1), 75. https://doi.org/10.1186/1475-9276-11-75

Turin, D. R. (2010). Health Care Utilization in the Kenyan Health System: Challenges and opporunities. Inquiries Journal, 2(9), 2–3. http://www.inquiriesjournal.com/articles/284/health-care-utilization-in-the-kenyan-health-system-challenges-and-opportunities

Health care in Kenya is financed through three main sources (Munge & Briggs, 2014):

• Direct payments (out-of-pocket payments (OOP)): This forms the highest proportion out of the sources of health-care financing for public health expenditure and fully for private health expenditure,
• Government expenditure (through taxation, employer schemes, health insurance etc.),
• Donors

OOPs are charged for health care services in public and private health institutions and accounted for nearly 30% of the total expenditure on health, thus reducing access to care. However, recently there has been an increase in government investment to reduce the financial burden on the poor and vulnerable populations through abolishing user fees in public health facilities (e.g., Makueni County), the provision of free maternity and the introduction of a Health Insurance Subsidy Programme. Half of the total health budget is allocated to the three referral hospitals and the remaining resources are allocated to the 47 counties. Payments are provided in block grants, depending on the size of the population, poverty levels, land share etc. Apart from the county Departments of Health budget from the national government (forming 36.4% of the total budget), the counties also collect their own revenue through households (37.3%), donors (16.3%) and NGOs (10.1%) (Maina et al., 2016). Donor funding is mainly concentrated in areas with high HIV prevalence such as Siaya, Kisumu, Migori, Mombasa and Turkana (T. Maina et al., 2016). This funding is channelled either through the government budgetary system referred to as “on-budget” or through the extra-budgetary known as “off-budget” via donor administered programmes e.g. the World Bank Multi-Country HIV/AIDS Programme (MAP) or NGOs (KNASA & NACC, 2014). The private sector is mainly funded by donors through grants/programmes to NGOs, health insurance (Marek et al., 2005) and out-of-pocket payments.

References:

KNASA, & NACC. (2014). Kenya National Aids Spending Assessment Report for the Financial Years 2009/10-2011/12. https://unaids-test.unaids.org/sites/default/files/unaids/contentassets/documents/data-and-analysis/tools/nasa/20141017/kenya_2009_en.pdf

Maina, T., Akumu, A., & Muchiri, S. (2016). Kenya County Health Accounts: Summary of Findings from 12 Pilot Counties. Washington, DC. https://www.healthpolicyproject.com/pubs/7885_FINALSynthesisreportoftheCHA.pdf

Marek, B. T., Farrell, C. O., Yamamoto, C., & Zable, I. (2005). Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery in Africa. Human Development Sector Africa Region, The World Bank. https://documents1.worldbank.org/curated/en/480361468008714070/pdf/336460AFR0HDwp931health1service.pdf

Munge, K., & Briggs, A. H. (2014). The progressivity of health-care financing in Kenya. Health Policy and Planning, 29(7), 912–920. https://doi.org/10.1093/heapol/czt073

References:

Kazungu, J. S., & Barasa, E. W. (2017). Examining levels, distribution and correlates of health insurance coverage in Kenya. Tropical Medicine & International Health, 22(9), 1175–1185.  https://doi.org/10.1111/tmi.12912

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya. http://khf.co.ke/wp-content/uploads/2018/03/2016-Kenyan-Healthcare-Sector-Report.pdf

In 2004 Kenya adopted a uniform user fee policy “the 10/20” policy to generate revenue at the lower-level facilities. Standardized fees were set at a flat rate of 10 Kenya shillings in dispensaries (table 2) and 10 Kenya shillings in health centres (table 2). Any fees are waived for people requiring treatment for malaria, tuberculosis, and sexually transmitted diseases, for children under 5 years old, for births and antenatal care (ANC) services and for people from poor households. However, clear guidelines on laboratory fees inclusion and criteria to identify patients from poor households were missing from the policy.

As a result, adherence to this policy was minimal with:

• patients paying for services at private shops that could have been free (but may not have been available at the facility)
• health facilities loading expenses associated with free services on other non-free services
• patients paying more than the specified amount due to:
  1. the facilities’ need for revenue
  2. the lack of strategies to compensate facilities for lost revenue or lack of awareness of the policy (Onsomu et al., 2014; Opwora et al., 2015).

It is estimated that out of pocket expense contribute to 26.1% out of the total health expenditure (World Health Organization, 2017b). In 2018, about  7% of households in Kenya faced catastrophic expenditures due to OOP payments (Salari et al., 2019). Furthermore,  75% of the population is not covered under any health insurance and typically relies on out of pocket expenses to cover the cost of care (Kenya Healthcare Federation and Task Force Health Care, 2016). However, it is the goal of the UHC, currently under trial, to tackle the high out-of-pocket costs by ensuring that citizens can access good quality and affordable (without paying out of their own pockets) basic health services (Wangia & Kandie, 2018).

References:

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya. http://khf.co.ke/wp-content/uploads/2018/03/2016-Kenyan-Healthcare-Sector-Report.pdf

Onsomu, D., Muthaka, G., Mwabu, O., Nyanjom, A., Dutta, T. M., Maina, C. B., & Muchir, S. (2014). Public Expenditure Tracking Survey in Kenya, 2012 (PETS-Plus). Washington, DC. https://www.healthpolicyproject.com/pubs/479_KenyaPETSPlusReportFINAL.pdf

Opwora, A., Waweru, E., Toda, M., Noor, A., Edwards, T., Fegan, G., … Goodman, C. (2015). Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue. Health Policy and Planning, 30(4), 508–517. https://doi.org/10.1093/heapol/czu026

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

Wangia, E., & Kandie, C. (2018). Policy brief: Refocusing on quality of care and increasing demand for services; Essential elements in attaining universal health coverage in Kenya. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2019/01/UHC-QI-Policy-Brief.pdf

World Health Organization. (2017b). Primary Health Care Systems (PRIMASYS): Case Study from Kenya, abridged version. Geneva. https://www.who.int/alliance-hpsr/projects/Alliance-PRIMASYS-Kenya-comprehensive.pdf

The new initiative for the country is to move towards universal coverage (funded by the World Bank). A pilot has been rolled out in 4 counties (described under 2.01.03.01). It is planned to roll out cover for all households by 2022 to guarantee access to equitable, affordable, and high-quality health and related services for all citizens. Other financing strategies by the government in addition to the UHC are through taxation and health insurance contributions (to cover basic essential services). The contributions are discussed in 1.04.01 under social protection schemes. General tax revenue is 30% of value added tax which is charged at 16%. Import and excise duty each account for 10% of the total revenue while corporate tax for companies ranges between 20% and 37.5% depending on the company’s existence. A proportion of the taxes are allocated to health care in Kenya (Chuma & Okungu, 2011). These financing mechanisms translate direct household payments into prepayment so that OOP are kept at a minimum (Njuguna & Pepela, 2019).

References:

Chuma, J., & Okungu, V. (2011). Viewing the Kenyan health system through an equity lens: implications for universal coverage. International Journal for Equity in Health, 10(1), 22. https://doi.org/10.1186/1475-9276-10-22

Njuguna, D., & Pepela, W. (2019). A Case for Increasing Public Investments in Health: Raising Public Commitments to Kenya’s Health Sector. Nairobi, Kenya. https://sparc.africa/wp-content/uploads/2020/01/Kenya-Health-Financing-Policy-Brief.pdf

The national government is funded through various channels and allocates specific proportions to each Ministry. The Ministry of Finance sets 3-year budget ceilings for each sector rather than each sector submitting a budget request based on actual needs. The Ministry of Health (MoH) then distributes the funds through the county Health Management Boards in each county (Nyakundi et al., 2011).

References:

Nyakundi, C. K., Teti, C., Akimala, H., Njoya, E., Brucker, M., Nderitu, R., & Changwony, J. (2011). Health Financing in Kenya: The case of RH/FP. Nairobi, Kenya. https://silo.tips/download/kenya-health-financing-in-t-h-e-c-a-s-e-o-f-r-h-f-p

Half of the total national health budget is allocated to three referral hospitals while resource allocation to the 47 counties is provided in block grants and is based on a resource allocation formula that takes into consideration factors such as the population, poverty levels, land share etc. The counties then decide the amount to be allocated to health. (Health Policy Project, 2016). Although the proportion of total government budget allocation to health (national and county) has increased over the past few years (7% in Financial Years (FYs) 2017/18 to 9.2% in FYs 2018/19) (Ministry of Health, 2018), it is still below the Abuja Declaration level of 15% .

During the financial year 2014/15, 38 of the 47 counties allocated at least 15% of the total county budget to health, with a larger share of the health budget given to conditions with a high burden (Health Policy Project, 2016). These allocations increased from 27% in FY 2016/17 27.2% in FY 2017/18 which is still below the pre-devolution level of 35% (Health Policy Plus, 2019). In Kenya, the financial year begins on 1^st July of the present calendar year and ends on 30thth June of the following year. The budget making process in each county is a cycle (each cycle contains four financial quarters of three months each) with four quarters as follows (Githinji, 2019):

• First Quarter (1st July to 30th September): Each county treasury to issue every county department and the public with a circular on the budget process guidelines for the following financial year
• Second Quarter (1st October to 31st December): The county treasury tables the county budget reviews before the county assembly and the county governments to publish first quarter implementation reports.
• Third Quarter (1st January to 31st March): The county governments publicize and publish second quarter implementation reports. The county treasury tables, publishes, and publicizes the County Fiscal Strategy Paper for approval by the county assembly.
• Fourth Quarter (1st April to 30th June): The county governments publicize and publish third quarter implementation reports and the county treasury submits the budget estimates to the county assembly who will pass the appropriation bill.

References:

Githinji, G. (2019). The County government budget process in Kenya. https://afrocave.com/county-government-budget-process/#the-budget-process-for-county-governments-in-kenya

Health Policy Plus. (2019). Kenya’s Health Sector Budget An Analysis of National and County Accounts for Fiscal Year 2018/19. Washington DC. http://www.healthpolicyplus.com/ns/pubs/11306-11586_KenyaBudgetAnalysis.pdf

Health Policy Project. (2016). Health Financing Profile: Kenya. Washington DC. https://www.healthpolicyproject.com/pubs/7887/Kenya_HFP.pdf

Ministry of Health. (2018). National and county health budget analysis FY 2018/19. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/11306-11563_NationalandCountyBudgetAnalysis.pdf

The sector working groups organized within the context of UN-classification of the functions of the government (COFOG) are responsible for formulation and prioritization of sector budget proposals. Within the health sector, the sector working group representatives are from the ministry of health and comprise of (Republic of Kenya, 2018a) page 15:

• “A chairperson accounting officer mutually selected by other accounting officers”
• “Sector governor appointed by the national treasury”
• “Sector governor appointed by State department for planning”
• “Technical working group appointed by the sector working group”
• “Sector working group secretariat appointed by the accounting officers to coordinate the activities of the sector”
• “Representatives from development partners”
• “Representatives from the private sector”

References:

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

The National Government will periodically release funds to the county governments. The amount of funding per county depends on several factors: population, poverty index, land area, basic equal share, and fiscal responsibility. The release of funds from the national government will depend on whether a county has prepared an integrated development plan with the Commission on Revenue Allocation setting the payment formula (Government of Kenya, 2016).

Before the disbursement process, the Ministry of Finance sets 3-year budget ceilings for each sector rather than each sector submitting a budget request based on actual needs. This is done through the Budget Review and Outlook Paper or the County Budget Review and Outlook Paper which is released in September and must be approved by the Cabinet and legislative assembly at each level of government (Ministry of Health, 2016b). The Ministry of Health (MoH) then disburses the funds through the county health Management Boards in each County (Nyakundi et al., 2011) and this depends on the population, poverty levels, land share etc.

The process of budget allocation to the specific sectors in counties is the same as at the national level where the county communicates to the various sectors the budget ceilings. National and county health departments determine how their budget is distributed to programs, but they are not allowed by the law to transfer funds between approved projects and recurrent allocations. They can shape the allocations in an efficient way while prioritizing cost-effective and efficient programmes (Ministry of Health, 2016b). Although, it is important to note that each county department of health decides using their own criteria or formula on how health services should be distributed. There is little information on how finances for health services should be distributed within specific departments. Each county department of health decides using their own criteria or formula on how health services should be distributed (Otieno, 2016). However, ministries and departments are required to prioritize allocations towards the achievement of “Big Four Plan”. The sector working groups then conduct a thorough review of the proposed budgets to ensure that they are not only directed towards improving productivity but also in achieving the “Big Four Plan” agenda. This is done by establishing resources required for different programmes and projects and the level of provision are within the ceilings provided by the sector working groups (Republic of Kenya, 2018a).

References:

Government of Kenya, E. of the K. N. (2016). Kenyan Healthcare Sector. Kenyan Healthcare Sector, 86.

Ministry of Health. (2016b). National and county health budget analysis FY 2016/17. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/6138-6239_FINALNationalandCountyHealthBudgetAnalysis.pdf

Nyakundi, C. K., Teti, C., Akimala, H., Njoya, E., Brucker, M., Nderitu, R., & Changwony, J. (2011). Health Financing in Kenya: The case of RH/FP. Nairobi, Kenya. https://silo.tips/download/kenya-health-financing-in-t-h-e-c-a-s-e-o-f-r-h-f-p

Otieno, M. (2016). Resource allocation to health sector at the county level and implications for equity, a case study of Baringo county. University of Nairobi. http://erepository.uonbi.ac.ke/handle/11295/98703

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

Private health insurance growth has stagnated over the years and slight decrease was even seen from 2009 to 2014, where the 32 private health insurers collectively covered 1.15%  from 1.17% of the Kenyan population (Kazungu & Barasa, 2017).

References:

Kazungu, J. S., & Barasa, E. W. (2017). Examining levels, distribution and correlates of health insurance coverage in Kenya. Tropical Medicine & International Health, 22(9), 1175–1185.  https://doi.org/10.1111/tmi.12912

The Insurance Regulatory Authority is the body in-charge of managing all insurance firms including the medical insurance firms under the Insurance Act (Amendment) 2006, CAP 487 (Government of Kenya, 2010).This body is in charge of setting the rules and regulations that govern all insurance companies in Kenya. However, it is not clearly stated whether private insurance health firms have specific market regulations set. Insurance companies use their own resources and strategies to reach a wider market, with particular interest in those employed.

References:

Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

The number of patients who for pay health services out of pocket is very high. It amounted to 26.11% out of the total health expenditure in 2014 (Index Mundi, 2019a). The high costs incurred from out-of-pocket health expenditure pose a barrier for Kenyans accessing healthcare services because it drives the poorer households into poverty. The costs of treatment continue to limit the access of care especially by the poor. The Ministry of Health estimates that 16% of the sick do not seek treatment due to financial constraints, while 38% of them must sell some of their assets or borrow in order to finance their medical bills (Luoma et al., 2010). In Kenya, one has to directly pay for health services at the point of consumption. This led to 7.1% of households in Kenya to face catastrophic expenditures and increased the poverty head count by 2.2% due to OOP payments in 2018 (Salari et al., 2019).

References:

IndexMundi. (2019a). Kenya – Out-of-pocket health expenditure (% of total expenditure on health). https://www.indexmundi.com/kenya/health_expenditures.html

Luoma, M., Doherty, J., Muchiri, S., Barasa, T., Hofler, K., Maniscalco, L., … Maundu, J. (2010). Kenya Health System Assessment 2010. Health Systems 20/20 Project, 20(August), 1–133. https://www.hfgproject.org/wp-content/uploads/2015/02/Kenya-Health-Systems-Assessment-2010.pdf

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

A large part of payments for healthcare come from remittances, where richer family members living in the cities or diaspora send money to less affluent family members often living in the slums or rural areas. Research based on household surveys, suggested that about one third of hospital bills in Kenya are paid through remittances (Stuart & Ph, 2011).

References:

Stuart, G. U. Y., & Ph, D. (2011). Cash In , Cash Out. (January).

With the steady population growth in Kenya, a greater health workforce is required in order to efficiently cater for people. Kenya has 20.7 doctors and 159.3 nurses (enrolled and nursing officers) per 100,000 (Republic of Kenya, 2014a). This is considerably lower than the minimum threshold (average of 21.7 doctors and 228 nurses per 100,000 people) recommended by the World Health Organization.

References:

Republic of Kenya. (2014a). Kenya Health Policy 2014-2030. Nairobi, Kenya. http://publications.universalhealth2030.org/uploads/kenya_health_policy_2014_to_2030.pdf

Vacancies in the health system vary according to cadre, and are mainly noticeable in the public health sector (Chankova, Muchiri, & Kombe, 2009). A report in 2010 indicated that the Ministry of Health had the highest vacancy rate for clinical officers at 35.5%, followed by medical officers at 34.2% then nursing officers at 23.2% with 6.8% unfilled positions for Medical laboratory technologists and technicians (Kiambati, Kiio, & Toweett, 2013). This is relatively high and poses a threat to the efficient delivery of health services (Ministry of Medical Services, 2009). These high vacancy rates have been worsened by  poor infrastructure, insecurity and harsh climatic conditions (MoH, 2013).

Extremely remote rural regions struggle the most with retention and recruitment of personnel. A study conducted in Northern Kenya counties representing 6% of Kenya’s population showed that the counties had access to only 3% of all health workers, while 9% of all health workers were located in Kenya’s capital, Nairobi (representing 8% of the population)  (Ministry of Health, 2015b).  Therefore, careful consideration in terms of better pay and/or hardship allowances needs to be given for health workers deployed in resource-constrained areas in order to increase retention since with better pay, health care workers state that they can work in the harshest areas (MoH, 2013).

Staff turnover rates have been relatively high with more than 50% of physicians and 81% of enrolled community nurses leaving the health workforce between 2005 and 2009. Furthermore, a turnover of 49% was reported among laboratory technologists and technicians during the same period (Kiambati et al., 2013). Some of the common factors resulting in staff turn-over rates in the public health system include retirement, voluntary resignation, death, better pay in private health sector or abroad  (Chankova et al., 2009).

Other factors that have contributed to compromised availability of the health care workers and play a role in turnover rate include lack of employment (not absorbed by the ministry) of trained workers, limited career development opportunities, huge workloads, high prevalence of HIV/AIDS, increased risk of occupational exposure, political violence and social instability (Gross et al.,  2011).

References:

Chankova, S., Muchiri, S., & Kombe, G. (2009). Health workforce attrition in the public sector in Kenya: a look at the reasons. Human Resources for Health, 7(1). http://doi.org/10.1186/1478-4491-7-58

Gross, J. M., Rogers, M. F., Teplinskiy, I., Oywer, E., Wambua, D., Kamenju, A., … Waudo, A. (2011). The impact of out-migration on the nursing workforce in Kenya. Health Services Research, 46(4), 1300–1318. https://doi.org/10.1111/j.1475-6773.2011.01251.x

Kiambati, H., Kiio, C., & Toweett, J. (2013). Understanding the labour of human resources for health in kenya. Working Paper, (November), 29. https://www.who.int/hrh/tools/Kenya_final.pdf?ua=1

Ministry of Health. (2015b). Kenya Health Workforce Report. https://taskforce.org/wp-content/uploads/2019/09/KHWF_2017Report_Fullreport_042317-MR-comments.pdf

Ministry of Medical Services. (2009). National Human Resources for Health: Strategic Plan 2009-2012. Nairobi, Kenya. http://guidelines.health.go.ke:8000/media/hrh-strategic-plan-revised.pdf

MoH. (2013). Human Resources for Health ( HRH ) Assessment report for Northern Kenya: Overview of Health Workforce Distribution across 10 Counties May 2013. https://www.health.go.ke/wp-content/uploads/2015/09/Final%20merged%20NK%20HRH%20Report.pdf

Migration of health care workers such as: (i) rural to urban or vice versa; (ii) private to public or vice versa; (iii) exit from the health sector to other sectors can reduce the number of health workers available to serve a certain population. Between 2005 and 2009, majority of those who left the service were enrolled nurses, followed by medical doctors (Ministry of Health, 2014c). It is clear that migration both within the country and out of the country play a role in the availability of health workers.

Migration to other countries

The rate of migration is higher than the rate of absorption after training. In 2006, Kenya indicated that 51% of doctors and 8.3% of nurses emigrated, most of them to the UK (Clemens & Pettersson Gelander, 2006). For every 4.5 nurses Kenya adds to the nursing workforce through training, one nurse in the workforce applies to out-migrate, with 70% of them aged between 21 – 40 years. This pattern poses a threat to Kenya’s ability to increase the number of nurses in the workforce through training by 22% (Gross et al., 2011).

Rural-Urban Migration

The national census held in 2009 indicated that Kenya had a population of 38.6 million with 26.1 million and 12.1 million living in rural and urban areas, respectively (Kenya National Bureau of Statistics, 2010). However, this marks different in terms of the health professionals distribution, as more than half of health workers and 80% of doctors were based in urban regions (Gondi, Otieno, & James, 2006). Rural dispensaries report only 20% staffing rates in their nursing establishments, while district/urban hospitals report staffing rates of 120% (Luoma et al., 2010). The migration to urban areas is influenced by the housing allowances, which are much higher for those living in urban regions compared to those living in remote rural settings (Luoma et al., 2010). Further intensifying the misdistribution of healthcare workers by cadre is the employment of 42% of Kenya’s doctors and 13% of all nurses in the two national referral hospitals (Luoma et al., 2010).

Migration from public to private sector

A number of Kenyans seek health services in the public sector because of the subsidized medical fees and free services such as maternity care and HIV and AIDS treatment. However, a study conducted in Kenya revealed that 50.9% of health workers preferred working in Non-Governmental Organizations (NGO’S), 26.9% in government institutions, 11.7% out of the country, 6.3% in Faith Based Organizations (FBO) and 4.2% in private institutions (Ojakaa, Olango, & Jarvis, 2014). One of the strengths of the public health facilities is the stability of employment. However, a recent study conducted in public hospitals in three counties revealed that nearly 90% of health care workers were employed on permanent terms but about three quarters experienced low levels of job satisfaction (Tengah & Otieno, 2019). The poor remuneration, understaffing, inadequate medical supplies and poor working conditions  in the public sector has contributed to health care workers migrating to private clinics/hospitals (Ndetei, Khasakhala, & Omolo, 2008).

There is limited data on the salaries of health care workers in Sub-Saharan Africa. However, it is important to note that increased salary is not the only issue contributing to retention of workers. The following non-financial incentives have been considered a priority by health care workers in Kenya and Sub-Saharan Africa (McCoy et al., 2008; Ndetei et al., 2008):

• Enhanced working conditions such as medical supplies and upgrading of facilities
• Training e.g., Continuous Medical Education and improving the quality of supervision
• Good living conditions and opportunities for health workers to further their education and their children.
• Addressing job safety and security concerns

References:

Clemens, M., & Pettersson Gelander, G. (2006). A New Database of Health Professional Emigration from Africa. Human Resources for Health (Vol. 6). http://doi.org/10.2139/ssrn.924546

Gondi, O., Otieno, A., & James, J. (2006). Report on Human Resources Mapping and Verification Exercise. Nairobi, Kenya.

Gross, J. M., Rogers, M. F., Teplinskiy, I., Oywer, E., Wambua, D., Kamenju, A., … Waudo, A. (2011). The impact of out-migration on the nursing workforce in Kenya. Health Services Research, 46(4), 1300–1318. https://doi.org/10.1111/j.1475-6773.2011.01251.x

Kenya National Bureau of Statistics. (2010). The 2009 Kenya Population and Housing Census. Home Healthcare Nurse. 371–372. https://s3-eu-west-1.amazonaws.com/s3.sourceafrica.net/documents/21195/Census-2009.pdf

Luoma, M., Doherty, J., Muchiri, S., Barasa, T., Hofler, K., Maniscalco, L., … Maundu, J. (2010). Kenya Health System Assessment 2010. Health Systems 20/20 Project, 20(August), 1–133. https://www.hfgproject.org/wp-content/uploads/2015/02/Kenya-Health-Systems-Assessment-2010.pdf

Ministry of Health. (2014c). Health Sector: Human Resources Strategy: 2014-2018. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Kenya-HRH-Strategy-2014-2018.pdf

Ndetei, D. M., Khasakhala, L., & Omolo, J. O. (2008). Incentives for health worker retention in Kenya: An assessment of current practice. EQUINET, 62, 29. https://www.equinetafrica.org/sites/default/files/uploads/documents/DIS62HRndetei.pdf

Ojakaa, D., Olango, S., & Jarvis, J. (2014). Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya. Human Resources for Health, 12(1), 33. http://doi.org/10.1186/1478-4491-12-33

Tengah, S. A., & Otieno, O. J. (2019). Factors Influencing Job Satisfaction among Nurses in Public Health Facilities in Mombasa, Kwale and Kilifi Counties, Kenya. Advances in Social Sciences Research Journal, 6(5). https://doi://doi.org/10.14738/assrj.65.6389

The Constitution of Kenya 2010, Article 57, mandates the state to take steps to make sure that the rights of older people are protected (Government of Kenya, 2010). Kenya’s Vision 2030 also aims to establish a Consolidated Social Protection Fund which is relevant to the care and protection of older persons through cash transfer programmes. Other vulnerable groups will also be a beneficiary to these funds (discussed under overall country context – social protection schemes) (Kenya vision 2030, 2019). The disbursement of funds to these groups is ongoing.

The care and protection of older members of society bill, 2018 part III provides for the care of older members of society, defined as those who have attained the age of 60 years. Specifically, it provides the establishment and implementation of community and home-based care programmes for older members by the government and prohibits their abuse (Republic of Kenya, 2018b).

At the moment, Kenya is developing a universal health coverage policy but older people have not been adequately factored into it (“Kenya Trends in ageing and health,” n.d.). The care of older people living with disabilities and chronic health problems is mainly undertaken by unpaid family members. Older people are expected to receive health care from public general hospitals, as there is only one geriatrician based in the national government (policy level) in Kenya. By 2017, 16 residential care homes that are run by religious organizations and mostly located in urban or peri-urban areas were unaffordable to family members. As a result, some homes become underutilized. For example, during a 2016 audit of residential institutions, the Fatima Home with a capacity of 20 persons had only housed three older persons (National Gender and Equality Commission, 2016). It is not clear from literature the current average bed capacity of residential homes in Kenya. In addition, so far no long-term care public insurance scheme is available in Kenya as of yet, limiting access to costly private health insurance to those who can afford it (L. Maina, 2017).

High levels of poverty, distantly located health facilities, poor attitude of health workers and a lack of confidence in the services provided in health facilities are some of the factors deterring older persons from accessing services in public health care settings (Waweru et al., 2003). Furthermore, older people are expected to receive the same public health services provided for all life cohorts, there are no specific arrangements in place for older people. This has resulted to increase in confidence in spiritual care (Waweru et al., 2003). In future, strategic attention should be paid  to geriatric health requirements or the ability to tackle one or more chronic illnesses at health facilities (Wairiuko et al., 2017).

The Focus Area of The IX Session of the Open-Ended Working Group on Ageing, established by the General Assembly on 21^st December, 2010  for the purpose of strengthening the protection of the human rights of older persons identified the following challenges facing older people in accessing Long Term Care (Republic of Kenya, 2016b), page 3-4:

• “Prohibitive medical costs and limited Human Resource and health center capacities” – page 3
• “Communities and family members have very little (indigenous) knowledge on how to manage long-term care” – page 3
• “Facilities available do not meet the required standards” – page 3.
• “The private institutions are very expensive to be afforded by many” – page 3.
• “High costs of diagnostic, medication and transport costs to access LTC services” – page 3
• “Assistive devices are expensive, should one need one” – page 3.
• “There are few formal centers offering long term care. Most of them depend on the social systems i.e., relatives for long term care” – page 3.
• “Non-existence of a regulatory or policy framework on long term care system”- page 3.
• “Ageism that results to stigmatization and discrimination of older people by society and policy makers” – page 3.
• “Lack of adequate resources hinder the provision for long term care and support” – page 3.
• “Lack of information and understanding on LTC and wider rights of older people by the older people themselves, community and policy makers. Manifested in lack of demand for action by the citizens and older people, which is necessary to improving the policy and programmatic change” – page 4.

The working group, considers the existing international framework for the human rights of older persons and identifies possible gaps and solutions (United Nations Department of Economic and Social Affairs (UNDESA), 2019).

References:

Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports.  http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

Kenya vision 2030. (2019). Consolidated Social Protection Fund.  https://vision2030.go.ke/project/consolidated-social-protection-fund/#

Maina, L. (2017). How Kenya can ensure adequate health care for its older people. The Conversation, 25 January. https://theconversation.com/how-kenya-can-ensure-adequate-health-care-for-its-older-people-70163

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

Republic of Kenya. (2016b). Focus Area of the IX Session of the Open-Ended Working Group on Ageing. Republic of Kenya. Nairobi, Kenya. https://social.un.org/ageing-working-group/documents/ninth/Inputs%20Member%20States/Kenya_LTC.pdf

Republic of Kenya. (2018b, June). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2018-08/The%20Care%20and%20Protection%20of%20Older%20Members%20of%20Society%20Bill%2C%202018.pdf

United Nations Department of Economic and Social Affairs (UNDESA). (2019). Open-ended Working Group on Ageing for the purpose of strengthening the protection of the human rights of older persons.

Wairiuko, J. M., Cheboi, S. K., Ochieng, G. O., & Oyore, J. P. (2017). Access to Healthcare Services in Informal Settlement: Perspective of the Elderly in Kibera Slum Nairobi-Kenya. Annals of Medical and Health Sciences Research, 7(1), 5–9. https://www.amhsr.org/articles/access-to-healthcare-services-in-informal-settlement-perspective-of-the-elderly-in-kibera-slum-nairobikenya.html

Waweru, L. M., Kabiru, E. W., Mbithi, J. N., & Some, E. S. (2003). Health status and health seeking behaviour of the elderly persons in Dagoretti division, Nairobi. East African Medical Journal, 80(2), 63–67. https://doi.org/10.4314/eamj.v80i2.8647

There are no public services specific for older people. Furthermore, most of the public health facilities accessible to the older persons do not have the appropriate services (Waweru et al., 2003). The basic inpatient and outpatient facilities are not sufficient to accommodate the long-term health needs of older persons (Wanja, 2016).

References:

Wanja, N. L. (2016). The viability of long term care insurance in Kenya. Strathmore University. https://su-plus.strathmore.edu/handle/11071/4475

Waweru, L. M., Kabiru, E. W., Mbithi, J. N., & Some, E. S. (2003). Health status and health seeking behaviour of the elderly persons in Dagoretti division, Nairobi. East African Medical Journal, 80(2), 63–67. https://doi.org/10.4314/eamj.v80i2.8647

An audit of residential institutions of older members of the society in selected counties conducted in 2016 found that there are very few faith-based and private institutions established for the care of older persons. The six counties included had no homes for older persons and none of the homes that were identified were run by the government. The institutions lack reliable and predictable means of funding (rely on donation from well-wishers and churches), yet play a crucial role in improving the quality of life for older persons as they provide services, such counseling, psychosocial support, healthcare services from resident nurses and feeding programmes (National Gender and Equality Commission (NGEC), 2016). It is however not clear how many people make use of the private long-term care services or the current size of the private sector.

References:

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

There is no specific funding allocated for long-term care services in Kenya. The overall financing details are discussed in part 2 under the overall health system financing. Families mainly provide long-term care support (Applebaum et al.,  2013).

References:

Applebaum, R., Bardo, A., & Robbins, E. (2013). International Approaches to Long-term Services and Supports. Generations: Journal of the American Society on Aging. 37:1. Pp. 59-65. https://www.researchgate.net/publication/273133611_International_Approaches_to_Long-term_Services_and_Supports

Similar to other departments in health, there is little information on how finances for LTC services should be distributed. However, the level of provision from the ministry of health should be within the ceilings provided by the sector working groups (Republic of Kenya, 2018a).

References:

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

The process of allocation in all sectors including LTC is determined by the ministry of health based on cost-effective and efficient programmes (Ministry of Health, 2016b).

References:

Ministry of Health. (2016b). National and county health budget analysis FY 2016/17. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/6138-6239_FINALNationalandCountyHealthBudgetAnalysis.pdf

Ministry of health decides using its own criteria or formula how funding should be distributed while prioritizing allocations towards the achievement of “Big Four Plan (Otieno, 2016).

References:

Otieno, M. (2016). Resource allocation to health sector at the county level and implications for equity, a case study of Baringo county. University of Nairobi. http://erepository.uonbi.ac.ke/handle/11295/98703

There is no funding specifically for long-term care services. However, the amount allocated within the health sector in counties is distributed within programs in an efficient way while prioritizing cost-effective and efficient programmes (Ministry of Health, 2016b). Programs that are directed towards achieving the “Big Four Plan”  agenda, reflect on the actual financial requirement and are in full compliance with government priorities are given priority in terms of funding (Republic of Kenya, 2018a).

References:

Ministry of Health. (2016b). National and county health budget analysis FY 2016/17. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/6138-6239_FINALNationalandCountyHealthBudgetAnalysis.pdf

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

There is no funding specifically for long-term care services.

The lump sum amount under health covers long-term care services. Also, the older persons cash transfer targeting those aged 65 and above has supported 833,129 households (i.e. one person per household regardless of the number of people who have attained the age of 60 in the household) (Kenya Institute for Public Policy Research and Analysis (KIPPRA), 2019).

References:

Kenya Institute for Public Policy Research and Analysis (KIPPRA). (2019). Social Protection Budget Brief (No. 67/2018-2019). Nairobi, Kenya. https://repository.kippra.or.ke/bitstream/handle/123456789/2278/social-protection-budget-brief-pb67.pdf?sequence=1&isAllowed=y

Access to private health insurance for older persons is limited (Maina, 2017) due to financial constraints. Although the proportion of people purchasing private long-term care insurance in Kenya is currently not documented, insurance companies provide inpatient and outpatient services depending on the ability to pay. For example, the Afya Imara Seniors insurance that provides health benefits for individuals between 65 and 80 years charge premium rates ranging between Kshs.57,755 to Kshs.113,565 per person for inpatient services and between Kshs.45,244 to Kshs.61,566 per person for outpatient services (UAP OldMutual, 2020). Further information on how private insurance markets are regulated in general (not specific to LTC) is provided in the overall health system under health system financing.

References:

Maina, L. (2017). How Kenya can ensure adequate health care for its older people. The Conversation, 25 January. https://theconversation.com/how-kenya-can-ensure-adequate-health-care-for-its-older-people-70163

UAP OldMutual. (2020). What you get with Afya Imara Seniors. https://www.uapoldmutual.com/h/health-insurance/solution/afya-imara-seniors

There is no data on the population that incurs out-of-pocket expenditure when purchasing long-term care services. Although the cost of residential homes is not included on the websites, only a few people can afford to pay for the high costs as indicated by the 2016 NGEC audit (National Gender and Equality Commission, 2016).

Studies on OOP spending in both public and private sector for the general population in 2005/2006, reveal that more than 50% of individuals spend their own resources in the public health sector (Barnes et al., 2010). While the percentage of households incurring OOP has been decreasing since 2003, 7.1% of households were still experiencing catastrophic health expenditures in 2018 (Salari et al., 2019). Measures such as Universal Health Coverage starting with four pilot counties may enhance access to care in the coming years.

References:

Barnes, J., O’Hanlon, B., Feeley, F., McKeon, K., Gitonga, N., & Decker, C. (2010). Private Health Sector Assessment in Kenya. 193(1). Washington, D.C. https://openknowledge.worldbank.org/bitstream/handle/10986/5932/552020PUB0Heal10Box349442B01PUBLIC1.pdf?sequence=1&isAllowed=y

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

Remittances in Kenya constituted 2.5% of GDP in 2015. They increased from US $934 million in 2011 to US $1.73 billion in 2016 and at an average of 14.3% in the past one decade (Misati et al., 2018). According to household surveys conducted in Burkina Faso, Kenya, Nigeria, Senegal, and Uganda in 2009 as part of the Africa Migration Project, households in Kenya devoted 7.3%, 5.8%, and 7.0% of outside Africa, intra-Africa, and intraregional remittances to health respectively. Regionally, food was the highest while health was the fifth highest in terms of remittances. Remittances may improve health outcomes through purchase of more food and access to health care, by increasing awareness on proper diet (Mohapatra & Ratha, 2011).  Even though there is no data showing the amount of remittances spent on LTC, it is assumed that the services provided through such remittances cover all life cohorts since some of the factors that motivate sending of remittances include (Jena, 2016):

1. The need to assist parents in old age
2. Financing younger siblings
3. Inheritance motives
4. Cultural norms and expectations

References:

Jena, F. (2016). The remittance behaviour of Kenyan sibling migrants. IZA Journal of Migration, 5(1), 11. https://doi.org/10.1186/s40176-016-0059-x

Misati, R. N., Kamau, A., & Nassir, H. (2018). Do migrant remittances matter for financial development in Kenya? (WPS/08/18). Financial Innovation. Springer. https://doi.org/10.1186/s40854-019-0142-4

Mohapatra, S., & Ratha, D. (2011). Remittance markets in Africa. The World Bank. The World Bank. Washington D.C. https://openknowledge.worldbank.org/bitstream/handle/10986/2292/613100PUB0mark158344B09780821384756.pdf?sequence=1&isAllowed=y

Kenya has 20.7 doctors and 159.3 nurses (enrolled and nursing officers) per 100,000 which is below the WHO-recommended average of 21.7 doctors and 228 nurses per 100,000 people (Republic of Kenya, 2014a). Other key cadres of staff in public health facilities include public health officers, pharmacists, laboratory technologists, nutritionists, health records officers, trained health workers, social health workers, and community health extension workers (World Health Organization, 2017b). The majority of the Kenyan health workforce work in the private sector with almost 75% of the medical doctors and 66% of nurses and clinical officers (Kenya HealthCare Federation, 2016). Currently, there are a total of 65 Hospices and palliative care providers across Kenya (Kenya Hospices and Palliative Care Association (KEHPCA), 2019). However, there is no literature on how many health care workers are providing LTC services in Kenya.

References:

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya. http://khf.co.ke/wp-content/uploads/2018/03/2016-Kenyan-Healthcare-Sector-Report.pdf

Kenya Hospices and Palliative Care Association (KEHPCA). (2019). Hospices. https://kehpca.org

Republic of Kenya. (2014a). Kenya Health Policy 2014-2030. Nairobi, Kenya. http://publications.universalhealth2030.org/uploads/kenya_health_policy_2014_to_2030.pdf

World Health Organization. (2017b). Primary Health Care Systems (PRIMASYS): Case Study from Kenya, abridged version. Geneva, Switzerland. https://www.who.int/alliance-hpsr/projects/Alliance-PRIMASYS-Kenya-comprehensive.pdf

There are no professional training and qualification systems for the long-term care workforce in Kenya. Furthermore, there is only one medical gerontologist who trained outside Kenya, working at policy level. According to the first palliative medicine specialist in Kenya, Dr. John Weru, “the duty for palliative medicine specialists is to teach other doctors and clinicians as this is a very new medical specialty practice in the country, to set up structures and processes for the growth and development of the service and to provide the much needed clinical care to patients and their families” (Star Correspondent, 2015).

References:

Star Correspondent. (2015). Meet Kenya’s first palliative medicine specialist. The Star, 23 February. Nairobi, Kenya. https://www.the-star.co.ke/sasa/2015-02-23-meet-kenyas-first-palliative-medicine-specialist/

There are 27 Professional bodies and Associations operating in Kenya and regulate the training and conduct of their members. Some have been established under Kenyan law, while others are loose associations representing members of the profession. For instance, the Kenya Hospices and Palliative Care Association (KEHPCA) is a national association formed to represent all palliative care service providers in Kenya (Kenya Hospices and Palliative Care Association (KEHPCA), 2019). The professional bodies that regulate the health professionals include the Medical Practitioners and Dentists Board for doctors, Nursing Council of Kenya for nurses and Clinical officer council for clinical officers. The Kenya National Qualifications Authority (KNQA) is mandate to set the standards for accreditation, Quality Assurance, assessment and examination, to guide all players operating in the Country (Kenya National Qualifications Authority (KNQA), 2019).

References:

Kenya Hospices and Palliative Care Association (KEHPCA). (2019). Hospices. https://kehpca.org

Kenya National Qualifications Authority (KNQA). (2019). Professional Bodies and Associations in Kenya.

There is no specific information on staff providing LTC. Information available focuses on general health care providers.

There is no information specifically on LTC workers.

There is no structured LTC workforce hence exclusive reliance on informal care. There is only one medical gerontologist working at the policy level and the rest of the health care workers are based in public facilities providing basic outpatient and inpatient services.

The National Volunteerism Policy in Kenya “recognizes the following categories of volunteers:

1. Youth Volunteers – These are young people aged between 18-35years as enshrined in the constitution.
2. Retired Volunteers – These are individuals retired from formal employment offering their services voluntarily.
3. Online Volunteers – Individuals or groups of people offering volunteer services virtually.
4. Institutional Based Volunteers– These includes individuals or groups offering volunteer services through organisations or institutions.
5. International Volunteers – These are Kenyans and non-Kenyans offering volunteer services in Kenya and abroad.
6. Diaspora volunteers – These are Kenyan citizens living abroad who come to Kenya to offer volunteer services.
7. Community based volunteers – These are individuals or groups that are engaging in volunteer activities informally within their communities.
8. Children volunteers – These include Kenyans below the age of 18years engaging in volunteer activities under guidance of an adult or institution.
9. Government volunteer initiatives
10. Professional volunteers – These are individuals who are in active formal employment in various sectors and offer their services voluntarily on part time basis

Different organisations have different approaches towards mobilisation, recruitment, induction, training, engagement, motivation, retention, and transition of volunteers” (Republic of Kenya, 2015b). The policy does not provide on the roles of the volunteer or the mode of shadowing. The current practice is that the roles are defined by the institution of higher learning or the host institution but are not specific to LTC.

References:

Republic of Kenya. (2015b). The National Volunteerism Policy. https://www.labourmarket.go.ke/media/resources/FINAL_VOLUNTEERISM_POLICY.pdf

Yes – see part 4.01.02.

The Ministry of Health is responsible for dementia detection and management, but this is not reflected in the existing literature. However, if the World Health Organization or the media or organizations creating awareness would like contributions on guideline development on dementia such as risk reduction of cognitive decline and dementia, they often invite expert opinion or participation from the Ministry of Health, particularly department of Mental Health.

Department of Mental Health – see part 4.01.02.

The director of Mental Health is frequently approached to give views on dementia in the context of Kenya, but there is no one specifically assigned to focus on issues around dementia at the national government level.

There is currently no national plan or policy on dementia. The STRiDE project in collaboration with the Ministry of Health (collaboration between department of mental health and ageing unit – non-communicable diseases) aims to lay the foundations for a national plan.

Not applicable. However, the STRiDE project and London School of Economics and Political Science (LSE) have funded the development and dissemination of the National Dementia Plan. The estimated cost is about USD 8600. Other partners have made in-kind contribution.

There is no mention of dementia in any policy document in Kenya whether at national or at county level. It is understood that the mental health policy would also cover people living with dementia as its definition provides a wide realm of potentially eligible people: “older persons especially those without social protection and social networks are often vulnerable to mental disorders” (Ministry of Health, 2015c), page 19.  They should therefore be targeted for mental health interventions.

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

Dementia appears to be falling under the realm of mental health; however, no specific mention has been made in the mental health policy (Ministry of Health, 2015c)

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

No. However, Kenya ratified the Convention on the Rights of Persons with Disabilities (‘CRPD’ of ‘the Convention’) in 2008. Subsequently the law was absorbed (Article 2(6)) in the Constitution of Kenya 2010 (Government of Kenya, 2010). However, people with disabilities including people with dementia, are still not able to enjoy the same benefits as non-disabled people (The Open Society Initiative for Eastern Africa, 2013).

References:

Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

The Open Society Initiative for Eastern Africa. (2013). How to implement article 12 of convention on the rights of persons with disabilities regarding legal capacity in Kenya: A briefing paper. Nairobi, Kenya. https://www.knchr.org/Portals/0/GroupRightsReports/Briefing%20Paper%20on%20Legal%20Capacity-Disability%20Rights.pdf

Article 54(1) of the Constitution of Kenya 2010 provides that “a person with disability is entitled;

(a) to be treated with dignity and respect and to be addressed and referred to in a manner that is not demeaning;

(b) to access educational institutions and facilities for persons with disabilities that are integrated into society to the extent compatible with the interests of the person;

(c) to reasonable access to all places, public transport and information;

(d) to use Sign language, Braille or other appropriate means of communication; and

(e) to access materials and devices to overcome constraints arising from the person’s disability.” (Government of Kenya, 2010), page 37.

Article 54(2) states that “The State shall ensure the progressive implementation of the principle that at least five percent of the members of the public in elective and appointive bodies are persons with disabilities” (The Republic of Kenya, 2013), page 37.

There are no other provisions for protecting the rights of people with dementia. However, a recent training workshop (July 2019) for clinicians, NGOs promoting research and advocating for the rights of people with psychosocial disabilities, government institutions and policy makers used the WHO Quality Rights Tool Kit (World Health Organisation, 2012) to create awareness and to transfer knowledge into practice. The Mental Health Amendment Bill of 2018 is the most recent legislation addressing Kenya’s infrastructure around Mental Health. It outlines, among other things, the obligations of  national and county governments to build systems that address mental illness (GoK, 2018). The document does not make mention of any specific illnesses, nor does it provide a protocol for addressing them.   

References:

GoK. (2018). Kenya Gazette Supplement. Finance Act, 2018, 59(59), 165.

Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

Republic of Kenya. (2013). The National Social Security Fund Act, 2013 No. 45 of 2013. 27 December. Nairobi, Kenya. http://kenyalaw.org/kl/fileadmin/pdfdownloads/Acts/NationalSocialSecurityFundAct2013.pdf

World Health Organisation. (2012). WHO QualityRights Tool Kit: Assessing and improving quality and human rights in mental health and social care facilities. Geneva, Switzerland. https://apps.who.int/iris/handle/10665/70927

There is no other document except the WHO Quality Rights Tool Kit outlining provision for supported decision making or advance planning in Kenya. Kenya’s legal capacity system does not meet the UN Convention on the Rights of Persons with Disabilities (CRPD). In 2011 the Kenyan government submitted a report to the UN Committee on the Rights of Persons with Disabilities, which contained an expression of intention to take legal steps to move towards supported decision-making from substituted arrangements. So far, this has not been implemented in practice (Mental Disability Advocacy Center (MDAC), 2014).

References:

Mental Disability Advocacy Center (MDAC). (2014). The Right to Legal Capacity in Kenya. Budapest, Hungary. https://tbinternet.ohchr.org/Treaties/CRPD/Shared%20Documents/KEN/INT_CRPD_ICO_KEN_19784_E.pdf

The care and protection of older members of society bill, 2018; PART III provides for the prohibition, notification, and register of abuse of an older member of society. PART VII indicates the manner in which matters concerning older members of society are to be tackled while taking into consideration the unique needs of such persons (Republic of Kenya, 2018b). However, this is not specific to people with dementia.

References:

Republic of Kenya. (2018b). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2018-08/The%20Care%20and%20Protection%20of%20Older%20Members%20of%20Society%20Bill%2C%202018.pdf

The care and protection of older members of society bill, 2018; PART III section 10 (1) states that “each county government shall establish and implement Community based programmes for the care and protection of older members of society residing within the county” (Republic of Kenya, 2018b), page 341. However, this is not specific to people with dementia.

References:

Republic of Kenya. (2018b). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2018-08/The%20Care%20and%20Protection%20of%20Older%20Members%20of%20Society%20Bill%2C%202018.pdf

The care and protection of older members of society bill, 2018; PART VI section 33 (1) states that “the county executive committee member shall, for purposes of monitoring and evaluating the provision of services by homes registered under this Act, appoint such number of inspectors as the county executive committee member may consider appropriate” (Republic of Kenya, 2018b), page 354.

References:

Republic of Kenya. (2018b). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2018-08/The%20Care%20and%20Protection%20of%20Older%20Members%20of%20Society%20Bill%2C%202018.pdf

Kenya still relies on the Convention on the Rights of Persons with Disabilities (CRPD). Article 16: Freedom from exploitation, violence, and abuse states that “in order to prevent the occurrence of all forms of exploitation, violence, and abuse, States Parties shall ensure that all facilities and programmes designed to serve persons with disabilities are effectively monitored by independent authorities” (United Nations, 2006), page 12.

References:

United Nations. (2006). Convention on the Rights of Persons with Disabilities and Optional Protocol. https://www.un.org/disabilities/documents/convention/convoptprot-e.pdf

Kenya’s Mental Health Policy vision is to have “A nation where mental health is valued and promoted, mental disorders prevented and persons affected by mental disorders are treated without stigmatization and discrimination” and one of the priority actions is to “undertake communication programs to reduce stigma” (Ministry of Health, 2015c), page 7, page 14. Provisions to end discrimination in the workplace are covered within core values or mission statements for certain organizations. However, this is not specific to people with dementia. A task force on mental health was constituted in December 2019 whose mandate was to assess Kenya’s mental health status, systems including legal, policy and administrative environment and social determinants of adverse mental health outcomes and report on the recommendations that would lead to improved mental health and quality of life (Ministry of Health, 2020). Preliminary results in early 2020 revealed existing issues around stigma for different mental disorders and provided recommendations for improved funding for mental health care and integration of mental health services in primary health care settings in all counties.

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

Ministry of Health. (2020). The Taskforce on Mental Health Public Hearing. https://www.health.go.ke/the-taskforce-on-mental-health-public-hearing/

Similarly, in promotion of good mental health, the mental health policy (Ministry of Health, 2015c) aims at involving persons with mental disorders and caregivers in planning and feedback of mental health services.

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

This is not reflected in any policy or document in Kenya. However, under the National Policy on Older Persons and Ageing policy statement, the government intends to collaborate with relevant stakeholders to “promote and protect the family as a fundamental unit of the society, to provide care, and assistance to older Persons (Ministry of Labour, 2014), page 10.” There are currently no ongoing programmes in Kenya protecting the family as a unit.

References:

Ministry of Labour, S. S. and services. (2014). The national policy on older persons and ageing. Nairobi, Kenya. http://www.partners-popdev.org/ageing/docs/National_Policy_on_Older_Persons_and_Ageing_Kenya.pdf

The care and protection of older members of society bill, 2018; PART III section 11 (1) states that “Home based care programmes established by a Home based care county government under section 10(2) (b) shall be implemented with respect to older members of society who (part d) are isolated and have no family member or care giver who can care for them” (Republic of Kenya, 2018b), page 342. This is an indication that before placement in a home-based care programme, the option on whether the person has a family member or caregiver is taken into consideration. In some cases, placement is made if the family member is not in a position to be a direct caregiver or has other responsibilities. Family carers often perform these duties due to cultural or spiritual reasons such as “fulfilment of a duty as a child”, “to return the favour of being a child” and” associated with a blessing i.e. to receive parental blessing.” PART III 59(f) also states Pursuant to Article 57 of the Constitution, every older member of society has the right to receive reasonable care, assistance, and protection from their family and the State  (Government of Kenya, 2010), page 38.

References:

Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

Republic of Kenya. (2018b). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2018-08/The%20Care%20and%20Protection%20of%20Older%20Members%20of%20Society%20Bill%2C%202018.pdf

There are currently no national or sub-national online accessible documents on standards, guidelines or protocols specific to dementia in Kenya. The national government has published clinical guidelines for management and referral of the following mental disorders: psychosis, alcohol withdrawal syndrome, substance use, anxiety, PTSD, psychosexual disorders, depression, bipolar disorder, schizophrenia, sleep disorders, and suicides (Crouch, 2009; Management & Guidelines, 2009). None of these documents mention dementia explicitly at primary care or hospital level.

References:

Crouch, M. (2009). Clinical Management and Referral Guidelines Volume II: Clinical Guidelines for Management and Referral of Common Conditions at Levels 2–3: Primary Care. Ministry of Medical Services and Ministry of Public Health and Sanitation. Nairobi, Kenya. 282–289. http://publications.universalhealth2030.org/uploads/clinical_guidelines_vol_ii_final.pdf

Management & Guidelines (2009). Levels 4–6 – Hospitals i.

Similar to mental health care, dementia care is not well integrated within health care delivery systems. Mental health care, which also covers dementia care is only provided in 29 of the 284 Level 4 hospitals and above but only few hospitals have a multidisciplinary team (psychiatric nurses, social workers, psychologists and medical doctors). There is also no structured needs assessment on the person with dementia and the caregiver. Often, the first point of entry is the outpatient clinic where a doctor gives a diagnosis and recommends referral to a psychiatric nurse for further psychosocial management after pharmacological and non-pharmacological prescription by the doctor. A care plan is then developed by the nurse or the psychologist rather than with the patient (focus group discussion with health care workers through the STRiDE project). There are no documents illustrating the existence of this process.

Care for people with dementia is provided in both, the public and private sector. The public sector is overseen by the Ministry of Health. However, there is no coordinated care across the two sectors as people who access public health care (often free or subsidized) may not be able to afford private health care. Those accessing private health care in turn may consider public health care as sub-standard or as a service that does not pay particular attention on patient needs.

The Ministry of Health is involved in coordinating care for all health issues. Its mission is “to build a progressive, responsive, and sustainable health care system for accelerated attainment of the highest standard of health to all Kenyans” (Ministry of Health, 2019). Dementia care activities are included within the health sector.

References:

Ministry of Health. (2019). About the Ministry. https://www.health.go.ke/about-us/about-the-ministry/

The Ministry of Labour and Social Protection is involved in coordinating social protection schemes for vulnerable populations e.g., persons with severe disabilities and older persons aged 65 years and above (Ministry of Labour and Social Protection, 2019b). These schemes are not specifically for persons with dementia but cover this population e.g., older persons who are an increased risk of having dementia and persons with a disability like dementia.

References:

Ministry of Labour and Social Protection. (2019b). Social Assistance Unit. https://www.socialprotection.go.ke

The Kenyan private sector is one of the most developed sectors in Sub-Saharan Africa. 47% of the poorest quintile of Kenyans use a private health facility (Marek et al., 2005). The private sector Partnerships – One project (PSP-One) conducted an assessment of the private sectors in Kenya and revealed a potential for this sector in providing quality care to Kenyans (Barnes et al., 2010). For example: One third of couples obtain their family planning methods from the private commercial sector and another 10 percent go to facilities run by non-governmental organizations (NGOs) and faith based organizations(FBOs) (Barnes et al., 2010). The public private partnerships and funding in this area shows the involvement of the private sector in planning for health care including policy development. Although not specific on dementia, there are already strides towards achieving government-private partnership in health which covers dementia.

References:

Barnes, J., O’Hanlon, B., Feeley, F., McKeon, K., Gitonga, N., & Decker, C. (2010). Private Health Sector Assessment in Kenya. 193(1). Washington, D.C. https://openknowledge.worldbank.org/bitstream/handle/10986/5932/552020PUB0Heal10Box349442B01PUBLIC1.pdf?sequence=1&isAllowed=y

Marek, B. T., Farrell, C. O., Yamamoto, C., & Zable, I. (2005). Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery in Africa. Human Development Sector Africa Region, The World Bank. https://documents1.worldbank.org/curated/en/480361468008714070/pdf/336460AFR0HDwp931health1service.pdf

There is no document describing the current practice on dementia.

There are no formal agreements.

There is an interdisciplinary team (psychiatric nurses, social workers, and psychologists) in some level 5 hospitals especially those with a mental health clinic. However, there is uncoordinated planning and weak monitoring and evaluation systems at both National and County levels which worsen in lower levels of care (John & Kiarie, 2019).

References:

John, T., & Kiarie, H. (2019). Building strong stewardship and collaborating systems towards UHC in Kenya’s Devolved Health system. Nairobi, Kenya.

Due to shortage of human resources and funding for mental health care, the current component of care coordination is often task-sharing (facilitated by NGOs). For instance, Africa Mental Health Research and Training Foundation has implemented task sharing approaches through training non-mental health specialists (nurses, clinical officers) to provide interventions to people with mental illness (including dementia) receiving care in primary health care facilities and community providers such as community health workers, traditional, and faith healers to identify and refer people with suspected mental illness for further care (Mutiso et al., 2018).

References:

Mutiso, V. N., Gitonga, I., Musau, A., Musyimi, C. W., Nandoya, E., Rebello, T. J., … Ndetei, D. M. (2018). A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low-and middle-income country: a case study of Makueni County, Kenya. International Journal of Mental Health Systems, 12(1), 1–13.  https://doi.org/10.1186/s13033-018-0234-y

The Kenya Mental Health Policy states that individuals, families, and communities will play a key role in promotion, prevention, treatment, and rehabilitation of persons with mental disorders. They will also participate and advocate for community mental health programmes (Ministry of Health, 2015c). This community-based approach involves dementia care.

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

There is uncoordinated planning and weak monitoring and evaluation systems at both National and County levels which worsen in lower levels of care (John & Kiarie, 2019).

References:

John, T., & Kiarie, H. (2019). Building strong stewardship and collaborating systems towards UHC in Kenya’s Devolved Health system. Nairobi, Kenya.

There is no document illustrating this. However, discussions with stakeholders indicate that the there is an increased interest among policy makers to contribute to policy change by first developing a National Dementia Plan.

Currently, the Ministry of Health, facilitated by Africa Mental Health Research and Training Foundation and ADOK is developing  a National dementia Plan with funding from the STRiDE project and London School of Economics (London School of Economics (LSE), 2018; C. Musyimi et al., 2019).  This is expected to increase awareness on dementia in community settings through evidence-based tools. Furthermore, members of the project work towards making dementia care a priority at policy level. The expected knowledge increase around dementia care is likely to result in a rise in the number of people receiving a timely diagnosis and adequate care and support for people with dementia and their carers. The aim of STRiDE is to build capacity to support the development, implementation, and evaluation of national strategies to deliver appropriate, equitable, effective, and affordable dementia care. STRiDE will support the development of a National Dementia Plan by offering recommendations based on a thorough situational analysis and other scientific results from the project. Following these changes, it can be expected that through future funding, guidelines, and protocols, dementia care in Kenya in future will be addressing the needs of people living with dementia, their families and those of health and long-term care professionals.

HelpAge International is also taking the lead in collaboration with Ministry of Health to develop a community care package – training manual for the care of older people in Kenya. It is expected that this manual will cover issues around dementia since it is intended to cover non-communicable diseases including mental illness (HelpAge International, 2019). Discussions around development of healthy ageing strategy are underway through the same partnership. This could result in dementia awareness and addressing risk factors related to dementia within community settings.  Africa Mental Health Research and Training Foundation (AMHRTF) and ADOK are part of the team involved in the development of this manual.

References:

HelpAge International. (2019). Terms of Reference for Development of Home Based Care (HBC)/Community care Package – Training Manual for the care of Older People in Kenya and Mozambique. https://www.helpage.org/silo/files/consultancy-on-development-of-hbc-package.pdf

London School of Economics (LSE). (2018). Strengthening Responses to Dementia in Developing Countries (STRiDE). https://www.lse.ac.uk/cpec/research/projects/dementia/stride

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

The current discussions on training and capacity building existing community providers through STRiDE and training manual will result in health systems strengthening at the county level. The use of existing personnel will result in sustainability of the activities and since dementia will be covered as part of the other modules in the training manual, part of dementia financing is expected to be incorporated within these programmes. The delay may occur in uptake of the manual or limited finances to train community provides.

The Government of Kenya is committed to supporting community health initiatives and accelerating the achievement of the Kenya Health Strategic Sector goals and providing support to Vision 2030 (Ministry of Health, 2014b). The Kenyan Government developmental initiatives, such as the Big4 Agenda and Vision 2030, must be realized by empowering communities to lead their own development (The Movement for Community-led Development, 2019).

References:

Ministry of Health. (2014b). Community Health Volunteers (CHVs) basic modules handbook. http://guidelines.health.go.ke:8000/media/CHV_handbook_PDF-F.pdf

The Movement for Community-led Development. (2019). The Community-led Development (CLD) Movement Launches Kenya Chapter. https://mcld.org/2019/01/30/launching-the-kenya-chapter/

Yes, the STRiDE project will contribute to development of a National Dementia Plan.

The development of the training manual for community health volunteers on healthy ageing for older persons is likely to lead to a healthy ageing strategy which will cover dementia.

The following strategies described in earlier sections are likely to contribute to increase in access to care for persons dementia and/or increase in treatment guidelines on dementia care:

1. Increase in the number of households receiving older persons and persons with severe disability cash transfers
2. 66% (31 out of 47 counties) coverage of hospital based palliative care services
3. The Constitution of Kenya 2010, Article 57, mandates the state to take steps to make sure that the rights of the elderly are protected government and private partnerships
4. Involvement of NGOs with the Ministry of Health in task-sharing approaches and development of training manuals for community health volunteers
5. Involvement of different partners with the Ministry of Health in policy and plans development e.g., national dementia plan by AMHRTF and ADOK; and healthy ageing strategy by HelpAge International
6. Commitment of the government in supporting community health initiatives

This is possible in the long-term since there are already evidence-based guidelines that can be used in developing countries such as Kenya to identify dementia and support persons with dementia and their families i.e., the mhGAP which covers priority mental disorders including dementia (World Health Organization, 2016). New clinical guidelines could be developed but a feasible way in the short-term could be to adapt and adopt what is already available. A systematic review on the effectiveness of interventions for dementia in low- and middle-income countries that is in draft form (protocol published) (Salcher-Konrad et al., 2019) could identify what has already been tested and proven to be efficacious, for adoption in Kenya.

References:

Salcher-Konrad, M., Naci, H., McDaid, D., Alladi, S., Oliveira, D., Fry, A., … Ndetei, D. M. (2019). Effectiveness of interventions for dementia in low-and middle-income countries: protocol for a systematic review, pairwise and network meta-analysis. BMJ Open, 9(6), e027851. https://doi.org/10.1136/bmjopen-2018-027851

World Health Organization. (2016). mhGAP Intervention Guide version 2.0. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241549790

The following stakeholder institutions/associations could contribute to policy change on dementia:

• Government e.g., Ministry of Health and Ministry of Labour and Social protection;
• Advocacy groups e.g., Alzheimer’s and Dementia Organization of Kenya (ADOK);
• Research organizations e.g., Africa Mental Health Research and Training Foundation (AMHRTF);
• NGO’s e.g., HelpAge International;
• National associations e.g., Kenya Hospices and Palliative Care Association (KEHPCA), private and public health care facilities.

Campaigns on dementia awareness were held on the 26^th of September 2018 and 20^th September 2019, at the Kenyatta National referral Hospital. These campaigns, which were open to everyone including the general public are as a result of a partnership between the Ministry of Health, the Alzheimer’s and Dementia Organization of Kenya and Kenyatta National Hospital. There were government officials, NGOs, dementia caregivers, student volunteers, health care workers, and other members of the general public present during the campaign. At the event, various gaps in dementia care and management were identified through formal and informal presentations (Alzheimer’s & Dementia Organization Kenya (ADOK), 2018). The STRiDE project is already addressing some of those gaps by training lay providers to reduce stigma in communities (London School of Economics (LSE), 2018). Specifically, the STRiDE Kenya team and partners developed a dementia anti-stigma intervention that uses a train-the-trainer approach to deliver four psycho-educational group sessions to members of the general public to create awareness on dementia (Musyimi et al., 2022). The components include: (i) understanding dementia; (ii) addressing common myths and misconceptions; (iii) indirect contact (video-based) to amplify voices of persons with dementia and their carers; (iv) social inclusion for people with dementia and their carers using a case vignette. To test the feasibility of the intervention, 50 members of the general public received the intervention which was delivered by 10 community health workers in a rural County in Kenya.

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2018). World Alzheimer’s Day 2018.

London School of Economics (LSE). (2018). Strengthening Responses to Dementia in Developing Countries (STRiDE). https://www.lse.ac.uk/cpec/research/projects/dementia/stride

Musyimi, C., Muyela, L., Mutunga, E., & Ndetei, D. (2022). Understanding dementia and its prevention in the African context. In World Dementia Council (Ed.), Global dialogue on LMICs: Reflections – The dementia landscape project, essays from international leaders in dementia (pp. 12–13). London, UK: World Dementia Council. https://worlddementiacouncil.org/sites/default/files/2022-01/DLP%20-%20Essays%20-%20LMICs.pdf

• The Alzheimer’s and Dementia Organization of Kenya (ADOK) hosted an awareness raising walk at Karura Forest on the 9^th of June 2018. The campaign was called Walk the mind (AND BODY). The main objective was to educate the public on dementia. Other aims were to support caregivers for persons with dementia and to promote social inclusion of those living with any form of dementia. The walk was organized in conjunction with the Ministry of Health, and was also used as a channel to raise funds for ADOK (Capital Digital Media, 2018).
• Demystifying dementia awareness campaign presented by the CEO and founder of the Alzheimer’s and Dementia Organization Kenya (ADOK) was hosted in September 2018. The show targeted all Kenyans and was aired live through five local media stations – 4 English speaking and one in Kikuyu language (local dialect ) (Demystifying dementia, 2018).

References:

Capital Digital Media. (2018). Alzheimer’s and Dementia Walk at Karura forest Saturday. Capital Group Limited. Nairobi, Kenya. https://www.capitalfm.co.ke/news/2018/06/alzheimers-dementia-walk-karura-forest-saturday/

Demystifying dementia. (2018). Kenya: NTV. https://alzkenya.org/blog/media/

The Alzheimer’s and Dementia Organization of Kenya provides caregiver training to volunteers who apply to receive support and training from them. Most of them already provide care to persons with dementia (Alzheimer’s & Dementia Organization Kenya (ADOK), 2019).

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2019). Training. https://alzkenya.org/wp-content/uploads/2019/08/ADOK_Newsletter.pdf

In Kenya, there is a lot of stigma surrounding dementia and many attribute symptoms of dementia to being cursed, bewitched, having annoyed the “gods” or failure to fulfil a certain obligation and as a result are being punished for their wrongdoings (Musyimi et al., 2019).

Other caregivers (particularly wives) are also seen as witches especially when the person with dementia is a spouse. This is very difficult for the families, as they are often cut off by their extended family, receive no support and suffer in silence (Njoki, 2018).

References:

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Njoki, M. (2018). Dementia in Africa: an exploration of Kenyan carers’ experiences supporting someone with dementia. https://dementia.stir.ac.uk/blogs/dementia-centred/2018-05-17/dementia-africa-exploration-kenyan-carers-experiences-supporting

Qualitative studies conducted in Kenya reveal that there is still lack of awareness and understanding of dementia, and in some communities, there is either no local term for dementia (Musyimi et al., 2021; Njoki, 2018) or the one in existence is considered derogatory (Musyimi et al., 2019; C. W. Musyimi et al., 2021). Although not documented, it is expected that with increasing awareness, a proportion of the population in Kenya will shift from negative perceptions of dementia to less stigmatized and acceptable terms on dementia.

References:

Musyimi, C. W., Ndetei, D. M., Evans-Lacko, S., Oliveira, D., Mutunga, E., & Farina, N. (2021). Perceptions and experiences of dementia and its care in rural Kenya. Dementia.  https://doi.org/10.1177/14713012211014800

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Njoki, M. (2018). Dementia in Africa: an exploration of Kenyan carers’ experiences supporting someone with dementia. https://dementia.stir.ac.uk/blogs/dementia-centred/2018-05-17/dementia-africa-exploration-kenyan-carers-experiences-supporting

Some of the factors that affect the perception of dementia at all levels include (Musyimi et al., 2019; Musyimi et al., 2021; Njoki, 2018);

• Lack of awareness and understanding of dementia– This is as a result of the ignorance about the disease and the lack of a definitive term for dementia in Kenyan culture.
• Lack of diagnosis or misdiagnosis– Since most physicians easily misdiagnose dementia as either depression, old age illness, Parkinson’s disease, diabetes, or high blood pressure, they end up with a misdiagnosis and without support for the underlying condition (dementia).
• Stigma– Assumed dementia to be witchcraft, curse from God, mental illness, part of aging. Abandonment and isolation of people with dementia and their carers.
• No government policies, legislations and services– Kenya does not have any laws and legislations concerning dementia, making it difficult to create awareness to the general public.
• Lack of statistics and data on number of people affected by dementia– To enable lobbying the government for positive changes.

References:

Musyimi, C. W., Ndetei, D. M., Evans-Lacko, S., Oliveira, D., Mutunga, E., & Farina, N. (2021). Perceptions and experiences of dementia and its care in rural Kenya. Dementia.  https://doi.org/10.1177/14713012211014800

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Njoki, M. (2018). Dementia in Africa: an exploration of Kenyan carers’ experiences supporting someone with dementia. https://dementia.stir.ac.uk/blogs/dementia-centred/2018-05-17/dementia-africa-exploration-kenyan-carers-experiences-supporting

The Alzheimer and Dementia Organization of Kenya offers caregivers/volunteers the following training modules (Alzheimer’s & Dementia Organization Kenya (ADOK), 2019):

• Understanding Dementia: This basically explains the nature and symptoms of dementia and the signs and symptoms that may progressively occur in later stages.
• Effectively communicating with an Alzheimer’s patient: Alzheimer’s being one form of dementia, the care givers learn about the best ways to communicate with the patients to avoid causing agitation by confusing them.
• Dealing with care giver burn-out: the organization has a psychologist who can assist the care givers in dealing with burn-out and how to cope with the difficulties of caring for a person with dementia.
• Dealing with behavior change (aggression): this highlights the basic ways to deal with situations when a person with dementia displays aggressive behaviour.
• Safety: since persons with dementia are prone to accidents and getting lost, the caregivers are taught about safety precautions that can help to ensure the wellbeing of the person with dementia.

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2019). Training. https://alzkenya.org/wp-content/uploads/2019/08/ADOK_Newsletter.pdf

There has not been formal evaluation for the campaigns. However, the awareness campaign that was held in local dialect (Kikuyu), had a greater number of views in YouTube (17,000) than the campaigns that were held in English language, which had about 1,000 views each. There was also more feedback on the awareness campaign held in kikuyu language (Alzheimer’s & Dementia Organization Kenya (ADOK), 2018). From preliminary discussions, STRiDE Kenya intervention revealed an increased interest among Community Health Workers in expanding coverage to target more community members.

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2018). World Alzheimer’s Day 2018.

There has not been an initiative by the government to support the accessibility for people with dementia.

The Self-Help Associations Bill 2015 provides a framework for the registration, operation and regulation of self-help associations at the county level of government. This allows people regardless of age to participate in economic activities within the counties and in turn, to improve their economic welfare. However, there are no planned activities specific to old age (Republic of Kenya, 2015).

References:

Republic of Kenya. (2015). The Self-Help Associations Bill 2015. Kenya Gazette Supplement No.21 (Senate Bills No.2), 27 February, Nairobi, Kenya. 5–35. http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2015/SelfHelpAssociationsBill_2015.pdf

The ministry of health in Kenya has no defined measures in place to either monitor the number of people nor indicators for dementia in the country, making it difficult to even aggregate the data by age or gender. A person diagnosed with dementia is often seen at a mental health clinic in a hospital setup; however, mental disorders are often reported as aggregate data rather than by specific conditions (Kiarie et al., 2019). This makes it difficult to monitor conditions such as dementia. Specific mental disorders are only monitored when NGO or research institutions have received funding to carry out a project. This is usually only done for certain conditions and within a specified time period due to limited funding, leading to evidence of mostly small-scale studies being available (Wekesah, 2019) and hamper the possibility of larger, ongoing data collection or data monitoring. Efforts during implementation of these projects have been made to disaggregate the data to advocate for specific policy. For disaggregation has been mentioned to increase the burden of recording and reporting for health care workers unless a rational approach is used to reduce data collection overload at the cost of service provision (Bernadette et al., 2019). The existing indicators although too many have little use particularly on mental health (Bernadette et al., 2019). Sub-Counties submit aggregated data to County and National Levels through the Kenya Health Information system (KHIS) for aggregate reporting (University of North Carolina, 2017) but no focus on dementia.

References:

Bernadette, A., Anthony, K., Ngaira, D., & Wanjala, P. (2019). Enhancing Health Information System for Evidence based decision making in the Health Sector. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2019/01/HIS-POLICY-BRIEF-.pdf

Kiarie, H., Gatheca, G., Ngicho, C., & Wangi, E. (2019). Lifestyle Diseases: An Increasing Cause of Health Loss. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2019/01/Revised-Non-Communicable-Disease-Policy-Brief.pdf

University of North Carolina. (2017). How Kenya Monitors Health Information System Performance: A Case Study. North Carolina. https://www.measureevaluation.org/resources/publications/fs-17-232.html

Wekesah, F. (2019). Adolescent Mental Health in Kenya: Where is the data? https://aphrc.org/blogarticle/adolescent-mental-health-in-kenya-where-is-the-data/

No indicators available.

No routinely monitored data available.

No routinely monitored data available.

No routinely monitored data available.

In 2016, the number of prevalent cases for dementia in Kenya was 61,120 and revealed a minor reduction of –2.1% (95% uncertainty Interval [UI] –2.8 to –1.5) from 1990 to 2016 (Nichols et al., 2019).

References:

Nichols, E., Szoeke, C. E. I., Vollset, S. E., Abbasi, N., Abd-Allah, F., Abdela, J., … Murray, C. J. L. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18(1), 88–106. http://doi.org/10.1016/S1474-4422(18)30403-4

A total of 3205 deaths were attributed to dementia in 2016 showing an increase of 15.3% (95% UI 2.0 to 43.5) in age-standardised rates from 1990 to 2016 (Nichols et al., 2019). However, there is no information on YLL due to dementia specifically for Kenya.

References:

Nichols, E., Szoeke, C. E. I., Vollset, S. E., Abbasi, N., Abd-Allah, F., Abdela, J., … Murray, C. J. L. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18(1), 88–106. http://doi.org/10.1016/S1474-4422(18)30403-4

Disability adjusted life years (DALYs) attributed to dementia was 42,739 in 2016, showing an increase of 9.6% (95% UI –0·4 to 26.2) in age-standardised rates from 1990 to 2016 (Nichols et al., 2019).

References:

Nichols, E., Szoeke, C. E. I., Vollset, S. E., Abbasi, N., Abd-Allah, F., Abdela, J., … Murray, C. J. L. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18(1), 88–106. http://doi.org/10.1016/S1474-4422(18)30403-4

It is not evident through literature whether the prevalence of dementia is pronounced in some specific geographical areas. However, a report by the Africa Mental Health Research and Training Foundation revealed a high rate of people with mild to moderate cognitive impairment in Makueni County in Kenya. Among all people with mental health problems, the rate of cognitive impairment using Mini-Mental State Exam (MMSE) was estimated to be 16%. This led to dementia (manifested as cognitive impairment) being ranked third, after depression and drug and substance abuse (Mutiso et al., 2016). This is the only study in Kenya that has been conducted to estimate prevalent rates on dementia.

References:

Mutiso, V., Pike, K. M., Ndetei, D., Musau, A., Nandoya’, E., Musyimi’, C., … Wambua, R. (2016). Multi-sectoral Stakeholder TEAM Approach to Scale-Up Community Mental Health in Kenya: Building on Locally Generated Evidence and Lessons Learnt (TEAM). Nairobi, Kenya. https://www.mhinnovation.net/sites/default/files/downloads/innovation/reports/TEAM%20Project%20Report%20to%20County_Final_31_01_17.pdf

It is difficult to indicate when dementia begins because the onset is gradual. However, Young Onset Dementia (YOD) typically occurs before the age of 65 (Alzheimer’s Disease International (ADI) and World Health Organization (WHO), 2012). There is no information on the average age onset in Kenya.

References:

Alzheimer’s Disease International (ADI) and World Health Organization (WHO). (2012). Dementia: A public health priority. United Kingdom. https://www.alzint.org/u/2020/08/Dementia-A-Public-Health-Priority.pdf

There is no information on the average life expectancy with dementia.

There is currently no study in Kenya to our knowledge that has provided estimates of dementia incidence or prevalence by gender or ethnic groups. According to the Global Burden of Disease reported by Alzheimer’s Disease International (ADI) and WHO in 2012, the estimates of dementia prevalence in East Sub-Saharan Africa was  highest among those aged 85 years and above (16.3%), followed by those aged between 80 to 84 years (8.2%), then 75 to 79 years (4.3%), 70 to 74 years (2.3%), 65 to 69 years (1.2%) and the least percentage (0.6%) seen among those aged 60 to 64 years (Alzheimer’s Disease International (ADI) and World Health Organization (WHO), 2012).

References:

Alzheimer’s Disease International (ADI) and World Health Organization (WHO). (2012). Dementia: A public health priority. United Kingdom. https://www.alzint.org/u/2020/08/Dementia-A-Public-Health-Priority.pdf

In Kenya, the average life expectancy is 66.7 years  (64.4 years for males and 68.9 years for females) (World Health Rankings, 2018). The average life expectancy for persons with dementia in Kenya is not yet available.  However, it varies depending on the type and of dementia, its severity at the time of diagnosis, age, sex, and general health (Brodaty et al., 2012). For instance, the life expectancy for a person with Alzheimer’s disease can vary between 3 to 10 years. Since the main predictor is age, caregiver and providers should plan on a median life span of between 7 to 10 years for persons whose diagnosis was made while in their early 60’s or 70’s and three years or less for those diagnosed at the age of around 90 years (Zanetti et al., 2009).

References:

Brodaty, H., Seeher, K., & Gibson, L. (2012). Dementia time to death: A systematic literature review on survival time and years of life lost in people with dementia. International Psychogeriatrics, 24(7), 1034-1045. http://doi.org/10.1017/S1041610211002924

World Health Rankings. (2018). Health Profile: Kenya. https://www.worldlifeexpectancy.com/country-health-profile/kenya

Zanetti, O., Solerte, S. B., & Cantoni, F. (2009). Life expectancy in Alzheimer’s disease (AD). Archives of Gerontology and Geriatrics, 49, 237–243. https://doi.org/10.1016/j.archger.2009.09.035

There are no national statistics on HIV-related dementia in Kenya.

One study associated dementia and poverty through qualitative interviews. Due to the huge financial cost of pharmacological treatment of dementia and reduction in a person’s productivity, families often have to sell off their assets to cater for diagnosis and care for the person with dementia. This can drain family resources and lead to poverty (Njoki, 2018).

References:

Njoki, M. (2018). Dementia in Africa: an exploration of Kenyan carers’ experiences supporting someone with dementia. https://dementia.stir.ac.uk/blogs/dementia-centred/2018-05-17/dementia-africa-exploration-kenyan-carers-experiences-supporting

There is no campaign in Kenya to specifically reduce the risk of dementia. However, the campaigns conducted by ADOK to create awareness on dementia care partly cover risk reduction.

Increasing age, illiteracy, vascular disease, low-fiber diet, depression, and genetic factors (presence of APOE-𝜀4 allele) have been identified as risk factors for dementia in two reviews on epidemiology of dementia in Sub-Saharan Africa and developing countries (three studies included findings from Kenya) (Kalaria et al., 2008; Olayinka & Mbuyi, 2014). A study conducted in Kenya revealed that there was no evidence between education or vascular factors and dementia status (Chen et al., 2010). According to a systematic analysis for the global burden of disease study involving 195 countries (including Kenya) in 2016, the four main risk identified to have a causal link to Alzheimer’s disease and other dementias are high Body Mass Index (BMI), high fasting plasma glucose, smoking, and high intake of sugar-sweetened beverages (Nichols et al., 2019). More studies are required to confirm inconsistencies in earlier findings.

References:

Chen, C.-H., Mizuno, T., Elston, R., Kariuki, M. M., Hall, K., Unverzagt, F., … Patel, N. B. (2010). A comparative study to screen dementia and APOE genotypes in an ageing East African population. Neurobiology of Aging, 31(5), 732–740. https://doi.org/10.1016/j.neurobiolaging.2008.06.014

Kalaria, R. N., Maestre, G. E., Arizaga, R., Friedland, R. P., Galasko, D., Hall, K., … Potocnik, F. (2008). Alzheimer’s disease and vascular dementia in developing countries: prevalence, management, and risk factors. The Lancet Neurology, 7(9), 812–826. https://doi.org/10.1016/S1474-4422(08)70169-8

Nichols, E., Szoeke, C. E. I., Vollset, S. E., Abbasi, N., Abd-Allah, F., Abdela, J., … Murray, C. J. L. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18(1), 88–106. http://doi.org/10.1016/S1474-4422(18)30403-4

Olayinka, O. O., & Mbuyi, N. N. (2014). Epidemiology of dementia among the elderly in Sub-Saharan Africa. International Journal of Alzheimer’s Disease, 2014. https://doi.org/10.1155/2014/195750

In 2015, the gross enrolment ratio (GER) (total enrolment regardless of age which is expressed as a percentage of the population within the official primary school education age) in primary education for Kenya was 109%. GER can exceed 100% because of the inclusion of over-aged and under-aged students related to repeating grade(s) and early or late school entry. In 2012, the net enrolment rate (NER) (ratio of the enrolled official primary school age children to total population of the official primary school age children) was 84.9% (Knoema, 2019c).

References:

Knoema. (2019c). World Data Atlas: World and regional statistics, national data, maps, rankings. https://knoema.com/atlas/Kenya

In 2012, the GER in secondary school for Kenya was 67.6% (Knoema, 2019c). Data on NER in secondary school is currently unavailable.

References:

Knoema. (2019c). World Data Atlas: World and regional statistics, national data, maps, rankings. https://knoema.com/atlas/Kenya

According to the Kenya STEPwise Survey for Non-Communicable Diseases Risk Factors 2015 Report, those who had raised blood pressure (defined as having Systolic Blood Pressure (SBP) of >=140 mm Hg and/or diastolic blood pressure (DBP) >=90 mm Hg) was 23.8%. Those with severe hypertension (SBP of >=160 mm Hg and/or DBP >=100 mm Hg) was 8% (MoH-Kenya et al., 2015). Moreover, Kenyans with high blood pressure or on medication revealed a significantly higher prevalence among rural residents (25.3%). Highest prevalence was also seen among the middle-class (about 30%) compared to approximately 20% for individuals in the lowest quintile in terms of socio-economic status.

References:

MoH-Kenya, KNBS, & WHO. (2015). Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report. MoH-Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Executive-summary-6-2.pdf

According to the 2014 Kenya Demographic and Health Survey (2014 KDHS), 33% of women are either overweight or obese with 10% of them being obese (Obudho et al., 2015). The focus is mostly on women and children under five with no focus on the older person or men. More recent (2016) reveal an adult prevalence rate of obesity at 7.1% (Index Mundi, 2019c).

References:

Index Mundi. (2019c). Kenya Obesity – adult prevalence rate. https://www.indexmundi.com/kenya/demographics_profile.html

Obudho, M., Munguti, J. N., Bore, J. K., & Kakinyi, M. (2015). Kenya Demographic and Health Survey 2014. Nairobi, Kenya. https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf

Hearing impairment was the third most frequently mentioned disability (10.4%) for those aged below 21 years (Republic of Kenya, 2014b). According to the 2009 census, 28% of individuals with disability were deaf and by 2016 this number had doubled (Chacha, 2016).

References:

Chacha, G. (2016). Reaching out to heal Kenya’s deaf, 9 November. Standard Media. Nairobi, Kenya. https://www.standardmedia.co.ke/wednesday-life/article/2000222734/reaching-out-to-heal-kenyas-deaf

Republic of Kenya. (2014b). Kenya National Special Needs Education Survey Report. Nairobi, Kenya. https://www.vsointernational.org/sites/default/files/SNE%20Report_Full%20-2.pdf

The rapid situation assessment of the status of drug and substance abuse in Kenya in 2012 revealed that 11% all the sampled respondents (15 – 65 years) were currently smokers (National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA), 2017). In 2019 it was found that  3.2% of primary school attending children smoked (National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA) and Kenya Institute For Public Policy Research And Analysis (KIPPRA), 2019). Overall, 10.1% of Kenyans use smoke, using products that include manufactured cigarettes, hand rolled cigarettes, pipes, and shisha (MoH-Kenya et al., 2015).

References:

MoH-Kenya, KNBS, & WHO. (2015). Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report. MoH-Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Executive-summary-6-2.pdf

National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA). (2017). The rapid situation assessment of the status of drug and substance abuse in Kenya, 2012. Nairobi, Kenya. https://www.nacada.go.ke/sites/default/files/2019-10/National%20ADA%20Survey%20Report%202017_2_2.pdf

National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA) and Kenya Institute For Public Policy Research And Analysis (KIPPRA). (2019). Status of Drugs and Substance Abuse among Primary School Pupils in Kenya. Nairobi, Kenya. https://nacada.go.ke/sites/default/files/2019-10/Report%20on%20the%20Status%20of%20Drugs%20and%20Substance%20Abuse%20among%20Primary%20School%20Pupils%20in%20Kenya.pdf

In the recent past, statistics by the WHO ranked Kenya on place eight (4.4%) in the international comparison of countries with the highest number of people (1,952,981) with depression (World Health Organization, 2017a). However, regional studies reveal that 19% to 25% of patients attending primary care settings or seeking care from community health providers, such as traditional healers, faith healers, and community health workers have depression (Musyimi et al., 2018; Musyimi et al., 2017; Mutiso et al., 2018).

References:

Musyimi, C. W., Mutiso, V. N., Haji, Z. R., Nandoya, E. S., & Ndetei, D. M. (2018). Mobile Based mhGAP-IG Depression Screening in Kenya. Community Mental Health Journal, 54(1), 84–91. http://doi.org/10.1007/s10597-016-0072-9

Musyimi, C. W., Mutiso, V. N., Musau, A. M., Matoke, L. K., & Ndetei, D. M. (2017). Prevalence and determinants of depression among patients under the care of traditional health practitioners in a Kenyan setting: policy implications. Transcultural Psychiatry, 54(3), 285–303. https://doi.org/10.1177/1363461517705590

Mutiso, V. N., Musyimi, C. W., Tomita, A., Loeffen, L., Burns, J. K., & Ndetei, D. M. (2018). Epidemiological patterns of mental disorders and stigma in a community household survey in urban slum and rural settings in Kenya. International Journal of Social Psychiatry, 64(2), 120–129. https://doi.org/10.1177/0020764017748180

World Health Organization. (2017a). Depression and Other Common Mental Disorders: Global Health Estimates. Geneva, Switzerland. https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf?sequence=1&isAllowed=y

Based on the global report on physical activity that was released by the World Health Organization (WHO) in 2018, 15.4% (13.9% for males and 16.8% for females) of adult Kenyans are not as active as per the recommended 150 minutes of moderate or 75 minutes of vigorous physical activity by WHO (Guthold et al., 2018).

References:

Guthold, R., Stevens, G. A., Riley, L. M., & Bull, F. C. (2018). Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1· 9 million participants. The Lancet Global Health, 6(10), e1077–e1086. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30357-7/fulltext

As of 2017, 2% (458,900 individuals) of Kenya’s total adult population (estimated at 23,147,000) had diabetes (International Diabetes Federation (IDF), 2017). This is likely to be an underestimation since 60% of people diagnosed with diabetes seek primary health care services for unrelated problems because they are not cognizant that they have the disease (Republic of Kenya, 2015a).

References:

International Diabetes Federation (IDF). (2017). IDF Diabetes Atlas – 8th Edition. https://diabetesatlas.org/upload/resources/previous/files/8/IDF_DA_8e-EN-final.pdf

Republic of Kenya. (2015a). Kenya National Strategy for the Prevention and Control of Non-Communicable Diseases 2015-2020. Nairobi, Kenya. https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf

Kenyans (aged 15 years and above) who are current drinkers for the past one year consume 3.4 litres (5.9 and 0.9 for males and females respectively) of alcohol per capita revealing a higher consumption of alcohol among men compared to women (World Health Organization (WHO), 2018).

References:

World Health Organization (WHO). (2018). Global status report on alcohol and health 2018. Geneva, Switzerland. https://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng.pdf?sequence=1&isAllowed=y

The Kenya STEPwise Survey for Non-Communicable Diseases Risk Factors 2015 Report revealed that about 98% of Kenyans had never had their cholesterol levels measured. Out of those that had been measured, only 13.3% who reported to have been diagnosed with elevated cholesterol levels were on medication. 10% of the respondents had either cholesterol ≥ 5.0 mmol/L or currently on medication for raised cholesterol (MoH-Kenya et al., 2015).

References:

MoH-Kenya, KNBS, & WHO. (2015). Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report. MoH-Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Executive-summary-6-2.pdf

A typical path to dementia diagnosis in Kenya is through assessment by a doctor via physical examination, review of medical history, MRI scans and characteristic changes in thinking, behaviour, and daily functioning. Laboratory tests are mainly done for younger people, to exclude any other possible causes that are treatable. In instances where one is diagnosed with dementia, referrals are made to neurologists (if resources allow) so as to determine the form of dementia for proper disease management (Mbugua, 2018).

References:

Mbugua, S. (2018). The condition affects the elderly, but is not a normal part of ageing. Daily Nation, 8 July. Nairobi, Kenya. https://nation.africa/kenya/healthy-nation/dementia-brain-disease-that-robs-people-of-sunset-years-64456

The prevalence of dementia in Kenya is unknown due to lack of available data.

Dementia cases are not routinely monitored in Kenya. According to a systematic analysis for the global burden of disease study involving 195 countries (including Kenya) in 2016, the number of prevalent cases for dementia in Kenya was 61,120 (Nichols et al., 2019).

References:

Nichols, E., Szoeke, C. E. I., Vollset, S. E., Abbasi, N., Abd-Allah, F., Abdela, J., … Murray, C. J. L. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18(1), 88–106. http://doi.org/10.1016/S1474-4422(18)30403-4

There are no national or county guidelines in Kenya on dementia management, making clinicians to rely on the typical path described previously. In one of the counties (Makueni) in Kenya, clinicians were trained by the Africa Mental Health Foundation (NGO) using the mental health Global Action Programme (mhGAP) (World Health Organization, 2016) to identify and manage priority conditions such as dementia. However, due to limited mental health budget, it was not possible to roll-out the programme to all the counties in Kenya  (Mutiso, Gitonga, et al., 2018). This makes it difficult to identify any differences in assessment in the different regions.

References:

Mutiso, V. N., Gitonga, I., Musau, A., Musyimi, C. W., Nandoya, E., Rebello, T. J., … Ndetei, D. M. (2018). A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low-and middle-income country: a case study of Makueni County, Kenya. International Journal of Mental Health Systems, 12(1), 1–13. https://doi.org/10.1186/s13033-018-0234-y

World Health Organization. (2016). mhGAP Intervention Guide version 2.0. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241549790

Neurologists, psychiatrists, geriatricians, psychologists, occupational, and physical therapists, specialist nurses are few but are responsible for coordinating the care of people with dementia (Alzheimer’s Disease International, 2017). Once neurologists make a diagnosis through clinician judgment and based on medical history, laboratory tests, and scans performed by laboratory technicians and radiologists respectively, they prescribe medications. Psychologists or psychiatric nurses provide psychosocial interventions while other specialists like psychiatrists and occupational therapists are referred for further management. Often, the specialists are not available (particularly in rural areas) and therefore reliance is on the general medical officers and nurses who may not have the expertise on dementia care (Musyimi et al., 2019).

References:

Alzheimer’s Disease International. (2017). Dementia in sub-Saharan Africa: Challenges and opportunities. London, UK. https://www.alzint.org/u/dementia-sub-saharan-africa.pdf

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

The Alzheimer’s and Dementia Organization in Kenya provides support services to persons with dementia, especially their carers, and equips them with skills necessary to care for the persons with dementia (Alzheimer’s & Dementia Organization Kenya (ADOK), 2019).

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2019). Training. https://alzkenya.org/wp-content/uploads/2019/08/ADOK_Newsletter.pdf

In primary care settings with a mental health clinic within the hospital, treatment for dementia focuses on reducing symptoms and improving the quality of life of the person with dementia by engaging caregivers. Pharmacological interventions are also provided to persons with dementia but with the help of the caregivers since the late stage diagnosis makes it difficult to sustain conversations with the person with dementia (Musyimi et al., 2019). Advice to caregivers by health providers is not always adhered to since different caregivers (some who may not have the full history of the individual) accompany the person with dementia to primary care settings (Sheilah, 2018).

References:

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Sheilah, M. (2018). The Potential of SMS Based Automated Reminders Towards Adherence to Clinical Instructions for Dementia Patients: A case of Healthcare Givers. University of Nairobi.

No dementia specific care is provided in levels 2 to 3. This means that referral is often made if the community providers or health care workers are not able to manage the conditions. Referral typically is made through a referral note and communication to higher levels of care. Sometimes patients refer themselves to the higher levels of care, bypassing the lower-level facilities either because they lack awareness on where to get the appropriate treatment or perceive those lower levels of care provide lower quality of care. The Kenya Health Sector referral Strategy outlines the roles of the providers (at the referral and receiving facilities) and ambulance crew for emergency referrals (Ministry of Health, 2014d). This strategy may not be specific for people with dementia but rather to all people in need of health emergency or referral services.

References:

Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House. https://www.measureevaluation.org/pima/referral-systems/referral-strategy

Apart from Makueni county and the four counties where Universal Health Care (UHC) has been implemented for the pilot (see Part 2, Health System Organisation for details on the exception of fees for people aged 70 and over), all persons requiring medical attention irrespective of their age or illness have to pay hospital fees (consultation, laboratory tests, medications, etc.) across Kenyan health facilities. Data from the 2013 nationally representative Kenya Household Expenditure and Utilization Survey revealed a mean annual spending of 5325.12 Kenya shillings and 941.04 Kenya shillings for outpatient services and hospital admissions respectively. Transport costs to and from the health facility (1966.67 Kenyan shillings) formed nearly a quarter of total costs incurred to access health care services (Barasa et al., 2017). These out-of-pocket expenses from the household survey are not specific to dementia but apply to any person accessing health care. The difference in cost of care depends on the level of hospital, distance to the hospital, and cost of medication. Patients do not pay at lower-level health facilities to receive care unless there are medications unavailable at the facility. If the latter case applies, they receive a prescription to buy the medications outside the health facility.

Even though the government has promised senior citizens free medical insurance, this has not taken effect since January 2018. This is due to a delay by the State Department of Social Protection in submitting the list of citizens aged 70 and above to the Ministry of Health. As a result, senior citizens are turned away on arrival at accredited health facilities if they are unable to pay for the services (Igadwah & Kabale, 2019). Other individuals (below 70 years) with dementia regardless of age still pay out-of-pocket expenses to cater for consultation, laboratory tests, and medications in health facilities where UHC is not being implemented unless they have a health insurance.

References:

Barasa, E. W., Maina, T., & Ravishankar, N. (2017). Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. International Journal for Equity in Health, 16(1), 31. https://doi.org/10.1186/s12939-017-0526-x

Igadwah, L., & Kabale, N. (2019). Payroll hitch delays free NHIF for senior citizens. Business Daily, March 2019. Nairobi, Kenya. https://www.businessdailyafrica.com/bd/economy/payroll-hitch-delays-free-nhif-for-senior-citizens-2243904

Access is through the UHC and within general health settings or in non-governmental residential homes. There is currently no government funded long-term care in Kenya. Admission into the private residential home depends on the ability to pay for the services by the person or the family members and does not require approval of a health care provider (National Gender and Equality Commission (NGEC), 2016).

References:

National Gender and Equality Commission (NGEC). (2016). Audit of residential institutions of older members of society in selected counties of Kenya. National Gender and Equality Commission Headquarters. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

Persons with dementia and their caregivers (often family members) experience a significant financial impact from the cost of social and health care and loss of income (World Health Organization (WHO), 2017). The cost of dementia in East Sub-Saharan Africa (which includes Kenya) increased by 267.4% from 2010 (US$ 0.4 billion) to 2015 (US$ 1.5 billion) with informal care costs estimated at 68.9%, direct medical cost at 20.8% and social care costs at 10.3% in 2015 (Prince et al., 2015). However, there is no study conducted in Kenya that has specifically evaluated the cost of dementia.

References:

Prince, M., Wimo, A., Guerchet, M., Ali, G., Wu, Y., & Prina, M. (2015). World Alzheimer Report 2015: The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends. Alzheimer’s Disease International. London. https://www.alzint.org/u/worldalzheimerreport2015summary.pdf

World Health Organization (WHO). (2017). Global action plan on the public health response to dementia 2017 – 2025. Geneva, Switzerland. https://apps.who.int/iris/bitstream/handle/10665/259615/9789241513487-eng.pdf?sequence=1

Persons with dementia are mostly taken care of by family members at home. The only services in community-based settings are at referral county hospitals at the mental health clinics and delivered by mental health nurses or psychologists. This involves counseling services mainly to the caregiver on the best ways of taking care of their loved ones. Little emphasis is made on the care of the carers and to people with dementia unless they are able to engage in a conversation. The mental health workers receive the person at advanced stage making it difficult to speak directly with persons with dementia (Musyimi et al., 2019; Musyimi et al., 2021).

References:

Musyimi, C. W., Ndetei, D. M., Evans-Lacko, S., Oliveira, D., Mutunga, E., & Farina, N. (2021). Perceptions and experiences of dementia and its care in rural Kenya. Dementia.  https://doi.org/10.1177/14713012211014800

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Diagnosis for dementia is made by a medical officer at referral county hospitals, but as a secondary condition. Often, diagnosis is received late, following admission to inpatient care diagnosis because the primary complaint at the outpatient clinic is dementia unrelated and the dementia symptoms are mostly identified during inpatient care (Musyimi et al., 2019).

References:

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Similar to diagnosis, management is provided at referral county hospitals by psychiatric nurses and psychologists in counties where psychologists are integrated within the health system.

This is often provided by family members.

These are provided at referral county and private hospitals by mostly psychologists (only in Makueni County for public health facilities) and/or social workers in addition to doctors and nurses team (Hospice Care Kenya, 2018; International Association for Hospice & Palliative Care, 2019). Not all county hospitals have put in place the scheme of service for social medical workers. The medical social workers are supposed to contribute to improvement of health care services and provide counseling to patients and relatives in institutions/hospitals, psychosocial rehabilitation, home based care, and placement of patients. Other roles include providing support services to curative/hospital based, primary, preventive and promotive programmes, and activities (Republic of Kenya, 2009). Private hospitals e.g., the Aga Khan University Hospital have also social workers in their palliative care team (International Association for Hospice & Palliative Care, 2019). In most cases, people with dementia receive these services especially those at advanced stages.

References:

Hospice Care Kenya. (2018). Paving the way for universal access to palliative care in Kenya.  https://www.hospicecarekenya.com/other-news/paving-the-way-for-universal-access-to-palliative-care-in-kenya/

International Association for Hospice & Palliative Care. (2019). Global directory of palliative care services and organizations. https://hospicecare.com/global-directory-of-providers-organizations/

Republic of Kenya. (2009). Scheme of Service for Medical Social Workers. Permanent Secretary Ministry of State for Public Service, Office of the Prime Mininster. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2015/09/SCHEME%20OF%20SERVICE%20FOR%20MEDICAL%20SOCIAL%20WORKERS.PDF

Only those above 65 years who are poor and vulnerable and none of their household members is receiving pension, regular income, or gainful employment, are entitled to cash transfers (Kshs. 4000) every two months. Those below the age of 65 years who have dementia and are classified as persons with severe disability, are also entitled to similar cash transfer. A person is required to enroll only for one of the schemes even if they qualify for both. Further details on cash transfer schemes are described in part 9 (social protection for people with dementia).

There are more private residential homes in urban centres compared to rural areas. According to a press statement in 2016, Nairobi  County alone had several retirement and assisted living from less than ten the previous decade (Achuka, 2016). It is possible that the pressure of working and taking care of older persons is unlikely to take place in the cities hence family carers resort to retirement homes for the ageing parents. However, it is important to note that there are no public residential homes but only hospital-based palliative care services where people with dementia and at advanced stages are taken if they cannot afford private residential homes.

References:

Achuka, V. (2016). The new age dilemma of caring for ageing parents. Daily Nation, 14 May. Nairobi, Kenya. https://nation.africa/kenya/life-and-style/lifestyle/the-new-age-dilemma-of-caring-for-ageing-parents-1198666?view=htmlamp

Community-based services for people with dementia are provided by the private sector through residential homes but admission is limited to those who can afford it (National Gender and Equality Commission (NGEC), 2016).

References:

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

There are no estimates on the number of people who receive community-based care for dementia (through private residential homes) available.

See information systems for dementia – Part 6. Mental disorders are often reported as aggregate data rather than individual conditions (Kiarie et al., 2019), making it difficult to monitor conditions such as dementia.

References:

Kiarie, H., Gatheca, G., Ngicho, C., & Wangi, E. (2019). Lifestyle Diseases: An Increasing Cause of Health Loss. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2019/01/Revised-Non-Communicable-Disease-Policy-Brief.pdf

Family members are neither registered nor recognized as part of dementia diagnostic services. However, their role in terms of responsibility to their family member with care needs is recognized in the care and protection of older members of society bill, 2018; PART III 59(f) which states that “Pursuant to Article 57 of the Constitution, every older member of society has the right to receive reasonable care, assistance and protection from their family and the State” (Republic of Kenya, 2018b).

References:

Republic of Kenya. (2018b, June). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya.

Management is mostly based on symptom reduction through pharmacological treatment (prescription by doctors). In counties where there are no psychologists to provide counseling services mainly to the caregiver, management is provided by psychiatric nurses or enrolled/nursing officers. The magnitude of the psychosocial interventions by the latter staff may not be sufficient because of lack of expertise as most health care workers are not very well equipped with information on dementia care. Caregivers are advised on the best ways to take care of their loved ones with little or no emphasis on self-care (Musyimi et al., 2019). The heavy reliance on informal care giving and families impacts negatively on the mental wellbeing and quality of life of caregiver especially in Kenya where respite care and caregiver training centers do not exist.

References:

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

Most of the services provided in residential homes may not target people with dementia but aim at improving the quality of life for older persons. Further information on the description of services is provided below (7.02.01.11) – home care services.

There is no information available on regional disparities in terms of residential homes. However, 31 out of 47 counties in Kenya have access to palliative care services (Hospice Care Kenya, 2018). Makueni County is the only county in Kenya that has integrated psychologists in the health system who are instrumental in providing palliative care and mental health services within hospitals.

References:

Hospice Care Kenya. (2018). Paving the way for universal access to palliative care in Kenya.  https://www.hospicecarekenya.com/other-news/paving-the-way-for-universal-access-to-palliative-care-in-kenya/

According to an audit of residential institutions of older members of society in selected counties of Kenya (National Gender and Equality Commission, 2016), the available home-based care programmes are managed by faith-based organizations and provide basic services such as;

1. Livelihood services e.g., feeding programmes,
2. Counseling and psychosocial support services provided by nurses. This type of counseling includes giving hope and encouragement and providing entertainment to relieve stress,
3. Healthcare services for chronic diseases such as pneumonia provided by resident nurses who refer cases to hospitals for advanced management.

The care and rehabilitation services are designed for senior citizens who live by themselves, are unwell or handicapped, or cannot properly look after themselves (National Gender and Equality Commission, 2016).

References:

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

Most residential homes do not have a clear admission policy except the ability to pay for the services (National Gender and Equality Commission, 2016).

References:

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

The Alzheimer’s and Dementia Organization of Kenya (ADOK) was founded in 2016 by a group of family caregivers. ADOK works to raise awareness of Alzheimer’s and provide support to those affected with Alzheimer’s and other forms of Dementia (Alzheimer’s & Dementia Organization Kenya (ADOK), 2019).

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2019). Training. https://alzkenya.org/wp-content/uploads/2019/08/ADOK_Newsletter.pdf

Alzheimer’s and Dementia Organization of Kenya has its main office situated in the capital of Kenya, (Nairobi): Soin Arcade 3^rd Floor in Westlands, but has no other sub-national offices (Alzheimer’s & Dementia Organization Kenya (ADOK), 2019).

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2019). Training. https://alzkenya.org/wp-content/uploads/2019/08/ADOK_Newsletter.pdf

All the staff are volunteers.

ADOK provides the following services (Alzheimer’s & Dementia Organization Kenya, 2019):

• Care giver training: with a limited number of trained doctors and effective patient-care options, ADOK provides training on:

1. 1. Understanding Dementia,
   2. Understanding Alzheimer’s,
   3. Effectively communicating with an Alzheimer’s patient,
   4. Dealing with care giver burn out,
   5. Dealing with behavior change (aggression),
   6. Safety.

• Support groups: Through monthly support group meetings, caregivers of persons with dementia meet and talk about their experiences in providing care to persons with dementia while giving each other support.
• Research and advocacy: ADOK conducts advocacy in the media, churches, and among community health workers.

References:

Alzheimer’s & Dementia Organization Kenya (ADOK). (2019). Training. https://alzkenya.org/wp-content/uploads/2019/08/ADOK_Newsletter.pdf

None of the activities are funded by the government. ADOK is a Non-Governmental Organization that depends on donors for funding (Alzheimer’s & Dementia Organization Kenya, 2019).

References:

Alzheimer’s & Dementia Organization Kenya. (2019). Home: Our programs. https://alzkenya.org

Through the STRiDE project, ADOK contributed to the National Dementia Plan (currently under development) by the Ministry of Health, Africa Mental Health Research and Training Foundation, and ADOK (London School of Economics (LSE), 2018; C. Musyimi et al., 2019).

References:

London School of Economics (LSE). (2018). Strengthening Responses to Dementia in Developing Countries (STRiDE). https://www.lse.ac.uk/cpec/research/projects/dementia/stride

Musyimi, C., Mutunga, E., & Ndetei, D. (2019). Stigma and dementia care in Kenya: Strengthening Responses to Dementia in Developing Countries (STRiDE) Project. In World Alzheimer Report 2019: Attitudes to dementia (pp. 121–122). London, UK: Alzheimer’s Disease International. https://www.alzint.org/u/WorldAlzheimerReport2019.pdf

The services provided by ADOK are only available in Nairobi, Kenya’s capital. It is therefore only accessible to people living in Nairobi and the neighbouring towns or those who can travel to participate in the support groups. However, there are some caregiver tips that have been provided on the website (Alzheimer’s & Dementia Organization Kenya, 2019).

References:

Alzheimer’s & Dementia Organization Kenya. (2019). Home: Our programs. https://alzkenya.org

The services provided by Alzheimer’s and Dementia Organization of Kenya are free.

Those that receive these services are mostly those with caregivers who are educated and, because of the location of the organisation, are predominantly living in the capital.

There are a total of 29 neurologists in Kenya, the majority of whom are located in Nairobi, Kenya’s capital (Medpages, 2019).

References:

Medpages. (2019). Neurologists in Kenya. https://www.medpages.info/sf/index.php?page=listing&servicecode=172&countryid=23&regioncode=&subregioncode=

As of 2018, Kenya had no geriatrician, but had one medical gerontologist and two social gerontologists (Wanja, 2018).

References:

Wanja, J. (2018). Why we should prioritise needs of older persons. Standard Digital, 2 March. Nairobi, Kenya. https://www.standardmedia.co.ke/commentary/article/2001271715/why-we-should-prioritise-needs-of-older-persons

In Kenya, mental health training/courses for the health and social workforce do not specifically focus on competencies around dementia. Some training includes components that focus on communication skills and different forms of psychotherapies, particularly in training for psychologists (University of Nairobi, 2019). Furthermore, visiting a residential home or an organization providing care to people with dementia is not included in practicums, electives, or community health programmes, unless a person makes special arrangement outside school requirements to visit such homes or institutions. In some universities, students are given an opportunity to select the organization they would like to work with during the attachment or internship. It is in such cases that students make requests to organizations to apply for internship opportunities. However, it is not clear how many approach institutions dealing with dementia care.

References:

University of Nairobi. (2019). Department of Psychology. https://psychology.uonbi.ac.ke

Nearly all healthcare professions (at one point or another involved in long-term care) have regulatory agencies that assist the government in delivering various professional activities in Kenya. Kenya’s health professionals regulatory boards and councils regulate the training and practice of health professionals by (Ministry of Health, 2015a);

1. Approving training program and school,
2. Admission and entry into internship,
3. Licensing exams,
4. Registration for license issuance.

Furthermore, some professions require Continuing Professional Development (CPD) points to renew licenses on an annual basis in various regulatory agencies.

References:

Ministry of Health. (2015a). Kenya Health Workforce Report: The Status of Healthcare Professionals in Kenya, 2015. Nairobi, Kenya. https://taskforce.org/wp-content/uploads/2019/09/KHWF_2017Report_Fullreport_042317-MR-comments.pdf

There is no training for ‘untrained’ paid workers. They learn on the job unless they make a request to ADOK to provide training through attending monthly support groups.

No.

Yes, the majority of these are managed by either faith-based organizations or private organizations. There are no government-owned facilities offering residential care in Kenya (National Gender and Equality Commission, 2016).

References:

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf

In 2016, there were two National referral Hospitals in Kenya with integrated palliative care services. In addition, the Kenya Hospices and Palliative Care Association (KEHPCA) had integrated palliative care services (Palliative Care Units) in 11 provincial hospitals across the country and was working towards expanding these services to 30 other county hospitals. The process of integrating the hospital-based palliative services involved the following (Ali, 2016):

1. Advocacy both at the national and at the hospital level;
2. Capacity building through training and mentorship;
3. Establishment of palliative care units through the renovation of an identified building/room and equipping them;
4. Ensuring supply of morphine and other essential palliative care medicines and;
5. Providing palliative care services to patients and their families

In 2019, there were 31 government hospitals with palliative care (Hospice Care Kenya, 2018), 15 free standing hospices, 11 hospices and palliative care services in the Mission hospitals, 8 in the rural community (FBO), 6  in private institutions and two in teaching and referral hospitals (i.e., Kenyatta National Hospital and Moi Teaching and Referral Hospital – Palliative Care Unit, housed in the Oncology Department – AMPATH) (Kenya Hospices and Palliative Care Association (KEHPCA), 2019).

References:

Ali, Z. (2016). Kenya Hospices and Palliative Care Association: Integrating Palliative Case in Public Hospitals in Kenya. Ecancermedicalscience. 10:655. https://doi.org/10.3332/ecancer.2016.655

Hospice Care Kenya. (2018). Paving the way for universal access to palliative care in Kenya.  https://www.hospicecarekenya.com/other-news/paving-the-way-for-universal-access-to-palliative-care-in-kenya/

Kenya Hospices and Palliative Care Association (KEHPCA). (2019). Hospices. https://kehpca.org

There is no available information on existence of adult day centres in Kenya.

The concept of outpatient (community) social centres does not exist in Kenya. There are social halls built by the counties to support social activities for community members. Sometimes these are rented out for social activities to NGOs and private organizations. None are specifically meant for long-term care.

There are no public residential long-term care facilities in Kenya and the total number of private long-term care facilities is not documented.

The total number of people with dementia in residential long-term care facilities in Kenya is not available.

None.

None.

None. Data is reported as aggregated at the County level and dementia detection is often made as a secondary condition.

None.

The concept of outpatient (community) social centres does not exist in Kenya.

None. Persons with dementia receive pharmacological treatment at the mental health clinic with the help of psychiatric nurses and psychosocial interventions for caregivers, delivered by psychologists.

Persons with dementia do not have access to a specific centre in hospitals. They are only admitted if they have another illness or if the next of kin is not available for home care and the hospital staff are not able to trace the relatives.

Most drugs are approved by the National Medicines Regulatory Authority but not included on the essential drug list of drugs in Kenya (Ministry of Health, 2016a) and are unavailable in public facilities. For instance, Donepezil is mostly available in private facilities (Mokaya et al., 2016).

References:

Ministry of Health. (2016a). Kenya Essential Medical Supplies List 2016. Nairobi, Kenya. http://publications.universalhealth2030.org/uploads/KEMSL-2016Final-1.pdf

Mokaya, J., Dotchin, C. L., Gray, W. K., Hooker, J., & Walker, R. W. (2016). The accessibility of Parkinson’s disease medication in Kenya: results of a national survey. Movement Disorders Clinical Practice, 3(4), 376–381. https://doi.org/10.1002/mdc3.12294

Yes. For example, Donepezil is marketed under the brand name Aricept (Mokaya et al., 2016).

References:

Mokaya, J., Dotchin, C. L., Gray, W. K., Hooker, J., & Walker, R. W. (2016). The accessibility of Parkinson’s disease medication in Kenya: results of a national survey. Movement Disorders Clinical Practice, 3(4), 376–381. https://doi.org/10.1002/mdc3.12294

No. These are dependent on the ability or interest of well-wishers to give through NGOs or private organizations, but none is provided or subsidized for persons with dementia.

The assistive devices and services provided within the National Development Fund for persons with disabilities (rather than just dementia) are free but after submitting a complete request form (National Council for Persons with Disabilities (NCPWD), 2019). The new application handbook is designed to clarify how decisions are made at the fund by providing the method and criteria for approving or rejecting applications. For instance, priority would be given to those who require the device for learning, training, or work related environments and those who have never received an assistive device unless it is worn out or too small for their age (National Council for Persons with Disabilities, 2011).

References:

National Council for Persons with Disabilities (NCPWD). (2019). National Development Fund. https://ncpwd.go.ke/ndfpwd-funding-summary/

National Council for Persons with Disabilities. (2011). National Development Fund for Persons with Disabilities: Application Handbook. https://ncpwd.files.wordpress.com/2011/08/application-handbook-56-pages.pdf

The Persons with Disabilities (Amendment) Bill, 2019 Part 2B (2f – iii) states that the county executive committee member in each county shall coordinate the implementation of programmes developed by the Council and the Authority relating to persons with disabilities in the county, in particular coordinate programmes on accessibility and reasonable accommodation (Republic of Kenya, 2019). There is no literature indicating whether persons with dementia or disability should have the housing adjustments for free or not (in their homes). However, the bill states that persons with disabilities should enjoy equal benefits and privileges of employment equal to those enjoyed by an employee without a disability (Republic of Kenya, 2019). This is an indication that working environments or areas of accommodation outside their home should have such adjustments. The owners or employers should pay for such or apply to receive the infrastructure through the National Development Fund for persons with disabilities (National Council for Persons with Disabilities, 2011).

References:

National Council for Persons with Disabilities. (2011). National Development Fund for Persons with Disabilities: Application Handbook. https://ncpwd.files.wordpress.com/2011/08/application-handbook-56-pages.pdf

Republic of Kenya. (2019). The Persons with Disabilities (Amendment) Bill, 2019. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2019-02/The%20Persons%20with%20Disabilities%20%28Amendment%29%20Bill%2C%202019.pdf

None.

None. Interventions such as mhGAP-IG have been implemented by the AMHRTF (Africa Mental Health Training and Research Foundation, 2020) using task sharing approaches i.e., the TEAM project (Mutiso et al., 2018). The focus on delivery of interventions by non-mental health specialists (health care workers) after training was on priority mental health problems (including dementia) listed under the mhGAP-IG which includes dementia (World Health Organization, 2016).

References:

Africa Mental Health Training and Research Foundation. (2020). Welcome to AMHRTF. https://africamentalhealthresearchandtrainingfoundation.org

Mutiso, V. N., Gitonga, I., Musau, A., Musyimi, C. W., Nandoya, E., Rebello, T. J., … Ndetei, D. M. (2018). A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low-and middle-income country: a case study of Makueni County, Kenya. International Journal of Mental Health Systems, 12(1), 1–13.  https://doi.org/10.1186/s13033-018-0234-y

World Health Organization. (2016). mhGAP Intervention Guide version 2.0. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241549790

None in Kenya.

Since they are not included on the essential drug list of drugs in Kenya (Ministry of Health, 2016a) and are unavailable in public facilities, the cost in private facilities is dependent on the distributor.

References:

Ministry of Health. (2016a). Kenya Essential Medical Supplies List 2016. Nairobi, Kenya. http://publications.universalhealth2030.org/uploads/KEMSL-2016Final-1.pdf

Older persons (similar to persons with dementia) in Kenya rely exclusively on informal care (Applebaum et al., 2013). Families or paid untrained caregivers are often the main caregivers for senior citizens who are not able to live independently, a scenario seen in most African countries (World Health Organization, 2017c).

References:

Applebaum, R., Bardo, A., & Robbins, E. (2013). International Approaches to Long-term Services and Supports. Generations: Journal of the American Society on Aging. 37:1. Pp. 59-65. https://www.researchgate.net/publication/273133611_International_Approaches_to_Long-term_Services_and_Supports

World Health Organization. (2017c). WHO series on long-term care: Towards long-term care systems in sub-Saharan Africa. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241513388

Employment for care workers for dementia is often informal (in Kenya unorganized and unregulated domestic workers often referred to as house helps are employed informally (through special arrangements between the individual (caregiver) and the family member) as caregivers). This is most commonly the case in families where family members are unavailable to provide care due to their employment status. The monthly pay for the informal care worker greatly varies depending on the location but without health care insurance or social security (Venas News, 2019). Less than 10% have formal contracts (International Labour Organization, 2017). There is no formal curriculum developed for training on dementia care giving in Kenya and thus the rights of informal care workers for dementia is not recognized at the health care system or at the policy level (World Health Organization, 2017c).

References:

International Labour Organization. (2017). Planning for success: a Manual for domestic workers and their organizations. International Labour Organization (ILO), Jakarta. https://www.ilo.org/wcmsp5/groups/public/—asia/—ro-bangkok/—ilo-jakarta/documents/publication/wcms_579472.pdf

Venas News. (2019). Salary of a Maid/House help in Kenya 2019. VENASNEWS, 24 Janyary. Nairobi, Kenya. https://venasnews.co.ke/2019/01/24/salary-of-a-maidhouse-help-in-kenya-2019/

World Health Organization. (2017c). WHO series on long-term care: Towards long-term care systems in sub-Saharan Africa. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241513388

Similar to other African countries, most care givers are female and range in age from children to older adults and could be family members (spouse, parent, or children) or unorganized and unregulated domestic workers (paid informally in the home of caregiving relatives) (World Health Organization, 2017c). This is because informal provision of care is considered as an obligatory role especially if the person with dementia is a family member making the activity less structured and undertaken in private (Burr et al.,  2005).

References:

Burr, J. A., Choi, N. G., Mutchler, J. E., & Caro, F. G. (2005). Caregiving and volunteering: are private and public helping behaviors linked? The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60(5), S247–S256. https://doi.org/10.1093/geronb/60.5.s247

World Health Organization. (2017c). WHO series on long-term care: Towards long-term care systems in sub-Saharan Africa. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241513388

Rural to urban migration in search of better opportunities for informal care givers or young women may result in minimal workers available to take care of a person especially with late-onset dementia. This could consequently  lead to reduced quality of care for persons with dementia (World Health Organization, 2017c) because of involvement of the available family carers in other household activities. Rural to urban migration for family members may create employment opportunities for informal care givers. However, many of the available domestic workers (untrained but informally given the role of care giving) may not be willing to take care of a person with dementia due to neurological decline and the progressive nature of the disease.

References:

World Health Organization. (2017c). WHO series on long-term care: Towards long-term care systems in sub-Saharan Africa. Geneva, Switzerland. https://www.who.int/publications/i/item/9789241513388

Informal care workers (untrained and often given the role of taking care of a person with dementia) who are commonly known as house managers, earn the least salary among employees of all ranks (Venas News, 2019). Most informal workers in high end homes are degree holders while those in the capital or informal settlements are either primary or secondary school leavers who dropped out of school or were unable to afford tertiary education.

References:

Venas News. (2019). Salary of a Maid/House help in Kenya 2019. VENASNEWS, 24 Janyary. Nairobi, Kenya. https://venasnews.co.ke/2019/01/24/salary-of-a-maidhouse-help-in-kenya-2019/

The monthly pay for an informal care worker (in general including those taking care of a person with dementia) greatly varies depending on the location but without health care insurance. For instance, those in informal settlements would be paid 3,500 Kenya Shillings (35USD), Kenya’s capital city-Nairobi (7,000 Kenya Shillings (70USD)), high end homes – but mostly degree holders (15,000 to 40,000 Kenya Shillings (150 to 400USD)). The current regulations demand that the informal workers should be paid at least 13,200 Kenya Shillings (USD 132) (Venas News, 2019).

References:

Venas News. (2019). Salary of a Maid/House help in Kenya 2019. VENASNEWS, 24 Janyary. Nairobi, Kenya. https://venasnews.co.ke/2019/01/24/salary-of-a-maidhouse-help-in-kenya-2019/

Family caregivers in Kenya experience financial instability due to costs of treatment and daily living expenses. In addition, they struggle due to limited access to information and evidence-based care. Carers have been found to experience burn out and stigma linked to misconceptions about the illness (Johnston, 2017). Unfortunately, they do not receive any monetary compensation from the government or other forms of formal support from health or social services (Chepngeno-Langat, 2014). ADOK, however, offers training and monthly support group meetings for caregivers of persons with dementia. There they can share their experiences around the provision of care while giving each other support.

References:

Chepngeno-Langat, G. (2014). Entry and re-entry into informal care-giving over a 3-year prospective study among older people in Nairobi slums, Kenya. Health & Social Care in the Community, 22(5), 533–544. https://doi.org/10.1111/hsc.12114

Johnston, H. (2017). Caring for caregivers: challenges facing informal palliative caregivers in Western Kenya. Independent Study Project (ISP) Collection, 2684.  https://digitalcollections.sit.edu/cgi/viewcontent.cgi?article=3707&context=isp_collection

None.

None.

None.

Family members who provide care in Kenya continue to keep this role because of the fulfillment they get from giving care to their family member. They may also perceive providing care as a biblical mandate or maintain their role to avoid shame (Cappiccie et al., 2017). Additionally, unpaid care work is seen as a women’s domain while working for pay is considered a masculine task hence the high percentage of women assuming caregiving roles (Ferrant et al., 2014).

References:

Cappiccie, A., Wanjiku, M., & Mengo, C. (2017). Kenya’s Life Lessons through the Lived Experience of Rural Caregivers. Social Sciences, 6(4), 145. https://doi.org/10.3390/socsci6040145

Ferrant, G., Pesando, L. M., & Nowacka, K. (2014). Unpaid Care Work: The missing link in the analysis of gender gaps in labour outcomes. OECD Development Centre: Issues Paper.  https://www.oecd.org/dev/development-gender/Unpaid_care_work.pdf

Although not documented in Kenya, caregivers to people with dementia are often called “invisible second patients” due to the high rates of psychological morbidity and physical ill-health (Brodaty & Donkin, 2009). Caring for a person with dementia is particularly associated with reduced self-efficacy, quality of life, mental health (including depression and anxiety), physiological changes such as irregular immune and metabolic function, cardiovascular reactivity, and increased stress hormones e.g., cortisol which may contribute to impaired cognitive function, risk of developing obesity, hyperinsulinemia, and inflammation. In addition, some carers report physical exertions due to little time for exercise and preparation of healthy meals (Cuijpers, 2005; Richardson et al., 2013; Sörensen et al., 2006).

References:

Brodaty, H., & Donkin, M. (2009). Family caregivers of people with dementia. Dialogues in Clinical Neuroscience, 11(2), 217-228. https://doi.org/10.31887/DCNS.2009.11.2/hbrodaty

Cuijpers, P. (2005). Depressive disorders in caregivers of dementia patients: a systematic review. Aging & Mental Health, 9(4), 325–330. https://doi.org/10.1080/13607860500090078

Richardson, T. J., Lee, S. J., Berg-Weger, M., & Grossberg, G. T. (2013). Caregiver health: health of caregivers of Alzheimer’s and other dementia patients. Current Psychiatry Reports, 15(7), 367. https://doi.org/10.1007/s11920-013-0367-2

Sörensen, S., Duberstein, P., Gill, D., & Pinquart, M. (2006). Dementia care: mental health effects, intervention strategies, and clinical implications. The Lancet Neurology, 5(11), 961–973.  https://doi.org/10.1016/S1474-4422(06)70599-3

Most caregivers feel inadequately trained for the skills that they perform because they do not have any formal education in caregiving. Being the primary caregiver, there can be a further delay in educational progress because they do not find time for themselves or social activities outside the family or time to continue with education. They may not look for employment because the needs of the person they support are too demanding to combine work with their care responsibilities. Carers in employment may face the risk of losing their job, limited promotional and training opportunities, and a reduction in retirement savings and Social Security benefits (Collins & Swartz, 2011).

References:

Collins, L. G., & Swartz, K. (2011). Caregiver care. American Family Physician, 83(11), 1309-1317.

None.

None.

The government of Kenya, through the National Development Fund for Persons with Disabilities, has set aside funds for persons with disabilities including cognitive disabilities through cash transfers (National Council for Persons with Disabilities (NCPWD), 2019). People who qualify for this cash transfer are those who are from extremely poor households and residing in a particular location for more than a year but are not enrolled in any other cash transfer program (Ministry of Labour and Social Protection, 2019a). The transfer value per month for each eligible person is 2,000 Kenya shillings (20USD).

1. According to the National Social Security Fund (NSSF) act no.45 of 2013, subsection 38, a member is entitled to invalidity pension if he/she suffers physical or mental disability of a permanent nature as certified by a medical board established under the Act and has made at least 36 monthly contributions immediately preceding the date of invalidity (Republic of Kenya, 2013). Retirement benefits are paid from the retirement age of 60 years with earlier retirement being at age 50 (Republic of Kenya, n.d.).
2. The government of Kenya provides Older Persons Cash Transfer (OPCT) for a Kenyan who is above 70 years and residing in a particular location for more than a year but neither receiving pension nor enrolled in any other cash transfer program (Ministry of Labour and Social Protection, 2019a). The transfer value per month for each eligible person is 2,000 Kenya shillings (20USD).

References:

Ministry of Labour and Social Protection. (2019a). FAQs. https://laboursp.go.ke/faqs/

National Council for Persons with Disabilities (NCPWD). (2019). National Development Fund. https://ncpwd.go.ke/ndfpwd-funding-summary/

Republic of Kenya. (2013). The National Social Security Fund Act, 2013 No. 45 of 2013. 27 December. Nairobi, Kenya. http://kenyalaw.org/kl/fileadmin/pdfdownloads/Acts/NationalSocialSecurityFundAct2013.pdf

Republic of Kenya. (n.d.). Legal provisions of the Pensions Act, Cap 189. The National Treasury Pnesions Department. Nairobi, Kenya. https://www.treasury.go.ke/wp-content/uploads/2020/11/Pensions-Act-CAP-189.pdf

None.

There is no financial carers’ benefit if the person with disability is above the age of 18. The laws in Kenya under the Persons with Disability Act, state that, “beyond the age of eighteen on the allowances payable under this regulation shall be paid directly to the person with disability and such person may be treated in his own right under the other regulations for Cost, Care and Maintenance, and the Council may recommend the person to whom such allowance may be made” (Legislation, 2010). Other than this, there is no other benefit that the carer is entitled to.

References:

Legislation, S. (2010). Persons with Disabilities Act, (14). https://www.un.org/development/desa/disabilities/wp-content/uploads/sites/15/2019/11/Kenya_Persons-with-Disability-Act.pdf

According to the Employment Act, an employee is entitled to sick leave of no more than seven days with full pay and thereafter to sick leave of seven days with half pay, in each period of twelve consecutive months of service if the employee has been in service for at least two consecutive months with his employer. The employee is required to present a certificate of incapacity to work that has been signed by a duly qualified medical practitioner or a person acting on the practitioner’s behalf in charge of a dispensary or medical aid centre (Republic of Kenya, 2012). This applies to all employed persons with or without a disability.

References:

Republic of Kenya. (2012). Employment Act: Chapter 226. The National Council for Law Reporting with the Authority of the Attorney-General. http://kenyalaw.org/kl/fileadmin/pdfdownloads/Acts/EmploymentAct_Cap226-No11of2007_01.pdf

Following the National Social Security Fund (NSSF) ACT No. 45 of 2013, employers are advised to make arrangements to submit their contributions in accordance with the new NSSF Act where pension contribution would be 12% of the pensionable wages made up of two equal portions of 6% from the employee and 6% from the employer subject to an upper limit of KES 2,160 for employees earning above KES 18,000. The Upper Earning Limit (UEL) is KES. 18,000 while the Lower Earnings Limit (LEL) is KES 6,000 (National Social Security Fund (NSSF), 2019). This applies to all employees and is not specific to persons with dementia.

References:

National Social Security Fund (NSSF). (2019). New NSSF Member Contributions. https://www.nssfug.org/about-us/membership/

None.

None.

None.

None.

There is no published document illustrating Kenyan government’s plan or proposed funding towards dementia research or involvement of people with dementia in the research development process.

No.

The STRiDE project in Kenya implemented by Africa Mental Health Research and Training Foundation (AMHRTF) and Alzheimer’s and Dementia Organization Kenya (ADOK), is the first to involve people with dementia in the research development process (Breuer et al., 2021; London School of Economics (LSE), 2018).

References:

Breuer, E., Comas-Herrera, A., Freeman, E., Albanese, E., Alladi, S., Amour, R., … Iveth Astudillo García, C. (2021). Beyond the project: Building a strategic theory of change to address dementia care, treatment and support gaps across seven middle-income countries. Dementia. 21(1), 114-135. https://doi.org/10.1177/14713012211029105

London School of Economics (LSE). (2018). Strengthening Responses to Dementia in Developing Countries (STRiDE). https://www.lse.ac.uk/cpec/research/projects/dementia/stride

There is little information about dementia in Kenya both at policy level and in community settings. In most mental health clinics in community settings, dementia is diagnosed as “senile dementia” making it a normal part of the ageing process, a perception common among community members. There are also no national guidelines on dementia care or support for caregivers. This is important because family carers provide a large share of care and paid informal workers do not receive any training on how to support people with dementia. Informal workers often provide care for people with dementia while performing other household chores. The development of the National Plan could be a starting point to develop better support for people with dementia and their carers in Kenya.

With the current community dementia attribution to witchcraft, inappropriate use of local idioms of dementia, there is a need to create awareness on dementia, reduce stigma by demystifying myths and misconceptions, and develop guidelines on dementia care and policies on protection of unpaid caregivers.

Prevention, early detection, and treatment of dementia using evidence-based and task-sharing approaches (using health care workers and/or community health providers such as community health workers, traditional and faith healers) to increase the capacity of the workforce is the road to a dementia free country or a significant reduction of the dementia treatment gap in Kenya.

Further research needs to be conducted to ascertain the risk factors for dementia in Kenya and work towards prevention, development, or adaptation of evidence-based tools for use in Kenya and coordinated care pathways that could contribute to robust assessments and improvement in quality of care for persons with dementia.