Kenya falters in family planning service provision

One pregnancy is challenging enough, but what if another follows hot on its heels? It is traumatising and daunting to be pregnant two months after giving birth.

 This is what befell Sharon Atieno, leaving her torn between attending a postnatal clinic for her toddler or antenatal ones for the foetus she was carrying.

 When her fourth child was two months old, she unexpectedly got pregnant again. Atieno, 24, is now a mother of five. She got married when she was 14 years old; the year she first had her period.  From then on, she would conceive after every two years.

“After delivering my fourth child I began to seriously think about planning my family because raising the ones I already had was becoming a problem. Before, my husband did not want me to use any method,” she said.

However, she fell pregnant once again because she was failed by the system.

 “Immediately I gave birth to my fourth child, I was told by a nurse to go slow on giving birth and told to go back for birth control four weeks after my scar healed,” she said.

She went to Wagai Health Centre when her baby was a month old but there were no birth control methods available. She was advised to go back the following week.

“Carrying the baby to the hospital given that the hospital is far away was tiring, but I had to make the trips because we were already having intercourse. I was worried I could get pregnant again. I went four times, but there was no method for me,” she said.

Fell pregnant

And that is how she fell pregnant with her fifth child, who turned two months old last week.

 “If I had got any method when I wanted it, I would still be breastfeeding my one year old son, but look at me;  she stopped breastfeeding at four months and is not in good health. Yet here I am, still struggling with the same problems; no contraceptives in health facilities.  I’m now ready to use any method provided I don’t become pregnant before my child turns three years,” she says

Last week, she says, she went to four hospitals but was told to wait.

 “I fear that I might get pregnant again. We have now decided that if we don’t get any method at the facility in the coming week, I might be forced to buy at the nearest chemist, though it is costly. The Sh200 required is enough to buy food for two days,” she told Healthy Nation at her home in Ulamba village, Gem sub-county, Siaya County.

The same case applies to 35-year-old Kubende Metrine, a mother of five. For years, she has been using pills since it is the only hormonal method that suits her. However, the pills have been out of stock, contributing to her unplanned fourth pregnancy.

“I got pregnant because I could not get the method I wanted and within the two-week wait for my next dose, I had conceived,” she says.

Since she was not able to get her preferred method after delivery in her county, Bungoma, she had to cross to Kakamega’s Matungu sub-county hospital for a ten-year non-hormonal intrauterine device (IUD), which was the only available method.

Mwanarabu Sahara, a mother of three, has not been able to get her preferred Depo-Provera injection, which is the method she has been using for years – it has been missing for a year now.

“This is the only method that works well with me. I have tried literally all the methods but I always develop problems, but with the three-month injection, I was good to go. I have not been able to get it for the last one year at Matungu sub-county hospital,” she told Healthy Nation.

For the first three months, she spent Sh200 to purchase the contraceptive in a chemist. However, she has not been able to get the money for subsequent doses. She now lives with the never-ending fear that she become expectant yet she is not ready.

Private facilities

 “I am just not pregnant by the grace of God. I don’t know what to do. I will keep checking for the method, maybe it will be delivered soon,” she says.

The three women represent hundreds of thousands of others of reproductive age who have had to go without their preferred birth control method for almost a year now because of frequent stock-outs. Those who can afford, opt to purchase or get them in private facilities at a cost.

According to the 2014 Kenya Demographic Health Survey, fewer than half the number of sexually active women in the country use contraceptives.

The data shows that 18 per cent of married women aged 15-49 have an unmet need for family planning, 9 per cent for spacing and 8 per cent for limiting. This marks a substantial decline since 2008/09 when 26 per cent of women had an unmet need.

Unmet needs are higher in rural areas (20 per cent) than urban areas (13 per cent). The unmet need decreases with education: 28 per cent of women with no education have an unmet need for family planning compared to 12 per cent of women with secondary school or higher education.

An unmet need for family planning refers to a situation where married women who want to space their next birth or stop childbearing entirely are not using contraception.  It decreases with household wealth.

 Family planning is for both health and wealth. When parents plan their families, they are more likely to realise their education goals and have careers to raise family income. And when countries develop as their fertility rates decline, the proportion of women earning wages rises and their children have greater chances of success.

However, in Kenya, because of the unmet needs, many pregnancies are unplanned, leading to many unplanned births that eventually overwhelm the education and health systems.

Better access to family planning, the World Health Organization (WHO) advises, largely contributes to planned children and a decrease in early pregnancies.

Mr Domnic Omollo, the Siaya County reproductive health coordinator, said the county has lost track of 30 per cent of women of reproductive age because of the frequent family planning commodities stock-outs.

Traditional methods

In the county, the uptake of family planning has reduced from 74 per cent in 2019 to 48 per cent in 2020 because the women are not getting their preferred methods. This, Mr Omollo says, has led to many unplanned pregnancies, more so in married women in rural areas who cannot afford the commodities in private facilities.

“Most women when they come to the facilities and fail to get their preferred methods three or four times, they move to traditional methods whose failure rates are noteworthy. We currently don’t have our population (of women seeking birth control services) that we had before stock-out,” Mr Omollo said.

The last consignment of family planning supplies received by the county was in May 2020, since then, no commodities have been delivered by the Kenya Medical Supplies Authority (Kemsa).

In December, the county redistributed the commodities in all its health facilities to bridge the gap, however, Depo-Provera has remained out of stock, thanks to birth control funding cuts by donors.

Currently, only two methods are in usage in the county: Jadelle implants (the five-year one, which is in short supply) and pills (combined oral contraceptive) with few progesterone only.

“If a client comes and requests for other methods, we try to convince them to take the available options, but this is always against their will,” he said

In Siaya, a bigger percentage of women, seven out of ten, prefer the three-month injection method, unfortunately, this is one of the methods that has been unavailable here and  in many other counties.

 “The frequent stock-out worries me because in the next few years, we will be talking about high numbers of children, and the frequent pregnancies also contribute to high maternal mortality,” Mr Omollo says.

 According to data from the World Bank, in areas where the under-five death rate is high, the fertility rate is also high; but the higher the number of children a woman has, the more likely those children are to die before their fifth birthday.

Implants

 In Kakamega County, Imelda Barasa, the reproductive health coordinator, told Healthy Nation that there have been frequent stock-outs for long-acting methods and the three-month injection method, which is preferred by a majority of mothers.

“Most of them prefer implants and Depo, which are currently out of stock. This is not because of Covid-19 because even before the virus was reported in the country, we experienced stock-out,” she said

The coverage of the commodities dropped slightly from 41.6 per cent in 2019 to 40.7 per cent in 2020. The percentage of women of reproductive age receiving using the different methods reduced from 41 per cent to 16 per cent in 2020.

Last year, Lukuyani sub-county led in the uptake of family planning at 52 per cent, Lugari (51), Malava (48), Ikolomani (44), Lurambi (43), Shinyalu (40), Butere (39), Khwisero (38), Mumias East (38), Matungu (32), Navakholo (32) and Mumias West 30 per cent.

A survey conducted between November and December last year in Nairobi, Kilifi, Nandi, Nyamira, Kiambu, Bungoma, Siaya, Kericho, Kitui, Kakamega and West Pokot counties by Performance Monitoring for Action (PMA) Kenya indicated that stock-out were still a problem both in public and private health facilities.

“With time, there have been changes in facilities reporting not offering the services and most of them are dispensaries. This could be because of personnel and materials stock-outs,” Prof Peter Gichangi, the principal investigator at PMA said.

Implants stock-out remained almost constant, while the stock-out of injectables, the most used method, reduced from 13 to 7 per cent between 2019 and 2020.

 Out of the 822 public hospitals surveyed, 70 per cent reported ordering but not receiving the shipment, 10 per cent increased consumption, 7 per cent ordered but did not receive the right quantity while another 7 per cent did not place an order.

“We need to look at where the disconnect occurs. Why would you order but not receive the shipment? It is clear there is a disconnect and we need to see a change since it is going to erode the gains,” said Ms Barasa.

All the 47 counties receive their commodities directly from the national government, with the country increasingly depending on external funds to procure contraceptives. However, the recent transition from external funding threatens sustainability.

Funding gap

With the country’s transition from a low-income country to a low-middle-income one in 2015, Kenya is now perceived as increasingly capable of financing its own programmes.

Some donors have begun to transition their support out of such middle-income countries and redirecting it to countries with greater needs.

This move will definitely leave a funding gap, which could be difficult to fill.

In the 2018/19 financial year, the estimated budget for contraceptives stood at $24.6million (about Sh2.7 billion) and $11.5 million (about Sh1.2 billion) for the 2019/20 financial year. The country secured $9.1 million for 2018/19 leaving a gap of US$15.5 million, which was to be filled through the domestic budget.

For contraceptive procurement in 2019/20, the government allocated Sh245 million, while the Universal Health Coverage (UHC) programme was also allocated Sh540 million for contraceptive procurement.

 Last year, donors funded 80 per cent of family planning commodities procurement, 15 per cent was funded by the World Bank, while the government funded about five per cent.

In 2019, donors announced that they will stop buying family planning products for Kenyans. From a budget of Sh8.7 billion that was allocated for a five-year period, it came down to Sh3 billion, with the government expected to foot the balance.

Some of the donors funding our reproductive health programmes include the United Kingdom’s Foreign, Commonwealth and Development Office (FCDO), United States Agency for International Development (USAID) and the Bill and Melinda Gates Foundation.

The United Nations Population Fund (UNFPA), which is the largest supplier of contraceptives in many countries, has faced a $253 million shortfall between 2016 and 2020. Projections show this is the largest gap in funding for contraceptives since governments committed to prioritise family planning at the 2012 London Summit on Family Planning.

“The government’s share will rise to Sh1.1 billion in 2021, Sh1.3 billion in 2022, and Sh1.7 billion in 2023. By 2024, the government should fully take over,” said former Cabinet Secretary for Health Sicily Kariuki.

While the government allocated limited funds to family planning in the 2019/20 financial budget, it committed to allocate Sh785 million towards commodity procurement and also increasing the portion of the national health budget for family services, specifically through a budget line.

The main driver of commodity insecurity in Kenya is the growing contraceptive financing gap. Currently, it is estimated that US $27.2 million is needed to cover the gap between 2019/20 and 2020/21.

According to Pharos Global Health Advisors, projections done estimate that as the number of modern method users grows, Kenya’s family planing resource requirements will also increase. To keep up with population growth and to reach a modern contraceptive prevalence rate of 67 per cent by 2030, resources also need to increase.

It also suggests that overall family planning spending in Kenya will have to grow by over 50 per cent in the coming decade, from $81 million (Sh8.6 billion) in 2019 to over $110 million (Sh11.7 billion) annually in 2030. This growth will put pressure on domestic spending and central budgets, assuming that donor contributions will level off and/or decline in the coming years.

In a best-case scenario of constant donor funding in the next decade, the government’s total contribution must increase five fold to cover all family planning programme costs by 2030. 

 The 2017-2020 Costed Implementation Plan (CIP) estimated that donors would contribute approximately $40 million (Sh4.2 billion) to the family planning programme in 2020, while national and county governments would contribute $13.5 million (Sh1.4 billion).

Dr Daniel Mwai, a health financing specialist from the University of Nairobi, told Healthy Nation that the shrinking donor basket creates a huge gap.

The government therefore needs to figure out how it can bridge this gap to ensure sustainability of the programmes.

Bill and Melinda Gates Foundation

He blamed the devolution of health, which resulted in erratic family planning commodity funding, with the government cutting it’s funding from $12 million (Sh1.3 billion) in 2013/14 to less than $1.5 million (Sh159 million) between 2014/15 and 2017/18 combined.

 The development partners have expressed willingness to provide additional funds equivalent to what the government will allocate to be used to address supply shortfalls.

The Bill and Melinda Gates Foundation, for example, has committed to contribute a total of $5 million (Sh530 million) between 2020/21 and 2023/24. In FY 2020/21, it has approved an allocation of $1.67 million (Sh177 million) to the Clinton Health Access Initiative (CHAI), to support Kemsa’s procurements. USAID has committed $3.2 million (Sh339 million) while FCDO has committed £2 million (Sh298 million).

Mr Omollo said that Siaya County has since allocated Sh21 million for reproductive health to address the frequent stock-outs.

“We will not depend on the national government to fund our commodities, this has proven impossible and we will not watch as our women suffer,” he said.

On his part, Prof Gichangi suggests that the country need to develop realistic cost estimates for the family planning programme and use these to guide planning and budgeting.

“For the country to also ensure that there are no frequent stock-outs, there is need for re-introduction of a centralised family planning budget line at the national level with ring-fenced funding for commodities while implementing the co-financing plan agreed upon with the donors,” he said

[email protected]