PRE-EXISTING BARRIERS TO THE HEALTHCARE SYSTEM IN KENYA

Kenya’s healthcare system has been classified as a regressive system due to its lack of responsiveness, inequity inaccessibility to healthcare services, and reduced financing. ( Dutta and Ojera 2019,ilinca, Giorgio,salari 2019).
Healthcare financing from the government remains low with the state spending USD.58 per person. Government healthcare financing accounts for an average of 5.2 % of the Gross domestic product (GDP) and 39 % of the total health financing.
The Bamako declaration mandated Governments increase funding to health care to 15% of its GDP; therefore there remains a deficit of 10% (National Health Accounts 2015/2016).

Health Insurance coverage.
The other barrier is reliance on donor funding which accounts for 26% (APHRC, 2021) and has been decreasing over the years. Donors fund mainly budget lines for example malaria, and HIV and when they are not able to fund, the particular program suffers.
The percentage of Kenyans on social health insurance accounts for only 13% of the population (APHRC, 2021), and therefore that leaves 87% to either subscribe to private insurance or pay for healthcare services from out of pocket.
The poor who are unable to take out private insurance are disadvantaged and have to meet healthcare bills from out of pocket. Many of them have to sell animals which are their livelihood and this leads to children in these homes being unable to complete their education due to lack of fees, and food insecurity and subjects these families to abject poverty.
Economic circumstances have been a barrier to the achievement of health for the majority of the population.
Health infrastructure
A dysfunctional healthcare system composed of dilapidated minimal opportunities for continuous medical training for the workforce and, a shortage of healthcare workers who are poorly paid and distributed has resulted in poor quality health service delivery (Oketch and Lelegwe, 2016)
Medical supply chain
The medical technologies supply chain is mired in corruption and has been ineffective in delivering technology promptly for effective use
Healthcare process

Management of healthcare services has remained bureaucratic with delayed and misallocation of funding and difficult procurement remaining the hallmark of healthcare services. This has led to low-quality services being offered in public facilities (Moses et al, 2021).
Governance
Healthcare needs assessment is important and should involve all stakeholders. In Kenya healthcare provision decisions have been made mainly by the government and the physicians, leaving out the consumer. Without their input, the quality of services will not improve.
A needs assessment has to include all stakeholders for it to be effective (wright, 1998)
The other aspect of governance is the corruption in dealing with healthcare finances and supplies, this has been one of the barriers undermining the health facilities capacity of health systems to contribute to better health. ( Vian,2020)

Legal infrastructure
Kenya’s devolution brought with it 47 County governments with the responsibility of delivering healthcare services. It was expected that these devolved units would legislate on health delivery to include clearly defining the inputs and outputs and also to govern the private health care providers. So far this has not been done. A lack of a legal framework remains a barrier to implementing impactful healthcare services (Kimathi, 2017).
Health care facilities organization.
83.3 percent of national hospitals are privately owned and charge heavily for their services. These payments are not affordable for many Kenyans leaving many of them unable to access specialized health care services. ( see Table I and Figure 4).

EFFECTS OF COVID-19 ON HEALTH CARE SERVICES.
Following the announcement by the World Health Organization on the presence of COVID-19 in the Wuhan province of China, Kenya was placed on high alert but this did not stop the Covid -19 arriving in Kenya with the first case being diagnosed in the country on the 12th of march 2021. (APHRC 2021).
The general effects that followed included a 7 pm-5 am curfew for Nairobi where the case was diagnosed, social distancing, wearing of masks, and contact tracing this was instituted to prevent the spread of the virus and mitigate the effects of the pandemic.
By April 29th of the same year there were 374 reported cases of COVID-19 with 14 deaths (Baraza et al,2021) and this continues to increase ( Aluga, 2021) see figure
Effects of COVID-19 on the health care systems and processes.
Kenya’s healthcare facilities do not meet the World Health Organization recommendations. ( see table 2) and of concern is the hospital bed capacity, and the healthcare workforce.
At the onset of COVID-19, isolation centers had to be created which means that some spaces in health care facilities normally used for accessibility by patients had to be used as isolation centers denying non-covid patients accessibility to the hospital. The result of this is a reduction in patient utilization of healthcare services ( Baraza et al, 2021).
“Only 22 out of 47 counties in Kenya had at least one count”. This was a result of the study of Baraza and others. The study found that Kenya would need 1511 ICU beds and 1609 ventilators during the 6 months transmission curve to 374 beds and 473 ventilators respectively,
https://www.stockholm50.global/
at 18 months transmission curve the total number of ICU beds in the country peaked at 537 and 256 ventilators. (Baraza et al 2020) this left no beds for non-COVID-19 patients.

Oxygen supply
About a year into covid-19 pandemic hospitals ran out of oxygen. This is evidenced in the commentary by Stein and others which appeared in the British medical journal. They did modeling and found out that the oxygen shortage would rise. ( Stein et al,2020).
In Kenya, a shortage of oxygen was witnessed approximately a year into the pandemic (see Annex 1).
Medical supplies
Medical supplies in Kenya are procured from a global market. As the world went into lockdown, there was disruption in the supply of medical supplies due to delayed shipping occasioned by the pandemic. Quite evident was the lack of antiretroviral drugs. A study done by Enane and others in western Kenya showed that the disruption in the supply chain of medical supplies to the country had led to the lack and shortage of ARVS prescribed to adolescents living with HIV( Enane et al, 2021).
Effects on human capital
The most vulnerable people in the ongoing Covid-19 pandemic are the elderly and the healthcare workers.
As explained by Evans and others from the Center of Global Development other than the loss of life, there is a direct economic impact on their families as well as the countries (Evans and Over, 2020).
In Kenya, there is a shortage of healthcare workers with 2.5 physicians for 109,000 people and 1.17 nurses per 100,000 (WHO)
A cross-section survey by Shah and others in three major hospitals shows that healthcare workers suffered from mental health disorders with depression, anxiety, insomnia, distress, and burnout being reported in 53.6%, 44.3%, 41.1%, 31.0%, and 45.8% respectively. ( Shah et al, 2021)
Many hospitals in Kenya have had insufficient infection prevention and control; this was aggravated by Covid-19. Maria’s study using a semi-structural interview guide reveals this. (Maina, 2020)
Healthcare workers are key in any healthcare system; without them, service delivery cannot be efficient according to Kenya’s health workers’ professional bodies, Kenya has 30 doctors, 26 nurses, and 10 clinical officers for a country that is deficient in healthcare workers this was to affect health services provision negatively.

Exposure to the existing weaknesses in healthcare systems.

One of the positive effects of | COVID-19 was the reminder of what the healthcare system needed to prepare for critical illness care during COVID-19. Wachira and Mwai in their baseline review of the ability of hospitals in Kenya to provide emergency and critical care services. The results of this study revealed that there was an urgent need (see figure 2) to strengthen pre-hospital emergency care and acquire sufficient numbers of life-saving equipment.”( Wachira and Mwai 2021)

MITIGATING THE COVID-19 PANDEMIC.

COVID-19 mitigation aimed to prevent transmission of the deadly virus and prevent the deaths that would quickly follow infection.
To achieve this the government imposed a curfew to reduce the socializing time and lockdown to prevent transmission to other counties from Nairobi and person to person enhancing hygiene measures. (Quaife et al, 2020)
The water sanitation hygiene (WASH), social distancing, wearing masks, and detailed action plan for the education sector. The action plan is comprised of providing handwashing and disinfection points and marking classroom space to ensure social distancing. The result was a reduction in RO numbers ( Quaife et al,2020).
Realizing the multi-sectoral factors that needed to be addressed to deal with COVID-19, the government appointed a National Emergency Response Committee through Executive Order No. 2 of 2020( Aluga, 2020).
Isolation centers were set up albeit not in hospital facilities but in other facilities such as the Kenya Medical Training Center, shopping centers could only serve a few people at a time, working from home became a policy, public transport had to observe social distancing, the public was encouraged to stay home., hospitals restricted visitation rights.
To mitigate the impact of Covid-19, on the economy a stimulus package included tax relief Pay as you earn and value-added tax and USD.896,057,340 Million for the vulnerable in society (Aluga, 2020.)
Covid-19 brought about changes to the accessibility to healthcare with many maternal healthcare cases preferring to stay away. The government instituted a toll-free telephone number for those needing consultation to virtually do so. Community health workers were trained and used to distribute contraceptives and the development of community health workers’ policy objectives.

POLICY RECOMMENDATION FOR KENYA’S HEALTHCARE SYSTEM AFTER THE COVID-19 PANDEMIC
The Covud-19 pandemic brought to the fore just how Kenyan healthcare lacks the infrastructure needed to run an effective healthcare system including policies for health emergencies(leadership and governance), healthcare workers’ inefficient medical supplies systems, inadequate financing to the healthcare sector, poor healthcare delivery, leading to Kenya policy which includes elaborate plans on hospital financing, accessibility to healthcare facilities by all, intervention strategies for loss of livelihood will be key going forward(Ouma, Masai, and Nyadera, 2020)
Policies that streamline the medical supply chain are urgently needed to efficiently provide the needed technologies to all health facilities.
Health in all policies (HIAP) should be accommodated in all country policies because of the multidimensional issues that affect health (Mauti et al 2019). Health in all policies would leave a positive impact on addressing social determinants of health which would, in turn, better the health of Kenyans.
Healthcare is grossly underfunded by the government without pocket payments rising. Critical healthcare is dependent on donor funding which has been decreasing over the years. Policies that will encourage universal healthcare for all would transform the healthcare system in the country. (Barasa, Nguhiu, and Mcintyre,2018).
Quality of healthcare
Healthcare in Kenya, especially in public facilities is not of optimum quality. There is often a mismatch between what the consumer needs and what is needed. Policies that improve the quality of care not only for the elite but for the poorer population by putting in place healthcare facilities that provide quality care and can be trusted are key to achieving health for all in the country. ( |Kruk et al, 2018)s
It is estimated that high-quality health systems could save over eight (8) million lives each year (Kruk et al, 2018)
Governance
Even though |Kenya has chapter six in the constitution which details the qualities of would-be leaders, leadership or governance in healthcare has remained a challenge. Policies that would conclusively deal with corruption in the healthcare sector would tremendously increase the quality of service.

REFERENCES.
APHRC. (2021). African Population and Health Research Center. Available at https:aphrc.org. Accessed on 13/10/2021
Alusa, M. A.(2020).Coronavirus Disease 2019 (Covid-19) in Kenya preparedness, response, and transmissibility, J. Microbial Immunol Infect.53(5): 671-673https:

Barasa, E., Nguhiu, P., Mcintyre, D. (2018). Measuring progress towards Sustainable Development Goal 3.8 on universal health coverage in Kenya, BMJ Global Health, Vol. 3,iss.3

Baraza E. W, Ouma P.O, Okiro E. A, (2020), Assessing the hospital surge capacity of the Kenyan health system in the face of the Covid-19 Pandemic.PLosone, 15(7): e236308, doi: 10:1371/ Journal.pune.0236308.
Barasa, E. W., Ouma, P. O., & Okiro, E. A. (2020). Assessing the hospital surge capacity of the Kenyan health system in the face of the COVID-19 pandemic. PloS one, 15(7), e0236308. https://doi.org/10.1371/journal.pone.0236308
Battle D. E (2020), The Impact of Covid-19 on Health Care, Education and Persons with Disabilities in Kenya Perspective, Vol.5 , 155-6, Pg 1793-1796.
Enane, L. A, Apondi, E, Aluoch, J,Bakoyannis ,G, Kulzer, L., Kwena, Z., Kantor, R., Chory, A., Gardner, A., Scanlon,M., Goodrich,S.,Wools, K. K., Elul, B., Vreemen, R. C. (2021). Socio, Economic and Health effects of the Covid-19 pandemic on adolescents retained in or recently disengaged from Hiv Care in Kenya. PLOS.ONE. 16(9):e0257210. https://doi.org/10.1371/Journal.Pone.0257210.
Evans, D and Over. M (2020), Economic Impact of covid-19 in low and middle-income countries, Centre for Global Development.
https://cdn.who.int/media/docs/default-source/campaigns-and-initiatives/world-mental-health.
https://www.cgder.org/economic-impact-covid-19-low-and-middle-income-countries.
https://www.who.int/healthinfo/systems/)
Jaguya F and Kwobah, E; (2020),Inter..Journ of mental health systems 14:68 (mental health response to the Covid-19 Pandemic in Kenya: a review. https://doi.org/10.1186/513033-020-00400-8.
Kamian Nayeri; Candido M; Lopez-Perdo;( 2005) Economic crisis and Access To Care: CUBA’S HEALTH CARE SYSTEM SINCETHE COLLAPSE OF THE SOVIET UNION, Inter.Journ of Health Services,Vol 35, Issue 4. Pp. 797-816.
Kimathi,L., Challenges of the Devolved Health Sector in Kenya; Teething problems or systemic Contradictions? Africa Development, Vol. XL II, No.1. pp55-77. ISSN: 8503907.
Kruk, M. E., Gage A. D., Arseneult, C., Jordan, K., Leslie H.,Roder- Dowen, S., Adeyi,O., Barker, P., Daelmans, B., Doubora, S. V., English, M., Garcia- Elorrio, E., Guanais, F., Matsoso, M. P., Meara, J. G., Inohanan, M., Ndiaye, Y., Northiem, O. F., Reddy, K. S., Rowe, A. K., Salomon, J. A., Thapa, G.,Twum-Danso., N. A.Y., Pate, M. (2018). High-quality health systems in the Sustainable Development Goals Era in time for a revolution. The Lancet, Global Health Commission.
Maina, M., Tosas- Augueto, English M., Shultz, C., Mcknight J.(2020), Infection Prevention and Control during COVID-19 pandemic: challenges and opportunities for Kenyan public hospitals: Welcome open research.5,211.https://doi.org/10:12688/welcome .162221.1.
Mauti, J., Gautier, L., De Neve, W. J., Beiersmann, C., Tosun J., Jahn, A. (2019). Kenya’s Health in All policies strategy: a policy analysis using kingdom’s multiple streams. Health research policy and systems.17:15. https://doi.org/10.1186/542961-019-0416-3.
Moses, M. W., Korir, J., Zeng, W, Musiega ,A.,Oyusi,J., Lu, R., Chuma, J., Giorgio, L. (2021). Performance assessment of the county healthcare systems in Kenya: a mixed-methods analysis. Bmj Glob Health:6(6):e004707.http:doi:10.1136/bm.PMCID:pmc.8230973.
Okech, T.C., Lelegwe, S. L., (2016). Analysis of Universal Health Coverage and Equity on Health care in Kenya. Global Journal of Health, Science,8(7):218-227.https://doi.10.5539/gjhs.v8n7p218.
Ouma, P. N., Masai, A. N., Nyadera, I. N.(2020).Health coverage and What Kenya can learn from the COVID-19 pandemic.J. Global Health: 10(20:020362. https://doi:10.7189/jogh.10.020362.
Quaife,M., Zandvoort, K., Gimma, A., Shah, K., Mccreesh, N., Prem, K., Barasa, E., Mwanga, D., Kangwana, B., Pinchott, J., CMMID Covid-19 working group, Edmunds, W. J., Javis, C. I., Austrian, K.(2020). The impact of COVID-19 control measures on social contacts and transmission in Kenyan informal settlements, BMC. Med, 18.316.https://doi.org/10.1186/512916-020-01779-4.
Shah,J., Wise, A. M., Talib, Z., Nabiswa, A., Said, M., Abeid, A., Mohamed, S., Ali, S. K. (2021). Mental disorders among health care workers during COVID-19 pandemic; a cross-sectional survey from three major hospitals in Kenya.BMJ.open.9:11(6): e050316. https://doi:10.1136/bmjopen-2021-050316.PMID.34108174;PMCID:PMC 8190985.
Stein, F., Perry,M., Banda, G., Woolhouse, F.,(2020), Oxygen Provision to fight Covid-19 in Sub-saharan Africa, BMJ Global Health. 5;e002786.https://doi:10.1136/bmjgh-2020-002786.
Vian, T. (2020), Anti-corruption transparency and accountability in health concepts, frameworks and approaches. Global Health Action, Vol.13, iss.sup.1. https://doi.org/10.1080/16549716.2019.1694744.
Wachira, B. W. and Mwai, M. (2020), A baseline review of the ability of hospitals in Kenya to provide emergency and critical care services for COVID-19 patients. Afri.Jour.of Emergency Medicine,11:pg213-217.
Wangamati, C.K, Sundby, J; (2020), The ramification of COVID-19 on Maternal health in Kenya: Sexual and Reproductive Health Matters, Vol.28, 155.1, Https://doi.org/10.1080/26410397.2020.1804716.
Wright, J. (1998). Development and Importance of health needs assessment, Bmj; 316(7140): 1310-1313. https://doi.10.1136/bmj.316.7140.1310.PMID: 9554906

The recent announcement by France that there is an invasion by Bed bugs of significant proportions is worrying and cannot be taken lightly by the global community.Further news that the bed bugs have spread to Britain is cause for alarm.

Based on the definition of health;” A state of complete physical, mental and social wellbeing”(WHO,1948), it is clear that infestation with Bed bugs takes a toll on all aspects of health. Bed bugs are ectoparasites which rely on blood for survival.According to Saari, Nareahoa ,Nikander they live in cracks, crevices and also in the seams of mattresses and furniture as well as textiles (Saari,Nareahoa ,Nikander, 2019).Two species of bedbugs exist namely Cimex lectularius in subtropical and temperate areas and Cimex hemipterus in tropical and equatorial environments.

These insects are known to cause severe dermatitis in both animals and people, where the symptoms are those of urticaria papules.In addition, they can be vectors for many diseases such as hepatitis B, HIV, plague, leprosy, leishmania, filariasis ,trypanosomiasis and many others.(Paller, Mancini,2016).

A study by Paller and Mancini recovered the Methicillin resistant Staphylococcal aureus and Vancomycin resistant enterococcus faecium from Bed bugs. (Pallet,Mancini,2016).This calls for attention based on the fact that Antimicrobial Resistance is on the rise and will decimate 10 million people by 2050 (WHO) unless prevention is done urgently.The Bed bugs could become super spreaders of this resistant bacteria thus undoing all the gains made in the control of Antimicrobial Resistance.

The Global health impact of this Bed bug infestation can be enormous due to increased globalisation with free movement of people and Animals and also due to the fact that bedbug transmission is through contact.

Bed bugs can attach to people’s clothing and spread onto anything by means of contact.This includes vehicles, planes ,trains ships and others.

It needs concerted effort in A ONE HEALTH MODEL to contain this menace. vigilance and care by the transport sectors is of essence; making sure that adequate fumigation with steam is done at the end of each journey.

Environmentalists, entomologists, physicians, veterinarians and others must work together by sharing Data to monitor the situation in each sector.

Architects must also design homes that give space to allow for the removal and fumigation of garments worn outside the home. Public education cannot be underestimated it is key to winning the war against Bedbugs.

References:

Paller,A,S;Mancini,A,J;(2016),Infestations,Bites and Stings,Hurwitz clinical pediatric Dermatology,fourth edition,pg:416-435.

Saari,S; Nareaho,A; Nikander,S;(2019) Canine Parasites and Parasitic diseases,Academic press,ISBN 978-0-12-814-112-0.

World Health Organization,(2023), Health and Wellbeing, The Global Health Observatory.

The year 2021 is ending in six days.While some people will breath a sigh of relief, many others have not so much .2020 has been one of the years humanity has faced major challenges emanating from an Emerging Infectious Disease namely COVID-19 leading to loss of life and livelihoods.Emerging Infectious Disease outbreaks are occurring at an alarming frequency and scientists have attributed this to the human destruction of ecosystems.Other signs that climate change is causing havoc can be witnessed all around us from the wild fires in the USA and Australia, draught in Africa, floods in Europe and Asia as well as the melting ice in the Antarctica.The Human instinct for survival compels us to take action and that’s why l am calling on each of us to take Individual action to mitigate against climate change. Our future survival as a species is dependent on our action.As we sit down to select on 2021 and enumerate our resolutions for the coming year;2022, let one of the resolutions be, to act against climate change.Simple things such as planting a tree, not using plastics, using sustainable energy can go along way in ensuring that the catastrophe that is bound to befall humanity does not occur.

I am committing to taking action; will you?