A new year’s wish for health from the village

It has been a strained holiday season for many, with a remarkable decrease in the intensity of the usual festive activities. Despite the crazy traffic snarl-ups and the grisly road traffic accidents,  travel from the cities and towns to the villages for family get-togethers on Christmas day has significantly reduced over the years.

Many old folks in the village, have had to contend with their children and grandchildren sending them a Christmas token on Mpesa to make up for their absence. The high cost of travel and celebration in these harsh economic times is crippling a Kenyan tradition that has glued families together for decades; slowly chipping away at the fabric of who we are as a people.

There has been a remarkable change in the demographics in most villages across the country in the past two decades or so. In many rural set-ups, especially those that heavily rely on cultivation, the growing populations and the decrease in land for farming, along with reduced production from the land as a result of overuse, have led to a mass exodus of the youth, in search of greener pastures. This is spectacularly obvious in places where there is heavy pressure on land, with sub-divisions resulting from the culture of land inheritance.

As our cities grow and their population expands, the rural areas are slowly being left to the old, who are either retired from their jobs or who have lived their entire lives on their farms. With most learned and ambitious youth leaving in search of jobs, or to settle elsewhere with better prospects, those left behind are largely those who are unable to find a way out of their circumstances.

This has resulted in a shift in the disease burden, which may not always be taken into consideration when it comes to availing health services for rural folks. It means that diseases associated with ageing, such as diabetes, hypertension, osteoarthritis, certain cancers and cardiovascular diseases, are way more prevalent in rural areas. Further, conditions such as alcoholism, trauma, and depression are more prevalent among younger people, who are more prone to risky behaviour and poorer social support structures to help reduce the incidence.

Unfortunately, capturing these statistics is likely hampered by the fact that treatment for these conditions will be sought in cities where specialized care is available. The data captured in the health information systems from hospitals will fail to show that these patients do not belong to the counties of treatment.

What many decision-makers fail to realise is that access to specialised care in rural areas is poor, with most people only accessing primary care, which is largely managed by non-specialised health care providers, with limited diagnostic resources, resulting in delayed diagnosis, and sub-optimal care, and poor referral networks for much-needed specialized care.

On one hand, Mama Sarah* bemoans the fact that she suffers from a mental illness, plagued by multiple relapses because of poor care provision at her local level three facility. Every time she has a major relapse, she has to travel to Nairobi, so that her children can take her to a specialist. She makes a good recovery, but once she is back in the village, she is unable to access her medication at the local facility. She hates being a burden to her children, simply because she cannot get a medication refill locally.

Mama Norah* on the other hand, is on an expensive medication for her heart failure, which resulted from inadequate treatment of hypertension. For years, she was on and off treatment for hypertension at her local level two facility. What no one told her was that she was now a chronic disease patient requiring life-long treatment and specialist follow-up. By the time she was seeing a physician for the first time, the inadequate blood pressure control had led to hypertensive heart disease, which is irreversible.

Now she has to take expensive medication to manage the hypertension and the resultant heart failure, yet she has lost her livelihood so she's unable to continue running her business. How then, pray do tell, will she afford to pay for her social health insurance, which is now twice as high as she previously paid for the defunct National Health Insurance Fund? The past few months have been rough, with the transition from NHIF to Social Health Insurance Fund (SHIF), causing her to miss her clinic appointments and medication while her regular level four hospital struggles to onboard her to receive treatment.

Mzee Solomon* buried his last remaining brother last week. He hasn’t seen his brother in the last three years as he had to move in with his son in Nakuru, to access the life-saving dialysis, previously paid for by NHIF. The deceased developed diabetes, which was diagnosed just eight years ago, but the doctors told him that he must have been living with the condition for even longer.

Unfortunately, the delayed diagnosis had cost him his kidneys and within five years of follow-up for the diabetes, he was declared to have chronic kidney failure as a complication, necessitating dialysis. He was one of the casualties of the messy NHIF to SHIF transition, leaving Mzee Solomon without a sibling.

Mzee Daniel* lost his wife to cervical cancer two years ago. For a year, she was treated at the local dispensary for vaginal bleeding in menopause. The only reason the correct diagnosis was made, was because she was attended to at a free medical camp organized by a local church, with support from a mission hospital. The doctor who saw her referred her to the level four hospital over 30 km away, where she was found to have stage three cervical cancer. It was the beginning of the end for her.

What the rural folk want, is the true taste of health equity. They want their local facilities properly staffed with qualified healthcare workers, in adequate numbers, who can provide correct diagnosis and treatment. They want the facilities to have the resources to carry out proper diagnosis, to prevent delays in initiating timely treatment. They want the drugs that are prescribed, to be available at the facilities they seek care from.

In addition, the rural folks want a functional referral system that is accessible. For many, highly specialised care is available miles away from home, with no consideration for the additional costs that come with this, such as transport, accommodation while seeking treatment, and the stress of being away from home. This specialised care is out of reach for many, because of financial costs, especially where social health insurance fails to cover the full cost of treatment. They already have to struggle with physical access; by God, they shouldn’t have to struggle with cost issues in a country that has promised free healthcare for all.

Of note is that rural folk who are not currently burdened with health issues have stubbornly refused to sign up for SHIF. Their reason is, “It hasn’t worked for those who are sick and signed onto it, why should we imagine that it will work for us?”

The rural folks do not care about health being devolved. They only understand that the government in Nairobi came up with SHIF, not their Governor. Therefore, the national government must ensure that SHIF works for them in the village, because it is the one receiving the member contributions.

The 2025 wish list for the National Government, about health, is here. Over to you decision-making folks…Happy New Year!