Earlier this month, I was given a fascinating opportunity to travel to Kenya for a conference on young people’s access of contraceptive services. I was invited by the Kenyan Ministry of Health and able to go thanks to support from pharmaceutical company MSD. The UK, and specifically Brook, is considered in other countries to have very good experience of improving young people’s services, and I hoped that as well as learning from the work happening in Kenya, I might be able to offer some insights from our experience over the last couple of decades.
I arrived in Mombasa on the beautiful Kenyan east coast first thing on Monday morning and barely had time to take in my surroundings before I received a warm welcome from my hosts and set off on a trip into the city with colleagues from MSD, the African Population and Health Research Centre (APHRC) and Marie Stopes Kenya (MSK) to visit some of the services. MSK runs three main service models for sexual and reproductive health in Mombasa and we saw examples of all three in a mixture of public and private settings.
Outreach – an MSK nurse and her team, who can do fitting of LARC as well as cervical screening and other services, runs a regular (usually monthly) outreach clinic at a number of different free health services around the city. The service we visited was in a large, very run down concrete building in the middle of a fairly poor part of the city. The MSK nurse had spent the day providing a contraceptive service - predominantly fitting implants for women, many of whom had already had one child and who had heard about the service by word of mouth.
Own clinics – We moved next to a comparatively smart and modern private clinic run by MSK offering a pretty wide range of contraceptive and sexual health services. What struck me here was that cost must surely be a barrier, with emergency contraception charged at 300 Kenyan Shillings (about £2), when the national median monthly salary is the equivalent of about £500 and much, much less than that for young people.
Franchise clinics – MSK also runs a social franchise model called Amua. Amua clinics are private practices across the country that deliver services through a franchise agreement with MSK. These services tend to be right in the heart of communities, run as small businesses by people living and working in the community. We visited one of those – a small building in a very poor part of the city that was half clinic, half shop, run by a doctor who also supported women with pregnancy and labour from the same building.
At each service we asked the same question; “How many adolescents come to your services?” and at every service we heard the same response: very, very few.
The conference, which ran over three days and was absolutely packed with speakers and presentations, was designed to look at the problem of service access for young people and really helped to identify some of the problems Kenya has with providing services to young people as well as highlighting some of the innovative and interesting work that’s happening across the country.
Meeting the needs of people living in serious poverty or incredibly remote and inaccessible rural areas is an immense challenge for Kenya on a scale that is beyond anything we have had to think about (even in Cornwall, or the Highlands of Scotland where Brook has experience of reaching out to rural communities), but policy makers and professionals know that they have to find solutions. The country has a stubbornly high teenage pregnancy rate of 18% and complications from pregnancy or unsafe abortion are the second highest cause of death amongst adolescent girls.
Kenya has invested in research to understand what works and, crucially, what does not in attempting to improve young people’s sexual and reproductive health. I was surprised, initially, to find out that the provision of ‘youth friendly services’ and the delivery of peer education was considered by researchers at APHRC to be things that do not work. Surprised, until I discovered that the understanding of what makes a service ‘young people friendly’ may be limited to a TV in the waiting room, and the training for peer educators is far from ideal.
None of the services I saw was genuinely ‘youth friendly’. In the public health centre I was shown the ‘young people’s area’ a dark, dusty corner with a single table in it for young people to congregate round. Nothing more. The nurse I spoke to told me that they had groups of young people that got together there and tried to engage with local communities using a range of interesting sounding techniques (like drama, for example) but when all they have to work with is a table in the corner of a waiting room and when young people in Kenya have the same fears about confidentiality and privacy as they do in the UK, it’s asking a bit much to expect an enthusiastic response.
There were some really interesting presentations at the conference from people who are getting it right. We heard from a nurse – Nancy Ngetha – who runs a service just for young people in Kenyatta National Hospital in Nairobi. Although I didn’t visit the service, Nancy spoke with a genuine enthusiasm and passion for young people and for improving their health and wellbeing that was inspiring and powerful and I would love to introduce her to our work and our staff at Brook. Similarly, hearing about work that Jhpeigo is doing which has young people right at the heart developing and leading it was fascinating and I really wish I could have spent longer and found out more about some of these exciting projects.
The one thing that does appear to be demonstrably effective when it comes to improving young people’s understanding of and access to contraception is Sex and Relationships Education, or what Kenyans call Comprehensive Sexuality Education (CSE). The average Kenyan stays in education for only six years, but a great deal can be achieved in that time if CSE is given a mandatory place in the curriculum (sound familiar?).
We talked quite a lot about language and the barrier it can be to effective working in communities. One woman working in Muslim communities to try and improve uptake of contraception said she made no progress as long as the term ‘family planning’ was still in use, but when she switched to the term ‘child spacing’ she was able to open up a much more effective and positive conversation. Similarly, some people had had success in delivering ‘Life Skills Education’ rather than CSE, though there was a real division in the room about whether it’s better, if you are to achieve social and cultural change, to be upfront about what you are naming. This is an interesting conversation we’ve also had in the UK context. When we talk about Sex and Relationships Education (SRE) too many people translate that as “teaching children about sex”, rather than understanding what it actually is.
It wasn’t just the need for good quality SRE/CSE that felt familiar. I was struck by many things that unite us. Devolved responsibility for health services is causing a challenge with data collection and analysis and makes quality control difficult, a nation of young people lacking good quality information and a prevalence of myths and misinformation leave young people ill-informed and looking for information on sex online so access to porn and the use of technology worries everyone. There is a cultural reluctance to engage with the issue of young people and sexual health and every time someone tries to do something to support young people accessing sexual and reproductive health services, the conservative media leaps on it with a hysteria that is very familiar.
I hope that some of the insights I was able to bring from the UK were helpful to my colleagues in Kenya. I’m certain that there are some straightforward and powerful things they can do quite quickly to begin to make a difference, not least by treating young people as partners in the solution (there was one young person at the conference, but she was not really given much opportunity to be involved). The conference gave the policy makers a real mandate to do things differently from now on and I wish them well.
But my visit was about much more than taking UK expertise to Kenya. More than anything, it helped me to think differently about the UK. It made me think we needed to just get on and work a bit harder to reduce our teenage pregnancy rate from one comparatively small number to another even smaller number. After all, we know what works and we just need to push on and keep delivering it, don’t we?
It made me wonder how we can be in a position that we’re still not seeing decent SRE in all schools when we have almost universal attendance between 5 and 18, comparatively well -resourced schools and the support of parents and teachers to do so.
It made me reflect that the right to access contraception gets put into a whole different context when you remember it does, literally, save lives. It’s easy to forget, from our position of huge privilege. It makes me want to make sure I don’t complain too much, but also to make damn sure that we don’t waste the privilege we have by not nailing some of the sexual and reproductive health problems we have in the UK.
I have condensed four busy days and many people’s contributions into a short blog, and there are many fascinating projects to discover more about that I’ve linked to in the text. I think there is shared learning to be had for us all. I’d like to maintain Brook’s links with Kenya and continue to share our experiences. It was easy to feel at home in a room of almost 100 people talking with care, respect and compassion about young people and young people’s needs.