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.
