Médecins Sans Frontières in Kenya by Médecins Sans Frontières (MSF) Australia

MEDECINS SANS FRONTIERES

Kenya

MSF IN FIVE WORDS MEDICAL CARE

IMPARTIALITY

Médecins Sans Frontières’ objective is to provide the best possible medical care to those in need, to ease suffering, to show solidarity and to respect people’s dignity. Our teams assist and care for people going through crises that endanger both their physical and mental health. More than two thirds of our volunteers in the field are surgeons, anaesthetists, nurses, midwives, psychiatrists, psychologists, epidemiologists, doctors, pharmacists or laboratory technicians. In the midst of wars, epidemics and famines, they operate on the injured; care for the sick; run vaccination campaigns; set up medical feeding programmes; and offer psychological support to the traumatised. They also help to reinstate and reequip existing health services and to train medical personnel.

Médecins Sans Frontières offers aid to populations in danger free from any ethnic, political, religious or economic discrimination. The organisation works independently, after evaluating the medical needs of the population. Médecins Sans Frontières strives to ensure that it always has the power to freely evaluate medical needs, to access populations without restrictions and to directly control the aid provided, giving priority to those in the most grave danger. Médecins Sans Frontières does not take sides in any armed conflict, and thereby strictly adheres to the principle of neutrality, which is not synonymous with silence.

A MOVEMENT Médecins Sans Frontières is an international movement composed of 19 sections. Five of them are operational centres (in Amsterdam, Barcelona, Brussels, Geneva and Paris) which manage MSF’s programmes in their country or abroad. The remaining sections, apart from participating in the work of the five operational centres, are devoted to recruiting international staff, raising funds and running public awareness campaigns. Each section is an association under the responsibility of a General Assembly and a Board, which is elected by its members.

INDEPENDENCE Médecins Sans Frontières is independent of all political, religious, military and economic powers. The organisation’s autonomy in decision-making and action derives principally from its financial independence. The majority of operating funds come from donations made by the general public. In 2007 91% of MSF’s income came from private sources. The remainder comes from institutional donors such as the European Union, individual government aid budgets and other international organisations.

INDEPENDENT FUNDING Since the creation of Médecins Sans Frontières, millions of individual donors worldwide have made financial contributions to the organisation to support its work. This regular support guarantees the stability of resources and activities. In 2007, 81% of the organisation’s expenditure was allocated to its social mission; 6% was spent on management and administration costs; and 13% on fundraising.

OVERVIEW

édecins Sans Frontières (MSF) has been present in Kenya since 1987, first opening an office as a support base for programmes in Somalia and Sudan, and then setting up projects in Kenya itself in 1992. Over the past decade the primary focus of MSF’s work in Kenya has become treating and fighting HIV/AIDS, whilst maintaining the capacity to respond to emergencies. Around 22.5 million1 people living in sub-Saharan Africa are infected with HIV. Kenya is home to 1.3 million2 of them. Despite some positive progress in recent years, HIV/AIDS continues to have a devastating impact on every sector of Kenyan society. While around 5.9% of adults in Kenya are thought to be infected with the disease, in some rural areas where MSF works, such as Homa Bay District, this figure can be as high as 30%. In many areas of the country, inadequate health infrastructure, a lack of resources and acute shortages of trained health workers are just some of the obstacles preventing more people living with HIV/AIDS in Kenya from receiving the treatment they need. MSF cares for over 17,000 Kenyans living with the disease and provides treatment to the 10,000 of them in need of anti-retroviral therapy.

In addition to long-running HIV clinics in Nairobi, Busia and Homa Bay, MSF also works in West Pokot, treating people infected with kala azar, otherwise known as visceral leishmaniasis. This disease, spread by the sandfly, is fatal if left untreated. In April 2007, MSF started working in Mount Elgon, providing medical care to people affected by ongoing land clashes. Through a system of mobile clinics and support to primary health care structures in the area, MSF teams provide access to free medical care.

EXPENDITURES IN 2007: INTERNATIONAL STAFF3: KENYAN STAFF:

$19,784,000 48 483

Over the years MSF has also launched a number of emergency interventions in Kenya. People living in the arid and semi-arid districts of the country are frequently affected by nutritional crises. Disease outbreaks and flooding are regular occurrences and violence can often cause the displacement of thousands of people. MSF teams respond to these emergencies when necessary.

UNAIDS epidemic update 2007. UNAIDS Kenya country report, 24 May 2007. 3 Yearly averages of staff. 1 2

BLUE HOUSE, MATHARE, NAIROBI

n Mathare, a slum with a population of over 300,000 on the eastern outskirts of Nairobi, MSF runs an HIV/AIDS project known as the “Blue House”. While the HIV prevalence rate in urban Kenya is officially estimated at 10%, more than one in five people in Mathare is thought to be HIV positive. Extremely cramped living conditions and poorly ventilated houses make it an ideal environment for tuberculosis (TB) to spread quickly, especially among people whose immune system has been weakened by HIV/AIDS. MSF opened the Blue House in June 2001 with the aim of providing integrated HIV/TB care. To meet the various medical, psychological and social needs of patients, the clinic provides a comprehensive package of care, including life-extending anti-retroviral therapy (ART), TB treatment and psychosocial and nutritional support. The twenty rooms in the clinic all serve different purposes, from registering patients to dispensing medicines and nutritional supplements. The clinic also has two laboratories, where diagnosis of both HIV and TB is done. While Blue House is designed as a “one-stop clinic” where both HIV/AIDS and TB treatment are offered, the way it is designed ensures that patients are not exposed to TB infection.

TB is the leading killer of HIV positive people. Up to 70% of all TB patients at the Blue House are coinfected with HIV/AIDS. From its inception, one of the objectives of the programme has been to develop an optimum treatment strategy to decrease the dual burden of HIV and TB. In May 2006, MSF started treating people with multi-drug resistant TB (MDR-TB). As of January 2008, 11 patients were receiving treatment. As the team expects to detect more MDR-TB cases, MSF has set up a special treatment centre near to the Blue House so that these patients can receive better medical and social support. Around 100-120 patients come to the Blue House every day, and over 2,100 consultations are carried out every month. Staff at the clinic are providing care for over 2,800 people living with HIV/AIDS. Almost 20% of them are under the age of 15. The clinic also runs a comprehensive prevention of mother-tochild transmission (PMTCT) programme for pregnant mothers throughout pregnancy and up to six months after childbirth. In addition to medical care, MSF provides nutritional supplements and psychosocial support to Blue House patients living in Mathare. Patients who have been referred to the national hospital receive regular visits from MSF medical staff and, depending on their needs, receive assistance with the costs of their treatment.

BUSIA DISTRICT, WESTERN PROVINCE

usia District in western Kenya, on the border with Uganda, has a population of 430,000 with an official HIV/AIDS prevalence of 6% for men and 9% for women. It is estimated that over 10,000 people from the district are in urgent need of treatment. Much of the population is poor and the road network is very bad, making it difficult for people to reach health facilities. During the rainy season a good part of the district gets flooded and/or water logged, which affects crops, further limits movement, and sometimes renders part of the population in the Budalangi area homeless.

structures so that HIV care can be integrated into the public health care system. The project started providing anti-retroviral treatment in July 2003. By February 2008, MSF was treating 2,526 people, including 146 children.

Since 2000, MSF, in collaboration with the Ministry of Health (MoH), has run an HIV/AIDS programme in the main district hospital and in nine rural health centres. In addition to the clinical care within these facilities, the project also offers home-based care, with over 150 volunteer community health workers providing basic medical care, psychological support and health education services to patients who are unable to get to health facilities. They also assist in tracing patients who do not return to the clinics for appointments and/or new prescriptions.

In 2007, MSF started handing over activities in two of the health centres where it works with a development partner and is supporting the MoH in establishing two new treatment sites increasing access to treatment and prevention of mother to child transmission (PMTCT) facilities in the most remote and highest HIV prevalence locations of the district. PMTCT is now a major focus of MSF’s work in Busia and involves training health workers, providing medical resources, developing monitoring tools, educating the communities on the services available and giving direct patient care.

The project has an information and education component that targets people living with HIV/AIDS and community groups in Busia. As well as providing medical resources, MSF has an extensive training programme for health personnel, provides additional staff to the MoH and has renovated health © Oscar Sanchez-Rey, 2008

EMERGENCY RESPONSE

eyond the core activities of providing assistance to people living with HIV/AIDS, tuberculosis and kala azar (visceral leishmaniasis), MSF has also responded to emergencies such as recurrent drought, nutritional crises, disease outbreaks and floods during its many years of operations in Kenya. In 1991, MSF began work providing medical assistance to refugees from Somalia in North Eastern Province. From 1994 to 1997 MSF provided aid to those displaced by ethnic clashes in the Western and Rift Valley provinces and since then has regularly carried out work in response to epidemics or nutritional crises in Turkana, Marsabit, Wajir, Samburu and in the Nairobi slums. MSF teams reacted to a sharp increase in malaria cases in West Pokot in July 2003 by assisting with the introduction of Artemesine-based Combination Therapy (ACT) in seven health structures in the area. In 2006, MSF teams intervened in Marsabit and North-Eastern Province, where three consecutively low-yield rainy seasons tipped the mainly pastoralist population of the region over the brink. In El Wak, an MSF therapeutic feeding centre treated hundreds of malnourished children as teams provided care and distributed thousands of litres of water across the area. In April 2007, MSF started an emergency project for access to quality medical care in the western location of Mount Elgon, following violent clashes over land. Two medical teams move around the area providing medical care, and MSF also enforces an effective referral system for emergency conditions.

Heavy flooding in Busia District in August 2007 saw MSF launch an emergency response in Budalangi. Together with Ministry of Health staff, teams assisted families living in five displaced people’s camps. MSF focused on water sanitation activities, such as digging latrines; installing taps, shower facilities and water tanks; as well as providing medical assistance, disease surveillance and health education. In December 2007 MSF started working in Molo District providing medical care through a system of mobile clinics to the estimated 19,000 people in the area who had been displaced by land clashes and violence. Following the post-election violence in December 2007, MSF opened several new projects throughout the country in order to meet the increased health needs. In the Nairobi slums, medical teams set up extra clinics and first aid posts in order to care for victims of violence. In the Rift Valley, teams that arrived in the country to help deal with the increased needs assisted thousands of displaced people and supported health facilities which had seen their activities disrupted. Surgical teams supported hospitals in Naivasha and Nakuru and mobile medical teams visited different areas around Molo, Eldoret, Kericho, Kuresoi, Kitale and Kisii districts providing consultations to people affected by the violence. MSF teams also distributed non-food items such as blankets and cooking sets to thousands of Kenyans and provided medical care, water, shelter and sanitation facilities in several internally displaced person’s camps. © MSF, 2006

HOMA BAY, NYANZA PROVINCE

ith an estimated HIV prevalence of around 30%, the densely populated Victoria lakeshore is one of the areas that has been badly hit by Kenya’s AIDS epidemic. The impact on the community has been devastating. In 2005, life expectancy in Nyanza province was estimated to be 45, while in Homa Bay District it was 38. MSF started working in Homa Bay in early 1996 in response to ethnic clashes in North West Migori. After this emergency intervention, MSF started providing structural support to the hospital as well as developing a home based care programme. In 2001, MSF and the Ministry of Health signed an agreement for the introduction of anti-retroviral therapy (ART), offering the first opportunity for Kenyans to receive free treatment in a public facility.

As tuberculosis is the leading killer of people living with HIV/AIDS, integrated HIV/AIDS and tuberculosis (TB) care has been offered to co-infected patients at the hospital’s Chest Clinic since August 2005. For this group, ongoing care is provided, including ART if necessary. MSF also supports the hospital’s TB ward, focusing on co-infected patients and those with multi-drug resistant TB. MSF constructed a TB culture laboratory in 2007 to make the diagnosis of TB in HIV positive patients easier. The laboratory enables all smear-negative results to be cultured, making more accurate diagnosis possible. The laboratory is only the fifth of its kind in Kenya.

Based at the District Hospital of Homa Bay and three peripheral health facilities, MSF continues to offer a free comprehensive package of care including: diagnostic testing and counselling; ART and adherence counselling; hospital treatment; prevention of mother-to-child transmission; and nutritional support for malnourished patients. As of March 2008, over 9,800 people were receiving HIV/AIDS care in Homa Bay Hospital, with more than 7,000 receiving ART.

MSF also supports three health centres in the District, working closely with the Ministry of Health, to provide comprehensive HIV/AIDS care and integrated HIV/TB care.

KACHELIBA, WEST POKOT, RIFT VALLEY PROVINCE

round the small town of Kacheliba in the West Pokot region of Kenya, visceral leishmaniasis, also known as kala azar, is widespread. Kala azar is a potentially fatal disease which is endemic in the lowlands of western Kenya and eastern Uganda, affecting one of the most marginalised populations in both countries, the Pokot people. MSF has been treating kala azar in Kenya and Uganda since 2000. Medical teams first started working in Amudat, Uganda, where they screened over 4,500 people and treated 2,500. However it soon became clear that over 70% of the patients in Amudat were coming from across the border, from Kenya’s West and North Pokot Districts, in the Rift Valley Province. As a result, MSF decided to relocate and set up an integrated programme in Kacheliba at the end of 2006. It is estimated that around 40% of the region’s 380,000 inhabitants are at risk of getting this disease, which is spread by the sandfly. In 2007, MSF teams screened over 1,678 people for the disease and successfully treated 850 of them. Due to the widely dispersed catchment area of the programme and the need to encourage early diagnosis and prompt treatment, MSF has decentralised diagnostics activities to two other health facilities in Sigor and Lomut.

As the early symptoms of kala azar resemble those of other more common tropical diseases such as malaria, kala azar is extremely difficult to clinically diagnose. MSF introduced an easy-to-perform rapid test (Opti Leish) to detect primary cases of kala azar. For secondary cases a potentially dangerous procedure of spleen aspiration has to be done. MSF is lobbying the Ministry of Health to include these rapid tests in their treatment guidelines and is encouraging their use in health centres around the district. Treating kala azar patients is very complex, as patients can have several complications such as bleeding, anaemia and secondary bacterial infections. On top of that, the treatment is often painful, toxic and long, lasting for 30 days. Until mid-2006 the only drug available in Kenya to treat kala azar was a patented drug called Pentostan. MSF has lobbied for the use of a cheaper, generic drug called Sodium Stibogluconate (SSG). In 2007, SSG was registered in Kenya. MSF continues to lobby for the inclusion of SSG into the Kenyan treatment guidelines for kala azar. Whereas Pentostan costs 150USD per treatment course, SSG costs 30USD which means it will be much more easily absorbed into the Kenyan health system. In 2008 MSF will explore the possibility of extending the kala azar project towards Baringo and East Pokot District as these areas are highly endemic and people from these districts often travel huge distances to get to MSF’s treatment centre in Kacheliba. © Brendan Bannon, 2007

KIBERA, NAIROBI

ibera slum, on the outskirts of Nairobi, is one of the largest slums in Africa. No one knows exactly how many people live in Kibera, but it is estimated that between 0.6 and 1.2 million people are crowded into an area not larger than 1km by 3km. Linked closely with Mbagathi Hospital, MSF provides primary health care services, including mother and child healthcare, for the people in the area, with a strong emphasis on HIV, tuberculosis (TB) and integrated care. MSF manages three clinics in Kibera; Gatwakera, Silanga and Kibera South, with the latter two being governmental structures. Since opening its programmes in Kibera in 1997, MSF’s work has evolved a great deal. In 1997 antiretroviral drugs were not available in Kenya, so MSF teams focused on providing psychological and social support to the few people who were known to have HIV/AIDS. As the national situation changed and anti-retroviral therapy (ART) became available, MSF started to rethink its strategy and to focus more on treatment activities. Patient support centres were converted into HIV clinics offering ART. Over the years MSF has tried to integrate HIV/AIDS and TB care into the existing primary health care systems in Kibera. With over 1.3 million Kenyans living with HIV/AIDS, MSF firmly believes that medical HIV/TB care should not be limited to specialised clinics, but should be offered as part of normal primary healthcare. HIV/TB care and related services are offered on a daily basis at MSF’s health facilities.

During consultations, clinicians see a mix of both HIV negative and positive patients. Prevention of HIV transmission from mother to child is addressed through a comprehensive set of activities, focused around ante-natal and post-natal consultations. HIV positive patients are followed up by a team made up of a midwife, clinical officers, nutritionists, social workers, counsellors and peer educators, who all work under the same roof. Based on the World Health Organisation’s “Building Blocks for Action” MSF is engaging with the community, patients and their families, and health care providers in Kibera to come up with a comprehensive approach for chronic disease care. Through a network of experienced patients organised into “Post-test Clubs”, MSF aims to provide psychosocial support and build the capacity of all HIV positive patients in terms of treatment literacy. MSF is trying to empower people living with HIV/AIDS, and their families, so that they can play a more active role in their treatment and can contribute to a health system that is more focused on, and responds better to, their needs. Working with the Ministry of Health and the Kibera Health Committee, MSF now provides around 5,000 outpatient consultations (including HIV and TB) and 2,800 mother-and-child healthcare consultations each month in Kibera. Some 1,500 patients are receiving anti-retroviral treatment.

MBAGATHI HOSPITAL, NAIROBI

bagathi District Hospital (MDH) is located on the edge of Kibera slum. MSF and the Ministry of Health have been providing comprehensive care to HIV/AIDS patients in MDH since 1997. When MSF first started working in MDH, its activities focused on treatment of opportunistic infections and palliative care for inpatients, providing clinical training, voluntary counselling and testing, and psycho-social support through Patient Support Groups. It was not until May 2003 that anti-retroviral drugs started being used in MDH. At that time, less than 1000 patients in the whole country were receiving anti-retroviral treatment from a public health institution. In 2004, MSF increased its outpatient activities, but limited its support to inpatient care in MDH. By simplifying how HIV/AIDS care was managed MSF teams demonstrated that it was possible to reach many more patients. By the end of 2004, MSF was treating more than 1,000 people with anti-retroviral therapy (ART). In early 2005 MSF built a comprehensive care clinic in the grounds of MDH, effectively integrating the Ministry of Health and MSF HIV clinics. Since 2003, more than 7,560 patients have benefited from comprehensive treatment or care at MDH (including more than 5000 patients started on ART). As of April 2008, over 4000 patients, including 400

ÂŠ Francois Dumont / MSF, 2005

children, were receiving care at MDH, the vast majority of whom are people living with HIV/AIDS. In recent years a lot of emphasis has been put on the management of children and adolescents living with HIV/AIDS. Different psycho-social activities and techniques, such as play therapy, have been introduced to improve the package of care for this specific group. Over the years, hundreds of healthcare providers have benefited from training packages offered at MDH. Due to the fact that MSF implemented a programme monitoring tool when it first started working at MDH, activities at the hospital have also been a source of information, guiding policy and decision-makers in Kenya. In 2006, MSF started handing over its activities to the Ministry of Health. By the end of 2008 the complete handover is expected to be finished. The handover is a gradual process which is monitored by a steering committee consisting of: MSF; the MDH management; the provincial health authorities (PMO, PASCO); APHIA 2; and NNEPOTEC (National Network of Post Test Clubs); and is open to future partners.

ÂŠ Felix Masi, 2007

The Charter of MEDECINS SANS FRONTIERES Médecins Sans Frontières offers assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict. They do so irrespective of race, religion, creed or political convictions.

Members undertake to respect their professional code of ethics and to maintain complete independence from all political, economic, or religious powers.

Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions.

As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them.

Médecins sans Frontières is a private international association. The association is made up mainly of doctors and health sector workers and is also open to all other professions which might help in achieving its aims. All of its members agree to honour the following principles.