Health Scoping in North Eastern Kenya

AUTHOR: DR IMARA GLUNNING

Your Brief

You’ve been asked to assist in a health scoping mission in North-Eastern Kenya on behalf of NRT. This is a remote and austere area suffering from a recent drought, and little is known of their healthcare requirements. At the end of the mission, you will be asked to present your findings to NRT, community leaders, and government officials.

What information would you like to know beforehand?

Who would you like to be involved in the mission?

What questions will you ask?

Pre-Departure Reading

Before boarding your flight to Kenya, you’ve already done some pre-departure reading on what will be expected of you, a summary of the context, and who you will be working for:

Health scoping is the process of:

1. Determining the health needs of a community or region
2. Communicating with relevant stakeholders
3. Considering appropriate interventions given available funding and support. 

Health scoping missions are often conducted by charitable organisations or governments to allocate resources towards sustainable and impactful projects. 

Kenya is a country in the Horn of Africa, bordered by Somalia, South Sudan, Ethiopia, Uganda, and Tanzania (Figure 1). As well as ongoing conflict in South Sudan, Ethiopia and Somalia, this region has recently experienced its worst drought since 1984, leaving remote communities in increasingly harsh environments (2). In North-Eastern Kenya, pastoralists are left without running water, without a stable source of revenue, and prone to malnutrition and infection. Given the isolated location, little is known about healthcare provision in this region.

Figure 1: A map of the countries in the Horn of Africa. Image from: https://commons.wikimedia.org/wiki/File:Horn_of_Africa_map.png

The Northern-Rangelands Trust (NRT) (3) is a community-based conservation organisation that encourages and supports communities to protect wildlife, enhance livelihoods and promote peace. Local leaders have expressed healthcare provision as a top priority within conservancies, prompting NRT to assess health needs in these areas.

Arriving in Lewa

You’ve just arrived in Lewa Conservancy. Enroute you’ve spotted an elephant, two rhinos, a herd of zebra, and a few grazing giraffes. A meeting has been organised between you, the senior health advisor, NRT officials, conservancy leaders and public health officers from the Government of Kenya. The itinerary is discussed, and final plans are put in place. It’s time to get started!

Discussions with conservancy leaders, public health officials and nurses outside a clinic

What You Find

The first thing that strikes you is how austere the region is. The landscape is incredibly dry and livestock carcasses line the dirt road. Access is limited and you travel in convoy along remote tracks in four-by-four vehicles. What would take an hour in the UK, takes four or five here. 

The clinics you visit have no running water, no stable form of electricity, and limited drug supplies. Staff struggle with low-morale, delayed pay cheques, and unsafe living environments. Each clinic serves a large population with a wide catchment area. The most common conditions are respiratory, diarrhoeal, and malnutrition. In addition, there is a high demand for improved maternal services. 

At night, you set up camp on the grounds of a very basic accommodation spot. Food is local cuisine of chapati, tea, goat stew and beans, and one of the NRT team finds you a Tusker Beer to enjoy as a sundowner.

Campside number two in rural Isiolo County

Enjoying a Tusker beer for sundowners

Needs, Demands and Supply

When undergoing a health scoping mission, or indeed any evaluation of healthcare services, it’s useful to consider the needs, demands and supply (1):

• Needs: What the community require from their healthcare service
• Demands: What the community want from their healthcare service
• Supply: What is currently being provided 

The difference between needs and demands is subtle, yet important to appreciate. For example, in the UK patients may demand antibiotics for a viral illness but it isn’t what they need. Instead, they need good public health education on antibiotic stewardship but that’s not what they are demanding from their healthcare service. 

These can be depicted as a Venn-Diagram (Figure 2). The goal of your mission is to identify an intervention that fits within the centre star; something that is wanted, required, and can be realistically supplied.

Figure 2: A Venn-Diagram depicting the overlap of Needs, Demands and Supply as outlined by Stevens A, Gabbay J 1991(1).

Can you think of healthcare interventions that fall into each of the Venn-Diagram numbered parts?

In most instances, needs and demands will largely overlap. During your mission in North-Eastern Kenya, interviewed communities want better water provision, electricity supply, drug supply and maternal services – all of which are clearly required. What is being supplied are buildings and general infrastructure, some solar electricity to power vaccine fridges, basic drug supply, and a workforce. Now it’s time to consider what interventions NRT can provide.

A maternal suite at a rural clinic

End of Health Scoping Mission Meeting

Time to highlight what you’ve found and present to government officials and NRT. Your presentation needs to be concise, considerate of a language barrier, and indicate clear recommendations going forward.

Table 1: A table highlighting the identified Needs and Demands from our health-scoping mission and categorised into three groups.

Following our mission in July 2022, we broadly categorised needs and demands into three groups: infrastructure, commodities, and workforce and capacity building (Table 1). We talked about ‘low-hanging fruit’, i.e. interventions that are relatively cheap and easy to organise, such as health management / leadership training, point-of-care testing equipment, and infrastructure like fencing or living quarters. Although useful, these fail to meet very basic demands of the clinics and communities – water, electricity, access. 

How can healthcare thrive without these fundamental components? 

You can build all the clinics you want, but if there is no water for cleaning in labour or during a procedure, no electricity to power lights at night or store medications appropriately, and no means of getting to the clinic, then will the clinic function at all? Addressing these elements will require long-term commitment and investment, which is why we have recommended a health-advocate role within NRT and solidified an ongoing positive relationship between NRT and the government.

Women and children awaiting treatment for Visceral Leishmaniasis (Kala-Azar) outside a remote clinic in North-Eastern Kenya

A remote clinic in North-Eastern Kenya

Health Scoping Mission : Final Reflections

Overall, the mission felt like a success. Together, we were able to see first-hand what is needed in this region and findings were effectively communicated back to both NRT and government officials. Conservancy leaders, local healthcare staff, and people from the community were given a space to discuss what they want from their healthcare service and advocate for change. The hope going forward is that interventions will focus on those basic requirements (water, electricity, and access) that are fundamental to health and wellbeing.

Going Back…

Since the health scoping mission in July 2022, I have been back to North-Eastern Kenya in January 2023 with a team of three other Global Health doctors. We re-visited one clinic, and were surprised to find that funding from a charitable organisation had gone into construction of a new ward despite there continuing to be no running water and limited electricity provision.

Unfortunately, poor resource allocation is a widespread challenge in aid delivery for numerous reasons. Here, it was a combination of the charity being specific in how they wanted their money to be used, and the government wanting to promote the clinic to a higher facility. In Kenya, healthcare facilities are categorised into ‘levels’ with specific criteria – the higher the level the more services are provided. By having the new inpatient ward, the clinic was re-categorised to a higher level facility. Ultimately, that inpatient ward will not be used given the lack of basic provision of water, electricity, access, staffing, lab equipment, drug supply and so on. 

As a result, we are now in the process of developing a new ‘checklist’ or categorising system to encourage basic needs to be met before promotion to higher facilities. We hope this will facilitate better resource allocation and improve healthcare provision in the region. Watch this space!

Are you interested in learning more about global health?

If so, why not check out our Global Health and Conservation course? Whilst you’re there, why don’t you take a look at our other expedition medicine courses too?