Kenya’s COVID-19 response: Chaos amid lack of information
Confusing numbers and scanty information on how effective curfews and lockdowns have been in breaking transmission have amplified coordination and planning challenges in Kenya’s response to COVID-19. Without accurate data, it is impossible to gauge the severity of a pandemic like COVID-19.
On July 7, Kenya lifted restrictions on movements in and out of the capital Nairobi which was considered the country's COVID-19 hotspot with the majority of the cases. The decision was followed by a similar easing of restrictions in Mombasa and Mandera, two other epicenters of the outbreak in the country.
While the restrictions on movement posed a grave threat to the livelihoods of many Kenyans and reopening decisions were advocated by many, the toll of cases in Kenya showed a confusing picture of the outbreak when these restrictions were eased.
Till June 30, Kenya had recorded 6,366 COVID-19 cases and 4,176 of them were active. This means that over 65 percent of the cases in the country were active and only about 34 percent of infected individuals had recovered. It continued in July and by the end of that month, Kenya had recorded 20,636 cases and about 63.6 percent of those cases were active. But a high number of active cases and low recovery rate didn't mean that more Kenyans were dying, instead, the death rate in Kenya has remained at around 2 percent – amongst the lowest in the world.
Moreover, active cases hovered around 13,000 for two months in August and September but suddenly fell from 13,037 on October 4 to 8,500 on October 7 – a 34 percent drop in 3 days. It doesn't necessarily point to poor health outcomes of Kenyans but it does point to information and data collection gaps in the health system.
In contrast to this, South Korea, with a similar population size, breached the 20,000 case-mark on September 1 but active cases in the country at the stood at 4,660 – 23.3 percent of the total cases.
Or take the example of South Africa – a country with a comparable population and a health system that faces similar challenges to that of Kenya. Total cases in South Africa were 20,125 on May 22 while active cases stood at 9,624 – 46.3 percent of the total cases.
Such confusing numbers and scanty information on whether national directives – such as curfews and lockdowns – have been effective in breaking transmission have amplified coordination and planning challenges in Kenya's response to COVID-19.
Kenya's COVID-19 response
Kenya reported its first COVID-19 case on March 13 and Health Cabinet Secretary Mutahi Kagwe had assured the citizens that the country was well prepared to handle any outbreak while urging Kenyans to follow the precautionary measures put in place to avoid the spread.
The country went on to ban social gatherings across the country on March 15 and all flights were canceled from March 25 as Kenya stepped up its response to COVID-19.
But as the cases kept rising, President Uhuru Kenyatta announced restrictions on movement in and out of the Nairobi Metropolitan Area, Mombasa, Kilifi, and Kwale counties in early April. Over the coming months, these restrictions were extended multiple times as the pandemic spread far and wide across the country.
Other precautions taken by Kenya include mandatory wearing of masks in public, encouraging work-from-home, a controversial dusk-to-dawn curfew, mandatory quarantines, and nationwide school closures.
While these restrictions seemed to be working, it was clear early on that they were unsustainable as the price of these measures was too steep for many Kenyans. So the government went on to ease restrictions.
On July 6, domestic travel restrictions were scrapped in Kenya and the government announced that international flights would resume on August 1.
Less than a week later, infections crossed the 10,000-mark, up from 8,000 on July 6. In another two weeks, cases stood at just over 15,000 and the number of cases crossed 25,000 two weeks after that. These numbers may not seem large compared to the situation in countries overwhelmed by the outbreak such as the United States and India, but the rate at which they increased was a cause for concern. It took the country 15 weeks to register its first 5,000 cases but it crossed 25,000 cases in just another six weeks. And this is when many experts believed Kenya is conducting a woefully low number of tests and thus cases are being undercounted.
So what really went wrong with Kenya's COVID-19 response?
- Low recovery rate or rather incapability to count recoveries
Kenya ranks 9th in Africa in total number of cases (43,143) but climbs up two places in the number of active cases (5,182) which gives the impression that alongside the swelling number of infections, the country is faced with another challenge that Kenyans are either taking longer to recover from the disease or the country is unable to timely collect relevant data to paint the true picture.
Fortunately, all these active cases aren't resulting in increased deaths and Kenya has a death rate of two percent, mirroring the low rate across Africa compared to the Western counterparts.
Authorities are aware of the discrepancies in the recovery rate and responding to the reports, Health director-general Patrick Amoth said that "remember as a country we are at the forefront of implementing home-based isolation and care and therefore we must get data from the lowest community levels so our reporting rate on recovery rate is lower than the global."
Without an integrated health information system that connects all levels of the health system and makes it seamless to keep track of patients, collecting data on recoveries among patients that are home isolated can be extremely difficult. In a pandemic, home-based care can be a very efficient alternative that reduces the burden on the healthcare system so the need is to improve the health information system in Kenya.
- Lack of information and coordination
Kenya has a fragmented health system and the country faces huge coordination and planning challenges at the local and national levels. For instance, precautionary measures announced by the national government weren't uniformly implemented at the county level leading to delays and gaps in communication.
There's also inadequate data or information to evaluate the effectiveness of national directives like curfews and lockdowns in reducing the spread of COVID-19. While some data is released daily, a more detailed set of data is needed to answer those questions and making evidence-based decisions. Information is either missing or is inadequate on how well the healthcare system is doing at all levels, such as average length of stay in intensive care units, number of beds and ICUs available, the effectiveness of contact tracing teams, or deaths in high-risk or vulnerable communities.
Moreover, data on other routine healthcare system activities in Kenya is scarce during the COVID-19 pandemic. Some of these activities are not happening or have been reduced and data is not easily available on infections, fatalities, and measures taken to address possible new cases of prevalent diseases like cholera, malaria, TB, HIV, and AIDS.
An integrated health information system that effectively utilizes automation technologies could be very efficient in reducing or even eliminating these information gaps as it will make data collection and dissemination seamless.
Further, a section of Kenyans turning up for mass COVID-19 tests provided inaccurate contact information to health authorities which strained contact tracing efforts and highlighted the immediate need for interoperable, nationwide electronic health records (EHR).
- 'Premature' lockdown and reopening
Kenya seemed to be proactive in taking measures against COVID-19 as it banned social gatherings in mid-March but there have since been concerns on whether those measures were taken too early.
COVID-19 cases were in single digits when the government initially announced restrictions intended to break transmission. But any restrictions on economic activity in Kenya must be well planned as many citizens depend on daily wages for their livelihood. As weeks of restrictions brought the economy to a standstill and anger among the public was rising, it was clear that the country would need to be reopened soon.
At the government started easing restrictions, infections were still ticking up and the country was clearly nowhere near its peak or was ready to handle the potential surge in cases with enhanced tracing and testing.
Moreover, numerous reports of police brutality and terrible conditions of quarantine centers further infuriated citizens over the government's strategy for the lockdown and resulted in them floating those measures.
Decisions to ease restrictions were also criticized for not being well thought out. WHO also cautioned Kenya against easing measures raising questions over testing strategy and capacity in the country. "Some laboratories supporting counties reported shortage of test kits and or specimen collection kits and did limited tests for suspected cases and their contacts," WHO said. "While the positivity rate gives an indication that the epidemic could be declining, we note that this rate can be adequately interpreted only with comprehensive surveillance and testing of suspected cases," it added.
In late March as Kenya was tightening restrictions to fight against the pandemic, an incident shocked the country. Dozens of people from a rural community in southwest Kenya had to self-isolate after they attended a funeral officiated over by a Catholic priest who was supposed to be in mandatory quarantine as he returned from Italy – one of the worst-hit countries at the time. The priest later tested positive for COVID-19 and was charged for knowingly spreading the disease.
Unfortunately, this wasn't the only incident and such negligence has so far defined the COVID-19 situation in Kenya. Even government officials including Nairobi Senator Johnson Sakaja have been fined for breaking curfew orders or ignoring precautions.
As early as May 5, just a couple of months into the outbreak, the rate of Kenyans who started going back to work also increased by 16 percent compared to the preceding week, according to Google's weekly Covid-19 Community Mobility Report.
Fortunately, the majority of Kenyans who get coronavirus - around 80 percent, seem to be asymptomatic, according to health cabinet secretary Mutahi Kagwe. While this is undoubtedly a positive sign, overestimating these numbers has led to many Kenyans neglecting precautions.
- Brutality and confused actions
Ever since movement restrictions were imposed in Kenya, cases of police brutality have dominated headlines. The situation was such that two deaths, including one of a teenager, had been linked to police brutality at a time when the death toll due to COVID-19 stood at one.
Several videos of alleged police crackdown went viral in late March and reports claimed that those detained were cramped into small places which flouted the curfew's goal of increasing social distancing.
These incidents continued in the following weeks and in May when about 8,000 people were dislodged from informal settlements and compelled to live on streets which not only increased the chances of them getting infected but also meant that they were flouting curfews by being on the streets.
- Corruption and shortages
Just like the rest of the continent, the availability, and quality of personal protective equipment such as protective clothing, helmets, and goggles have been a cause of concern for healthcare workers across Kenya.
But it's not only shortages that healthcare staff is worried about. Even before COVID-19, the Kenyan markets were flooded with substandard and fake drugs and medical equipment and the risk heightens during COVID-19 due to corruption.
An integrated health information system equipped with inventory management tools for the healthcare supply chain could not only increase accountability but also ensure the most efficient use of resources by enabling informed decision-making.
Moreover, media reports have claimed that several labs across the country had backlogs of unprocessed samples due to shortages of testing kits just as Kenya was approaching its "peak". But it's rather difficult to ascertain a peak when testing is inadequate reducing the reliability of statistics on COVID-19 cases in the country.
Kenya Health System
Kenya has a decentralized health system where counties are responsible for providing good-quality healthcare services. County governments deal with service provision at the local level while decisions regarding policy and referral hospitals are made by the national government. Apart from the public sector, private hospitals and NGOs also serve Kenya's health system.
Health insurance coverage is not widespread in the country and only about 20 percent of citizens are covered. Even the coverage of national health insurance varies by region. 41 percent of residents in Nairobi and covered but the percentage drops to just 3 percent in marginalized rural areas such as Wajir and West Pokot.
Kenya's health system also struggles due to shortages, not only of equipment and drugs but also of specialist care and other workforce from doctors and trained nurses. For instance, chest specialists, hospital physicians, and emergency care nurses were found to be less than what is needed in a nationwide study in 2015.
Further, an assessment of health facilities by the Ministry of Health in 2018 also revealed that only 12 percent of health facilities had all the items required for infection prevention while only 24 percent of facilities had all basic equipment items. These equipment are crucial for saving the lives of both health workers and patients in a pandemic like COVID-19.
An integrated health information system equipped with logistic management tools for the healthcare supply chain could ensure the most efficient use of resources by giving accurate and timely information to policymakers and other stakeholders.
Kenya Health Information System
Kenya Health Information System (KHIS), sometimes also referred to as KHIS2, is a web-based platform at the center of the country's national health information system. The platform is used for routine reporting, analysis, and dissemination of health data for all health programs, across all health facilities in-country for aggregate health data reporting.
In recent years, Kenya has revised its health strategies with an emphasis on improved data quality using the latest technologies but on the ground, much of the data collection is still paper-based which is transferred to the web-based system at a later stage. This impacts efficiency, accuracy, completeness of data, and results in duplication of efforts.
At the community level, Kenya has two main cadres - Community Health Volunteers (CHV) and community health extension workers (CHEWs), to assist the population with health needs and collect critical data.
CHVs often collect health and wellness data in paper-based forms which is then transferred to CHEWs to aggregate data from each community unit. This aggregated data is again transferred to the sub-county health management office for digital entry into the web-based national health information system.
In the case of private hospitals, most of the facilities are equipped with a digital health system, especially in urban areas. But these systems are primarily installed for administrative purposes and aren't necessarily interoperable which results in duplication of efforts and impacts completeness of data when it is to be fed to the national health information system. This also results in the inability to track community referrals due to the lack of interoperable health systems has been identified as one of the major barriers to the use of health data and information in policy and decision-making.
Lack of training on data management is a key shortcoming across the health system of Kenya. Many healthcare workers aren't aware of indicator definitions or haven't received formal training for data collection. It has also been reported that the CHV service delivery logbook is only available in English and contains technical language which makes it difficult for some workers to understand it.
Conclusion and agenda for discussion
Kenya has recognized the potential of eHealth and an integrated health information system in improving the efficiency of other components of its health system. Such an information system is vital to tackling the pandemic as timely availability of reliable data can support in planning the response. Without accurate data, it is impossible to gauge the severity of a pandemic like COVID-19.
In recent years, Kenya's Ministry of Health has taken various initiatives to strengthen the health information ecosystem but those initiatives have largely been tailored around specific functions resulting in the mushrooming of domain-specific and parallel information systems that aren't necessarily interoperable.
On the other hand, data collection on the ground by community health workers is still largely paper-based which is transferred to the digital information system at a later stage resulting in duplication of efforts and decreasing efficiency. An integrated health information system should aim to connect all levels of the health system and reducing the time gap in data collection cycles.
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