Understanding And Promoting A Culture of “Equity” and Addressing “Disparity” With Examples From Kenya, Tanzania and Uganda

If they are not housed, fed and in a trade, they are likely to fall through the safety-net through isolation, alienation, and no form of contact. If they are housed but congested, if they are fed but on an unbalanced diet and in a trade but not paid or treated with dignity, the likelihood of morbidity is high. Housing stability, food security, livelihood and economic production and environment conservation practices as well as involving communities empowers people to see themselves as contributors to the eradication of HIV, TB, and Malaria by 2030, they become fully engaged. But, when it comes to zero HIV, TB, and Malaria by 2030 goal, there are different levels of engagement and motivation by communities of the 3 East African countries. This paper shows that the different levels of engagement are due to?(1) the near absence or existence of social welfare facilities linking civil, economic, cultural, political, social and gender determinants as mediators to good health and wellbeing aspirations; (2) the motivation to disengage/engage in social transforming and purpose-driven activities; (3) high inflation, which creates issues of internal inequity and exclusion — it is true those who are sick are getting the initial care services, but the cost of living is affecting existing health seekers and in turn adherence; and (4) the realities of elective politics for positions from bottom to top which in introducing power and authority at the communities have also monetized social connections and hierarchies. This in turn has affected the way people interact or address issues of scarcity, fulfillment, stigma, and discrimination in East African countries. The question is now how near or far is one from the holder of power and authority centers which include the traditional altruistic kinship most African communities are known for. We defined the health care index as?the ability to navigate the upstream, midstream, and downstream prevention value chain without housing, food and income hardships or catastrophes; an estimation of the overall quality of the health care system, health care professionals, equipment, staff, doctors, cost, and committing to adherence practices. A Nubeo ranking of 7 African countries health care systems:

South Africa: Has a health care index score of 63.97

Kenya: Has a health care index score of 63.40

Tunisia:?Has a health care index score of 56.54

Algeria:?Has a health care index score of 52.88

Nigeria:?Has a health care index score of 48.49

Egypt:?Has a health care index score of 47.01

Morocco:?Has a health care index score of 46.69

?In all three countries healthcare goes hand in hand with community health where they have established and institutionalized community health care services with attendant housing stability, food security and livelihood programmes. Community health ensures a healthy setting??where?all residents have access to a quality education, safe and healthy homes, adequate employment, transportation, physical activity, and nutrition, in addition to quality health care. Under such as arrangement communities are mobilized to avoid unhealthy communities which lead to infections such as malaria, TB, HIV, Ebola, COVID-19, STIs; and chronic disease, such as cancers, diabetes, and heart disease.

In all three East African countries possible solutions to food insecurity are:

Reduce Food Waste

Reduce the Risk of Commercialising

Improve Existing Infrastructural Programmes

Improve Trade Policies

Promote Diversification

Close the Yield Gap

Work Towards Defeating Climate Change

Establish Climate resilient agriculture

Demystify traditional climate resilient practices

Modern food crop harvesting techniques

?Through established community health structures therefore, communities manage care and care transitions for vulnerable populations. Reduce social isolation among health seekers and create a culture of making informed life promoting decisions such as enrolling individuals in health insurance plans, ensuring cultural sensitivity and?competence among healthcare providers serving vulnerable populations.

In all 3 countries, the healthcare system offers four broad types of services:?health promotion, disease prevention, diagnosis and treatment, and rehabilitation. The term “health care services” means any services provided by a health care professional, or by any individual working under the supervision of a health care professional, that relate to— (A) the diagnosis, prevention, or treatment of any human disease or impairment; or (B) the assessment or care of the health of people.

Uganda

As far as food goes, subsistence households continue to support and are a source of daily food even if it is facing below-average food availability from crop and livestock production and constrained food access between pre-harvest and post-harvest periods.

The 22 major threats to food security disrupt the four components of food security—availability (having enough appropriate food available), access (having adequate income or other resources to access food), utilization/consumption (having adequate dietary intake and the ability to absorb and use nutrients in the body) and stability (sustained food supply chain). In Uganda these are:

Exhausted traditional altruistic family or clan extended families

landlessness

high fertility

natural disasters

high food prices

lack of education

unpredictable weather which disrupts planting patterns, yet most Ugandans depend on agriculture as a main source of income.

Poverty

Unemployment

Low income

Lack of affordable housing

Chronic health conditions or lack of access to healthcare.

Systemic racism and racial discrimination.

Habits such as substance and drug abuse

Sexual/Gender Based Violence

Inadequate Safety Nets

Poor households characterized by few income-earners

Households with many dependants

Weak Support Networks and Disaster Management Systems

Inadequate and Unstable Household Food Production

Lack of purchasing power

Poor Nutritional Status and poor knowledge of dietary planning

Food security is of significance to good health and wellbeing, because it means?ensuring that sufficient and adequate food is available, that supplies are relatively stable and that those in need of food can obtain it. Food insecurity is associated with?increased risks of some birth defects,?anaemia,?lower nutrient intakes,?cognitive problems,?aggression, anxiety, lack of focus, low energy, low self-esteem, lack of confidence, low self-worth, and demotivation.

Housing stability means people can settle where they like or can afford to. It means they will not face housing hardships too when they spend money on say, paying health care services.?As far as housing goes, Uganda has a deficit of?3 million?housing units according to the National Housing Corporation (NHC). There is a growing need for housing, mainly attributed to the rapid rate of urbanisation and population growth. Housing stability is key to?reducing intergenerational poverty?and increasing economic mobility. Increasing access to affordable housing is the most cost-effective strategy for reducing childhood poverty and increasing economic mobility and for those recuperating from illnesses it provides motivation to keep taking medication and engaging in health promoting practices.

Uganda’s healthcare system is ranked 149th out of 191 countries. The Total Health (THE) in Uganda accounted for 7.2% of GDP (about USD 70-75 per capita), with 1 medical doctor per 1,000 inhabitants.

In Uganda healthcare services include but not limited to:

Mental health care

Dental care

Laboratory and diagnostic care

Substance abuse treatment

Preventative care

Physical and occupational therapy

Nutritional support

Pharmaceutical care

emergency, preventative

rehabilitative

long-term hospital care

diagnostic,

primary, palliative, and home care

The Community health services:

allied health services

child health services

chronic disease management (including support for self-management)

dental health services

disability services

drug and alcohol services

family planning

health promotion

The health service providers:

Hospitals

Clinics

Medical facilities a

Drug stores

Medical laboratories

Medical outreaches

Special health facilities

?

Mortality in Uganda:

Malaria, HIV/AIDS, TB, and respiratory, diarrhoeal, epidemic-prone and vaccine-preventable diseases?are the leading causes of illness and death. There is also a growing burden of non-communicable diseases (NCDs) including mental health disorders. Maternal and perinatal conditions also contribute to the high mortality.

Leading Causes of Death:

Heart disease

Cancer

COVID-19

Accidents (unintentional injuries)

Stroke (cerebrovascular diseases)

Chronic lower respiratory diseases

Alzheimer's disease

Diabetes

?

The health system in Uganda operates on a?decentralized referral system. A patient's first point of contact within the health system is often through the Village Health Team (VHT), who are responsible for ?supporting self-management; entry into further community or health care services; advocate for food security or housing stability for beneficiaries, basic health interventions within local communities and villages; mobilization for HIV/TB/Malaria screening, treatment and follow up.

Kenya

As far as food goes, subsistence households continue to support and are a source of daily food even if it is facing below-average food availability from crop and livestock production and constrained food access between pre-harvest and post-harvest periods.

The 24 major threats to food security disrupt the four components of food security—availability (having enough appropriate food available), access (having adequate income or other resources to access food), utilization/consumption (having adequate dietary intake and the ability to absorb and use nutrients in the body) and stability (sustained food supply chain). In Kenya these are:

?

Landlessness exacerbates the effects of poverty whereby the poor, especially children and women, elderly and persons with?disabilities are the most at risk.

Under the newly developed government?system, housing delivery is the responsibility of county governments who often lack the resources and know-how to deal with the situation.

Limited access to land (68%?of Kenyans are without land?documentation or tenure security) has its ripple effects which manifest as insufficient income, lack of affordable?housing options and lack of decent homes for everyone.

high fertility

natural disasters

high food prices

lack of education

There is a proliferation of?informal settlements in urban areas with 60% of the population living in?informal settlements. Families live in overcrowded homes typically with?one room and no adequate ventilation.

Informal settlements families are at high risk of?diseases such as TB, HIV, malaria, respiratory infections, or bedbug, flea, lice, jigger (worm) infestation, substance, and drug abuse consequences.

Unemployment

Low income

Lack of affordable housing

Chronic health conditions or lack of access to healthcare.

Systemic racism and racial discrimination.

Habits such as substance and drug abuse

Sexual/Gender Based Violence

Inadequate Safety Nets

Poor households characterized by few income-earners

Households with many dependants

Weak Support Networks and Disaster Management Systems

Inadequate and Unstable Household Food Production

Lack of purchasing power

Poor Nutritional Status and poor knowledge of dietary planning

Food security is of significance to good health and wellbeing, because it means?ensuring that sufficient and adequate food is available, that supplies are relatively stable and that those in need of food can obtain it. Food insecurity is associated with?increased risks of some birth defects,?anaemia,?lower nutrient intakes,?cognitive problems,?aggression, anxiety, lack of focus, low energy, low self-esteem, lack of confidence, low self-worth, and demotivation.

According to Kenya-Habitat for Humanity, Kenya has an annual housing demand of 250,000 units with an estimated supply of 50,000 units, culminating in a housing deficit of 2 million units, or 80% deficit. Housing affordability is a key challenge in Kenya with many people unable to afford to buy or build their own home. There is a growing need for housing, mainly attributed to the rapid rate of urbanisation and population growth. Housing stability is key to?reducing intergenerational poverty?and increasing economic mobility. Increasing access to affordable housing is the most cost-effective strategy for reducing childhood poverty and increasing economic mobility and for those recuperating from illnesses it provides motivation to keep taking medication and engaging in health promoting practices.

The Total Health Expenditure (THE) in Kenya accounted for 5.7% of GDP (about USD 52 per capita), with 1 medical doctor per 5,000 inhabitants.

Mortality in Kenya: HIV, Hypertension, Cardiovascular diseases, Respiratory infections and tuberculosis, Neoplasms (cancer), Enteric infections, Stroke and Malaria.

In 2017, President Uhuru Kenyatta made UHC a priority as part of the Big Four Agenda for development. This ensures that all Kenyans access the healthcare services they required without experiencing financial hardship. The Central and local government leaderships are working together with development partnership to ensure that the devolved subnational governments (the counties and other actors) are facilitated. A strategic plan exists that is focused on providing community level health services for all, building the capacity of the community health extension workers (CHEWs), strengthening health facility-community linkages, and strengthening the community to progressively realize their rights for accessible and quality care.

In July 2020, Kenya launched the Community Health Policy 2020–2030, alongside the Primary Health Care Strategic Framework 2019–2024. This established, remunerated and recognized the key role that CHVs play in delivering PHC services.

The policy's key objectives are to provide guidance for establishing and implementing a strong, comprehensive, integrated, equitable, holistic, and sustainable community health structure in Kenya. The policy is the legal framework to facilitate implementation and achievement of 100% coverage with community units and recognition of community health personnel by the counties. This policy addresses issues such as recruitment, remuneration, training, and deployment of the community health workforce and a stronger community health information system.

Public healthcare programmes and facilities are scattered and accessible by the people. The Central Province and Nairobi offer the best public healthcare facilities. Healthcare in public hospitals is free for some services, such as maternity care, and for those with national health insurance, in-patient treatment is free. Healthcare provided by private hospitals, faith-based institutions or NGOs usually comes at a cost and charges will vary. Health care in Kenya is financed from three main sources:?Out of pocket expenditure (households), government expenditure and donors

List Of Health Insurance Companies In Kenya

AAR Insurance Kenya

APA Insurance

Madison Insurance

UAP Insurance

Britam

Pan Africa Life

Heritage Insurance along Mamlaka Road in Nairobi

Kenindia Assurance Company

Employment based Insurance

Religious Institutes’ based Insurance

Private or employer arranged Insurance

Informal Sector Insurance

Kenya's community-based health workers are called?Community Health Volunteers (CHVs). CHVs deliver services in a defined geographical area location called a Community Health Unit. These Community Health Units are composed of approximately 5,000 people (or 1,000 households) and are served by approximately 10 CHVs.

Kenya has more power centers that people can rely on to engage in health promoting and seeking practices. Kenya's MOH has institutionalized community health services in policy form. This in turn has built the contexts for synergies, evidence-based approaches, meaningful engagement of all actors, and alignment to political priorities. The approaches are participatory, and they recognize and reward CHVs at different ceremonies. This means that CHVS feel part of the healthcare structures in Kenya and that their contribution is a political priority (such as advocating for housing or food for beneficiaries) that is financed as a core component of the health system. The health system in Kenya operates on a?devolved referral system. A patient's first point of contact within the health system is through the Community Health Volunteers (CHVS), who are responsible for producing strategic community health plans informed by their experiences in the communities;, liaise with the County Public Health Department; update the leadership and governance through established community health structures and participation mechanisms, provide basic health interventions within local communities and villages; mobilization for HIV/TB/Malaria screening, treatment and follow up.

Tanzania

The housing need in Tanzania is estimated to be?3 million units?with an annual increase of 200,000 units (Shelter Afrique). The existence of house deficit which is high also means that the quality of houses and congestions in line with important services like water and electricity are severe. Several dwellings are constructed from mud and poles or from mud bricks and blocks. A smaller percentage of dwellings are made of concrete and stone, or of baked and burned bricks. Piped indoor water is available to about one-fourth of households, and over half have indoor plumbing and water closet.

A person is considered “food secure” when they have the?physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life?(as defined by the United Nations Committee on World Food Security). According to relief web, as of May 2022, 5.3 million people in Tanzania lacked sufficient food for consumption. That corresponded to 9.4 percent of the country's population. As far as food goes, 15% of rural households are food insecure, with 15% more at risk of becoming food insecure. Food consumption is not at par with international standards in all households. Small farmers, wage labourers and household with low income are shown to have poor food consumption levels.

The 24 major threats to food security disrupt the four components of food security—availability (having enough appropriate food available), access (having adequate income or other resources to access food), utilization/consumption (having adequate dietary intake and the ability to absorb and use nutrients in the body) and stability (sustained food supply chain). In Tanzania these are:

A prolonged dry spell

Fall Armyworm infestations

Erratic rainfall which disrupts planting season

Decreased food production in food basket areas of Tanzania

Limited or insufficient income

high fertility

natural disasters

high food prices

lack of education

There is a proliferation of?informal settlements in urban areas with 60% of the population living in?informal settlements. Families live in overcrowded homes typically with?one room and no adequate ventilation.

Unemployment

Low income

Lack of affordable housing

Chronic health conditions or lack of access to healthcare.

Systemic racism and racial discrimination.

Habits such as substance and drug abuse

Sexual/Gender Based Violence

Inadequate Safety Nets

Poor households characterized by few income-earners

Households with many dependants

Weak Support Networks and Disaster Management Systems

Inadequate and Unstable Household Food Production

Lack of purchasing power

Poor Nutritional Status and poor knowledge of dietary planning

Food security is of significance to good health and wellbeing, because it means?ensuring that sufficient and adequate food is available, that supplies are relatively stable and that those in need of food can obtain it. Food insecurity is associated with?increased risks of some birth defects,?anaemia,?lower nutrient intakes,?cognitive problems,?aggression, anxiety, lack of focus, low energy, low self-esteem, lack of confidence, low self-worth, and demotivation.

Tanzania’s healthcare system is ranked 156th out of 191 countries. The Total Health Expenditure (THE) in Tanzania accounted for 5.6% of GDP (about USD 51 per capita), with 1 medical doctor per 30,000 inhabitants.

There is an apparent hierarchical health system which is in tandem with the political-administrative structures. At the village level, there are the dispensaries found where the village leaders (chiefs, elders and community leaders) have a direct influence on its running. The health centers are found at ward level and the health center in charge is answerable to the ward leaders. At the district, there is a district hospital and at the regional level a regional referral hospital. The tertiary level is usually the zone hospitals and at a national level, there is the national hospital. There are also some specialized hospitals that do not fit directly into this hierarchy but are nevertheless linked to the ministry of health.

The leading causes of mortality in?Tanzania include:?HIV, lower respiratory infections, malaria, diarrheal diseases, tuberculosis, cancer, ischemic heart disease, stroke, STDs, sepsis, high maternal mortality, child mortality, HIV/AIDS, pneumonia, and malaria.

6 Major Classified Types of Healthcare Service Facilities

Medical Laboratory

Hospitals

Surgical Center

Doctor's Polyclinics

Doctor Consultation Clinic

Nursing Home

Dispensaries

?As of 2019, 32% of Tanzanians had health insurance coverage, of which 8% have subscribed to NHIF, 23% are members of Community Health Fund (CHF), and 1% are members of private health insurance companies. Low insurance coverage leads to over-reliance on direct payment at the point of use of health care, which is among the fundamental problem that restrain the move towards?universal health coverage?in many developing countries. Direct payment can lead to high level of inequity, and in most cases denying the poorest access to needed health care. It also leads to housing stability and food security related hardships.

Tanzania’s hierarchical health system which is in tandem with the political-administrative structures is a reliable feed-back mechanisms for un-met needs among communities.This is the basis of the contexts for synergies, evidence-based approaches, meaningful engagement of all actors, and alignment to political priorities. This means that the government can deploy resources and materials to fill healthcare gaps where the need arises such as mobilization for HIV/TB/Malaria screening, treatment and follow up.?

Understanding the "culture" of equity requires breaking down the contexts that may be barriers or enablers to quality health outcomes. This report attempted to showcase the nuances in all three countries as far as healthcare goes. It shows that the countries have established and institutionalized community health care services but these have to go hand in hand with attendant housing stability, food security and livelihood programmes. Community health ensures a culture of equity means that a healthy setting is??where?all residents have access to a quality education, safe and healthy homes, adequate employment, transportation, physical activity, and nutrition, in addition to quality health care.