Sep 25th, 2010 by Mars Group Kenya
Kenya’s Rapid Population Increase:
Our bane, boon or both?
Professor Japheth Mati MD
Former Chairman of
Department of Obstetrics and Gynaecology
University of Nairobi
The revelation by the 2009 Population & Housing Census[i] that Kenya’s population has increased by close to one million people annually over the period 1999 – 2009 seems to have awakened Kenyans to the reality of negative impacts of unregulated population growth (and by implication unregulated fertility) on socioeconomic development and welfare. It can certainly worry ‘hearing’ that “at least two children were born in Kenya every minute”[ii]. By the way, the global human population increased by an average of 203,800 people every day in the year 2000, rising to 211,090 people every day in 2007, and again to 220,980 people every day in 2009[iii].
To quote the Hon Minister of State for Planning, National Development and Vision 2030: “This high rate of population growth has adverse effects on spending in infrastructure, health, education, environment, water and other social and economic sectors. In order for the Government to achieve Vision 2030 goals, there is need to invest in education to meet the demands of the growing school age population and the demand for future manpower. In addition, critical investment will be required in family planning services, health and other social and economic sectors to improve the welfare of Kenyans.” Indeed, this must be one of the rare occasions when a minister of Kenya government has publicly recognised the wisdom of investing on birth control for socioeconomic imperatives, at least since the pioneering efforts of Tom Mboya and Mwai Kibaki, who were instrumental in spelling out population regulation sentiments in the famous “Sessional Paper No. 10 of 1965 on African Socialism and its application to planning in Kenya”. It is quite possible that this initiative was spurred by the global population movement of the 1950s and 1960s, which advocated neo-Malthusianism[iv] and actively promoted the adoption of population policies, and implementation of family planning programmes in emerging nations, including Kenya. Kenya’s Family Planning Programme was established within the Ministry of Health in 1967.
Kenya’s Family Planning Programme: its ups and downs and achievements
Family planning practice was not received with open arms everywhere in Kenya, and indeed in most African countries. There were fears that the intention was to weaken Africa for continued Western domination. Even in Kenya with the 1965 Sessional Paper No. 10 clearly showing preference for the demographic rationale for family planning (see below), soon there were strong opposing views from the floor of Parliament, including calling for banning of certain contraceptive methods. The research work we carried out in the Department of Obstetrics and Gynaecology at the University of Nairobi played no mean role in sustaining confidence in both the providers and recipients of family planning methods in the 1970s and 1980s. Even so, it was necessary to tone down the demographic objectives with caveats such as “have as many children as you can support” which risked the interpretation that only the wealthy were permitted to have many children.
Three rationales of family planning are recognised, these are: demographic, health and human rights rationales. The demographic rationale focuses on the socio-economic benefits of reduced fertility; it emphasises the slowing of population growth rate. The health rationale promotes family planning for improved health of the mother, children and the family; it emphasises the importance of child-spacing. The human rights rationale became more widely emphasised since the 1994 International Conference on Population and Development (ICPD), which defined reproductive rights, including the “right to reproduce and the freedom to decide if, when and how often to do so…”. The health rationale has been the most favoured in most African countries, and has guided Kenya’s family planning programme since the setting up of the National Welfare Centre (later renamed the Division of Reproductive Health) in 1974.
Perhaps not many Kenyans know that a decade before the official programme was launched in 1967, family planning practice was already ongoing in certain sectors in this country, albeit informally and at a modest scale. Among the pioneers was Dr Samson N. Mwathi, who with others founded the Family Planning Association of Kenya[v] (FPAK), which became affiliated to the International Planned Parenthood Federation (IPPF) in 1967, becoming the first sub-Saharan African Family Planning Association to join IPPF. In fact, up to 1998 Kenya’s Family Planning Programme was considered the success story of sub-Saharan Africa, having contributed immensely to the decline in the high fertility rates of the 1960s and 1970s.
The Total Fertility Rate (TFR) or the total number of children born to a woman during her reproductive life, estimated at 8.1 in 1977/78 had declined to 4.7 children per woman by 1998. This drop was largely attributed to increased practice of modern contraceptive methods over the time, and improved educational status of women. Use of family planning methods in Kenya rose sharply since the early 1980s; rising from 17% in 1984 to 33% in 1993 and to 39% of married women in 1998. Although the KDHS of 2003 showed that the contraceptive prevalence had leveled off at 39 percent in the period 1998-2003, the KDHS of 2008/9 has suggested an increasing trend, with 46% of married women currently using a family planning method. The TFR has reduced slightly to 4.6 children per woman, down from 4.9 reported in the 2003 KDHS.
Kenya’s population growth rate increased steadily from 2.5 percent in 1948, peaking at 3.8 percent in 1979, this being one of the highest growth rates ever recorded. Demographic transition[vi] began to manifest in 1989, when population growth rate declined to 3.4 percent and further to 2.5 percent in 1999[vii]. The current annual growth rate of about 2.9 percent per annum is still considered to be high, and owing to the past growth rates the population is still youthful with nearly half being aged 18 years or below. This is a clear demonstration of the so-called demographic momentum- a phenomenon of continued population increase despite reducing fertility rates, which is brought about by waves of large populations of young persons entering reproductive years (age) in successive years. This may in part explain the addition of one million people annually to Kenya’s population referred to above.
Can Kenya make use of its “youth bulge”?
Can we make the “youth bulge” a source of strength not a threat? Let’s consider the million children born in Kenya during 2009, and just focus on two boys called X and Y. We expect both will be entering reproductive age around 2024 (defined as age 15-49), and the job market age in 2034. Let us consider the following two scenarios in which X and Y may find themselves, say in the year 2040.
- · X has a university degree in commerce, and after having been on the tarmac for just over a year he landed a low-paying job as a salesman. He is married with five children, and also takes care of his ageing parents who have no pension or health insurance. He is often in rent arrears, while food and transport to work are a major stain. He cannot save anything for future educational and health needs of his children.
- · Y also has a university degree in commerce, and during his final year he had come across through the internet, several companies advertising for trainee managers, and so immediately after graduation he was in a job, and was enjoying it very much. He has a nice house, company car and membership of a golf club. He is already married to a lawyer, and they have two well spaced children. Both his and his wife’s parents live on good pensions and are not dependent on him.
I suppose most of us would wish that Kenya promised its youth the kind of life enjoyed by Y. This can happen with better planning and viable economic policies that mobilise the potential of every corner of this nation. Strengthening of institutions and equitable investment of resources can unleash a strong and better-educated workforce with fewer children to support and no elderly parents totally dependent on them. In such a scenario, the “youth bulge”, generated by our recent demographic history and fertility decline through effective fertility regulation measures, could transform to the driving force behind economic prosperity in future decades[viii]. This is what has been dubbed ‘demographic dividend’- and as witnessed in the economies of the so called Asian Tigers[ix], Kenya’s large youthful population can become our boon not our bane. However, this will only happen in the presence of social, economic, and political policies that allow realisation of the growth potential created by the demographic transition. To that end, family planning will remain a key driver of Kenya’s sustainable economic growth now and in the foreseeable future.
Challenges for an effective Family Planning Programme
We welcome the statement by the Minister of State for Planning, National Development and Vision 2030 that “critical investment will be required in family planning services, health and other social and economic sectors to improve the welfare of Kenyans”. However, a review of some of the factors that have interfered with effectiveness of Kenya’s Family Planning Programme is needed; we need to ask ourselves ‘what went wrong? The contributing factors may broadly be categorised into two groups: First, an uncertain environment for effective promotion of birth control measures (political commitment; gender equity; child survival, among others), and second, serious chronic institutional weaknesses that interfere with effectiveness of the family planning programme (coverage of FP services; commodity security; quality of services and care, among others).
An uncertain environment for reduced birth rate
- · Political commitment
Political commitment on the part of the government is critical for any population regulation measures to succeed. Yet since the times of Tom Mboya and Mwai Kibaki (in his ‘youthful’ years), it has been hard to find committed champions of family planning in the Government of Kenya. It is no secret that many of Kenya’s members of Parliament overtly oppose family planning practice for demographic reasons, a few only voicing approval for ‘health reasons’. In fact, since the GOK established the national Family Planning Programme over 40 years ago, commodity procurement has been almost entirely financed through donor support; it being only in 2005 that some action was taken for the first time to allocate some funds for commodities. All in all, inadequate allocation of resources to the health sector has negatively affected the provision of family planning services.
- · Gender equity
Gender consideration is important in the context of family planning, including some of the major impediments to women’s access to family planning services. In many cultural traditions the male partner exerts control over reproductive decision-making, including decisions touching on female partner’s health seeking behaviour in the case of illness affecting her or the children.
Women’s empowerment is a strong variable that affects contraceptive prevalence. Family planning practice is influenced by a woman’s level of education, income generation, household decision-making including decisions on health seeking for herself and her children. According to KDHS 2008/9, there is a positive association between women’s status and contraceptive use. For example, the proportion of married women who are using any method of contraception rises steadily, from only 28 percent of women who do not participate in any household decision-making to 50 percent of women who participate in all decisions.
Male involvement in discussions about family planning is essential for a number of socio- cultural, economic reasons. Men as partners need to be engaged in the practice of family planning- as users of male methods of contraception, and as facilitators for the partner’s access to services. It is encouraging to note from KDHS 2008/9 that 77 percent of men feel strongly that decisions on how many children to have should be made together with their wives.
- · Child survival
Where childhood mortality is high women (and men) will strive to have as many children as the Almighty permits, in the hope that they may still have some survivors. Thus, programmes for child survival have important direct influence on whether or not a woman practices contraception. The continuing high rates of child loss are a major counter force to fertility reduction strategies in Kenya.
The 2008/9 KDHS reported that during the period between 2004-2008 Kenya’s infant mortality rate was 52 per 1,000 live births while the under-five mortality was 74 deaths per 1,000 live births. This implies that one in every 19 children born in Kenya dies before its first birthday, while one in every 14 does not survive to age five. Neonatal mortality rate was 31 deaths per 1,000 live births, implying that 60 percent of infant deaths in Kenya occur during the first month of life. Many of these die from causes associated with the care the mother receives during pregnancy and childbirth.
The above figures suggest remarkable declines in all levels of childhood mortality from rates observed in the 2003 KDHS. These improvements in child survival could be attributed to the various health interventions, including childhood immunization, and prevention and effective treatment of malaria. The above notwithstanding, wide variations in early childhood mortality persist across the provinces with Nyanza Province having the highest levels of both under-five and infant mortality rates. Almost one in seven children in Nyanza dies before attaining his or her fifth birthday (149 deaths per 1,000), compared with one in 20 children in Central Province (51 deaths per 1,000), which has the lowest under 5 mortality rates. Nyanza Province also has the highest infant mortality rate in the country (95 deaths per 1,000); Eastern Province has the lowest rate (39 deaths per 1,000). The data clearly shows that a mother’s education and wealth status exert a positive influence on children’s health and survival.
Weaknesses in the national FP programme
- · Coverage of FP services
Successive surveys have shown the existence of wide disparities in important reproductive health indicators including family planning practice. While these disparities relate to area of habitation (urban or rural, province/county) and socio-economic status, what really matters is the level of poverty. The poor segments of the population demonstrate worse health indicators compared with the wealthy, irrespective of area of habitation. In terms of fertility, for example, the KDHS of 2008/9 showed that rural areas recorded higher fertility than urban areas (TFR of 5.2 and 2.9, respectively). The disparities in fertility can also be attributed to the significant role played by women’s education in population growth. When education of women improves, fertility rates tend to decrease. In the 2008-09 KDHS, the TFR decreased from a high of 6.7 for women with no education to 3.1 for women with at least some secondary education. Fertility rates tend to be lower where women have access to decent jobs, good health care, and family planning services, which are more available in urban than in rural areas. Fertility is also very closely associated with wealth. The disparity in fertility between the poorest women (who have the most children), and the richest women (who have the fewest children), is up to four children.
Based on this data, it is apparent that the national family planning programme cannot succeed in lowering fertility without a deliberate targeting of the poor and marginalised segments of Kenya’s population, wherever they live. Clearly, Kenya cannot hope to achieve national (Vision 2030) and international (MDGs) targets, otherwise. Targeting is particularly important since it is known that by and large public spending on health (including on family planning services) tends to benefit the better off more than the marginalised poor. In other words, government’s investment in health services, far from promoting equity, can work against it[x]. Both equity and human rights principles dictate the necessity to strive for equal opportunity for health for groups of people who have suffered marginalization or discrimination[xi].
- · Commodity security
One of the major challenges to effective provision of family planning services has been persistent stock-outs of contraceptives and other reproductive health supplies in Kenya. This is an area of chronic concern, which results in loss of trust among potential users and high contraceptive discontinuation rates. The over-reliance on donors as the lead financiers (see above) will remain a serious challenge to sustainable commodity security.
Besides procurement, the other reason for stock-outs at the facility level is a weak distribution logistic system, especially from the district headquarters to dispensaries and health centres (levels 2 and 3), which also becomes a bottleneck to supplies at the community level (level 1).
- · Quality of care
Access to family planning services is to a large measure dependent on availability of health facilities. Hence, the state and quality of the health infrastructure has strong impact on the quality and effectiveness of family planning services. There are approximately 4,214 health facilities in Kenya[xii], and although the majority of them (about 95 percent) are below hospital level, all should have the potential to provide a range of family planning methods. About 51 percent are public, 20.1 percent are operated by Faith-Based Organisations (FBO) and NGOs, while 29% are privately run.
Most public and FBO health facilities are almost perennially plagued by chronic human resource constraints, especially shortage of trained nurses. Kenya is blessed by having many nurse training schools, but unfortunately, many qualified nurses remain unemployed! The other concern is the skewed and inequitable pattern of deployment, with overcrowding of trained personnel in some districts while facilities in marginalised areas remain understaffed.
Another important aspect of quality is ensuring a good balance of contraceptive method-mix, in order to cater for the varied client needs. In order to ensure that family planning practice is voluntary (as it ought to be), the family planning programme must facilitate this by availing a wide choice of contraceptive methods. This should be an important consideration in procurement policies.
We welcome the expression of concern by the Hon Minister of State for Planning, National Development and Vision 2030, over Kenya’s population growth rate. However, it would be appreciated further if he advocated the same among the entire cabinet and the parliament. He needs to assure us that the time for lip-service is gone; this is a situation requiring the commitment of the entire government. In particular, we would wish to see the Minister and his colleagues in the health ministries undertake serious reviews of why we are where we are today, and to begin applying that knowledge in the design and implementation of evidence-based interventions.
Kenya should take note of, and respond to lessons learnt, from the several successive surveys in the last two decades, all of which have shown wide regional and socioeconomic disparities in the adoption of family planning practice, and to take immediate steps to address these. For example, the KDHS 2008/9 shows very wide disparities in contraceptive prevalence rates (CPR), which range from 67 percent in Central province to 4 percent in the North Eastern province. The survey shows that among the key determining variables for contraceptive use and fertility levels are area of residence (urban/rural and province), women’s education, child survival, and wealth status.
Narrowing of disparities in access to health care including family planning services, remains a major challenge for Kenya’s achievement of national and international goals, including the Millennium Development Goals (MDGs). Indeed, it can be argued that overall, Kenya’s performance towards attaining these goals will be determined by the outcomes among the poorer and remote parts of the country. At this point in time, it’s anyone’s guess as to whether the eventual devolution of resources and increased empowerment of communities will be the answer. In the meantime, targeting the needy, not just the region, may be the better option, considering that even in marginalised areas it is the poorest of the poor that generates the worst outcomes.
[i] Kenya’s 2009 Population & Housing Census results were announced on 31st August, 2010 by Hon. Wycliffe Ambetsa Oparanya, Minister of State for Planning, National Development and Vision 2030
[ii] Daily Nation Thursday 2 September 2010
[iii] CIA’s 2005–2006 World Factbooks , and http://en.wikipedia.org/wiki/World_population#cite_note-54
[iv] A belief that the world is characterized by scarcity and competition in which too many people fight for too few resources. Thomas Malthus (1766-1834) predicted a dismal cycle of misery, vice, and starvation as a result of human over-population. www.mhhe.com/biosci/pae/glossaryn.html
[v] Precursor to today’s Family Health Options Kenya (FHOK)
[vi] Demographic transition refers to the transformation of countries from having high birth and death rates to low birth and death rates. Whereas western European countries took centuries to reach low birth and death rates, it is possible for this to happen in mere decades, as in the case of the so-called Asian Tigers.
[vii] Peter W. Thumbi. Kenya Country Report on Reproductive Health and Reproductive Rights: emphasis on HIV/AIDS. National Council for Population & Development Nairobi, Kenya, 2002
[viii] Lori S. Ashford Africa’s Youthful Population: Risk or Opportunity? Population Reference Bureau, 2007
[ix] David E. Bloom and Jeffrey G. Williamson, Demographic Transitions and Economic Miracles in Emerging Asia World Bank Economic Review, Vol. 12, no. 3 (September 1998): 419-455. http://ideas.repec.org/p/nbr/nberwo/6268.html
[x] Davidson R. Gwatkin (2003) Free Government Health Services: Are They the Best Way to Reach the Poor?
[xii] Ministry of Health Kenya NHSSP II- 2005-2010