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DEPARTMENT OF GEOGRAPHY AND DEVELOPMENT STUDIES

GE6001 Dissertation

Name: Helen Wood Assessment number: H17 064 Dissertation title: Factors that affect women’s access to, and use of healthcare in Western Kenya Primary supervisor: Gill Miller Year: 2014 Degree programme: International Development Studies with Geography

Declarations This work is original and has not been previously submitted in support of a degree or other qualification. Material drawn from other sources, published and unpublished, is fully acknowledged. The project adheres to the principles of good ethical practice as outlined in the University’s Research Governance handbook. Signature ……………………………… Date ………………………………

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Factors that affect women’s access to, and use of healthcare in Western Kenya

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Abstract

Women’s use of healthcare in Kenya is low, particularly in rural areas. This research adds to the

discussion surrounding the factors which affect women’s access to, and use of healthcare in

Kenya, with particular focus on Western Kenya. Interviews were conducted with medical

professionals, educated and uneducated women in Western Kenya. The research showed that

there are four main factors which influence women’s access to, and use of healthcare. These

include financing healthcare, cultural issues, perceptions of healthcare, and education. The

study shows that the factors which had the largest influence on women’s access to, and use of

healthcare, were HIV stigmatisation and the patriarchal nature of the culture in Kenya. The

findings of this study call for Kenya’s Ministry of Health to use education to change attitudes

surrounding HIV stigmatisation, and increase women’s decision making autonomy within

relationships. Addressing these concerns will help to reduce the main barriers which prevent

women from seeking healthcare.

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Table of Contents

Chapter 1- Introduction

1.1 Kenya………………………………………………………………………………………………….. 1

1.1.1 Kenya’s health statistics……………………………………………….. 2

1.2 Vision 2030………………………………………………………………………………………….. 3

1.3 Kenya healthcare policy……………………………………………………………………….. 3

1.4 Western Kenya....................................................................................... 4

1.5 Aims and objectives…………………………………………………………………………….. 5

Chapter 2- Literature Review

2.1 Introduction………………………………………………………………………………………… 6

2.2 Government literature ………………………………………………………………………. 6

2.2.1 Kenya Health Policy 2012-2030……………………………………. 6

2.2.2 Financing health care in Kenya…………………………………….. 7

2.3 Academic Literature……………………………………………………………………………. 8

2.3.1 Affordability of health care in Kenya……………………………. 8

2.3.2 Cultural issues……………………………………………………………… 8

2.3.3 Perceptions of healthcare……………………………………………. 9

2.3.4 Education……………………………………………………………………. 9

2.4 Conclusion…………………………………………………………………………………………. 10

Chapter 3 - Methodology

3.1 Aim of research…………………………………………………………………………………… 11

3.2 Ethics…………………………………………………………………………………………………. 11

3.3 Research methodology……………………………………………………………………….. 12

3.4 Critique of methodology……………………………………………………………………… 15

Chapter 4 – Results and analysis

4.1 Introduction………………………………………………………………………………………… 17

4.2 Characteristics of healthcare……………………………………………………………….. 18

4.3 Factors which may act as barriers to accessing healthcare……………………. 20

4.3.1 Financing healthcare……………………………………………………………. 20

4.3.2 Cultural issues…………………………………………………………………… 22

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4.3.3 Perceptions of health………………………………………………………… 24

4.3.4 Education…………………………………………………………………………… 27

4.4 Conclusion……………………………………………………………………………………. 28

Chapter 5 – Conclusion and evaluation

5.1 Conclusion……………………………………………………………………………………………… 29

5.2 Recommendations…………………………………………………………………………………. 30

5.3 Final Evaluation……………………………………………………………………………………… 30

Reference list ………………………………………………………………………………………………. 32- 38

Appendices

Appendix 1 – Consent form………………………………………………………………………… 39

Appendix 2 – Risk Assessment……………………………………………………………………. 40- 44

Appendix 3 – Interview Questions………………………………………………………………. 45

Appendix 4 – Interview transcripts……………………………………………………………… 46 - 62

List of Figures

1.1 Map of Republic of Kenya……………………………………………………………………... 1

1.2 Total births attended by skilled health staff by region in Kenya…………….. 2

1.3 Vision 2030 slogan…………………………………………………………………………………. 3

1.4 Hierarchy of service delivery of Healthcare in Kenya……………………………… 3

1.5 Map of Western Kenya …………………………………………………………………………. 4

3.1 Map of locations of key towns for study………………………………………………… 12

3.2 Map of Research location ……………………………………………………………………… 14

4.1 Hierarchy of medical facilities in Kakamega region, Western Kenya………. 18

List of Tables

3.1 Details of medical facilities and research undertaken……………………………… 13

3.2 Details of Interviewees…………………………………………………………………………… 14

List of Plates

4.1 Drug supply at Musanda Dispensary………………………………………………………. 19

4.2 Rural road in Western Kenya………………………………………………………………….. 20

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4.3 Members of CCS farming group……………………………………………………………… 21

4.4 Poster in Namasoli Health Centre…………………………………………………………… 23

4.5 Quality of facilities at Lyanaginga Health Centre…………………………………….. 24

4.6 Medical equipment at Lyanaginga Health Centre……………………………………. 25

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Acknowledgements

I would like to take this opportunity to express my gratitude to all those who made this

dissertation possible. Firstly, I would like to show my greatest thanks and appreciation to my

supervisor, Gill Miller. Your time, academic support, and encouragement have motivated me

throughout, and have made writing this dissertation extremely enjoyable. I would also like to

express my gratitude to the medical staff and women in Western Kenya who took part in the

research. Their opinions and time have been invaluable, and have enabled me to write a

dissertation, which, I hope, reflects the true situation of women’s access to healthcare in

Western Kenya.

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Chapter 1- Introduction

1.1 Kenya

The Republic of Kenya is a low income country, located in East Africa (Figure 1.1), with a

population of forty three million (Kenya Census, 2009). Gross domestic product was $40.7 billion

in 2012, and Gross national profit per capita stood at $942.5 in the same year (World Bank,

2013). Across Kenya, there are vast disparities in income, with forty six per cent of the

population living below the national poverty line in 2005 (World Bank, 2005). Development is

centred around urban areas, in particular the capital city, Nairobi, which is highlighted in Figure

1.1. Subsequently, rural areas including Western Kenya experience higher poverty levels, with

approximately sixty per cent of the population of Kenya living below the poverty line (ibid). High

poverty levels have contributed to low literacy rates as children do not attend school, and the

patriarchal culture in Kenya has led to disparities between male and female education levels.

Adult literacy rates in 2007 were seventy two per cent, but youth literacy rates (15 to 24 years)

were higher, standing at eighty two per cent (World Bank, 2007). This suggests that education

levels in Kenya are improving, however, male literacy rates still stood at two per cent higher

than female rates (ibid). This shows how the patriarchal culture impacts society, as it is often

seen as more important for boys to be educated than girls.

Figure 1.1. Map of Republic of Kenya. Source: Encyclopaedia Britannica, 2011

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1.1.1 Kenya’s health statistics

Income disparity and level of poverty within Kenya mean that much of the population does not

have access to healthcare, and there are only 1.54 health workers per 1,000 people (Kenya

Health Workforce Project, 2010). This is below the World Health Organisation recommendation

of 2.3 health workers per 1,000 people (ibid), which may suggest why there is a high prevalence

of communicable diseases such as tuberculosis and malaria within Kenya (Global Health

Observatory, 2013). One of the major health challenges facing Kenya is the predominance of

HIV/ AIDS, with 3880 people per 100,000 living with an HIV positive status (ibid). This is

significantly higher than the average for sub-Saharan Africa, which is 2725 per 100,000 people.

Maternal mortality is also an area of concern for the Government of Kenya as rates are high,

standing at 360 per 100,000 in 2010 (World Bank, 2010). The prevalence of HIV is particularly

important concerning women’s health, as twenty per cent of maternal deaths in Kenya per year

are HIV related (ibid). Only forty seven per cent of women in Kenya make four or more antenatal

visits during pregnancy, and only forty four percent of women give birth with a skilled health

professional in attendance (WHO, 2013). This may be why maternal mortality rates are so high.

Figure 1.2 provides details of the percentage of births attended by a skilled health professional

by region in Kenya. Western Kenya, which is highlighted, stands at 41.52 – 53.8 per cent.

Figure 1.2. Percentage of total births attended by skilled health staff, by region, in Kenya. Source: World Bank, 2010

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1.2 Vision 2030

In August 2010, the Government of Kenya adopted

a new constitution which introduced a ‘rights

based approach’ to development for all Kenyans

(National Council 2010). The new constitution is in

line with Kenya’s long term development plan,

‘Vision 2030’ (Figure 1.3) (Ministry of Planning and

National Development, 2007). The aim is to

transform Kenya into a newly industrialising,

middle income country, with a high quality of life

for all its citizens by 2030 (ibid). Vision 2030 is based around three key pillars, including

economic, social, and political governance. The social pillar encompasses improving the health

sector, with the aim of ‘investing in the people of Kenya to improve the quality of life for all

Kenyans’ (ibid). The focus is on curative rather than preventative healthcare, with particular

attention paid to HIV/ AIDs, and lowering infant and maternal mortality (ibid).

1.3 Kenya healthcare policy

The current healthcare system in Kenya is governed by the Ministry of Health, which makes and

oversees health policies. At the district level, public health services, including curative services

are provided by district and mission hospitals (Muga, Kizito, Mbayah, & Gakuruh, 2005). At the

sub-district level, which includes health centres and dispensaries, curative and preventative

services are also provided to the public, by the Ministry of Health. The hierarchy of service

delivery is illustrated in Figure 1.4.

Figure 1.3. Kenya Vision 2030 slogan. Source: Ministry of Planning and National

Development, 2007

National Referral Hospitals

Provincial hospitals

District Hospitals

Health Centres

Dispensaries

Community level

Figure 1.4. Hierarchy of service delivery of Healthcare in Kenya

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In 2009/10, twenty nine per cent of Kenya’s total health expenditure came from the

Government of Kenya, thirty four per cent from donor contributions, and the remaining thirty

seven per cent came from the private sector (Kenya National Health Accounts 2009/10). The

private sector includes household out-of-pocket payments, meaning that individual household

payments contributed the largest percentage towards financing Kenya’s healthcare system.

1.4 Western Kenya

More than three quarters of the population of

Kenya live in rural areas, with forty nine per

cent of rural dwellers living below the national

poverty line (World Bank, 2005). The poorest

twenty per cent of the population held an

income share of just 4.8 per cent in 2005,

highlighting the income disparity across Kenya

(ibid). Western Kenya is a rural region of

8,361km (Figure 1.5), with a population of 4.3

million (Kenya census, 2009), the majority of

whom rely on subsistence farming for their

livelihoods (International Fund for Agricultural

Development, 2013). Low incomes and high

levels of poverty are found in this area due to

the reliance on subsistence farming.

It has been reported by Van Eijk et al. (2006), that utilisation of healthcare is lower in rural areas

with high levels of poverty. Western Kenya was therefore chosen for the study to explore the

factors which affect women’s access to, and use of healthcare, as women’s use of healthcare is

low (Ouma et al. 2010). The study took place in the area surrounding Kakamega (Figure 3.1), at

four different medical facilities. Research was also conducted at a rural farming group, and with

primary school teachers, details of which are provided in the methodology.

Figure 1.5. Map of Western Kenya. Source: World Bank, 2005

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1.5 Aims and objectives

Aim

The aim of the project is to explore women’s access to, and use of healthcare in Western

Kenya

Objectives

1. Identify factors affecting women’s access to, and use of healthcare, from the

perspective of medical professionals, educated, and uneducated women

2. Evaluate the relative importance of the factors affecting women’s access to and use of

healthcare

3. Analyse how these factors can be addressed in order to increase access to, and use of

healthcare for women

Chapter two provides a review of the current literature surrounding women’s access and use of

healthcare in Kenya. Chapter three provides an overview of the ethical issues and methodology

employed in collecting research for this project. Chapter four presents the research results,

identifying, and providing analysis and discussion of the factors which affect women’s access to

and use of healthcare in Western Kenya. It concludes by evaluating the relative importance of

each of the factors. Chapter five analyses how the findings of the research may be used to

increase women’s access to and use of healthcare in Western Kenya, providing three

recommendations for the Government of Kenya. A final evaluation of the research, and

suggestions for future research is then provided.

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Chapter 2 – Literature Review

2.1 Introduction

This literature review provides an overview of the current situation regarding healthcare in

Kenya, and aims to assess the currently recognised factors which may affect women’s access to

and use of healthcare. The Kenya Health Policy 2012-2030 is discussed, which highlights current

issues in Kenya’s healthcare system, and provides new initiatives to address such issues.

Academic literature is then discussed, which raises issues including affordability of healthcare,

cultural issues, perceptions of healthcare, and education, and how these may impact access to,

and use of healthcare for women in Kenya.

2.2 Government literature

2.2.1 Kenya Health Policy 2012-2030

The Kenya Health Policy 2012-2030 was introduced to work towards attaining the Vision 2030

goal. The aim of the policy is to ‘attain the highest possible health standards in a manner

responsive to the population needs’ (Ministry of Medical Services and Ministry of Public Health

& Sanitation, 2012. p1). The Kenya Health Policy 2012-2030 follows the 2nd National Health

Sector Strategic Plan, which aims to reduce inequalities in health care services. It focuses on

equity of availability, efficient use of resources, and social accountability in delivery of

healthcare services. It lays out key reforms and projects including restructuring governance,

improving procurement, and developing equitable financing.

These key reforms emanate from the Kenya Health Policy 1994- 2010. The 2012-2030 Health

Policy identified that during 1994- 2010, government resources were not allocated where they

were most needed. Cost effectiveness and efficiency of resources were not factors in

determining allocation, due to a lack of management knowledge and resources (Kenya Health

Policy 2012-2030). Another issue was managing the population growth from 1994- 2010, which

was growing at an average of 2.4 per cent annually. Measures were put in place before 2012 to

devolve power to district and local level governments. However, weak management capacity

and lack of training meant that health managers were unable to manage decisions and resources

effectively. One of the final key challenges for the Government of Kenya has been simply

increasing funding to the health sector. The Abuja Declaration in 2001 stated that all African

Union countries should increase their government funding for health to 15 per cent of their total

government expenditure, which Kenya has not been able to do so far (Kenya Health Policy 2012-

2030).

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2.2.2 Financing health care in Kenya

One of the projects outlined under the social pillar of Vision 2030 is to develop a fair system of

allocating funds and paying for healthcare. The project will be implemented by the Ministry of

Health on a countrywide basis, with the aim of enhancing access to healthcare (Ministry of

Planning and National Development, 2007). The project will develop a strategy to improve

financial management in hospitals, and ensure all finances are utilised for the intended purpose

(ibid). A voucher scheme aimed at enabling access to quality reproductive health for poor

women has been put into place at a local level, and is now being scaled up, in order to enhance

access to healthcare (ibid).

Kenya’s new policy initiatives are focussed on improving the quality and accessibility of health

care, as there is still a large percentage of the population for whom healthcare is inaccessible.

According to the 2003 Kenya Household Health Expenditure and Utilization Survey twenty two

per cent of people who were reported as being ill did not seek healthcare (Wamai, 2009). In

2004, user fees at dispensaries and health centres were abolished, and a registration fee of ten

Kenya shillings was introduced. This initially increased utilisation by seventy per cent, however

it was not sustained, and general utilisation of healthcare was only thirty per cent higher than

before the user fee removal. Kenya is a low income country, and for much of the population

affording even the registration fee is a strain on their limited income, subsequently forcing many

households forgo professional healthcare (Chuma & Okungu, 2011).

The largest source of funding for Kenya’s national health expenditure remains out-of-pocket

payments which comprised thirty seven per cent of national health expenditure in 2009/10.

Out-of-pocket payments per capita vary between rural and urban locations, with rural

households reporting significantly lower levels of out-of-pocket payments (Chuma & Okungu,

2011). Western Kenya reported the lowest levels of out-of-pocket payments per capita in 2007

at 205 Kenya Shillings. Nairobi reported the highest at 1089 Kenya Shillings, highlighting the

disparity in health care utilisation across Kenya (Chuma & Okungu, 2011). Out-of-pocket

payments can create a major barrier to health care due to the fact that they are regressive, and

among the poor can increase or maintain high poverty levels (Chuma & Okungu, 2011). Such

payments can be a disincentive for women to seek healthcare as they find themselves ‘the

poorest among the poor’ in disadvantaged segments of society (Ahmed, Creanga, Gillespie, &

Tsui, 2010).

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2.3 Academic Literature

2.3.1 Affordability of health care in Kenya

There has been significant research conducted in Sub-Saharan Africa which explores the factors

that affect women’s access to healthcare. Much of the literature highlights that poverty is a

major barrier to accessing healthcare, and that healthcare utilisation in sub-Saharan Africa is

higher among wealthy women, as they are more able to cover health care costs (Bazant, Koenig,

Fotso & Mills 2009); (Aye, Champagne & Contandriopouls 2002). In 2010, Duff, Kipp, Wild,

Rubaale, and Okech-Ojony reported that economic concerns, including transport costs from

home to the clinic, were the greatest barrier to women accessing highly active antiretroviral

therapy in Kenya. Otieno et al. conducted a study into the determinants of failure to access care

in mothers referred to HIV treatment in Nairobi, Kenya in 2010. The results showed that a lack

of money was one of the reasons given for not accessing care. Ochako, Fotso, Ikamari, and

Khasakhala (2011) also note that cost of accessing healthcare, and household wealth had a

strong influence on the timing of the first visit to Antenatal Clinic (ANC) in Kenya. In 2012,

Nikiema, Haddad, and Potvin found socio- economic barriers to be of significant importance

when accessing healthcare in Kenya. The study found that out of pocket payments, coupled with

travel costs created a particular challenge to accessing healthcare for women. It has been

reported by Gulliford et al. (2002) that the extent to which a population has access to healthcare

is dependent on financial barriers that can limit the utilisation of healthcare.

2.3.2 Cultural issues

In Kenya, cultural issues including HIV based stigma, and gender norms within the household

can determine women’s access to healthcare. Okoror, BeLue, Zungu, Adam, and Airhihenbuwa

(2012) report that stigmatisation of HIV positive women in healthcare settings can complicate

future health care seeking behaviour, and may lead them to avoiding utilisation of healthcare

altogether. Medema-Wijnveen et al. (2012) have reported that pregnant women in Kenya who

intended to give birth outside a clinic, had negative attitudes towards anticipated HIV stigma.

Medema et al. (2012) also noted that traditional gender roles and patriarchy in Kenya may limit

women’s access to healthcare, as women will often have to gain permission and finance from

their husbands. Gulliford et al. (2002) has noted that access to healthcare is not determined

simply by adequacy of supply, but is also by affected by social or cultural barriers which may

inhibit access. Nikiema et al. (2012) report that cultural restrictions, including household and

functional behaviour, can heavily influence women’s access to healthcare. Otieno et al. (2010)

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report that many women have to consult with their husbands and mothers-in-law before

seeking maternal healthcare. Namasivayam, Osuorah, Syed, and Antai (2012) concur with these

findings and report that cultural practices and gender norms can result in lack of access to, and

use of healthcare for many women. Lack of autonomy, male dominance in relationships, and

gender-based violence are examples of how cultural practices may affect access to healthcare.

Gender based violence in many cases is used as way of dominating and controlling women,

maintaining their status of dependence upon men and lack of empowerment (Namasivayam et

al 2012). This leaves women in a position where they have no decision-making autonomy, which

creates a significant barrier to accessing healthcare.

2.3.3 Perceptions of healthcare

Research has illustrated that perceptions and attitudes towards quality of healthcare are also

important factors which affect utilisation of healthcare for women in Kenya. Hill et al. (2013)

have found that the poor healthcare provider performance has led to many women choosing

not to access healthcare. Gabrysch and Campbell (2009) report that the perceived quality of

care in clinics can have a strong influence on a woman’s decision as to where to give birth. Kruk,

Paczkowski et al. (2010), note that perceived quality of care is more important than distance

and cost in decision- making for delivery location. Adamu and Salihu (2002) report that the lack

of a skilled attendant at birth can be due to the perceived lack of quality of care the women will

receive from the attendant. Mwaniki, Kabiru, and Mbugua (2002) found that lack of

commitment by staff, poor quality of food and lack of cleanliness all contributed to the fact that

women perceived a low quality of care in health facilities, and prefer not to seek medical care

in Kenya. Warren et al. (2013) also found that the perceived quality of care experienced by

women, including disrespectful and abusive behaviour by health workers, was a key factor in

decision making about utilising healthcare facilities in Kenya.

2.3.4 Education

The level of education of women in Kenya can affect women’s use of healthcare. Ahmed et al.

(2010) report that a woman with complete primary education is five times more likely to have

a skilled attendant when giving birth, than a woman who is less educated. It was also found that

the likelihood of using modern contraception methods and attending four or more antenatal

clinics are significantly higher for more educated women. It has been found by Fotso, Ezeh,

Madise, Ziraba, and Ogollah (2009) that education status is one of the factors which influence

the decision about whether to deliver at home or in a health facility with skilled attendants. Hill

et al. (2013) note that education is a key determinant in coverage of intermittent preventive

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treatment in pregnancy (IPTp) and insecticide-treated nets (ITNs). Skinner (2010) reports that

education of patients and their families has led to improved mortality, irrespective of economic

capacity. Rai, Singh, Kumar, and Singh (2013) have reported that with an increase in the level of

education, compared to no education, the proportion of adolescent women choosing to receive

post-natal care increased. Otieno et al. (2010) report that education levels had a strong

influence on timing of first ANC visit and, subsequent location of delivery in Kenya. Women with

secondary education were more likely to go for earlier ANC than those with just primary

education. Ahmed et al. (2010) notes that women will be the ‘least educated among the

inadequately educated’ (P.1) and therefore the worst off when it comes to accessing healthcare

in poor regions.

2.4 Conclusion

Much of the population in Kenya have difficulty accessing healthcare due to high levels of

poverty, but existing literature shows that women are often the most marginalised. This

literature illustrates currently recognised factors including affordability of healthcare in Kenya,

impact of cultural fears, education, and perceptions of healthcare, which may affect access to

healthcare. This research aims to update the discussion of these factors as they are presented

in rural Western Kenya.

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Chapter 3 – Methodology

3.1 Aim of research

The aim of this research project is to explore the relative importance of factors which affect

women’s access to and use of healthcare in Western Kenya, and analyse how these factors can

be addressed in order to increase use of healthcare for women. This research was underpinned

by a humanistic approach, which allows for substantial depth, and people’s opinions,

motivations and perceptions to be explored (Kitchin and Tate, 2000). This type of research is

generally illustrative rather than representative of the topic, as the sample sizes are often

smaller (Flowerdew, & Martin, 2005). Humanistic research lends itself more towards more open

methods of research such as interviews, focus groups as well as observation.

3.2 Ethics

There are many ethical issues for a project which involves collecting primary research data, in

particular regarding health. Hay (2003) states main areas to consider including consent,

confidentiality, harm, and cultural awareness. The researcher must gain full consent, and ensure

the participant fully understands the project they are consenting to, before collecting

information (Gregory, 2003). When collecting research in Western Kenya, written consent was

obtained (Appendix 1), and where the participant was illiterate, and therefore unable to give

written consent, a verbal agreement was made.

To ensure confidentiality, where possible, the information was collected in a private space, in

an environment where the participant was able to respond without fear that they would be

overheard by individuals not involved in the study. It was particularly important to ensure

confidentiality for women who may have been at risk of harm, if their responses were made

available to their husbands. It was made clear to the women that their personal information

would not be shared with people other than those involved in writing the report.

Cultural awareness, which includes conduct and dress of the researcher, is of paramount

importance when collecting information. In Kenyan culture, modest dress is appropriate,

particularly in a rural setting, where more traditional and modest dress than in urban areas is

expected. It was also important to respect social order when collecting information, by gaining

permission from the individual who appeared to be in charge of the group or situation before

collecting information from individual participants. A risk assessment of the study was also

conducted prior to beginning data collection, to ensure risks were prevented (Appendix 2).

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3.3 Research methodology

Qualitative data collection techniques including observations and semi-structured interviews

were employed in this research. The importance of understanding the social, cultural and

economic context of the research locations was founded in a qualitative epistemological

position (Kitchin & Tate, 2000). Semi- structured interview questions were developed based on

the literature, in order to explore the factors which affect access to, and use of healthcare. Semi-

structured interviews are generally respondent led, less structured, and involve flexible and

open questions which have an unlimited range of possible answers. These methods were

appropriate for collecting research on women’s access to and use of healthcare because they

gave the respondents opportunity to fully express their views. Research was conducted in the

Western Region of Kenya, in the area surrounding Kakamega, highlighted in Figure 3.1.

Figure 3.1. Map of locations of key towns for study. Source: Google Maps, 2014

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Interviews and observation were conducted at four medical facilities in the area surrounding

Kakamega. Table 3.1 provides details of each of the medical facilities, and the research

undertaken.

Table 3.1. Details of medical facilities and research undertaken

Name Type (See Figure 1.4)

Owner Location (See

Figure 3.2)

Services Number of beds

Research undertaken

Busia District Hospital

District Hospital

Ministry of Health

Busia Antiretroviral Therapy

Curative In-patient Services

Family Planning

HIV Counselling and Testing

Immunisation

185 Interview

Musanda ACK Clinic

Dispensary Anglican Church of Kenya

Musanda Family Planning

Immunization

0 Interview and

observation

Namasoli Health Centre

Health Centre

Christian Health Association of Kenya

Khwisero Antiretroviral Therapy

Curative In-patient Services

Family Planning

Immunisation

25 Observation

Lyanaginga Health Centre

Health Centre

Ministry of Health

Mahanga Antiretroviral Therapy

Curative In-patient Services

Family Planning

HIV Counselling and Testing

Immunisation

12 Observation

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Research was also conducted with women from a Christian Community Services (CCS) farming

group (Figure 3.2) and in Burumba Primary school in Busia (Figure 3.2). Table 3.2 provides

details of each of the interviews conducted in the research.

Table 3.2. Details of Interviewees

Figure 3.2 provides the locations within Western Kenya where the research was conducted.

Name Sex Location – (See Figure 3.2.) Occupation

Bernard Kweyu

Wamukoya

M Musanda ACK Clinic Community health

nurse

Dr Ambuchi F Busia District Hospital Gynaecologist

Phidelis Nekesa F CCS farming group Rural farmer

Everline Akinyi F CCS farming group Rural farmer

Ginosuma Ome F CCS farming group Rural farmer

Ruth Wanda F CCS farming group Rural farmer

Carmilitas Ekwarasi F CCS farming group Rural farmer

Wilfreda Olweyo F Burumba Primary School Health Teacher

Margare Kwedlow F Burumba Primary School P.E Teacher

Figure 3.2. Research locations. Source: Google Maps, 2014

Busia District Hospital

Burumba Primary School

CCS farming group

Musanda ACK clinic

Lyanaginga

Health Centre

Namasoli Health Centre

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The interview questions (Appendix 3) for the medical staff were based on the literature. They

focused on the supply side of medical services, with the aim of understanding from the

perspective of medical professionals, the reasons why women may or may not visit a health

clinic. The interview questions for the educated and uneducated women (Appendix 3) focused

more on the social context in which they live, and how this may affect their access to healthcare.

To provide further information about the available health facilities in the location surrounding

Kakamega, primary research in the form of photographs were taken. These photographs will

assist in the analysis of the available health facilities.

3.4 Critique of methodology

One of the challenges of conducting research was that there were limited opportunities to

collect information, particularly from medical professionals. Therefore the interviews took place

with the medical professional who was available at the time, and willing to participate in the

research. If the research were to be conducted again, the most appropriate medical professional

to discuss women’s health would be asked, and the interviews would not be conducted during

working hours, so that there would be no distractions during the interview.

Using a male translator for the interviews with the women may have affected their responses

because they may not have been comfortable disclosing personal information to a man they did

not know, and may have also been concerned about confidentiality. Due to the language barrier,

the translator also selected the interviewees, which, due to the patriarchal culture in Kenya,

may have meant that a woman who did not want to be interviewed felt she had to oblige. If the

research were to be conducted again, it may be beneficial to use a translator who is a woman,

and if possible, a woman from their community, which may make the women feel more

comfortable disclosing personal information.

Another challenge of using the translator was that he simply paraphrased the overall response

of the participant, which meant that the individual’s choices, and reasons for those choices were

not necessarily captured. If the research was to be conducted again, it would be beneficial to

brief the translator more clearly on the research. This would enable them to identify the sections

of the responses which are particularly relevant to the study, and avoid a generic translation if

the responses from each of the participants were similar.

Denscombe (2007) presents that idea that how the participant perceives the researcher may

influence how they respond. The sex, age, and in particular ethnic origins, of the researcher

have an influence on how much information the participant is willing to disclose.

P a g e | 16

In this case, the researcher is a white British woman, which may have influenced the responses

of the interviewees, particularly the women from the CCS farming group, as they may have had

limited contact with white women. Gomm (2004), recognises that what the participant thinks is

required from the situation, will often influence their response. If the participants did not feel

they had to give the responses they felt the researcher wanted to hear, the information

gathered in the interviews may have been able to offer a greater insight into healthcare seeking

behaviour in Kenya.

P a g e | 17

Chapter 4 – Results and analysis

4.1 Introduction

This chapter provides analysis of the factors which may affect women’s access, and attitudes

towards healthcare. It aims to add to research concerning why women do not access healthcare

in sub-Saharan Africa, by focusing on the Kakamega region of Western Kenya (Figure 3.1). The

aim is to explore the factors which affect women’s access to, and use of healthcare, and provide

the Government of Kenya key areas that need to be addressed, in order to improve women’s

attitudes towards, and access to healthcare.

Kenya’s development plan for the next twenty years is outlined in Vision 2030, which aims to

create an efficient and high quality health care system that is available to all members of the

population. To achieve this, it is important to ensure that there are sufficient medical services

available at all clinics, and in particular rural clinics (Ministry of Planning and National

Development, 2007). This is because many people currently have to travel long distances to

reach the nearest clinic, and would be unable to travel further to another clinic, if their nearest

one did not have the required medical facilities. Government hospitals should also be equipped

to offer efficient and high quality health care to achieve the targets set by Vision 2030, which

include shifting the focus of national health from curative to preventative care (ibid). Dr

Ambuchi, a gynaecologist at Busia District Hospital stated that all services, including antenatal

care (ANC), are available to women, as it is the primary government hospital in the area (Figure

3.2, Table 3.2) (Appendix 4.1.A). Providing full ANC services is important in shifting the focus

from curative to preventative care, as many complications during pregnancy and childbirth can

be prevented, if they are monitored from an early stage (Weiser et al. 2010).

Bernard Kweyu Wamukoya, a community nurse at Musanda ACK Clinic (Figure 3.2, Table 3.2),

stated that family planning, examinations and anaemia prevention for expectant mothers, HIV

testing, immunisations, and malaria prevention are available for women (Appendix 4.2.A). There

was a particular focus on HIV testing and prevention of mother to child transmission (PMTCT),

which is in line with Vision 2030, as one of the targets is to lower incidences of HIV/AIDs. The

services provided at Musanda ACK clinic in theory, are in line to achieve the targets set by Vision

2030, as the clinic provides all the necessary services for antenatal and post-natal care. Figure

4.1 provides details of the medical facilities which serve the area of the study.

P a g e | 18

Despite the availability of such healthcare services in Western Kenya, a lack of funding,

resources and staff within the Kenya Health System, means that healthcare is not always of a

high quality. Women in Western Kenya face many barriers to accessing, or choosing to seek

healthcare. The factors which act as barriers are discussed in relation to characteristics of

healthcare, finance, cultural issues, perceptions of healthcare, and education. The relative

importance of each factor, and their effect on women’s attitudes towards use of healthcare is

then discussed.

4.2 Characteristics of healthcare

Establishing what medical services are available, and the characteristics of such services, is

important in order to understand women’s access and attitudes towards to healthcare. In 2008,

Kenya adopted Universal Access to HIV testing and counselling (HTC), an initiative created by

UNAIDs (National guidelines for HIV testing and counselling, 2008). To achieve Universal Access,

and expand HTC across the country, it became mandatory for all pregnant women in medical

facilities across Kenya to be tested for HIV.

National Referral Hospitals

Moi Referral and Teaching Hospital (Eldoret)

Provincial hospitals

Nyanza Provincial Hospital (Kisumu)

District Hospitals

Busia District Hospital (Busia)

Health Centres

Lyananginga Health Centre, Namasoli Health Clinic

Dispensaries

Musanda ACK Clinic

Community level

Villages, Households, Families, Individuals

Figure 4.1. Medical facilities in Kakamega region, Western Kenya

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While Musanda ACK Clinic (Figure 4.1) offers HIV

testing, it often has to refer HIV positive patients to

other health clinics, as it does not always have a

sufficient supply of antiretroviral drugs: “we are

supposed to give them the drugs here, but at the

moment, the drugs are not here” (Appendix 4.2.B).

Plate 4.1 illustrates the limited store of drugs at the

dispensary. The clinic should be equipped with the

drugs to offer complete HTC care, but a poor system of

procurement and distribution of medical supplies

within Kenya means that they are currently unable to

do this (Maoulindi, 2011).

The 2002- 2008 National Health Sector Plan and the 2010 Kenya Health System Assessment

identified the supply of drugs and other medical products as one of the constraints to effective

service provision, which needs to be addressed by the Kenya Medical Supplies Agency. Wide

variations in access across Kenya to pharmaceutical services and availability of medicines,

particularly in rural areas, were also identified in the reports. This highlights the difficulty in

achieving Universal Access to HTC, because implementing and maintaining complete HTC care

for every patient is hindered by weaknesses in the Kenya health system as a whole. The Kenya

Health Systems Assessment (2010), also found that that the increasing demand and lack of

funding may compromise availability of ARVs further in the future, highlighting the importance

of strengthening medical services (Marc et al. 2010).

Maternal health, and therefore antenatal care, has been made a particular concern of the Kenya

Health Policy 2012-30, in line with the Millennium Development Goal to improve maternal

health (United Nations Department of Economic and Social Affairs, 2000). Busia District Hospital

(Figure 3), is the main district hospital for the area, and offers full ANC services, “this hospital

offers four clinics that the women can attend, if they attend from the beginning of their

pregnancy, but many women only come in the third trimester of pregnancy” (Appendix 4.1.B).

Field research showed that despite the availability of ANC, the percentage of women who

attended all four sessions throughout their pregnancy was only 13.3% in 2012 (Appendix 4.1.C).

Many women will attend one or two sessions, coming to the hospital during their third trimester

of pregnancy only. This demonstrates that even when medical facilities are available, women

Plate 4.1. Drug supply at Musanda ACK Clinic. Source: Own photograph

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do not always utilise them, indicating that it is not simply availability of care that determines

access to healthcare for women in Western Kenya. Other factors such as attitudes to healthcare,

financing healthcare, cultural issues, perceptions of healthcare and education will be explored

as factors which may influence use of healthcare.

4.3 Factors which may act as barriers to accessing healthcare

4.3.1 Financing healthcare

One of the main concerns for the Government of Kenya regarding health, is that many of the

population are unable to afford to pay for healthcare, as incomes are low, particularly in rural

areas (Chuma & Okungu, 2011). Given these low incomes, even if a person is able to afford the

medical costs, they may not be able to afford transport, or the time off work which is required

to receive medical care. Under the social pillar of Vision 2030, the Ministry of Health aims to

create a fair system by which people pay for healthcare, which may help to increase utilisation

of healthcare for the general population, including women. A project aimed at enabling poor

and vulnerable women subsidised reproductive health care, has also been created, with the

view to improve access to health services for those who currently struggle, or choose not to use

healthcare (Ministry of Planning and National Development, 2007).

Research by Duff et al. (2010) has found

that economic concerns, including travel to

and from the clinic, can prevent women

from accessing healthcare in Kenya. Plate

4.2 illustrates the rural roads in Western

Kenya, which, particularly during seasonal

rains, can be difficult and expensive to

travel on. In Busia, Bernard Kweyu

Wamukoya, a community nurse, has noted

that financing and travelling to healthcare

can be difficult, and that many women give

excuses as to why they could not visit the clinic. He stated “they are not well off, because

sometimes getting even 20 shillings together is difficult for the women. Some excuses for not

returning to the clinic are that they had to travel, or attend a funeral or other such things”

(Appendix 4.2.C). Dr Ambuchi also noted that, “the cost of getting to hospital is just too much

Plate 4.2. Rural road in Western Kenya. Source: Own photograph

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for some women” (Appendix 4.1.E). She stated that “if a woman only has 100 shillings to spare

she will not want to travel to the hospital…because it does not seem as important as other things

such as food that she might have to spend her money on” (Appendix 4.1.D). Being unable to

afford to pay for either the medical care, or the costs associated with seeking medical care can

act as a significant barrier for many women to access healthcare.

Nikiema et al. (2012) has found that socio-economic barriers can affect access to healthcare.

This concurs with Margaret Kwedlow, a primary school teacher (Table 3.2), who stated that

many women of low socio-economic status do not utilise healthcare because they cannot afford

it: “they have to pay money to go so they do not want to go to the hospital” (Appendix 4.3.A).

In Kenya, the husband is in control of the household money, meaning that the woman will have

to ask her husband to pay for her medical care (Medema et al. 2012). Dr Ambuchi stated “never

will a women pay with her own money to come to the hospital. She will always have to get

money from her husband” (Appendix 4.1.F). This demonstrates that a lack of financial

independence may act as a barrier to utilising healthcare, because many women are not free to

seek healthcare as and when they need. Margaret Kwedlow and Wilfreda Olweyo are both

primary school teachers (Table 3.2), who stated that they pay their own medical bills and do not

financially rely on their husbands (Appendix 4.3.B & 4.4.A). They are educated and working

women, who have independent salaries and are therefore free to utilise their income for

medical care as they need to.

In contrast, the women interviewed at the

Christian Community Services (CCS),

farming group, illustrated in Plate 4.3, are

of a low socio-economic status, and do not

have financial independence. Everline

Akinyi has stated that she can only afford

to travel to the nearest clinic to receive

medical care, and that her husband would

pay for any treatment she may require

(Appendix 4.5.A). Carmilitas Ekwarasi

stated “because of my financial

dependence on him [my husband], I would need to ask him for money to go” (Appendix 4.6.A).

Not having financial independence may act as a barrier to accessing healthcare because she may

be denied money from her husband, as he may not see medical care as a priority, because there

Plate 4.3. Members of CCS farming group. Source: Own photograph

P a g e | 22

are so many other demands on the limited money supply. Western Kenya is an area of low

income, and Ahmed et al. (2010) stated that women within disadvantaged segments of society

women will be ‘the poorest among the poor’ (P.1). This means that many women, particularly

those of a low socio-economic status, will often be the least financially able in any society,

meaning that they are not able to access medical care freely, as they may need.

4.3. 2 Cultural issues

Cultural practices and gender norms in Kenya can influence a woman’s access to healthcare

(Namasivayam et al. 2012). This is being addressed under the social pillar of Vision 2030, with

gender mainstreaming being one of the flagship projects. This means ensuring the needs and

interests of each gender are addressed in government policies, plans and programmes (Ministry

of Planning and National Development, 2007). The Kenyan culture is patriarchal, which extends

into relationships, where men dominate. Dr Ambuchi stated that “the dowry means that he

[husband] owns her [wife] and she has to do what he says” (Appendix 4.1.G). Particularly in

rural settings, where traditional values are upheld, the payment is often seen as the groom

buying the bride, and therefore women are often viewed as being owned by men, and expected

to do as their husbands say. Dr Ambuchi stated that a woman will have to get permission from

her husband to seek medical care, and if he refuses her permission, she will not go (Appendix

4.1.H). This means that it can be extremely difficult for a woman to seek healthcare when she

needs to, as often women will also lack any financial empowerment to independently seek

healthcare. Gender-based violence may also be used within a relationship to control, and

dominate women (Namasivayam et al. 2012). The fear of gender-based violence, should a

woman go against her husband, may be a reason why many women do not seek healthcare

when their husband has refused.

HIV testing and stigma is a common reason for a husband to refuse his wife permission to seek

medical care (Maman, Mbwambo, Hogan, Kilonzo, & Sweat, 2001). Wilfreda Olweyo, a primary

school teacher, stated that during pregnancy, a man knows that his wife will be tested for HIV if

she seeks professional medical care, and that “some of [the women] sneak to go [to hospital]

without their husbands permission” (Appendix 4.4.B). Bernard Kweyu Wamukoya, a community

nurse, stated that a husband may refuse to allow his wife to seek medical care because he knows

he could have passed HIV to his wife, having contracted it as a result of infidelity (Appendix

4.2.D). Bernard also stated that “we usually advise this mother to go and bring the husband,

[but] husbands never come here, they fear” (Appendix 4.2.E).

P a g e | 23

Plate 4.4 illustrates a poster in Namasoli Health

Centre which encourages individuals to inform

their partners if they have HIV. Dr Ambuchi stated

that culturally, men “see [the hospital] as a

woman’s place and they will only drag themselves

to the hospital when they feel they are dying”

(Appendix 4.1.I). The fear that they may also be

encouraged to go to hospital may be a reason why

some men are reluctant to let their wives be tested.

The patriarchal nature of relationships in Kenya

may create significant barriers to women seeking

healthcare. This is because even if a woman has

physical and financial ability to access healthcare,

but her husband has refused to allow her to seek

medical care, it is very rare for a woman to go against her husband, particularly when the fear

of gender-based violence is very real.

Okoror (2012) has found that HIV testing in medical facilities can be a reason women choose

not to seek healthcare. This was also noted by Ginosuma Ome, a rural farmer (Table 3.2) and

Wilfreda Olweyo (Table 3.2), who stated that many women choose to give birth at home to

avoid HIV testing (Appendix 4.7.A & 4.4.C). HIV testing was the only barrier to utilising

healthcare mentioned by all the interviewees, demonstrating that it acts as a significant barrier

to many women accessing healthcare. The fear of being tested may be related to stigmatisation

of HIV, but also to women fearing their husband’s reaction, if they are found to be HIV positive.

Bernard stated that in Kenya, “if the women happens to be [HIV] positive, they usually send her

away, divorce and what have you” (Appendix 4.2.F). This concurs with evidence from a study by

Zachariah et al. (2008) in Nairobi, Kenya, which found that an HIV positive result for a woman

may result in her being divorced by her husband. This is because regardless of how the woman

has contracted HIV, even if it was through her husband’s infidelity, she will often be accused of

being unfaithful, and blamed for bringing HIV to the relationship. Due to the patriarchal nature

of relationships in Kenya, the woman will be in no position to disagree, as she may fear gender-

based violence.

Plate 4.4. Poster in Namasoli Health Centre.

Source: Own photograph

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All the women who were interviewed recognised cultural practices and gender norms within

Kenya as reasons why some women were unable or unwilling to seek healthcare. Despite being

able to describe how this may affect many women, both the educated and uneducated women,

were keen to clarify that these cultural practices and gender norms did not apply to them,

particularly in a healthcare seeking context. The primary school teachers, Margaret Kwedlow

and Wilfreda Olweyo both stated that they do not need permission from their husbands to go

to the hospital, and their independent salaries and lifestyles would suggest that this is the case

(Appendix 4.3.C & 4.4.D).

The uneducated women emphasised that they were also not restricted by gender norms. For

example, Ginosuma Ome stated that “I would inform my husband that I was going to the

hospital, but I would not ask permission [as] these are two different things” (Appendix 4.7.B).

Phildelis Nekeda, Everline Akinyi and Carmilitas Ekwarasi (Appendix 4.8.A, 4.5.B & 4.6.B) all

stated that they would not need permission from their husbands to seek medical care, but that

they are free to seek it when they feel it is required. However, the uneducated women had

stated that their husbands would pay for their medical care, indicating that the choice to seek

medical care was not necessarily as independent as they would like to portray. This may

demonstrate that the idea of patriarchy is increasingly being seen, by many Kenyan women, as

a concept that they not want to be seen as entirely adhering to, even if a patriarchal relationship

is indeed the reality for many women.

4.3.3 Perceptions of health

The perceived quality of care at health

facilities is also a significant factor in a

woman’s decision about seeking

healthcare. It has been found by

Gabrysch et al. (2009), that a

woman’s decision about where to

give birth, can be strongly influenced

by the perceived quality of care at

they will receive at a health clinic.

Plate 4.5 illustrates the quality of the

facilities at Lyanginga Health Centre.

A study conducted at municipal

health facilities across Western Kenya

Plate 4.5. Quality of facilities at Lyanaginga Health Centre. Source: Own photo.

P a g e | 25

concluded that there is under-utilisation of maternal and child health services, and that this is

related to perceived quality of care at the facilities. There was only forty six per cent satisfaction

with physical examinations, and twenty two per cent satisfaction of drug availability, which

concurs with evidence from Musanda ACK Clinic (Figure 3.1, Table 3.2), and the antiretroviral

(ARVs) that are often unavailable (Audo, Ferguson, & Njoroge, 2005).

Dr Ambuchi stated that one of the reasons why many women have a negative perception of

quality of care is due to staffing issues, particularly within government hospitals. She stated that

“there are not enough members of staff the hospital so the staff become very tired and they

can sometimes be harsh to the patients” (Appendix 4.1.J). She noted that this may cause a

woman to avoid returning, either for follow up appointments, or if they require medical care for

a different ailment. She also stated that if a woman is treated badly at hospital, it is likely that

she will return home and inform her friends as to how she was treated. This may influence other

women’s perception of healthcare, meaning that other women may avoid accessing healthcare,

for fear they may be treated in the same way.

Margaret Kwedlow, a primary school teacher,

stated that many women have a negative

perception of medical care, noting that they

“fear the unknown idea of going to hospital”

(Appendix 4.3.D). Plate 4.6 illustrates the

vacuum extractor at Lyanaginga Health

Centre, which is used for assisted births.

Equipment such as this may cause women to

be anxious about giving birth in a medical

facility. She stated that many women may not

be comfortable with professional medical

care, particularly as they will often have no

experience of medical care prior to becoming

pregnant. This means that many women still

prefer traditional birth attendants, because

they feel they will be treated well. This

concurs with evidence from studies in Kenya by Wanjira, Mwangi, Mathenge, and Mbugua

(2011), and by Cotter, Hawken, and Temmerman (2006) which found that many women were

more comfortable with traditional birth attendants than professional medical care. This is

Plate 4.6. Medical equipment at Lyanaginga Health Centre. Source: Own photo

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because the women feel that traditional birth attendants will provide personal care because

they will stay with them throughout labour, where as in a hospital, they will be left on their own

while in labour, as many hospitals are understaffed. Dr Ambuchi also noted that many women

may see it as a “waste of time” to access medical care, particularly when they have had many

children, and do not have any problems with their pregnancy (Appendix 4.1.K).

The perceived quality of care they will receive is also one of the factors identified by the women

interviewed from the CCS farming group. Phidelis Nekesa (Table 3.2) stated that many women

fear that they will not be treated with dignity by the doctors (Appendix 4.8.B). Everline Akinyi

(Table 3.2) concurs with this, noting that the doctors and nurses can be “crude, and abusive”

towards women when they are being treated in hospital (Appendix 5.4.C). Ruth Wanda, also

noted that medical staff can be “crude and harsh to patients” (Appendix 5.9.A). This concurs

with evidence from a study by Warren et al. (2013) in Kenya, which found that disrespectful and

abusive behaviour by health workers was one of the key factors women considered when

making a decision about utilising healthcare. This may act as a barrier because if a woman has

been treated harshly in the past, she will not want to risk being treated badly again, and may

avoid accessing health care in the future. Women who have not received medical care in the

past, may also choose not to access medical care, as their perceptions of how they will be

treated may be based on the negative experiences of other women.

In terms of quality of care, surprisingly, government hospitals are perceived to have a better

quality of care than private hospitals and clinics. Ginosuma Ome, a rural farmer (Table 2.3),

stated that she would prefer to go to a government hospital, rather than a private clinic as she

believes “some private hospitals will tell you that you are sick and just do anything when you

are not just to make money” (Appendix 4.7.C). Wilfreda Olweyo and Margaret Kwedlow, both

primary school teachers, stated that Government hospitals are more accurate in their test

results, giving the correct diagnosis, and not charging for anything unnecessary (Appendix 4.4.E

& 4.3.E). Ruth Wanda and Carmilitas Ekwarasi, members of the CCS farming group, stated that

government hospitals are better equipped, having more tools and facilities than private

hospitals (Appendix 4.9.B & 4.6.C). The fact that government hospitals are generally thought of

as being better equipped, and offering superior care to private hospitals, is positive for the

government of Kenya. This is because it is already where the women in the study, and many

other people in rural areas currently choose to seek healthcare, which may help the government

to increase women’s access to healthcare.

P a g e | 27

The perceptions and attitudes that women have towards quality of medical care are highly

influential in the decision about when and where they choose to seek medical care. This is

because many women struggle to finance healthcare, and are not supported by their husbands,

meaning that they already face barriers to seeking healthcare. If they also have a negative

perception about the quality of care, seeking healthcare will become even less of a priority. This

is particularly true for pregnant women when it is not their first child, and they do not appear

to have any problems with their pregnancy. They may see it as a waste of time and money to

travel to a clinic, and undergo a physical examination where they will be treated roughly. This

presents the government of Kenya with the difficult task of changing attitudes towards

perceptions of healthcare, as well as increasing affordability and quality of care.

4.3.4 Education

Fotso et al. (2009), has found that education status is one of the factors which affects a women’s

decision about where to give birth, in that the more educated she is, the more aware she will

be about the importance of healthcare. Rai et al. (2013), has also found that education increased

the proportion of adolescent women choosing to access antenatal care. Bernard Kweyu

Wamukoya, a community nurse, has noted that women who are more educated will be more

knowledgeable about HIV testing, and more willing to be tested (Appendix 4.2.G). This is

because the educated women know that if they test positive, they can receive treatment. He

stated that the women who come to the clinic “are not well educated, most of them did not go

to school” (Appendix 4.2.G). This may suggest why many women in rural areas do not seek

medical care, as they are not educated and do not want to be tested. Dr Ambuchi concurs,

stating that the more educated a woman is, the more she will be aware of her medical needs,

and be able to access the care she requires (Appendix 5.1.L). Carmilitas Ekwarisi, a member of

the CCS farming group, agreed, stating that “education is very important, and it creates

appreciation of all procedures and makes people more willing to go to the hospital” (Appendix

4.6.D).

Education levels in Kenya, particularly for girls, are low, with net enrolment ratio of females in

secondary school being only forty eight percent from 2008-2011 (UNICEF, 2011). The fact that

education correlated with health care seeking behaviour in the research by Fotso et al. (2009)

and Rai et al. (2013) may mean that low education levels also act as a barrier to accessing

healthcare. Low female education levels may be due to the patriarchal society of Kenya, which

means that often women are not seen as requiring an education, and rather it is the boys within

the family who are encouraged to continue their education. This is often at the expense of the

P a g e | 28

girls, as the family can often not afford to send all their children to school (Warrington, & Kiragu,

2012). Western and central Kenya are home to seventy per cent of the poor in Kenya

(International Development for Agricultural Development, 2013), meaning that in Western

Kenya, where incomes and education levels are already low, women will be the least educated.

This may act as a significant barrier to accessing healthcare, as many uneducated women either

do not know when to seek medical care, or the importance of medical care and follow up

appointments.

4.4 Conclusion

In order to increase women’s utilisation of healthcare in Western Kenya, the importance of each

factor which influence women’s access, and use of healthcare must be assessed. Women,

particularly rural uneducated women in Western Kenya, face two different types of barriers.

The first type of barriers include factors which prevent them from being able or allowed to

access healthcare, and the second type of barriers influence a woman’s choice as to whether to

seek healthcare or not.

The lack of freedom that many women experience within their relationships acts as a significant

barrier to women accessing healthcare. The women who were part of the CCS farming group

were allowed by their husbands to become empowered to improve their livelihoods, by being

part of a local community development group. However, the women relied on their husbands

financially for medical care, showing that in the context of healthcare seeking, and engaging in

the wider community, the women remained dominated by their husband’s decisions.

HIV stigmatisation, and therefore HIV testing can act as a reason why women are not able or

allowed to seek healthcare, and as a reason why women choose not to access healthcare. The

fear of HIV testing and stigma is an attitude deeply rooted in the Kenyan culture, and is therefore

difficult to change how both men and women view HIV. Education levels in Western Kenya are

low, which may suggest why stigmatisation of HIV, and low healthcare utilisation for women are

found in this area. While other factors, such as travelling to, and financing medical care create

significant barriers to accessing healthcare for many women, the predominant barrier remains

the attitudes of both men and women towards healthcare. Changing negative perceptions and

attitudes towards healthcare is where the Government of Kenya needs to focus its strategy in

order to increase female access to, and use of healthcare facilities.

P a g e | 29

Chapter 5 – Conclusion and evaluation

5.1 Conclusion

Kenya’s long term development plan, Vision 2030, has recognised that utilisation of medical

services, particularly for poor women in rural communities, is low (Ministry of Planning and

National Development, 2007). To increase utilisation, the main focus is on increasing availability

and quality of services, and financing healthcare (ibid). While this is important, the attitudes of

both men and women towards healthcare are key areas which need to be addressed by the

Government of Kenya, in order to increase women’s utilisation of healthcare.

This study has found that in Kenya’s patriarchal society, decisions around when, where and even

if, a woman should seek healthcare, often fall to men. The study has also found that negative

attitudes, of both men and women, towards healthcare, have been found to be partly founded

in a fear of HIV based stigma. It has been found by Simkhada, Teijlingen, Porter, and Simkhada

(2008), that in developing countries, husband education is an important factor in utilisation of

medical care for women. Women’s education was also a significant factor, as educated women

are more likely to realise the benefits of healthcare, and have increased autonomy and decision

making power within the household (ibid). It has also been found by Rai et al. (2013) that

education can influence people’s attitudes towards HIV, and women’s use of healthcare

generally. This is because an educated woman is more aware of her medical needs, and the

importance of seeking professional medical care as a preventative measure, rather than

curative.

These findings suggest that the Government of Kenya needs to view education for both men

and women as the way to address patriarchal relationships and the dominance of men, which

currently acts as a significant barrier to women utilising healthcare. An increased awareness and

education about HIV for both men and women needs to be made a priority for the Government

of Kenya, in order to reduce HIV based stigma, which also acts as a significant barrier to women

utilising healthcare.

P a g e | 30

5.2 Recommendations

While Vision 2030 is going some way to improve healthcare and utilisation of healthcare in

Kenya, there needs to be more of a focus on changing attitudes towards healthcare, which this

study has found to be at the root of low healthcare utilisation for women in Western Kenya. In

order to address negative attitudes towards healthcare, the following recommendations are

made:

1. Educate both men and women as to the importance of healthcare seeking, through

community based schemes

2. Emphasise gender equality in primary and secondary education, in order to teach the

next generation as to the importance of equality in relationships, and that healthcare

seeking decisions need to be made with input from both husband and wife

3. Increase HIV education in both communities and schools, as HIV knowledge has been

shown to decrease stigmatisation

5.3 Final Evaluation

Positionality and researcher bias was of consideration when collecting the data. It may have

been beneficial to conduct more research and observation at the health facilities prior to the

interviews, in order to gain a deeper understanding of the general attitudes towards

professional healthcare in Kenya. This may have allowed the researcher a greater understanding

of the interviewee’s responses in the context of how healthcare is viewed in Kenya, rather than

comparing healthcare seeking behaviour to the United Kingdom, where the researcher is from.

If the research were to be conducted again, it would be beneficial to interview those women

who live in particularly patriarchal and traditional communities where there is no education,

and where women are not empowered at all. This may offer a deeper understanding of the

factors that truly affect healthcare utilisation for poor rural women in Kenya, as women in these

communities may not have a perception of what they think the researcher, who is a white

woman would want to hear. This may mean that they offer a more honest account of their

health care seeking behaviour, as they are not trying to present themselves in a light that

suggests they are empowered to make their own choices about healthcare.

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During the interviews, there were contradicting opinions from the medical staff and women

about the factors that influence access to healthcare for women. Dr Ambuchi stated that it is

very rare for a woman who visits a government hospital to have complete financial

independence, and seek medical care without her husband’s permission (Appendix 4.1.F). In

contrast, the women from the Christian Community Services (CCS) farming group stated that

they were able to seek medical care without permission from their husbands. If the research

was to be conducted again, it would be beneficial to visit the interviewees more than once prior

to interviewing, to establish a relationship of trust. This may result in the participants being

more willing to have an extended discussion about their healthcare seeking behaviour, rather

than give the responses they believe are required, or give tentative responses to the interview

questions.

Given the time frame within which the research had to be conducted, and word count of the

report, there were elements of interest concerning healthcare in Kenya, which could not be

explored. For example, the unanimous preference of government hospitals, over private clinics

from the women was a surprising insight. Exploring the reasons behind this was not possible for

this study, but if it were to be conducted again, it would be interesting to explore in depth, the

reasons why many women prefer government hospitals.

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Appendix 1 - Consent form

As part of my undergraduate degree at the University of Chester, I have to carry out a project which involves collecting primary research. The study is concerned with women’s access to and use of healthcare in Western Kenya. The study involves conducting interviews with both medical professionals and women in Western Kenya, to explore the factors which affect women’s access to and use of healthcare. Taking part in this research is entirely voluntary, and where requested, anonymity will be respected. The information will be kept confidential during the study, and on completion of the project, the project and results will be seen by my supervisor, a second marker, and the external examiner. The project may be read by other students on the course. I have gained ethical approval for collecting this research by the Department of Geography and Development studies, at the University of Chester. If you agree to take part in the study, please sign the consent form, or give verbal consent where written consent is not possible. I ……………………………………… (print name) agree to participate in this research study.

The purpose and nature of the study has been explained to me.

I am participating voluntarily.

I give permission for my interview to be recorded.

I understand that I can withdraw from the study, without repercussions, at any time, whether

before it starts or while I am participating.

I understand that extracts from my interview may be quoted in the written project if I give

permission below

Signed……………………………………… Date………………………

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Appendix 3 – Semi- structured Interview questions

Medical Staff

1. What services are offered to women?

2. What is the reliability of women attending services?

3. If the reliability is poor, what are the reasons for the women not attending? Travelling,

money etc?

4. How frequently do the women attend the services?

5. What is the socio economic status of the women who attend the services?

6. What is the marital status of the majority of the women who attend clinics?

7. What is the nutrition of the women who attend?

8. What are the attitudes of their women to their partner?

9. What are the attitudes of the partner to the women attending the services?

Educated and uneducated women

1. Where do you go if you need medical attention? Would you go to a clinic or to a

traditional doctor?

2. Would you have to ask your husband’s permission to receive medical attention?

3. If you go to a clinic

a. What are your reasons for going to a clinic?

b. Which type would it be, (private or state) and why?

c. If you had to pay, how would you pay for it? Would you have to ask your

husband for money?

4. If you would not go to a clinic

a. What are the reasons?

5. At the beginning or during a pregnancy, did you or would you go to a clinic? If not, why

not?

6. Where would you give birth, at home or at hospital? Why?

7. Once you had/ have given birth, would you take your child to a clinic? Why/ why not?

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Appendix 4 - Interview Transcripts

Appendix 4.1

Name Dr Ambuchi

Location Busia District Hospital

Occupation Gynaecologist

Date 05/06/2013

Time 14:00

What services are offered to women?

All services including ANC

What is the average age of women who attend ANC?

Generally between 20 and 30, but some older women as well

How many women attend ANC?

This hospital offers 4 clinics that the women can attend, if they attend from the

beginning of their pregnancy, but many women only come in the third trimester of

pregnancy. They see it as a waste of time to come to the clinic for check ups early in

their pregnancy, and they only come for the last one. Attendance of all four clinics is

only 13.3% in 2012 for Busia District Hospital, because so many come just in the late

stages of their pregnancy. Delivery in the hospital is higher with 31.79% of women who

have attended clinics delivering in the hospital in 2012

Why do you think the numbers are so low, especially for ANC?

There are many reasons why a woman may not come to the clinics. Many women have

had many children and see it as a waste of time when they do not have any problems

with their pregnancy. Other women are very poor, and they cannot afford to travel to

the clinic. If a woman only has 100 shillings to spare she will not want to travel to the

hospital and she will also have to have something for lunch, so you see how she may

not be able to afford to come, because it does not seem as important as other things

such as food that she might have to spend her money on.

A

B

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If a woman comes to the hospital, how does she pay?

Never, never will a women pay with her own money to come to the hospital. She will

always have to get money from her husband. The man will create the budget for the

house, and he is the head of the house and the woman will always have to get money

from him. She will also have to get permission, and if he says she cannot go, she will not

go. And also the dowry you see means that he owns her and she has to do what he says.

Why might he not want her to come to the hospital?

He may not want her to be tested to know her HIV status because he does not want to

go the hospital because when a woman is tested positive, it is encouraged that her

husband also comes to the hospital to be tested but many men do not want to come to

the hospital. They see it as a woman’s place and they will only drag themselves to the

hospital when they feel they are dying. But they like to stay away, and they do not want

their wives coming to the hospital and telling them they also have to go and be tested.

Also, the men do not get as sick as the women because they have better nutrition. The

men go away in the day, and they eat in the hotels and have good food in the day, and

at night they eat first and they eat as much as they want. Once the men and the children

have eaten then the woman will then eat which means that she can often be very

malnourished so she gets sick more easily.

So is it important to have the husband involved in these matters?

Yes, its very important to have him involved. If the partner is more aware and more

involved, then it is easier for the women to get the care they require, because the

husband understands the woman’s needs. You find that the more educated the woman

is she will be more aware of her needs and be able to get the care she requires.

What do you think is the major reason why women do not access medical care?

I think one of the reasons is the staffing issues in the hospitals. There are not enough

members of staff the hospital so the staff become very tired and they can sometimes

be harsh to the patients. But you know if you have to do a vaginal examination and the

woman refuses to open her legs, you do not have time for that so you can snap at her

and it can give her a bad impression of the hospital that she will be treated badly so she

does not want to come back. Or she tells her friends about the treatment she got at

hospital and they do not want to go. Many women still prefer traditional birth

F

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attendants because they are comfortable with them and they feel that they will be

treated well. Another reason is the cost of getting to hospital is just too much for some

women, they do not want to spend their money on going to hospital, or they do not

have the money in the first place to be able to go. Many of the women who come to

hospital are of very poor socio-economic status, so they do not want to have to make

unnecessary trips.

Appendix 4.2

Name Bernard Kweyu Wamukoya

Location Anglican Church of Kenya- Musanda Clinic

Occupation Community Nurse

Date 16/05/2013

Time 14:45

Tell me about the facility, who runs it, who pays for it?

This is a FBO clinic, and me I am a government employee and second to the facility. And

the facility, basically in the room we are sitting is a room we are seeing child welfare

clinic, those ones are the under-fives, children and then the expectant mothers and

then we also do family planning in the same room

What services are offered for women?

Women in general, one we offer family planning services, and mothers who are

expecting, we are offering examining them, HIV testing is also done here, and then you

also give the immunisation here, that is tetanus, we also offer them malaria

preventative, and iron to prevent anaemia of the pregnant woman. For the family

planning, we are offering them pills, injections and the woman who has just arrived

they are given implants (for contraception) the lady I was giving here now

When a pregnant woman comes to you, what is the procedure for testing, do they

have a choice or do you advise it?

You know when an expectant mother comes, we usually have to council them, to tell

them why we have to do an HIV testing. Though it is mandatory, an expectant mother

has to be tested, it is compulsory, but some will opt to refuse and when a mother

D

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refuses, we don’t force her, but you know at the moment, the moment she refuses

here, any time she may be delivering at the hospital, she will be tested there, but we

have to do counselling and if she accepts we have to do testing straight away, so that it

will depend now that when it is negative, the client will come again maybe after three

months for testing, but when shes positive, we should then refer to the main site,

because a the moment we do not have the antiretrovirals, we shall refer to the other

health facilities

Why do some women refuse the test, what are some of the reasons?

Some of them refuse because they fear to be tested. Some will tell you my husband has

some other girlfriends out here, so she usually feels maybe she has the disease, but

after counselling and you examine her, you will get she is negative, but some just fear

because of the movement of their husbands, and some fear because they know how

they move, but when you examine them most of them tend to be negative, not even

positive.

So it’s the fear that they know what their husbands have been doing?

They know their husbands movements, and even themselves, they fear, because you

know sometimes she is married and she has boyfriends outside here again, so they fear,

its just fear

Are there any fears that their husbands will tell them they are not allowed to get the

test?

No. It never happens. Another problem is that after examining these mothers again, the

husbands will like to know the results, if the husband is known they wife is negative,

the husband also assumes he is negative. But if the women happens to be positive, they

usually send her away, divorce and what have you, because if a mama is positive after

testing, we usually advise this mother to go and bring the husband, husbands never

come here, they fear, that is another problem again, so it takes time, sometimes what

happens is if a husband is not come like that they will not come to this clinic, he will opt

to come to another clinic, the mother is picking drugs here, the husband in another

place, maybe at long last he will come and accept it here, but at first contact they don’t

they refuse

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Why do you think the husband will refuse?

You know with them, the husband usually refuse because if the wife is infected, it is the

wife who has brought the disease, not the man though we usually tell them… you get

two types. You will maybe get a husband who is negative and a wife who is positive,

and we call them discordant couples. If a woman is positive, and she explains to her

husband then it is not very easy for her to come. Sometimes when the husband comes

he will test negative, those ones we are calling the discordant couples, those one we

refer them to the high levels.

So this clinic is just for the initial stages?

Yes, though at this stage we are planning to order the drugs to prevent the PMTCTs.

We are planning so that when we get a positive mother, we do not send her away we

just offer her drugs from this facility. At the moment, when someone like you and me

tests positive, we don’t deal with her here, we send her to another facility. But

expectant mothers we are supposed to complete with them here, give them the drugs,

give them the drugs here, but at the moment, those drugs are not here

What is the average age of the expectant mothers?

Middle aged women, because the young ones are not very common, once in a while, it

is just the middle aged, even the old ones, no, just the middle ones

Do you think younger women are having children, but they just don’t come to the

clinic?

Some fear also coming here, embarrassment, the young ones fear embarrassment,

because she is still young, she feels she will be quarrel at the clinic, or she fears just

walking, when the young ones get expectant they don’t like to be seen outside, so she

will stay in the house until she delivers. Because most of the mothers here opt to be

seen by traditional birth attendants at home, not in the facility, we shall only just

receive them now carrying their babies now

Is that due to culture?

No it is not cultural, it’s just fear, if she went to school, here (next door) don’t expect

her to come here, because she fears her colleagues will see

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What is the average number of children women have that you see?

Range between three to six or seven children, others even nine, ten

What is the socio- economic status of many of the women?

They are not well off, because sometimes getting even 20 shillings together is difficult

for the women. They are not well educated, most of them did not go to school. The

ones who are educated have more knowledge to be tested. They know that if they are

tested, then they can deal with the problem.

What are the reasons women do not come to the clinic?

They come when they are near delivering, three months to delivery. Some only come

to get a card so when there are complications they have a card to show that they are

already registered. Some excuses for not returning to the clinic are that they had to

travel, or attend a funeral or other such things

What is the marital status of many of the women?

They are married, mostly married

Do their husbands even stop them from being tested?

No, because in this clinic, they have to pay, so it is the husband who gives them money

to be tested. If the man comes with the wife, he will stay across the road, he will not

come near here, because he fears

Appendix 4.3

Name Margaret Kwedlow

Location Burumba Primary School

Occupation Teacher

Date 04/06/2013

Time 10:30

If you needed medical attention where would you go?

If I had money I would go to a hospital

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If you did not have money where would you go?

I would go to a traditionalist, to a herbalist. I would just go and get some herbal

medicine from the traditional doctor.

If you needed to get medical attention, would you ask your husband’s permission, or

would you just go?

I would not need his permission, I would just go to the hospital

But if you needed money to go to the hospital, would you need his permission?

If you are working you will go with your own money, but if you are not you will just ask

him for help

If you went to a clinic, would it be a private or state clinic?

I would go to a state clinic

What are your reasons?

I would prefer state because they can give you the correct diagnosis of what is wrong

with you and they will not charge you extra for things that you do not need, which

private can do because they want to make money from you

How many children do you have?

I have four children

Did you go the clinic for ANC before they were born?

Yes I did go to the clinic before they were born, and to have my children, they were all

born in the hospital

Why do you think it’s good to have your children in the hospital?

It is good because if anything goes wrong, you can be sure that they are going to be safe

because they have good medical care.

What are some of the reasons why people choose not to give birth in the hospital?

There are different reasons. Sometimes they are scared of being tested for HIV in the

hospitals so they do not want to go. Also the have to pay money to go so they do not

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want to go to the hospital. They also fear being operated on… basically they fear the

unknown idea of going to hospital.

Are there women who are not allowed to go to hospital because their husbands do

not allow them to?

Yes this happens. Because when they go to the hospital they have to be tested for HIV

and the husbands know that this happens so they do not want their wives to go and be

tested.

Appendix 4.4

Name Wilfreda Olweyo

Location Burumba Primary School

Occupation Teacher

Date 05/06/2013

Time 11:00

If you needed medical attention where would you go?

I would go to a hospital

Would you go to a government or private hospital?

Government

Why?

The reasons why I like government hospital are that you know the screening, it is

accurate results. But you know private because you know they need money, they will

just be treating you on a disease that they complicate and magnify so that you have

very expensive drugs, that is the reason why I prefer government hospitals because

even if it is laboratory examination you now it is real but you know it is private they can

say they that the result is positive when it is negative so that you can pay for the drug

If you need medical attention do you need your husband’s permission?

No, I just go without permission

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Would you pay for the hospital yourself?

It depends, you know sometimes it is admission you always use the NHF card but

sometimes if it is outpatient I pay if I have money, if I don’t have money my husband

chips in

What is the card?

If it is admission, the card pays some admission for you, because you put some small

amount in each month contribute each month to the government

How many children do you have?

I have 6 children

Where did you go to have your children?

I had all of them in the hospital

Why do you think it’s good to go to hospital to have your children?

I think for safety it is better for you to have your children in the hospital and it is also

proper for a pregnant woman to go to antenatal clinics and get care and advice. Maybe

you are observed, they can always check the blood and check on STIs, maybe it is HIV

and AIDs and then you are guided on how to go about it. It is the reason why it is good

to go to hospital

Do you know any reasons why women may not want to go to hospital?

The reason why is that issue of examination of screening the blood they can be tested

for HIV. They fear that being tested for HIV viruses that they fear. They always screen

everything, they check on the virus, the STIs, the presence of the HIV virus, if it is there

then you are guided, counselled they take care of you so that during delivery you are

advised to go to the hospital so that maybe if the proper care can be taken so that a

child can be born free of the virus. But you know other people don’t want because they

are scared, they fear.

If you go to the hospital can you refuse to be tested?

You cannot refuse, it is an absolute must, for them to attend to you u must know their

status. They fear the stigma against HIV, and that can be a reason why they do not go.

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They do not want other people to know that they are victims. There are also those ones

who don’t want their wives to go to the hospital because they know what they have

been doing and they don’t want their wives to know they have given them the virus.

Because you know that when you are tested you are advised to call your partner to

come and be tested as well, but some of them don’t want they can really quarrel with

the reason why you went to the hospital. Some of them sneak to go without their

husband’s permission.

Appendix 4.5

Name Everline Akinyi

Location Christian Community Services Farming group

Occupation Subsistence farmer

Date 17/05/2013

Time 12:30

If you needed medical attention would you go to a clinic or to a traditional doctor?

I would go the hospital to see a doctor

Why would you prefer a clinic to a traditional doctor?

I would prefer a clinic because they would be able to do a test and they would be certain

of what illness I have got

Would she have to gain her husband’s permission to get medical attention?

I would not have to gain my husband’s permission, but he would pay for the treatment

Would you go to a government or private clinic?

I would go to a government clinic. The private hospitals are in town, and are too far to

travel to. The government clinics are more rural and closer to where I live. The cost of

the private hospital is also too much, I cannot afford it. My husband will help me pay

for any medical bills I have from a government hospital.

When you were pregnant, did you go to the clinic for check-ups?

Yes I did, medical attention is important, to make sure everything is OK with the baby

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Where did you give birth?

I went to the hospital because they told me that by baby was breech, so if there were

any complications I would be able to get medical attention quickly.

Do you know women who still choose to give birth at home?

Yes many do

Why do you think they choose to give birth at home?

Many are scared of going to the hospital. One reasons is that they are scared of being

tested for HIV. They fear the stigma that goes with HIV. Also the doctors and nurses in

many hospitals are crude and abusive and are not very kind to the women. They do not

want to be treated badly so they choose to stay at home to give birth.

Appendix 4.6

Name Carmilitas Ekwarasi

Location Christian Community Services Farming group

Occupation Subsistence farmer

Date 17/05/2013

Time 13:17

Where would you go if you needed medical attention?

To the hospital

What are your reasons?

Hospitals are better because there is examination to ascertain what they are suffering

from

Would you have to gain your husband’s permission?

I would inform, not ask my husband because of my financial dependence on him, I

would need to ask him for money to go.

Would you go a private or government hospital?

I attend both clinics, one time the doctors were on strike so that means that I could not

get treatment in the government hospital so I had to go to the private hospital to get

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treatment. Sometimes in private hospital due to the lower of number patients you get

more individual attention than in a government hospital, but overall I think government

hospital are better equipped than private hospitals. One time in 1977 I was seriously ill

and I got treatment from a government hospital.

Did you have your children in a hospital or at home?

The first born was in 1963, and as much as I attended the clinics I delivered at home,

for the second born I attended the clinics and the baby was born at home because the

baby came very quickly. The third born I attended clinics and delivered in the hospital.

For your first two did you intend to give birth at home?

Back then, there were not so many medical issues so many women decided to give birth

at home, but now there are many more complications, and the government has said

that all deliveries should be done in health facilities

Do you know anyone who is scared to go the hospital, and why are they are scared?

So many people, so many people. It is individual choice and it is not clear as to why

they are scared.

Do you think if people are more educated and knowledgeable they are more willing

to go to the hospital?

Education is very important and it created appreciation of all procedures and makes

people more willing to go to the hospital.

Appendix 4.7

Name Ginosuma Ome

Location Christian Community Services Farming group

Occupation Subsistence farmer

Date 17/05/2013

Time 13:00

If you needed medical attention would you got to a clinic or traditional doctor?

I would go to the hospital?

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Why?

Hospitals are better because you have to undergo examinations to determine what you

are suffering from

Would you go to a government or private hospital?

Government

Why?

I prefer government because of the cost, it’s cheaper to go to a government hospital

and these days some private hospitals will tell you that you are sick and just do anything

when you are not just to make money

Does they distance to each hospital make any difference?

Some times in government hospitals you are treated with kind treatment and dignity

as compared to private hospitals. Private hospitals are operated by people who are not

even qualified, I would not simply go to someone who says they are qualified when they

are not.

Would she have to ask her husband’s permission to get medical attention?

I would inform my husband that I was going to the hospital, but I would not ask

permission these are two different things. If I can afford it I would just use my own

money but if it was more than I could afford I would ask my husband for money

Did you attend clinics when you were pregnant?

Yes I did and I gave birth in hospital. Did this because there are trained and qualified

personnel to take care of the child

Do you know why some women choose to give birth at home?

Many are scared of going to the hospital

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Why?

There are no clear reasons; each person has a different reason for not wanting to go to

the hospital. Some are scared of being tested for HIV and they fear that if they went to

the hospital they would be forced to be tested and they do not want that.

Appendix 4.8

Name Phidelis Nekesa

Location Christian Community Services Farming group

Occupation Subsistence farmer

Date 17/05/2013

Time 12:06

If you needed medical attention would you go to the hospital or clinic?

Yes I would

Would you ever go to a traditional doctor?

Yes

Why, or what illness would make you go the traditional doctor?

Priority one would be to go to the hospital, but if she could not get medical attention

there she would go to a traditional doctor

What are the reasons why she may not be able to get treatment in the hospital?

One, for pregnant mothers it’s a condition that you have to know your HIV status, and

that creates a lot of fear, scaring them from going to the hospital, so they fear the HIV

screening. Sometimes resistance from the men, if they don’t cooperate especially if its

related to STI infections, sometimes you must be undergoing treatment and when you

go back in the house, husband is still sick, you get infected again

Would you have to get your husband’s permission to get medical attention?

No, I would just go by myself

Would you go to a government hospital or a private clinic?

Government

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So you don’t have to pay?

Just a little bit, so I can pay by myself

What happens if you go and its costs a lot of money, would you have to get your

husband’s permission?

The father of the child works in Nakuru, and I came here (to her mother’s house) when

she was six months pregnant. I wanted my husband to come so we could live together,

but he didn’t want to. When I returned here, he didn’t take my calls. He only called me

on Sunday asking if I had had the child and is the child well. I asked him what the child’s

name should be, his family or mine but he didn’t reply. So the bill, my mother and my

sister helped me to pay it. I had to stay in the private hospital for two nights which cost

1500 KEs. My husband still would not take my calls. But he phoned me on Sunday and

he just asked how the baby was, he didn’t ask about the bill. The baby is now six months

old and he has not seen him, he has never come here. My mother and sister helped me

with the bill. The burden of bringing up the child lies on my shoulders with the help of

my aunties and family.

During your pregnancy did you go to the clinic for check-ups?

Yes all along I went to the clinics and pre natal classes

Did you give birth at home in the hospital?

I gave birth in the hospital, because I had started in the hospital with the check-ups so

I wanted to finish in the hospital

Why do you think some women give birth at home?

They don’t want to be tested for anything, especially HIV. They are forced to be tested

for HIV if they go the hospital and they do not want to be. Also some women are afraid

of how the doctors will treat them, they may not treat them with dignity.

Do you take your child to the clinics now he has been born?

Yes I take him to get his vaccinations, because I want to take care of him and make sure

he does not get ill

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Appendix 4.9

Name Ruth Wanda

Location Christian Community Services Farming group

Occupation Subsistence farmer

Date 17/05/2013

Time 13:45

Would you rather go to a hospital or a traditional hospital?

Hospital

Why?

The hospital you will be told exactly what you are suffering from and intervention and

treatment

Do you have to gain your husband’s permission?

I would inform, not ask permission

Do you go to a government or private clinic?

Government hospital

Why?

One, the cost. They subsidise the facilities and in private you have to cough up the cost

Does the distance to each hospital make a difference?

Government facilities are better equipped, they have better tools and facilities to

ascertain the illness?

Do you know why people may prefer to stay at home and not go the clinic especially

if they are pregnant?

One is that the medical staff can be very crude and harsh to the patients so that one

scares away

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Did you go the clinic when you were pregnant?

Yes I went to the hospital to have two of my children and two I had at home for the

other two children

Why did you have two at home and two in the hospital?

I went to the hospital because the doctors told her the baby was big and there could be

complications. For the second baby there were complications. There was fluid coming

out but no labour pains, so thought I should go to the hospital

Why did you stay at home to give birth to your other children?

The birth was very abrupt and there was no time to go to hospital. There were no

complications and it was a very smooth birth

Once the children were born did you take them to the clinic?

Yes I did take them to the clinic, I went because they needed to get their vaccinations