Kenya’s vision for an equitable, rights-based health system fails to address specific health needs and barriers to accessing health care of vulnerable populations.

By

Mohamed Isaack Maalim*

Centre for Global Health, Trinity College Dublin

Joanne McVeigh**

Centre for Global Health & School of Psychology, Trinity College Dublin

Hasheem Mannan***

Nossal Institute for Global Health, University of Melbourne & Centre for Global Health, Trinity College Dublin

*Mohamed Isaack Maalim, Diploma Occupational Therapy, is an Occupational Therapist, and a Masters Candidate in the M.Sc. in Global Health at the Centre for Global Health, Trinity College Dublin, Dublin, Ireland [E: maalimm@tcd.ie].

**Joanne McVeigh is a Doctoral Researcher at the School of Psychology and Centre for Global Health, Trinity College Dublin [E: jmcveigh@tcd.ie].

***Hasheem Mannan, Ph.D., is a Senior Research Fellow at the Nossal Institute for Global Health, University of Melbourne, Victoria, Australia, and a Visiting Research Fellow at the Centre for Global Health, Trinity College Dublin, Dublin, Ireland [E: hmannan@unimelb.edu.au].

 

Abstract

This paper assesses the strength of the Kenya Health Policy 2012-2030 to determine the extent to which it upholds the right to health and explicitly addresses the health needs and aspirations, as well as facilitators and barriers to accessing health care services, of vulnerable and marginalised groups.  The Kenya Health Policy is guided by Kenya’s principles of the right to health, in accordance with the Constitution of Kenya 2010.  The policy aims to comprehensively adopt a human-rights-based approach to health care delivery by striving to base the policy’s design, implementation, monitoring and evaluation on the principles and norms of human rights.  The researchers conducted a Health Impact Assessment of the Kenya Health Policy to assess its inclusion of the four essential elements of the right to health, as described in United Nations General Comment number 14 on “The Right to the Highest Attainable Standard of Health”: (a) Availability; (b) Accessibility; (c) Acceptability; and (d) Quality of public health care facilities, goods, and services.  The assessment finds that the policy’s aims to ensuring equity in distribution of health services, a people-centred approach to health care, a participatory approach to intervention delivery, a multi-sectoral approach to realizing health goals by applying a ‘Health in all sectors’ approach through the focus on health-related sectors including Agriculture, Education, Roads, Housing, and Environmental factors in realizing the objectives of the policy, efficiency in health technology application, and a promotion of social accountability fully correspond with principles and norms of human rights.  However, the policy fails to give adequate attention to the specific health needs and aspirations of vulnerable groups.  In particular, while the policy identifies some segments of the Kenyan population as vulnerable or marginalised, it does not demonstrate specific contexts in which a particular vulnerable group might require an accelerated or specialized treatment, nor does it address particular populations of vulnerable groups’ specific barriers to health care experienced.  The overall objective of this policy is to attain universal coverage of health services as outlined in its policy objectives.  In the absence of explicit disaggregation of the Kenya Health Policy to ensure equitable access of vulnerable groups, significant barriers to universal coverage of health services will continue to exist.  Keywords: Kenya Health Policy 2012-2030, health impact assessment, policy content, right to health, vulnerable/marginalized groups, equity.

Introduction

The Constitution of Kenya, promulgated in 2010, has guaranteed various rights and freedoms to its citizens, in particular under articles in Chapter 4 – The Bill of Rights[i].  These rights and freedoms are either partly or entirely domesticated from a number of international human rights instruments.  The Constitution, therefore, provides a legal framework for diverse public and private service sectors – including those related to the field of healthcare – to design and implement policies and procedures in accordance with the provisions of the Constitution.  In particular, the Ministry of Health in Kenya enacted a policy document entitled ‘Kenya Health Policy 2012-2030’ in a quest to adopt a rights-based approach to health, aiming for each citizen in Kenya to have the right to the highest attainable standard of health[ii]. This paper will analyze Kenya’s health policy’s adherence to right to health standards by using the backdrop of an international standard of the right to health.  Previously, researchers have provided assessments of Kenya’s past health policies and healthcare systems, which have focused on the adequacy of Kenya’s health policy implementation[iii].  The analysis reported in this research article, by contrast, is a health impact assessment of policy content of the Kenya Health Policy 2012-2030.   The relatively recent development of this health policy implies that its implementation and monitoring are arguably also in their infancy, and that detailed assessments of these aspects of the Kenya Health Policy may be forthcoming.

 

Literature Review

 

The Right to Health

International, national, and regional health documents and treaties have focused on promoting health as a human right, based on fundamental principles of equity and an enhanced “health for all” agenda.  For instance, the Constitution of the World Health Organization (WHO) has enshrined the right to health, declaring that, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”[iv].  Indeed, Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR)[v] recognizes that everyone has the right to the highest attainable standard of health, or “right to health”[vi].  To elaborate upon this article, the Committee on Economic, Social and Cultural Rights (CESCR) published General Comment No. 14 to define the “right to health”:

The right to health embraces a wide range of socio-economic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment. (art. 4)

According to General Comment No. 14, the right to health is based on four essential and interrelated elements, the precise application of which will depend on the conditions existing within a State: (a) Availability; (b) Accessibility (comprising Non-discrimination; Physical accessibility; Economic accessibility (affordability); and Information accessibility); (c) Acceptability signifying that all health facilities, goods, and services are respectful of medical ethics and are culturally appropriate;and (d) Quality  of public health-care facilities, goods and services, known hereafter as (AAAQ) (art. 12)[vii].  General Comment No. 14 therefore sets the standard for every national government to ensure systems and structures are in place to establish an environment in which individuals can make informed decisions about their health and can easily access health care.  Further to, but also related to, the four essential elements of the right to health of AAAQ, there are six concepts crucial to the right to health: Progressive Realization; Core Obligation; Equality and Non-discrimination; Participation; Information; and Accountability[viii].

To develop policies that enhance the right to health, the Declaration of Alma-Ata 1978 (Alma-Ata 1978) certified primary health care as a foundation for achieving “health for all”: primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford (art. 6, 10).

 

Correspondingly, a report by the WHO Commission on Social Determinants of Health called for measures to eliminate causes of health inequities, such as poor social policies and programmes as well as unfair economic situations[ix].

It is therefore apparent that health as a human right is based on the principle of equity, and an enhanced “health for all” agenda.  Braveman and Gruskin define equity in health as, “the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage”[x].  Equity in health rests on the assumption that the bias and discrimination that result in differences in access to the resources and opportunities for health is unfair, created by, for example, unequal burden of payment for health services of vulnerable groups[xi].  Health inequities occur often on a socioeconomic scale, whereby there is an increased health gap between the poorest and the remainder of the population[xii].

 

Inclusion of Vulnerable Groups

Focus on health as a human right ensures social inclusion of vulnerable populations in health system planning.  It cannot, however, be achieved by merely mentioning vulnerable population groups, but policies must make explicit the principles that govern vulnerable groups’ inclusion (i.e. core concepts of health-related human rights).  A vulnerable population is a social group(s) with poor limited resources, placing them on a very high relative risk for morbidity and premature mortality[xiii]. Vulnerable populations most often include women, children, the aged, displaced people, ethnic minorities, people with disabilities, or people suffering from some form of illness or disease[xiv].  These populations’ experience with health inequities is rooted in a lack of political, social, and economic power[xv].

 

Therefore, health equity can only become a reality when policy is focused on ensuring the fair distribution of service-delivery that meets people’s needs, rather than healthcare distributed according to social privilege[xvi]. The failure by a State to identify health needs of a vulnerable population may result in breach of the non-discrimination tenet and consequently, in lack of essential service delivery[xvii], and this includes identification and explicit reference to the specific health needs of vulnerable groups as outlined in health policies.

To evaluate Kenya’s Health Policy against the benchmark of the internationally delineated right to health, it is important to ascertain this policy’s focus on equality and non-discrimination, particularly as it relates to vulnerable populations.  Indeed, it is vital to assess the content of any health policy document to assess whether it focuses attention on issues of equity and non-discrimination, and effectively disaggregates its objectives and priorities by clearly and explicitly addressing the health needs of marginalised and vulnerable populations[xviii].  Disaggregation of health-related data is specified in the “Outcome Document of the Durban Review Conference 2009”, which stipulates that “States… establish mechanisms to collect, compile, analyse, disseminate and publish reliable and disaggregated statistical data”[xix].

The multidimensional experiences of risk and vulnerability of diverse marginalised population groups requires in-depth, context specific assessments, which identify health, economic, socio-political, and environmental sources of vulnerability, and how these correlate[xx]. These assessments necessitate ascertaining not simply heterogeneity between population groups, but also within population groups[xxi]; for example, people living with congenital as opposed to sudden-onset diabetes have different risk profiles, as do people with disabilities whose injuries were acquired during conflict versus those born with disabilities[xxii].  Affording specific and detailed attention to marginalised and vulnerable populations ensures total health system coverage of all sectors of society[xxiii].

 

Methodology: Health Impact Assessment

 

A Health Impact Assessment (HIA) is a key tool for analysing the effect of policies on public health and the extent of fair distribution of health resources within the population.  A HIA promotes an equitable approach to policy assessment, whereby the aggregate impact of a policy on the health of a population is assessed, while also assessing the distribution of that impact with regards to such factors as gender, ethnicity, age, and socio-economic status[xxiv]. The WHO’s definition of a HIA is: “a combination of procedures, methods and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population”[xxv]. HIAs have a variety of tools to use for assessing the impact of a programme, project, or policy aimed at health.

Mannan et al. (2011) produced the “EquiFrame Manual”[xxvi], a framework for analysis of the inclusion of core concepts of human rights and vulnerable groups in health policies and international health documents[1].   Similarly, the Norwegian Agency for Development Cooperation (NORAD) published a “Handbook in Human Rights Assessment”[xxvii], which provides guidance on whether conducting a comprehensive human rights impact analysis is warranted.  Further, the AAAQ essential elements of the right to health provide a benchmark for evaluating a policy’s impact on health-related human rights[xxviii]. This paper seeks to analyse the strength of the content[2] of Kenya’s Health Policy 2012-2030 primarily through the lens of the four essential elements of the right to health of AAAQ[xxix].

 

Background

The Constitution of Kenya of 2010 established a framework for expanding rights and freedoms for Kenyans.  For example, Article 21(4) of Chapter 4 – The Bill of Rights – states that, “The State shall enact and implement legislation to fulfil its international obligations in respect of human rights and fundamental freedoms”.  Furthermore, the Constitution allows for adoption of international laws to domestic Kenyan laws, as demonstrated by Article 2(5), which states that, “The general rules of international law shall form part of the law of Kenya”, and Article 2(6), which declares that, “Any treaty or convention ratified by Kenya shall form part of the law of Kenya under this Constitution”.

These articles set the pace and parameters for change in policy and practice, as well as application and monitoring of international human rights standards as it relates to health care in Kenya.  For example, the Constitution gives special mention to vulnerable populations most often at risk of health issues and least likely to be able to access health services, specifically denoting women, children, and persons living with disabilities as priority populations.  Additionally, the underlying determinants of health such as adequate food, housing, clean safe water, education, and social security are guaranteed for all.

As it relates to women particularly, the United Nations Committee on the Elimination of Discrimination against Women declared that the adoption of a new Kenyan Constitution in 2010 provided for the immediate domestication of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and included a comprehensive Bill of Rights, which enhances protection for women.  However, the Committee expressed its concern inter alia with regards to the inadequate recognition and protection of the reproductive health and rights of women in the State, and with regards to the Reproductive Rights Bill, which is yet to be enacted[xxx].

In response to these elements outlined in the Kenyan Constitution pertinent to the right to health, the Ministry of Health in Kenya planned and designed the ‘Kenya Health Policy 2012-2030’[xxxi].  The Kenya Health Policy 2012-2030 is also consonant with ‘Vision 2030’[xxxii], Kenya’s national long-term development blue-print, which sets an overall aspiration to secure the country as a globally competitive and prosperous industrialized middle-income country by the year 2030.

 

Kenya Health Policy 2012-2030

The overall goal of the Kenya Health Policy[xxxiii]  is “attaining the highest possible standard of health in a manner responsive to the needs of the population” (art. 4.1).  To realize this goal, the policy aims to deliver “equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans” (art. 4.1).  In addition to conforming to the goals of ‘Vision 2030’, the health policy aims to realize the fundamental human rights comprised in the Constitution of Kenya 2010.  Further, it envisions policy principles based on an equitable health delivery system; efficient application of health technologies; a multi-sectoral approach to realizing health goals by applying a ‘Health in All Sectors’ approach by focusing on health-related sectors including Agriculture, Education, Roads, Housing, and Environmental factors in realizing the objectives of the policy; social accountability; and a people-centred  and participatory approach to healthcare services delivery.  The policy’s guiding principle of a people-centred  approach to health acts to ensure informed participation in the delivery of health care services.  The policy outlines that community involvement in decision-making, delivery, and monitoring of interventions is important, thus providing every citizen of Kenya with an opportunity to participate and gain information on policy implementation.

The policy’s aims to strengthen collaboration with other sectors through its adoption of a ‘Health in All Sectors’ approach may help to influence the design, implementation and monitoring of policies and programmes in other sectors that may have an impact on health, including Education; Housing; Agriculture; Roads; and Environment.  By adhering to this approach, the policy aims to influence the social determinants of health, such as access to safe drinking water and adequate sanitation, gender issues, safe housing, food security, nutrition, road safety, occupational hazards, income and security, which subsequently affect the right to fulfilment of a good standard of living.

Results: HIA of Kenya Health Policy 2012-2030

 

Availability

An essential element of the right to health is availability of public health and healthcare facilities, goods, services, and programmes within a State[xxxiv].  The CESCR (2000) provides a description of the concept of availability: “Functioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party” (art. 12(a)).  Availability also comprises the social determinants of health, such as safe water, adequate sanitation facilities and other health-related buildings, adequately qualified staff receiving domestically competitive salaries, as well as availability of essential drugs.[xxxv]

To satisfy Availability criteria, the Kenya Health Policy supports the provision of “equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans” (art. 4.1).  The policy adopts a primary health care approach to ensure availability of services and to organize the health system (art. 4.1).  The policy seeks to realize its objectives through a number of policy orientations: 1) An efficient service delivery system that enhances health outcomes through, inter alia, specialized systems that enable delivery of services to marginalized populations (art. 5.2.1); 2) A comprehensive leadership system that delivers on the health agenda, for which leadership and governance in health are related to the following: (a) management systems and functions; (b) partnership and coordination of health care delivery; (c) governance systems and functions; (d) engaging of public and private service providers; (e) planning and monitoring systems and services; (f) health regulatory framework and services (art. 5.2.2); 3) Adequate number and equitable distribution of health personnel (art. 5.2.3); 4)  Equitable, efficient, transparent and accountable resource mobilization, allocation and use, with assurance of social and financial risk protection (art. 5.2.4); 5) An adequate health information system to ensure that decisions are evidence-based (art. 5.2.5); 6) Universal availability of essential health products such as drugs and vaccines as well as appropriate technologies (art. 5.2.6); 7) Adequate and appropriate health infrastructure based on consumer needs; for example, buildings, transport, medical equipment, and technology including information and communication technology (ICT) (art 5.2.7).

 

Accessibility

Accessibility comprises four distinct components (CESCR 2000), namely; Non-discrimination; Physical accessibility; Economic accessibility (affordability); and Information accessibility (art. 12(b)).  For the most part, the Kenya Health Policy assures a health system that is accessible to all, particularly ascertaining the need to treat vulnerable populations with dignity by focusing attention to their needs.  Under ‘Policy Goal’, the Kenya Health Policy refers to “attention to the needs and rights of vulnerable groups, and an emphasis on ensuring that health systems are made accessible to all” (art. 4.1).

Ensuring accessibility, by virtue of non-discrimination, implies that all people are afforded access to health facilities, goods, and services, and the most vulnerable and marginalized populations receive particular attention and assistance in ensuring their equitable access to such services, in law and in fact, without bias, favour, prejudice, or discrimination[xxxvi]. To conform to the norm of non-discrimination, the Kenya Health Policy outlines an equity-based distribution of health services; “Equity in distribution of health services and interventions” is listed as a “Policy Principle”, under which it is stipulated that: “Focus shall be on inclusiveness, non-discrimination, social accountability, and gender equality” (art. 5.1.1).  The policy specifies that no social disparities or exclusion will be employed in the delivery of healthcare services, but rather: “Services shall be provided equitably to all individuals in a community irrespective of their gender, age, caste, colour, geographical location, and socio-economic status” (art. 5.1.1).

Physical accessibility, according to the CESCR (2000), ensures close and safe proximity of health facilities, goods and services for all sectors of society, especially vulnerable or marginalized groups.  “Policy Objective 4” of the Kenya Health Policy is to: “Provide essential health care”, which is “affordable, equitable, accessible, and responsive to client’s needs”; a priority policy strategy in order to realize this objective is to “scale up physical access to person-centred health care by prioritizing solutions targeting hard to reach, or vulnerable populations” (art. 4.2)

Furthermore, economic accessibility (affordability) can be assured by making health care as well as services relating to the underlying determinants of health, such as safe and potable drinking water and adequate sanitation facilities, affordable to all, including disadvantaged groups, such that vulnerable and poorer households are not subjected to disproportionate financial strain when compared to richer households[xxxvii]. The Kenya Health Policy guarantees that payment at the point of use of health services will be progressively eliminated, particularly for marginalized and indigenous populations (art. 5.2.4).  This will increase utilization of health facilities and services, and thus reduce mortality and morbidity, especially for poorer households[xxxviii].

 

Finally, information accessibility entails the right for individuals to seek, receive, and distribute information and ideas with regards to health issues, while avoiding any breach in personal data confidentiality[xxxix]. The Kenya Health Policy is oriented towards the provision of adequate health information to consumers and other stakeholders in order to inform their decision-making process.  The policy aims to promote this health information for evidence based decision-making by “strengthening mechanisms for health information dissemination to ensure information is available where and when needed” (art. 5.2.5).

 

Acceptability

Acceptability denotes that all health facilities, goods and services are culturally appropriate and medically ethical.  This means that health facilities, goods and services must respect the culture of individuals, minorities, peoples and communities, be sensitive to life-cycle and gender requirements, and be designed to respect confidentiality, and improve the health status of those with health care requirements.  For example, with respect to medical ethics, since 2000 national and regional clinical trial registries have been established in Africa (Pan African Clinical Trial Registry); Asia (including the Japan Primary Registries Network); Australia/Oceania (Australian/New Zealand Clinical Trials Registry), and across the remaining continents; the International Clinical Trials Registry Platform has also been established (ICTRP)[xl]. Viergever et al. (2014) have outlined that benefits of the registration of clinical trials include increased transparency of clinical trials for both health care workers and patients, and increased accountability of those conducting the trial.  From a random sample of four hundred records of clinical trials registered between 2012 and 2013 extracted from the ICTRP, the authors reported that substantial problems with quality are still evident, and continue to impede the meaningful utilization of registered information on clinical trials.  Acceptability is explicitly mentioned in the Kenya Health Policy: “Primary health care approach aims to provide essential health care, based on practical, scientifically sound, and socially acceptable methods and technology” (art. 4.1).

 

Quality

Quality in the realm of acceptable health implies that, in addition to health facilities, goods and services that are culturally acceptable, a health system is scientifically and medically appropriate and of good quality.   Ensuring quality requires, for example, a skilled healthcare workforce, drugs, and hospital equipment that is scientifically approved and medically and ethically appropriate, safe and potable water, and adequate sanitation[xli].

Ensuring the provision of quality health services is explicitly mentioned several times in the Kenya Health Policy.  Indeed, with respect to the policy’s overall goal of “attaining the highest possible standard of health in a manner responsive to the needs of the population”, it is explicitly outlined that the “policy aims to achieve this goal through supporting provision of equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans” (art 4.1).  Further, with respect to the policy section on ‘Contribution to development’ (art 4.1), the policy explicitly states: “the policy will contribute to the attainment of the country’s long term development agenda outlined in Kenya’s Vision 2030.  This will be through the provision of high quality health services with a view to maintain a healthy population able to deliver the development agenda” (art 4.1).  The term ‘quality’ is also explicitly mentioned in the policy, inter alia, under ‘Policy objectives’ (art 4.2) and specifically in this section under ‘Policy objective 1: Eliminate Communicable Conditions’, under which it is explicitly cited that priority policy strategies include: “ensure quality of care in provision of the preventive and promotive services addressing major causes of the burden due to communicable conditions” (ii).

 

Limitations of Kenya’s Health Policy 2012-2030

While Kenya’s Health Policy explicitly refers to the rights and needs of vulnerable and marginalised populations, it fails to demonstrate specific contexts in which a particular vulnerable group might require an accelerated or specialized treatment, or to address specific barriers to accessing health services experienced by particular populations of vulnerable groups[xlii]. This failure prevents Kenya from fully complying with international health norms[xliii].

For example, with respect to physical accessibility, the policy fails to specify how to establish interventions for people with physical disabilities.  India, by contrast, fulfils this mission.  The ‘National Policy for Persons with Disabilities’ of India stipulates that “persons with disabilities are provided with devices, such as prostheses and orthoses, tricycles, wheel chairs, surgical footwear, and devices for activities of daily living, learning equipment (Braille writing equipment, Dictaphone, CD player/tape recorder), low vision aids, special mobility aids like canes for blind, hearing aids, educational kits, communication aids, assistive and alerting devices, and devices suitable for persons with mental disabilities”[xliv].   While the above example relates specifically to a national disability policy and not a health policy per se, Kenya’s policy goal of a ‘Health in All Sectors’ approach, according to the Kenya Health Policy 2012-2030 (art 5.1.4) provides a justification for disability and health policy to be examined or considered under the same umbrella.  In fact, Kenya’s vision for a  multi-sectoral approach will require more robust coordination with other health-related sectors, including Education; Roads; Housing; Agriculture; and Environmental factors.  As such, the importance of including explicit specific provisions for people with disabilities, and for vulnerable groups more generally, in the Kenya Health Policy 2012-2030 must not be underestimated; specific provisions in Kenya’s Health Policy for the equitable access of vulnerable groups, such as persons with disabilities, to health services will undoubtedly be reflected in the health policies formulated by Kenya’s health-related sectors, such as those listed above.  The explicit inclusion of human rights and vulnerable groups in national health policies may significantly increase the likelihood of such provisions for the health-related human rights of vulnerable groups, and for all people, to be inculcated in health service provision.

The Kenya Health Policy amalgamates the health-related needs, aspirations, and barriers and facilitators in relation to access to health care services of vulnerable and hard-to-reach populations in its specifications, but it fails to take the next step in explicitly including health requirements and barriers to healthcare experienced by particular populations of vulnerable groups that would lend themselves to more equitable and inclusive distribution of health interventions.

 

Conclusion

The Kenya Health Policy 2012-2030 is guided by the principles of the right to health, as outlined in the Kenyan Constitution 2010[xlv].  The policy clearly outlines its aim to comprehensively adopt a rights-based approach to health care delivery.  It evidently understands and strives to base the design, implementation, monitoring and evaluation of the policy on the principles and norms of human rights.  As evidenced by the HIA of policy content conducted in this analysis, it is evident that the policy’s guiding principles relate to AAAQ[xlvi]. However, the HIA of policy content reported here has also highlighted a failure of the Kenya Health Policy to make explicit provisions for the health-related needs, aspirations, and specific barriers to health services experienced by vulnerable groups.  In the absence of such provisions, the health-related human rights explicitly included in the Kenya Health Policy 2012-2030, and outlined by the AAAQ framework, will ensure only access to health services ‘for some’ but not ‘for all’.


References

 

 

[1] For further details on EquiFrame and its previous application to health policies, as well as international health documents and International Donors’ policies, please see: Amadhila et al. 2013; Amin et al. 2011; Eide et al. 2012,2013; MacLachlan et al. 2012; Mannan, Amin, MacLachlan, and the EquitAble Consortium 2012; Mannan, MacLachlan, McVeigh, and the EquitAble Consortium 2012; Mannan et al. 2012,2013; Schneider et al. 2013; and Van Rooy et al. 2012.

 

[2]As the policy only recently took effect, there is not enough data to draw significant conclusions about the impact of its provisions on Kenya’s healthcare system.

 

 

 

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[v]United Nations (UN) General Assembly. 1966. International Covenant on Economic, Social and Cultural Rights (General Assembly Resolution 2200A (XXI)). http://www.ohchr.org/Documents/ProfessionalInterest/cescr.pdf

[vi]CESCR (Committee on Economic, Social and Cultural Rights). 2000. Substantive issues arising in the implementation of the International Covenant on Economic, Social and Cultural Rights. General Comment No. 14 (2000). The right to the highest attainable standard of health (Article 12 of the International Covenant on Economic, Social and Cultural Rights). United Nations Economic and Social Council.www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En

[vii]ibid

[viii]Hunt, P., and G. MacNaughton. 2006. Impact assessments, poverty and human rights: A case study using the right to the highest attainable standard of health (Health and Human Rights Working Paper Series No 6). World Health Organization and UNESCO. http://www.who.int/hhr/Series_6_Impact%20Assessments_Hunt_MacNaughton1.pdf

[ix]CSDH (Commission on Social Determinants of Health). 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization. http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

[x]Braveman, P., and S. Gruskin. 2003. Defining equity in health. J Epidemiol Community Health57 (4):254-58. doi:10.1136/jech.57.4.254

[xi]Whitehead, M., and G. Dahlgren. 2006. Levelling up (part 1): A discussion paper on concepts and principles for tackling social inequities in health. Studies on Social and Economic Determinants of Population Health, no. 2. Copenhagen, Denmark: World Health Organization Europe. http://www.who.int/social_determinants/resources/leveling_up_part1.pdf

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[xiii]Flaskerud, J. H., and B. J. Winslow. 1998.Conceptualizing vulnerable populations health-related research. Nursing Research 47 (2):69-78. http://journals.lww.com/nursingresearchonline/pages/articleviewer.aspx?year=1998&issue=03000&article=00005&type=abstractGilson L., and D. McIntyre. 2005. Removing user fees for primary care in Africa: the need for careful action. BMJ 331:762-765.

[xiv]MacLachlan, M., M. Amin, H. Mannan, S. El Tayeb, N. Bedri, L. Swartz, A. Munthali, G. Van Rooy, and J. McVeigh. 2012. Inclusion and human rights in health policies: Comparative and benchmarking analysis of 51 policies from Malawi, Sudan, South Africa, and Namibia. PloS ONE 7 (5):e35864. doi:10.1371/journal.pone.0035864

MacLachlan, M., C. Khasnabis, and H. Mannan. 2012. Inclusive health. Tropical Medicine & International Health 17 (1):139-41. doi:10.1111/j.1365-3156.2011.02876.x

UNHCR (Office of the United Nations High Commissioner for Refugees). n.d. Caring for vulnerable groups; Attending special needs. http://www.unhcr-centraleurope.org/en/what-we-do/caring-for-vulnerable-groups.html

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Mohamed Isaack Maalim and Joanne McVeigh and Hasheem Mannan
Mohamed Isaack Maalim and Joanne McVeigh and Hasheem Mannan