in Kenyan Health Facilities Failure to Deliver Human Rights Violations of Women’s Failure to Deliver Violations of Women’s Human Rights in Kenyan Health Facilities © 2007 Center for Reproductive Rights and ISBN: 1-890671-35-5 Federation of Women Lawyers–Kenya 978-1-890671-35-5 Printed in the United States Center for Reproductive Rights 120 Wall Street, 14th Floor Any part of this report may be copied, translated, or New York, NY 10005 adapted with permission from the authors, provided United States that the parts copied are distributed free or at cost Tel +1 917 637 3600 (not for profit) and the Center for Reproductive Fax +1 917 637 3666 Rights and the Federation of Women Lawyers–Kenya [email protected] are acknowledged as the authors. Any commercial www.reproductiverights.org reproduction requires prior written permission from the Center for Reproductive Rights or the Federation of Federation of Women Lawyers—Kenya (FIDA) Women Lawyers–Kenya. The Center for Reproductive Amboseli Road off Gitanga Road Rights and the Federation of Women Lawyers–Kenya PO Box 46324-00100 would appreciate receiving a copy of any materials Nairobi, Kenya in which information from this report is used. Tel 254 (020) 3870444 Fax 254 (020) 3876372 [email protected] Cover photo: © Stock Connection RM, 2007 www.fidakenya.org TABLE OF CONTENTS Acknowledgements ..................................................................................... 5 Executive Summary ..................................................................................... 7 Introduction .............................................................................................. 11 Lack of Access to Family Planning Services and Information ....................... 15 The Devastating Effects of Kenya’s Restrictive Abortion Law (Inset) .................24 Abuse and Neglect Around Delivery ........................................................... 26 Pumwani Maternity Hospital (Inset) ..............................................................40 Structural Barriers to Quality Maternal Health Care ..................................... 44 Discrimination in the Health Care System ................................................... 51 Detention in Health Facilities for Inability to Pay (Inset) .................................56 The Challenges of Seeking Redress ........................................................... 63 The Human Rights Implications of Violations in the Health Care System ....... 77 Recommendations ..................................................................................... 86 Note: This page has been left blank for printing purposes. ACKNOWLEDGEMENTS We are grateful to the women who shared their experiences with us and whose voices are the heart of this report. Without their courage and candour, this report would not have been possible. This report is a joint publication of the Center for Reproductive Rights (CRR) and the Federation of Women Lawyers—Kenya (FIDA Kenya). Claris Ogangah, Legal Counsel at FIDA Kenya, Elisa Slattery, Africa Program Legal Adviser at CRR, and Avani Mehta Sood, International Legal Program Fellow at CRR, conducted the interviews and research and drafted the report. Failure to Deliver benefited from the invaluable input and support of Jane Onyango, Executive Director of FIDA Kenya, Anne Amadi, Deputy Director of FIDA Kenya, Luisa Cabal, International Legal Program Director at CRR, and Laura Katzive, Deputy Director of the International Legal Program at CRR. At FIDA Kenya, special thanks to Evelyne Opondo, Senior Legal Counsel, for her assistance in conceptualizing the project; to Diana Wambui, Counselor, Hilda Nguyai, Client Services Manager (Nairobi), and Nancy Ondeng, Client Services Manager (Kisumu), for arranging and conducting excellent focus group discussions; and to the Legal Aid Team for their assistance with the project. At CRR, special thanks to: Morgan Stoffregen, International Program Associate, and Zachery Milan, Communications Production Assistant, for coordinating the production and publication process; Suzannah Phillips, International Legal Program Intern, for her extensive help with the fact-checking and final editing of the report; Tori Okner, International Legal Program Assistant, for her assistance with finalizing the report; and the entire International Legal Program for their insightful feedback during several brainstorming sessions on the report. Dr. Elizabeth Muli, Professor of Law at Moi University, was the research consultant for this report, and Julia Barke, Jessica Evans, Johanna Fine, Suzannah Phillips, David Lachman, and Swati Mehta of the Columbia Law School Human Rights Clinic, directed by Peter Rosenblum, contributed invaluable research assistance. Araz Shibley copyedited this report, and Pascale Kahwagi at Alarm Sarl designed the cover and layout. The Tumaini and Tumuasi Women’s Groups in Kawangware and the Liverpool’s Victory Post-Test Group in Kisumu assisted with the formation of several of the focus group discussions. Dr. Stephen Ochiel (Chairperson of the Kenya Medical Association), Dr. Joseph Karanja (former Chairperson of the Kenya Obstetrical and Gynaecological Society), and Mrs. Anne Mulinge (Administrator of Kasarani Maternity Hospital) provided crucial insights into the key issues affecting women’s reproductive health in Kenya during our preliminary research. The Reproductive Health and Rights Alliance, a coalition of individuals and organizations dedicated to reproductive rights advocacy, facilitated this project. While there are far too many to name here, we are indebted to all of the health care providers, government officials, journalists, and others for generously sharing their time and knowledge with us. 5 Violations of Women’s Human Rights in Kenyan Health Facilities Note: This page has been left blank for printing purposes. EXECUTIVE SUMMARY The Kenyan government has taken many positive steps to advance women’s reproductive health and rights. However, as this report from the Federation of Women Lawyers–Kenya (FIDA Kenya) and the Center for Reproductive Rights (CRR) demonstrates, much work remains to be done. For decades, women seeking reproductive health services in Kenya have been suffering serious human rights violations, including physical and verbal abuse and detention in health facilities for inability to pay. Shortages of funding, medical staff, and equipment plague the health care system, particularly the public sector, dramatically interfering with the ability of health care staff to provide adequate care. These systemic problems have persisted, in part, because of a dismal lack of accountability within the health care system, which in turn stems from a lack of basic awareness about patients’ rights and the absence of transparent and effective oversight mechanisms. The situation at Pumwani Maternity Hospital (PMH), Kenya’s largest public maternity hospital, vividly illustrates the Kenyan government’s failure to take responsibility for severe human rights violations in health facilities. PMH’s patients are among the poorest and the youngest women in Kenya, making them particularly vulnerable to discrimination and abuse. Women who delivered at PMH described decades of egregious rights violations—including unsafe conditions for delivery and behaviour by medical staff that abused and humiliated women and endangered their lives and the lives of their infants. While the problems that plague PMH are not unique to the hospital, they have been exacerbated by the facility’s large number of patients and its struggles with mismanagement and corruption. Despite the fact that PMH’s shortcomings have been public knowledge for decades, only piecemeal and inadequate measures have been taken to address them. The lack of funding for public health facilities contributes to the emergence of a two-tiered health care system in Kenya, which discriminates against poor women and prevents or delays access to much-needed care. The government of Kenya controls slightly over half of all health facilities in the country while the rest—including the majority of maternity homes—are controlled by non-governmental, private, and mission organizations. While government facilities cost less money, they tend to have long lines, suffer from congestion, lack supplies, and treat patients unequally. Women expressed a firm belief that money usually buys better treatment, and when they could afford it, they opted for private facilities. The difference between delivery in public and private facilities was often stark, with women contrasting the rude treatment from staff and dirty, overcrowded quarters at public facilities with the attentive care they received in a private facility. However, the care at private facilities is not uniformly good. The private sector also suffers from lack of government regulation and private health facilities are not required to establish complaint processes for patients as a condition of registration. Nearly half of all women obtain their contraceptives from private facilities, a fact that has specific implications for women. Health facilities run by faith-based organizations often provide limited services and information depending on the facility’s religious affiliation. For instance, Catholic facilities offer counselling only on natural family planning and do not supply condoms. Although Catholic and non-Catholic Christian facilities treat survivors of gender-based violence, these facilities do not provide emergency contraception, as the method is considered