Urban Population and Health Status, Challenges and Prospects in Kenya Mr. John Mwondo Anampiu, BA, MA (Demography), (PhD Student, University of Nairobi, Kenya), Assistant Director of Population - Policy National Council for Population and Development, Kenya ESRC, Global Challenges Research Fund Conference, University of Leeds November 23-24, 2016 A well managed population for quality life

Outline Population and Health Status – urban relative advantage declining due to rural policy focus Challenges and lessons learnt from MDGs Way forward for SDGs Need for an urban survey focused on vulnerability in urban areas

With a 3% growth rate, population will reach about 65 million by 2030 Population Growth Rate (%) 1948 – 2009 (urbanisation rate 2010 4.3% - NB high urbanization rate could be due to a rise in rate of natural increase) With a 3% growth rate, population will reach about 65 million by 2030 Source: Kenya National Bureau of Statistics

Births per woman for the three-year period before the survey Fertility Trends Births per woman for the three-year period before the survey Fertility has decreased from 8.1 births per woman in 1977-78 to 3.9 birth per woman in 2014. The total fertility rate of 3.9 is the lowest ever recorded. Data from 2003 and later are nationally representative. Data from surveys before 2003 exclude North Eastern region and several northern districts in the Eastern and Rift Valley regions.

Fertility by County – great diversity, more than urban/rural split Births per woman 2014 Counties with TFR > 6.0 Narok: 6.0 Garissa: 6.1 Samburu: 6.3 Turkana: 6.9 West Pokot: 7.2 Wajir: 7.8 Urban 3.1 Rural 4.5

Urban variation by ethnicity Nairobi’s major slums are ethnically quite distinct (Mathare mostly Kikuyu, Kibera mostly Luo/Nubi, Kangemi mostly Luhya etc) How urban is the urban population? Are people in Kangemi more influenced by norms related to health and reproduction which derive from rural Luhya or urban Nairobi? Political pro-natalism.

Percent of currently married women age 15-49 Trends in Use of Contraception 2014 Urban Any Method 62%; Modern Method 57% Rural Any Method 56%; Modern Method 51% Percent of currently married women age 15-49 Any method Any modern method Use of any method of family planning has greatly increased from 39% in 2003 to 58% in 2014. Modern method use has increased from 32% in 2003 to 53% in 2014. Use of injectables has increased more than any other method.

Current Use of Modern Contraception by Residence Percent of currently married women age 15-49 using any modern method of contraception Use of modern methods is higher in urban areas. 57% of married women in urban areas use modern methods, compared with 51% of women rural areas.

Place of Delivery (medical facility urban 82%, rural 50%) Percent distribution of live births in the five-year period before the survey 61% of births in Kenya take place in a health facility; 46% in a public facility and 15% in a private facility. More than one-third of births nationwide take place at home. Delivery in a health facility is more common in urban areas (82%) than in rural areas (549%). In rural areas, nearly 50% of births are delivered at home.

Counties with > 80% health facility deliveries Delivery in a Health Facility by County: to think of an urban-rural split is too simple Percent distribution of live births in the five-year period before the survey Counties with > 80% health facility deliveries Kirinyaga 93% Kiambu 93% Nyeri 89% Nairobi 89% Nyandarua 86% Murang’a 85% Mombasa 82% Meru 82% Embu 82% [Kisumu below 80%...]

Maternal Mortality Maternal mortality includes all deaths that occur during pregnancy, during birth, and up to 2 months after birth or the end of the pregnancy. Maternal mortality ratio (MMR) for the 7- year period before the survey (national) = 362 deaths per 100,000 live births (CI: 254,471)

Childhood Mortality Rates Kenya deaths per 1,000 live births for the five-year period before the survey: Nairobi City County has Kenya’s second highest under-5 mortality rate, and the highest neonatal mortality rate Infant and under-5 mortality rates in the five-year period before the survey are 39 and 52 deaths per 1,000 live births, respectively. At these mortality levels, about 1 in every 26 Kenyan children dies before reaching age one. About 1 in every 19 children does not survive to their fifth birthday. The neonatal mortality rate in the past 5 years is 22 deaths per 1,000 live births.

Early Childhood Mortality Rates by Place of Residence Nairobi City County has Kenya’s second highest under-5 mortality rate, and the highest neonatal mortality rate Infant and under-5 mortality rates in the five-year period before the survey are 39 and 52 deaths per 1,000 live births, respectively. At these mortality levels, about 1 in every 26 Kenyan children dies before reaching age one. About 1 in every 19 children does not survive to their fifth birthday. The neonatal mortality rate in the past 5 years is 22 deaths per 1,000 live births.

Trends in Childhood Mortality Kenya deaths per 1,000 live births for the five-year period before the survey Childhood mortality rates have declined in the past 11 years. Infant mortality has declined from 77 deaths per 1,000 live births in 2003 to 39 in 2014. During the same time period, under-5 mortality has sharply declined from 115 to 52 death per 1,000 live births.

Maternal Factors Associated with High Risk of Childhood Mortality Children are at an elevated risk of dying if: Too short birth interval: less than 24 months after a previous birth (urban 16.7%; rural 18.4%) Mother is “too young” (under 18) (urban 14%; rural 15%) or “too old” (over 40) (urban/rural not known…) High birth order: mother has four or more children (urban/rural not known…)

Childhood Mortality by Previous Birth Interval Deaths per 1,000 live births for the 10-year period before the survey Children who are born less than 2 years after a previous birth have an extremely elevated risk of dying. Doctors recommend that women wait 3 years between births. Under-5 mortality is twice that among children born less than 2 years after a preceding sibling than among children born 4 or more years after a previous child (83 deaths and 44 deaths per 1,000 live births, respectively).

Challenges and Lessons from MDGs Not member-state driven: Developed by a small group of experts – behind closed doors Largely based on transfer of aid and expertise from global North to global South MDGs were static with no consideration of national or regional differences (Not Contextual) Half the time was spent on preparations, advocacy and sensitization. To transform Kenya into a globally competitive, newly industrializing ,middle income country and provide a high quality of life to all of its citizens in a clean and secure environ The Population Policy for National Development and its implementation plan addresses the SDG

Lessons learnt from MDGs Inadequate support for the National Steering Committee (NSC) on MDGs for urban issues Lack of a context-specific (urban-rural) Campaign Strategy on MDGs Inadequate mobilization of Resources for urban areas Lack of National Long-Term Framework on urban health (Beyond 2015) Inadequate context-specific Policy Research and Analysis on MDGs Related Issues for evidence-based decision-making

Way Forward (for SDGs) Undertake research to better Understand and Address the prevailing inequalities in population and health (i.e. social, economic and regional/county – within urban populations) Implement the unfinished business of the MDGs on urban health Future interventions should reflect Lessons learnt from MDGs and other related programmes. Eg Need capacity building among partners in various sectors on urban-focused SDGs

Way Forward (for SDGs) Need support in further analysis of existing relevant survey datasets urban vulnerability, e.g. Kenya Health Assessment Surveys (1999, 2004, 2010, 2016/7); Kenya Integrated Household Budget Survey 2015/2016; Kenya STEPS NCD Risk Factor Survey 2015 (prevalence of smoking, hypertension, inactivity, poor diet, obesity etc.) Kenya DHS 2014 – only urban-rural split; need to analyse vulnerability within the urban population Policy briefs – vehicle for academic research to influence evidence-based decision-making. Demystify demographic, health, climate projections.

ASANTENI SANA To transform Kenya into a globally competitive, newly industrializing ,middle income country and provide a high quality of life to all of its citizens in a clean and secure environ The Population Policy for National Development and its implementation plan addresses the SDG