Challenges in policy reforms for non-communicable diseases: the case of diabetes in Kenya

Figures & data

Figure 1. Flowchart showing the process of policy document collection and screening.

Figure 2. Multi-level stakeholders influencing diabetes policy processes in Kenya (2016).

Table 1. Informants’ perceptions of the policy development process for diabetes/NCDs in Kenya.

Ministry of Health	‘The ministry takes the leadership but we involve all other partners in terms of we call them for a retreat or meeting then we discuss what are the priority areas – which areas do we need to cover to reverse the burden. We even involve the patients through an organization called the Kenya Defeat Diabetes Association which is the national umbrella for all the diabetes support groups.’
Donor in the Pharmaceutical Industry	‘It is very MoH driven. They involve us in development of guidelines. They do call us where they need our support.’
Civil Society	‘It (policy development) is inclusive within the health sector but on the other hand I feel it’s kind of exclusive. When you look at diabetes and other NCDs, you see that some of the other things that impact health, in terms of causative or predisposing factors to diabetes and other NCDs are beyond the health docket and yet we never involve these people.’
County	‘Before we used to receive the policy documents from the ministry and implement depending on the funds they send us. Now we receive the policies then develop our own depending on our priorities.’

Table 2. Perceptions on non-health sector involvement in policy development for diabetes and NCDs.

‘[…] NCDs in this country is something that is just gaining popularity it was not there before. Diabetes- as much as people are living with it and in the communities, they are suffering, most of the partners who are non-health partners do not see the need for them to be involved in diabetes for example let’s say finance, agriculture, trade, transport, security. They didn’t think that they can be involved in diabetes care or diabetes policy making so what we do is we give technical support then other NGOs that are dealing with diabetes come on board to give technical advice.’ (representative from MoH NCD department)

Referring to transport, agriculture, trade, urban planning, housing and security sectors: ‘So if we (the health sector) are talking about these things ourselves and not involving the other sectors – so that they are also sensitive to the issues around predisposing factors and put them into their development plans in the different sectors- then we are basically talking to ourselves. And I think we would be more effective when we involve them to create ownership at implementation level.’ (representative from IDF Africa)

‘We should involve non-health partners in everything so that we are not talking to them or directing them but they are part of the development of policy and implementation…because most of the times we are meeting them after we have developed the policies and we are now trying to negotiate. In my opinion we need to involve them earlier than later.’ (county health representative, Kenya)

‘Actually, the level of awareness outside the health sector and even within the health sector and among policy makers is still very low. These guys either they are closing their eyes or because there is no funding they just keep quiet but that is one of the challenges. We have low awareness among policy makers in terms of what needs to be done to reverse this trend or what needs to be done for prevention and also for care and treatment of the patient.’ (representative from diabetes civil society Kenya)

‘Players that contribute to NCD risk factors and those that contribute to prevention – their budgets are miles apart! This is clear even in our media. The advertisements that contribute to risk factors are more than those of prevention.’ (key informant from pharmaceutical sector)

‘We had tried to push the parliament to develop an NCD bill to become an act of parliament. Unfortunately, when it came back to the ministry some guys felt that we should have one act of parliament covering all NCDs instead of separately for each NCD. That proposed act of parliament was unfortunately shelved.’ (key informant from MoH-K)

Table 3. List of diabetes and/or NCD-related policies in Kenya.

policy document	level	lead agency/source ^a	pre/post UN NCD declaration	considering NCDs	covering diabetes	covering NCD risk factors	prevention emphasis ^b
United Nations Political Declaration on NCDs 2011	international	UN	(reference)	yes	yes	yes	p, s, t
Kenya Health Policy 2014–2030	national	MoH	post	yes	yes	yes	not defined
Kenya Health Sector Strategic Plan 2014–2018	national	MoH	post	yes	yes	yes	not defined
Kenya Vision 2030 Second Medium Term Plan 2013–2017	national	MoH	post	yes	no	yes	not defined
Kenya National Strategy for the Prevention and Control of NCDs 2015–2020	national	MoH	post	yes	yes	yes	p, s, t
Kenya National Nutrition Action Plan 2012–2017	national	MoPHS	post	yes	yes	yes	p
Kenya STEPwise Survey on NCD Risk Factors Report 2015	national		post	no	no	yes	p
Kenya Demographic Health Survey 2014	national	KnoBS	post	no	no	yes	not defined
Global Adult Tobacco Survey (ITC Policy Evaluation Report)	national		post	yes	no	yes	not defined
MoH Ministerial Investment Strategy 2014–2018	national/in-ministry	MoH	post	yes	yes	yes	p, s, t
Kenya National Health Accounts fiscal years 2012/2013, 2014/2015	national	MoH	post	yes	no	no	not defined
Kenya National Diabetes Strategy 2010–2015	national	MoPHS	pre	yes	yes	yes	p
Kenya National Clinical Guidelines for Management of Diabetes Mellitus July 2010	national	MoPHS	pre	yes	yes	yes	p, s, t
Kenya Diabetes Comprehensive Care Manual July 2010	national	MoPHS	pre	yes	yes	yes	p, s, t
Kenya National Diabetes Educators Manual July 2010	national	MoPHS	pre	yes	yes	yes	p, s, t
National Food and Nutrition Security Policy 2011	national	GoK	pre	yes	yes	yes	p
Kenya national Physical Activity Action Plan	national	MoPHS	post	yes		yes	p
Kenya Health Policy 1994–2012	national	MoH	pre	no	no	yes	not defined
Kenya National School Health Strategy 2010–2015	national	MoPHS/MoE	pre	yes	no	yes	p
Kenya Vision 2030 First Medium-Term Plan 2008–2012	national	GoK	pre	no	no	yes	not defined
2008–2013; 2013–2020 Action Plan for the Global Strategy for the Prevention and Control ofnon-communicable Diseases	international	WHO	pre, post	yes	yes	yes	p, s, t
WHO Framework Convention on Tobacco Control	international	WHO FCTC	pre	yes	yes	yes	p
Global strategy on diet, physical activity and health	international	WHO	pre	yes	yes	yes	p
Global Strategy to reduce the harmful use of alcohol	international	WHO	pre	yes	yes	yes	p
Moscow Declaration of the First Global Ministerial Conference on Healthy Lifestyles andnon-communicable Disease Control	international	WHO	pre	yes	yes	yes	p, s, t
Ministerial declaration high level segment of the Economic and Social Council, 2009	international	WHO	pre	yes	yes	yes	not defined
Brazzaville Declaration on NCD Prevention and Control in WHO AFRO Region	regional	WHO AFRO	pre	yes	yes	yes	p, s, t
Libreville Declaration on Health and Environment in Africa, August 2008	regional	WHO AFRO	pre	yes	yes	yes	p, s, t
NCD Statement of the Commonwealth Heads of Government, November 2009	international		pre	yes	yes	yes	p, s, t
IDF Diabetes Strategy for sub-Saharan Africa	regional	IDF Africa	pre	yes	yes	yes	p, s, t
Diabetes Strategy for WHO Africa Region 2007	regional	WHO AFRO	pre	yes	yes	yes	p, s, t

^a UN: United Nations, MoH: Ministry of Health, MoPHS: Ministry of Public Health and Sanitation, GoK: Government of Kenya, MoE: Ministry of Education, WHO: World Health Organization, WHO FCTC: WHO Framework Convention on Tobacco Control, ITC: International Tobacco Control, WHO AFRO: WHO African region, IDF Africa: International Diabetes Federation Africa

^b p: primary, s: secondary, t: tertiary

Table 4. Summary of policy interventions for diabetes prevention and control in Kenya.

field	prevention type	target groups, institutions	measures	responsibility/executers	status in June 2016
education, advocacy, and empowerment	primary	children in schools	integrate nutrition in school curriculum physical exercises offering healthy meals healthy school policies	national government (MoH, MoE, Teachers‘ Service Commission, etc.) county governments	physical education and nutrition education is integrated into the school curricula school health policies are currently being implemented in some parts of Kenya
	primary	workplaces, employers and employees	information of workers on the role of physical activity encouragement and facilitation of the implementation of work-related healthy lifestyle practices	all public and private sectors	implementation and monitoring at the national level are difficult the public sector has no policy private sector companies and cooperatives have in-house policies private and NGO sectors sponsor national walks, e.g. at the World Diabetes Day, and World Health Day.
	primary	public/com-munities/high risk groups and indivi-duals, health facilities and public campaigns	advocacy, distribution of IEC materials on healthy lifestyle habits usage of social and mainstream media	MoH at national and county level partners: health-care workers, religious leaders, community leaders, media entities	IEC materials are available in all public health facilities and diabetes clinics according to informants (no means of verification) media campaigns happen during World Diabetes Day the rest of the year campaigns is too expensive with less effect according to MoH the Kenya Defeat Diabetes Foundation formed as a MoH-led initiative 300 patient support groups with 40,000 members across the counties
	secondary	diabetes patients, the public, health facilities/hospitals	patient education and empowerment IEC materials self-management training	patient support groups MoH and partners: health-care workers, civil society, media entities	country wide capacity building trainings by MoH and partners taking place in health-care facilities and schools, etc. diabetes clinics established in all sub-counties across Kenya
	primary secondary tertiary	schools, communities, hospitals	capacity building of health-care workers (in-service and pre-service for medical schools) IEC materials implementation of care, treatment and management guidelines	MoH civil society patient support groups	diabetes centers of excellence present in Machakos, Kakamega, Mombasa 1,300 health-care workers trained on diabetes foot care, management of diabetes wounds and ulcers.
food policy	primary	population-wide	food regulations (to include fortification with micronutrients, limiting salt contents, food labeling, advertising) incentives for food manufacturers to replace unhealthy ingredients with healthy ones trans-fats regulations agricultural policies towards the production of traditional/indigenous food varieties food price policies to make healthy food more affordable	MoH nutrition department agriculture sector manufacturing and processing industries	food and nutrition policy developed but implementation status currently unknown high taxation in the agriculture sector has discouraged local production of fresh food leading to increased purchasing in urban areas positive: counties are now encouraging farming and agriculture as a development agenda the Kenya Manufacturers Association is now part of the MoH Inter-Agency Coordinating Committee for NCDs
tobacco and alcohol policies	primary	population-wide	implementation and scaling up of the Tobacco Act 2007 and of the recommendations of the Global Adult Tobacco Survey/International Framework Convention on Tobacco Control implementation of alcohol regulations (including minimum drinking age, banning of illicit alcohol)	county council authorities nationwide national authority for the Campaign Against Alcohol substance and Drug abuse the Kenyan police (for enforcement)	Tobacco Act developed in 2007 but its regulations not implemented until 2014; currently in the process of implementation Global Adult Tobacco Survey conducted, report disseminated. smoking zones developed and smoking in common areas fully outlawed Alcohol Act fully implemented illicit brews fully outlawed.
urban design and transportation policy	primary	population-wide	inter-ministry collaboration in urban planning development	inter-ministry collaboration city and county council authorities	so far, no inter-ministerial policy for city planning relevant ministries not involved in the policy development.
medical interventions	secondary, tertiary	patients with diabetes and high risk groups	reduction of the price of insulin increase the supply of insulin and essential medicines and testing kits optimization of the value chain adherence to treatment care and management guidelines	MoH pharmaceutical industries Kenya Revenue Authority	‘Base of the Pyramid’ project for increased insulin access by subsidizing costs (initiative of the pharmaceutical industry and the government of Kenya) ‘Change Diabetes’ project for diabetes prevention and control among children and young people
screening	primary: high risk groups, secondary: blood sugar monitoring	population-wide	routine blood glucose test in patient triaging Malaria testing combined with a blood glucose screening	health-care workers self-management for patients with diabetes health-care facilities (all levels)	glucose screening integrated into malaria testing for children in some counties
treatment and prophylaxis	primary: IGT/high risk groups, secondary/tertiary: diabetes patients	high risk indi-viduals (with IGT) and dia-betes patients	glucose monitoring adherence to treatment care and management guidelines self-monitoring/self- management	patients (self-management), health-care workers MoH (capacity building)	The National Hospital Insurance Fund has included coverage of diabetes patients in its outpatient care package

Abbreviations: MoH: Ministry of Health; MoE: Ministry of Education; IEC: information, education, and communication; IGT: impaired glucose tolerance; NGO: non-governmental organization.