The Beginning

Kenya confirmed her first case of COVID-19 on March 12, 2021, in a 27-year-old lady who had traveled from the United States via London [1]. Three days later it was announced that the two passengers that had sat next to her on the airplane had also tested positive. In addition to the trepidation that came with these announcements and given the significant traffic between Kenya and COVID-19 hotspots at the time such as China, there was a healthy skepticism as to whether this was indeed the prime case in our country. Many told of serious ‘colds and flus’ in the months preceding the announcement. This was the first confirmed case, but in all likelihood was not the first case. The concern that coronavirus may have been spreading among us already as the announcement was being made, was valid, and not at all comforting.

Evolution of the Pandemic

Prior to the big announcement, we had been keenly following international news and had heard about the epidemic that had ravaged Wuhan, China as well as Northern Italy. Now our focus shifted to our local networks as daily updates of case numbers were announced by the Ministry of Health in the most somber, and often times stern manner. Numbers of confirmed cases were climbing fast rising to 3,305 in three months. By this time, 90% of cases were locally transmitted [2]. It was no longer an imported disease. There was an established local transmission.

Containment Measures

Strict containment measures followed. Travel by non-residents of Kenya from any country with any case of coronavirus was restricted. Schools and higher learning institutions were closed in March, 2020. People were advised to work from home unless they were providing essential services. Cash transactions were discouraged.

In-person meetings were banned. Visits to hospitals were highly restricted. Every private and public facility was to provide soap and water/hand sanitizers to its patrons. On March 25, 2020, all local and international flights were banned. We were cautioned that if we behaved normally, the coronavirus would treat us abnormally. We were urged to practice hand hygiene, social distancing, and wearing face masks to curb the spread of the virus.

Confirmed cases, whether they were symptomatic or not, were isolated in health facilities. Mandatory quarantine at one’s own expense was instituted for case contacts. Dusk to dawn curfew was imposed. Televised cat and mouse games between commuters and police at curfew time became a source of amusement in a tense time. Those arrested were subjected to forced quarantine, a practice that was later abandoned due to its obvious counter-productiveness in preventing the development of stigma to the novel illness.

Life as we knew it changed dramatically. We stocked up on what supplies each person could afford. We worked from home. Our kids stayed home for nine months.

COVID-19 response committees and task forces at national, county, public and private sector levels were constituted. The tasks at hand were risk communication, health promotion, disease surveillance, infection prevention and control, case management, health facility preparation, and resource mobilization.

Risk Communication, Health Promotion, and Public Education

Pervasive false narratives that had already begun to emerge when the disease was first announced by World Health Organization (WHO) in late 2019 began to take root in our country, spreading like wildfire and growing out of proportion. ‘The disease was a plot to wipe out the elderly’; “the developed West had hatched a plot to annihilate the populations of poorer countries”. On and on the narratives went. They were evocative, emotive, and confusing.

Later when vaccines became available, the perceived fast pace with which they were developed came into question. A new wave of misinformation ensued. It became apparent that it is difficult indeed to have a common understanding when it comes to complex science such as vaccine science.

Science and scientific research for that matter is not a public facing field. Healthcare is visible to the public, sure, but health science and pharmaceutical science are not. Most scientific breakthroughs are attained after years of work by hundreds of scientists working in numerous laboratories, publishing pieces of their work in peer-reviewed scientific journals that are available only to paid subscribers and are presented only in scientific symposia and whose titles do not catch anyone’s attention (except the attention of the scientists themselves!).

There was a vaccine that seemed to have come out of the woodwork mysteriously and quickly. How was the scientific establishment to plausibly explain that there had been decades of work leading to the timely breakthrough? ‘Nobody had heard’ of these ‘so called’ mRNA vaccines. Attempts to bridge the information gap between the scientists and the public became a challenging undertaking indeed. How can one package the science of nucleic acid therapeutics in public-friendly and believable language?

Efforts to combat the pervasive false narratives were notable but not as effective as expected. This was largely because they were undertaken by the same ‘suspect’ people from the health science ‘establishment’. Vaccine experts could then not successfully advance effective counterclaims to the misleading propaganda as this would further alienate the intended audience. Influencers from the entertainment industry and community lay leaders had much better success. We enlisted them in our risk communication and public education strategy.

Disease Surveillance

In those early days, contact tracing was paramount to disease surveillance. Once a case was identified, all contacts were tested and quarantined. There was also active surveillance in hot spots, which led to useful information that guided geographically limited interventions such as cessation of movement. Quarantine was expensive, and in the early days also fearful, for the quarantined. Later, when self-quarantine and self-isolation were encouraged and people felt trusted to comply, the stigma of being quarantined diminished. It became common for people to state publicly that they were in self-managed quarantine due to possible exposure.

Public Health Cultural Tension

The country enlisted the help of trained public health officers that had participated in the containment of Ebola in West Africa. This was a prudent move that meant we did not have to reinvent the wheel or unnecessarily use our resources to provide extensive training to new public health teams. At the very onset, we had a trained army of fighters. This, however, had its challenges. Given their experience with the Ebola epidemic, their approach to handling both live cases as well as the remains of COVID-19 patients was, at least at the onset, overreaching. Families were not allowed to view the remains of their departed loved ones if they had succumbed to COVID-19. Public health teams, in full protective suits, buried bodies in hurriedly dug graves, sometimes in the cover of night and without participation of the deceased’s family members. Video footage of such burials quickly made the rounds. People were appalled. Affected families, lay leaders, and even Members of Parliament protested to the authorities, questioning whether such drastic measures were warranted. WHO released guidelines on handling COVID-19 human remains and the strict burial practices were relaxed. The period of time allowed between death and burial still remained 72 h—a period that is way too short for burial rites which would otherwise last up to two weeks in some communities.

Impact on Mental Health

Kenya has a high burden of mental illness due to ill health, psychosocial disability, and premature mortality. Depression and anxiety disorders are the leading mental illnesses in Kenya. Huge gaps exist in access to mental healthcare. This bleak scenario was exacerbated by the effects of COVID-19 [3]. Lost livelihoods, the fear of contracting COVID-19, the out-of-reach hospital bills for families of those hospitalized with COVID-19, sudden deaths of colleagues and loved ones, and the disrupted social order where children were not going to school, were some of the factors that had a negative impact on mental wellbeing.

Cases of suicide rose. It was reported that more than 500 people in the country took their lives in the first six months of 2021, more than in all of 2020 [4]. Judging from the timing of this sharp rise, it is imaginable that the disheartening trend was due to the deleterious effects of the pandemic.

His Excellency the President had ordered the formation of a task force on mental health in June 2019, mandating its members to study the status of this issue and make appropriate recommendations for health system reform to better address mental health problems. The task force report in October 2019 made strong recommendations around mental health. The principal recommendation was to declare mental ill health as a national public health emergency. Other key strategies recommended were to raise mental health awareness and to increase the capacity to detect and treat mental health illness.

In terms of COVID-19 and mental health, the task force report observed that COVID-19 containment measures, particularly restriction of movement, threatened the already marginal access to mental health services. This was resulting in undiagnosed mental illness as well as the worsening of existing disease particularly in rural communities.

The mental health impact of COVID-19 was notable amongst healthcare professionals. There was a new infectious disease, about which so little was known. They were expected to have answers for the inquisitive public while their own practice guidelines were constantly changing due to the evolving, and sometimes contradictory, published findings. There were times when the supplies of personal protective equipment were so strained, they had to improvise with non-optimal methods of protection to keep themselves safe. Many lost their jobs due to the decline in the business of healthcare establishments. For those who kept their jobs, their workload particularly during the surges, was grueling. Even as the disease was taking out their most valiant frontline soldiers, they were expected to relentlessly carry on the battle. They were concerned for themselves but most of all for their families. Some would spend the night in their vehicles for fear of passing on the virus to their loved ones.

Impact on Availability of Medicines and Health Commodities

One of the first negative impacts of the pandemic even before it arrived in our country was a strain on global medical supplies availability. As a country, we import more than half of our medicines and medical supplies, largely sourced from India and China. Hubei Province, China, a global hub for pharmaceutical raw materials, was locked down for months. A lot of medicines sourced from India are dependent on China for their active pharmaceutical ingredients. India ring fenced threatened supplies for their local use. The effect of this double jeopardy was a shortage of pharmaceuticals and other health supplies in our market.

This shortage revealed our over-dependence on imports for our pharmaceutical and medical device supplies. We were faced with the inadequacy of our capacity to locally produce not just complex medicines, but even simpler technologies like personal protective equipment. There was also a self-induced artificial shortage of essential medicines when we scrambled to buy and hoard perceived coronavirus therapies, a behavior fueled by misinformation on the internet.

The pandemic necessitated massive procurement of commodities such as hazmat suits, ventilators, and personal protective equipment that would otherwise be procured in much smaller quantities. The rushed procurement process bypassed established protocols of public procurement, for good reason, but naturally attracted shrewd business entities wanting to benefit from this state of a public health emergency. Public procurement scandals ensued, revealing gaps in the governance of our public health institutions.

Oxygen Woes

The third and fourth waves of COVID-19 saw a sharp rise in hospitalizations and consequently in the number of patients needing oxygen. The life-saving gas that is the mainstay of managing hospitalized COVID-19 patients was in ultra-high demand. Hospitals began to look for ways to increase their oxygen capacity. It was not easy to do this overnight.

Effect on Human Resources for Health

No country in the world has adequate human resources for health. According to estimates by the World Health Organization, the global health worker shortage is estimated to rise to 18 million by 2030. This has led to policy initiatives around task shifting and task sharing in order to maximize the utilization of each cadre of health workers.

The pandemic brought these issues to the fore. There was heightened demand for intensive care nurses, anesthetists, pulmonologists, medical officers, pharmacists, laboratory technologists, and many other healthcare workers. The need for health workers was compounded by the need to quarantine COVID-exposed health workers. We had to urgently assess our health human resource capacity if we were to adequately combat the ravaging pandemic.

Health Facility Preparedness

Initially, all confirmed cases of COVID-19 were isolated in health facilities. Later on, as we embraced home-based isolation and care, we reserved hospitals for moderately to severely ill patients. As each wave came, more wards were converted to isolation wards, or new ones built from scratch. Building and equipping more intensive care units was, however, not that easy. We had a few sleepless nights having realized that we had less than 500 critical care beds during the first three months of the pandemic, and even less ventilators. We however breathed a collective sigh of relief when the first wave did not overwhelm our capacity. Estimates by experts showed that we would have several waves of infection before we could achieve herd immunity, and so we still needed to quickly expand our critical care surge capacity.

Economic Impact

During the initial months of the pandemic, business slumped in many sectors. The private for-profit sector suffered the most. Many establishments shut down. Hotels closed their doors for lack of customers. Private schools could not keep up with the overheads needed to maintain the schools in the absence of students. People were afraid to go to the hair salon, to the open-air market, and even to the hospital. The hospitality industry suffered the biggest blow. Airlines downsized. Staff were subjected to pay cuts—these were the lucky ones. Many people lost their livelihoods altogether.

A World Bank report in November 2020 indicated that most households had lost income with unemployment increasing five-fold between October 2019 and October 2020. Families were mitigating this lost income largely by reducing consumption such as by skipping meals. One in four adults did not have enough food to eat and female-headed households were disproportionately affected. COVID-19 was not just a medical issue, it was a social and economic issue [5, 6].

Impact on Health Targets

Contraception

Family Planning (FP) 2020 goals support the rights of women and girls to freely decide for themselves when, whether, and how many children they want to have. Kenya had made FP2020 commitments which they exceeded. Kenya surpassed its target of contraceptives prevalence rate among married women of reproductive age of 58%, attaining 61% by November 2019 [7, 8].

There were concerns that the gains made in our family planning strategy would be lost due to the negative effects of COVID-19 on the availability of health commodities as well as the hesitancy of family planning clients to access health facilities for fear of contracting COVID-19.

HIV

By 2020, 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. These were the ambitious global targets to help end the AIDS epidemic. By mid-2020, Kenya had made significant strides in achieving these targets, performing at 90%, 82%, and 92%, respectively [9, 10].

Kenya has 1.2 million Kenyans on life-long anti-retroviral (ARV) medication, the mainstay of HIV treatment [10]. There was a period of time in 2021 when due to insufficiency of supplies, patients would get a one-month dose or less of ARVs, rather than the usual 90-to-180-day dose. This was because supplies were stretched but thankfully had not run out. Patients had to make more frequent trips to the clinic to pick up refills.

COVID-19 clearly affected every facet of our lives, impacting us socially, and economically, and not sparing our mental and physical health.

Collective Action to Build Back Better

The response to the pandemic, though it was largely led by government ministries of internal security and health, enlisted input from all of the government and all of society. Individuals, families, communities, health professionals, civic leaders, lay leaders, religious leaders, and the private and public sectors continue to combine efforts to minimize, mitigate, and combat the negative effects of the pandemic.

The giant telecommunication companies donated their expertise in providing mass communication on protective measures and public health education. They sponsored text messaging that gave tips on how to report a suspected case of COVID-19, where to get psychosocial support, and how to protect oneself from contracting the disease. In a country with pervasive use of mobile phones, this method of mass communication was effective and far-reaching.

Religious leaders, in an act of self-regulation, penned the guidelines by which their faithful would safely gather for congregational worship. They spoke together as a unified voice regardless of their creed, collectively negotiating with the government to allow in-person worship services. They bargained successfully and were allowed to open places of worship in strict conformance to the guidelines they had developed, bearing the responsibility of enforcing the guidelines on their faithful. This demonstrated the power of unity and the appeal of self-regulation.

To address mental health among healthcare professionals, various health professional associations combined efforts to ease the mental and psychosocial burden of COVID-19 on health workers by setting up a call center manned “by health workers for health workers”. This call center provided psychological first-aid and directed health workers to further care as needed. It raised the morale of health workers a great deal and was a heartening example of inter-cadre collaboration.

The way healthcare is delivered evolved. Digital health interventions were embraced as a way to contain the spread of the virus in the process of accessing healthcare. The ‘call a doctor’ types of mobile and web-based applications proliferated, and hospitals, pharmacies, and laboratories increased their home care services. A notable innovation was the Wheels for Life Initiative which was formed to respond to pregnancy-related emergencies during curfew hours and across the locked down county boundaries. This initiative brought together private sector partners and healthcare professionals to provide a hotline for pregnant women to consult an obstetrician and to get a paid cab or ambulance should they require to visit a health facility. By October 2021, 10,570 mothers had been assisted by doctors through telehealth consultations, 1,322 cabs were dispatched, and 899 emergency ambulance trips were done, resulting in hundreds of women having safe deliveries [11].

Kenya is second only to China in the usage of mobile money for financial transactions [12]. The already pervasive mobile money grew by leaps and bounds fueled by reduced transaction charges and the demand for cashless modes of transacting money. Mobile money transactions rose to USD 32.6 million between January and June 2021 compared to USD 30.6 million between July and December 2020 [13].

To ease the financial strain on businesses occasioned by COVID-19, the government committed to expedite pending bills owed to the business community. These were the bills of monies owed by the government to the private sector for services and products rendered. These bills would accrue and accumulate a great deal due to the bureaucratic nature of government. The need to cushion businesses against the effects of COVID-19 caused a positive shift in the speed of settling these debts. One hundred and forty million dollars in pending bills were cleared by the government between January and March 2021, easing cash flows and injecting life into numerous businesses that were on the brink of collapse.

The Kenyan textile industry rose to the rising demand for face masks. The government placed orders for masks with local suppliers who had passed quality checks from the Kenya Bureau of Standards. By the end of April 2020, we were able to locally produce as many surgical and cloth masks as were required, without a need to import. In addition to this, local entities began to manufacture full personal protective gear such as aprons, face shields, goggles, and full-body suits at prices comparable to imported ones. Furthermore, with partnerships between institutions of higher learning and the private sector, we started to assemble ventilators.

Oxygen Supply

It takes significant investment to install an oxygen production plant—some reports put the initial minimum capital outlay at one million US dollars. Hospitals could not install oxygen plants overnight to take care of patients already in their isolation wards and intensive care units. They needed quick and innovative solutions.

As hospitals scrambled desperately for oxygen to manage the surge of moderate to severe COVID-19 patients during the second and third waves, it was realized that steel manufacturers produce high quantities of oxygen as a necessary part of their production process and they had plenty of industrial oxygen gas to spare. They generously offered the life-saving gas free of cost to hospitals in need. All that the hospitals needed to do was to find cylinders and the steel plants would fill them with oxygen. Medical gas regulators worked with the steel industry to put in place an abbreviated set of requirements to ensure that the donated gas was safe for medical use. Meanwhile, medium to large-sized hospitals began the process of oxygen plant installation and piping, and smaller hospitals purchased more cylinders to refill from their larger counterparts.

Donor Support

During the time of the pandemic, we experienced diminishing support from donors for our health programs, in part due to our achieving the status of a lower middle-income country, and in part due to the global economic shrinkage occasioned by the COVID-19 pandemic. This brought the idea of sustainable financing of our health system to the fore. The triple threat of non-communicable diseases, communicable diseases, and epidemics needed to be largely funded by our exchequer. Advocacy was in high gear to ensure that we took care of some of the previously heavily donor-dependent budget lines in our health sector. This was even more important seeing as we are at the last mile of reaching several important targets across many health areas including contraceptive prevalence, neglected tropical diseases, and HIV. We must be in control of our pace at this critical time to reach these targets.

Going Forward

Multi-stakeholder collaboration continues. The private sector, organized under the Kenya Private Sector Alliance (KEPSA), which is the apex body of the private sector in Kenya, continues to donate both cash and health equipment to national and county governments as well as to private and public health facilities. KEPSA also continues to support the government in the procurement of vaccines by raising funds from members to complement the government’s orders of vaccines. As a result, tens of thousands more vaccines were shot in the arms of Kenyans.

Local COVID-19 vaccine production plans began in earnest, aimed at easing access amidst global supply constraints. This production will start in the form of ‘form and fill’ where we will package already made vaccine into primary and secondary packaging [14].

Efforts are intense to ensure gains made in meeting health targets prior to the pandemic are not eroded. For instance, to preserve the upward trajectory of the prevalence of modern contraception and to mitigate the effects of fear of accessing health facilities, the Ministry of Health directed that women be given longer refills of their preferred contraceptive method.

A lot continues to be done to achieve greater self-reliance in medicines and medical commodities. Looking into the future, we have drafted policies to spur the growth of our local pharmaceutical manufacturing sector and have diversified our drug supply chains to prevent stock outs.

The general public tremendously increased its health literacy. Vaccine hesitancy dramatically declined. As of October 30, 2021, a total of 5,307,181 COVID-19 vaccine doses were administered across the country, with demand outstripping the supply [15].

COVID positivity rate went below 1% in October 2021, a clear indication that containment measures were successful. A concerted effort by a multiplicity of stakeholders created a sense of national pride in increasing our self-sufficiency in managing the pandemic. COVID-19 has been a rough and painful journey for our health system. One thing, however, is certain; we are in a much better place than where we began. The lessons we have learned have made us build back better, stronger, and together.