Volume 10 Issue 2
Peer reviewed article
Child mortality remains a significant concern globally with 6 million deaths in children under 5 years of age in 2012. In relation to Millennium Development Goal (MDG) 4 to reduce vaccine-preventable disease mortality and morbidity by two-thirds by the end of 2015 compared to 2004, Sub-Saharan Africa is unlikely to reach this tar- get with the current projection. In Kenya, childhood mortality remains highly elevated and this can be correlated to a number of risk factors including poor physical environments, limited access to resources and medical facilities, lack of maternal welfare and antenatal care, and outbreaks of infectious disease. This is especially evident in low resource settings such as informal settlements, or slums as they are colloquially referred to, in Kenya’s capital, Nairobi. Despite there has been some effort to address the health and living conditions of slum dwellers, more actions are required to improve the health and quality of life in this population. Some fundamental examples include interventions relating to immunisation programmes, water sanitation, and safe waste removal. Diversity in racial and ethnic origins, cultural taboos and sensitivities must be considered when formulating policies and interventions. This article will explore and discuss barriers and focus on strategies and changes that can be implemented to raise the health status. In particular, immunisation strategies will be examined and discussed as a major intervention in the minimisation of childhood mortality rates.
A UN-Habitat (United Nations Human Settlements Programme) report projects that one in three of the world’s population will live in urban informal settlements by 2030.  In Nairobi, there is significant rural to urban migration with a significant proportion of population growth being directed into the slums. More than 60 percent of the city’s population of more than 3 million resides in slum communities, which occupy only 5 percent of the total residential land area. This rapid rate of population growth in urban areas is concerning as it exceeds the rate of possible economic development  and is not accompanied by equivalent socio-economic and environmental development. 
The UN-Habitat defines slum as a community characterised by insecure residential status, poor structural quality of housing, overcrowding, inadequate access to safe water, sanitations and other infrastructure.  It is associated with a high concentration of poverty and substandard living. There is also insecurity of tenure and marginalisation from the formal sector, including basic health services. It is an area of concentrated disadvantage.
Slums are characterised by population density and diversity where the population is often transient, thus erecting unique barriers which stand in the way of achieving health, especially in the context of continuing care.  In the context of Nairobi, the city is comprised of seven divisions which contain over 78 informal settlements with Kibera, Korokocho and Kasarani making up the top three slums in terms of population. 
Disaggregated urban data shows health outcomes in slums are often worse than similar groups in rural communities, especially with regards to infant and under-five mortality rates.  A number of factors attributed to poor health outcomes include limited access to healthcare services, lack of finances, and poor health seeking behaviours.  The rapid increase in population density further exacerbates the social and medical problems in these resource poor settings.  In particular, vaccine-preventable infectious diseases, which often progress to end-stage diseases, are a major burden for the communities as they may require high-level care and treatment. 
Child immunisation has been identified as a key factor in the prevention of many communicable diseases, as it is considered and has been proven to be the most cost-effective and efficient method of preventative health.  The increased rural to urban migration is associated with a decline in health due to negative trends in immunisation and lack of access to resources such as clean water.  Due to the complex nature of slums, factors such as cultural appropriateness cost, and accessibility must be considered for successful health interventions.
The Nature of Informal Settlements in Nairobi
Nairobi, the capital of Kenya, is situated in the South West of the country. It is Kenya’s largest city with a population of over three million people.  The annual rate of population growth in Nairobi is 4.3 percent, which is primarily due to the rural- urban migration, also known as the ‘urbanisation of poverty’ with 75 percent of the population growth occurring in informal settlements.
Over 70 percent of the population in Nairobi resides in informal settlements where the physical environment is hazardous to health and is characterised by: a lack of basic services such as roads or waste disposal;  substandard housing; illegal or inadequate building structures; overcrowding; and a high population density. [5,8] The dwellings are generally poorly constructed with temporary materials that have been carried away by the floods during wet season. 
Despite the Kenyan government owning all land upon which these informal settlements stand, it continues to not officially acknowledge these settlements.  This translates to a near absence of any formal or official basic government services or facilities including schools, clinics, running water, electricity, or proper lavatories.  In the rare instances that these facilities do exist, they tend to be privatised services in which cost erects a barrier for access. 
Waste disposal and water sanitation facilities are absent, along with any formal services providers such as basic healthcare. These poor living conditions leave a negative impact on the health of the residents as there is limited access to safe drinking water, sanitation, garbage and sewage treatment. All of these factors add to the increased prevalence and spread of pathogens, thus perpetuating constant infection and risk of an epidemic in slum dwellers. [2, 5]
Health and Social Services
Private clinics and private pharmacies are the most popular destinations for health-seeking individuals. However, these private institutions are generally managed by unlicensed or poorly trained professionals, sometimes non-professionals, and are often associated with poorer health outcomes. [6,9]
The health and disease pattern of the slum dwellers is congruent with the physical environment of the informal settlement. Water, in particular, is concern with difficulty with access, cost, and quality. The access points for water collection is only located far from their houses, and water collection may even only be available on certain days and times. These barriers result in resident using sewage for bathing and washing, or using other sources, such as borewater and rainwater. All of these sources are highly contaminated and perpetuates the spread of waterborne diseases. 
Legal Issues and Crime
According to Mutisya and Yarime, the Kenyan government policies have yet to focus on making low-cost housing available, or providing populations within these informal settlements with viable long- term alternative which have further exacerbated the growth of slums.  In particular, informal settlements have been excluded from city authority planning and budgeting processes. Furthermore, the people who undergo the rural to urban migration in search of employment often have no realistic alternative to life as slum dwellers.
This results in a state of hopelessness which leads to an environment and a population who are vulnerable to maladaptive coping mechanisms such as self-medicating with alcohol, addictive substances and drugs. In addition, difficulty accessing education, employment, or recreational facilities translates to unlimited free time, which further increases their risk to alcohol, drugs, and crime, which is prevalent in informal settlements. 
Adding to the list of social issues within slums is the increase in commercial sex workers, and easy access of a list of drugs and substances including bhang (marijuana, cocaine, glue, petrol, and chang’aa (an illicit local brew believed to be responsible for both morbidity and mortality in users). 
Due to the complex nature of the illegal status of the slums and the residents, health and social services are virtually non-existent within these settlements.  For the same reasons, slum dwellers are often excluded from the usual benefits provided to or required for formal sectors. In essence, slum dwellers are often employed and exploited on a day-to-day basis on low wages. [3,11]
In a study published by La Ferrara, the main source of income for slum dwellers takes the form of hawking, short term day employment, and the operation of small businesses without licenses. Something positive within these informal settlements are these ‘self-help groups’ that are comprised of sub-populations, in particular women, who support each other and pool together their resources to build social capital for start-up projects. 
The education level in populations in informal settlements is low. Only 14 percent of the population have completed high school, and
33 percent have not attained education beyond primary school.  A mere 2 percent have achieved post secondary school education. Within the slums, schooling facilities are inadequate and often inappropriate. Most schools are initiated as business ventures and do not meet the requirements for a learning institution. Moreover, attendance remains low hence perpetuating the vicious cycle of low education and poverty.
Often school are initiated as business ventures and do not meet their requirements as learning institutions. The class size ranges from 50 to 60 students, and are often lead by unqualified teachers. 
Millenium Development Goal 4 and Sustainable Development Goal Note #1
The target of Millennium Development Goal (MDG) 4 is to reduce the under-five mortality rate by two- thirds between 1990 and 2015. There is overall progress with MDG 4, but Sub-Saharan Africa is amongst the regions showing the least progress in reducing the child mortality rate. Statistics show an increasing trend of child death within the first month of live in these regions due to many factors including:  high communicable disease prevalence and transmission (constant risk of epidemic);  overcrowding; poor hygiene; contaminated water sources. [4,13] With the expiration of the MDGs imminent, it is unlikely that the target will be reached in Kenya. Neonatal mortality rates are especially grim in the slums of Nairobi. The under-five mortality rate in Nairobi slums is 156 per 1000, which is greater than any other urban site within Kenya. 
It is equally important to consider the sustainability of any health interventions that are implemented to improve the status of public health in urban informal settlements in Nairobi. In accordance with sustainable development goals (SDG) Note 1 titled “Leave no one behind and provide a life of dignity for all”, improving the health of vulnerable and at-risk populations can help improve their standard of living and quality of life by reducing any disabilities or limitations stemming from chronic end-stage diseases that are easily preventable.  For example, at risk populations are vulnerable musculoskeletal injury and their chronic sequelae,  mental illnesses, complications of substance abuse, and chronic infections, all of which can negatively impact their psychological and physical ability to find and retain employment, or the ability to care for their self and family.  It is imperative that effort and energy is diverted into prevention strategies to stop precipitating events leading to poor health from occurring. Strategies such as vaccination and maternal education beginning from the antenatal period have been shown to be effective in improving neonatal mortality rates, and improve the health status of children.
At present, informal settlements comprise 43 percent of combined urban populations in all developing countries.  The urban regions are home to 78 percent of the population in the least developed countries. Current trends show a significant continuing shift towards urbanisation of population in one-third of the world’s population projected to live in urban informal settlements by 2030.  Hence, it has become increasingly important to address the issues leading to concentrated disadvantage in slum dwelling populations including: physical environments hazardous to health; lack of health and social services due to the illegal nature of slums; increasing crime rates; and poverty of opportunity in education and employment. [2,10] Recognising informal settlements into government planning and budgeting will assist in building the necessary basic infrastructure (roads, water sanitation, sewage treatment, and waste disposal), and fund primary healthcare centres which is expected to have a positive impact on the health status of the slum population.
The Evidence for Immunisation as a Health Intervention
According to WHO, immunisation remains one of the most successful and cost effective health interventions to date,  with an estimated six million deaths prevented worldwide annually. WHO also estimates that 2.5 million deaths amongst children under 5 years of age worldwide are prevented annually through immunisation against diphtheria, tetanus, pertussis, and measles.  The expanded programme on immunisation (EPI) in Kenya is primarily funded by the Kenyan Government and the GAVI Alliance (International organisation funded by public and private sectors for the increase of vaccination coverage. 
Immunisation programmes have a positive effect on public health and disease control through eradication and elimination of communicable diseases with potentially fatal outcomes.  For example, smallpox has been successfully eradicated globally through population immunisation and surveillance for health and outbreaks. Elimination involves high levels of immunity in the population whereby transmission no longer occurs indigenously, and imported cases no longer result in sustained transmission leading to epidemics. Furthermore, immunisation also have a positive health impact, not only on the population being vaccinated, but also in reducing disease incidence amongst non-vaccinated individuals. This indirect effect, known as ‘herd immunity’, [9,18] occurs when transmission of the disease is decreased in a population with high levels of immunity, thus essentially breaking the chain of infection. Herd immunity have been demonstrated in Gambia with Hib vaccine (for the prevention of influenza caused by the pathogen Haemophilus influenze type b) coverage of approximately 70 percent of the population, there were similar findings in a West African Community vaccinated against Pertussis, commonly known as Whooping Cough. 
There is compelling evidence in favour of vaccinations for the reduction of death and disease, as well as minimising the associated burden to
the health care system. There is also mitigation of disease severity with multiple studies showing evidence of decreased severity with shorter duration of illness in vaccinated populations in comparison to unvaccinated populations. [15, 19- 21] On an individual basis, there is a reduction in the burden on health and better prevention of chronic sequelae from vaccine-preventable infectious disease.
Current National Immunisation Programme in Kenya
The Global Immunisation Visions and Strategy (GIVS) was approved and endorsed in the World Health Assembly in 2005. The primary objective
of GIVS aligns with MDG 4 and SDG Note 1 in terms of reductions in morbidity, mortality and disability due to life threatening infection from vaccine-preventable diseases by two-thirds. The Division of Vaccines and Immunisation (DVI) under the Ministry of Public Health and Sanitation of Kenya have formulated a multi-year plan running from 2011 to 2015. To minimise and prevent children from succumbing to infectious diseases that are prevalent in the community, especially low resource settings, a specific programme for infants has been formulated to reduce childhood mortality rates. Immunisations included in this programme include vaccines against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenza type b, measles, and pneumococcus51. All of these diseases are highly infectious and are significant contributors to child mortality rates. The immunisation schedule for Kenya also has additional vaccinations, such as yellow fever, for children in high-risk populations and districts. The vaccines are provided free of charge to the recipients.
The African Population and Health Research Centre (APHRC) facilitates the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) which runs research projects and data collection on longitudinal Maternal and Child Health within the Korogocho and Viwandani slums of Nairobi. [6,9] The NUHDDS project enrolled women in these areas which have given birth since September 2006, and administered a questionnaire about the vaccination history of their children. Data was collected from 1848 children aged 12-23 months who were expected to receive all the WHO- reccommended vaccinations.  Compared to the estimated global DTP3 (diphtheria-tetanus- pertussis3) immunisation coverage of 83%,  there are regions in Sub-Saharan Africa where communities are significantly undervaccinated.
 Within Kenya, the number of children who are reported to have received complete vaccination range from 48.5 percent in the North Eastern regions, and 85.8 percent in the Central regions.  Focussing on Nairobi, 74 percent of 12-23 month old are reported to have completed the WHO recommended vaccination programme,  but the percentage drops to 44 percent for children living in informal settlements. 
In this particular study, Mutua et al, found that protective factors for complete vaccination according to the WHO recommended guidelines include older maternal age, maternal education (primary school), low parity with previous vaccination nation with older siblings, birth taking place in a health facility, and attendance of antenatal and postnatal care follow-up. Maternal age under 20, high parity, and education levels lower than primary school were identified as risk factors.  The study concludes that children living in slums are underserved with vaccinations with the limited and lack of access to public health facilities flagged as a major barrier.  This is an important consideration to take into account when formulating new public health policy.
In addition to the routine vaccination schedule, the Kenyan Ministry of Health also conducts supplemental immunisation activities (SIA) to identify and minimise gaps in health and increase the vaccination rate. Essentially, the aim of SIAs is to address inequities in the vaccination coverage, especially in sub-populations, who were not targeted or were missed with regards to the
routine vaccination programmes. This may be achieved by delivering the standard vaccination schedule and catch-up immunisations. Other
goals of the SIAs include documenting the coverage and epidemiology of health within the targeted populations in addition to micronutrient supplementation (Vitamin A, zinc and electrolytes) to boost the general health and immune status. 
Vulnerable populations living in the slums benefit the most from SIAs due to their poor vaccine coverage with routine programmes. The SIAs were also able to reach the small percentage of the previously unreached population in high-coverage districts. 
Vaccinations are primarily given in fixed temporary sites, most often in venues such as schools, churches and mosques.  Due to the informal and often illegal nature of the slums, there is very little infrastructure and few facilities contained within the complex. As a result, there is the implication of decreased rates of health seeking behaviour and vaccination due to the physical barrier of distance. This argument is supported by a study which demonstrated a general trend of mothers with unimmunized children living the furthest from vaccination sites, as well as comprising the lower end of the wealth and social status.  Furthermore, as shown in Bangladesh there is evidence to show increased vaccination coverage amongst children who are within close proximity to vaccination venues and clinics. [27,28]
Funding of the GIVS Expanded Programme on Immunisation
The targes of the EPI of the Kenyan DVI are to increase vaccination rates through routine immunisation of children with outreach strategies with particular attention diverted at sub-populations with elevated risk factors, such as children in the lowest socioeconomic brackets and slum residents. The particular EPI has secured over $46 million of funding in 2011, and the amount will increased to $91 million by the end of 2015. In addition, the Kenyan Government, and the GAVI Alliance, other significant financial donors include WHO, UNICEF, and foreign aid. [6, 23, 29] According to WHO Global Health Observatory Data, the expenditure for public health in Kenya is 4.49 percent of their Gross Domestic Product (GDP) or USD 14.35 per capita which remains low on the global scale despite increasing from previous years.  The low funding is a key factor leading to and perpetuating poor health status and outcomes. overflow effects of poor health conditions include loss of productivity and decreased socioeconomic growth in communities. Vulnerable populations include slum dwellers, especially due to an increased risk factors associated with absolute poverty, high susceptibility to famine, overcrowding and disease outbreak.
The Australian Government has made some contributions to projects and programmes that assist in achieving the MDGs on a global scale.
The fundamental objective of the former AUSAID programme is to help people overcome poverty through multi-lateral pathways: microscopic and macroscopic finance and economics strategies: health and community engagement; and funding of basic supplies and health provisions.  Australia’s Official Development Assistance (ODA) target of 0.37 percent of the gross national income totalling USD 5251 million in the financial year of 2013 – 2014 was met.  This translated to USD 429 million donated to Africa and the Middle East, with USD 93 million being allocated to Kenya. However, with recent changes to AUSAID being amalgamated under the Department of Foreign Affairs and Trade (DFAT), funding to the Sub- Saharan programme has been cut. The anticipated budget for 2013-2014 of $249.9 million has been slashed to $133 million resulting in the many programmes under this particular portfolio to be completed earlier or have reduced funding. The funding is projected to decrease, and will fall well below the internationally recommended target (ODA target of 0.7 percent of the gross national income) set by the United Nations as a strategy towards meeting the MDGs.
Despite the funding cuts to the Sub-Saharan African programme, the Federal Australian Government has pledged $250 million over the five year period of 2011-2015 towards the GAVI alliance, with further ongoing support of another $250 million contribution over 2016-2020. 
GAVI estimates over 7 million lives have been saved since the implementation of GAVI programmes for children in developing nations.
The limited and lack of public health infrastructure in the informal settlements within Nairobi are a major barrier to poor health seeking behaviours and health outcomes in particular in relation to vulnerable population such as women and children. It is estimated that 21 percent of children under five in Sub-Saharan Africa are moderately or severely underweight. This proportion is increased in children living in slums. 
Despite the establishment of the EPI and the national immunisation schedule for infants and children, barriers to accessing health services and vaccinations still exist. Common themes include limited maternal education, young maternal age, physical distance, and monetary constraints. With regards to physical barriers, the delivery of antenatal care and immunisation are quite centralised with fixed facilities and posts within Nairobi city. Strategies to address this issue to implement public health facilities within the informal settlements or outreach services which does increase the cost of delivery. Many studies have shown compelling evidence in favour of publically funded health facilities and with associated positive outcomes in health,  thus comprehensive policy making and significant efforts towards building a public health system in slums must be undertaken to help in closing the gap in health disparities.
Furthermore, the establishment of public health facilities within the informal settlements bring along other benefits to the community. There is creation of opportunities for education, training, empowerment, and employment. The opportunity for up-skilling and employment can assist in reducing some of the financial and societal burdens associated with living on or below the poverty line and reduce the unemployment rate within informal dwellings. 48 percent of Sub-Saharan Africans live on less than $1.25 each day, and residents within slums are overrepresented in this statistic. 
Another major advantage of training local people is the flow-on effect of education and awareness trickling out into the wider community. The intended effects are the dissemination of information relating to health and disease implications, raising awareness of risk factors, and more important, the preventative measures involving hygiene and nutrition that can be implemented without specialised equipment. In a population that has been displaced with very little social or community networks and support, community ownership and access to information will lay the foundations in re-establishing connections and reduce gaps in knowledge for health.
A multitude of factors impact the state of health and wellbeing in low resource settings, such as in the context of informal dwellings in Nairobi. At present, the projection of progress of MDG 4 is not on track for the targets to be reached by 2015, thus child mortality prevention strategies and implementation requires further discussion and efforts at the post- 2015 agenda meetings.
Many long-standing issues exist including malnutrition, overcrowding, high disease prevalence, and poor access to resources. These issues have a detrimental influence on the health status of the residents of the Nairobi slums, and require long term solutions requiring extensive planning. Immunisation is one of the most cost effective and efficient strategies that can be implemented rapidly and can vastly minimize many of the harmful factors skewing towards infectious diseases and poor health outcomes. In addition, the EPI also supports SDG target of providing a
life of dignity for all, especially through improved health of at-risk populations. An emphasis on the DVI having establishments in and working together with the local community should be highlighted as evidences indicate the positive effect of community integrated approaches to healthcare, especially in low resource settings, and to negate cultural barriers which may otherwise impede the delivery of essential immunisations.
Phoebe Shiu is a 6th year medical student studying at James Cook University,
Queensland. She has a special interest in Global Health and is looking forward to working with underserved populations. Phoebe travelled to United Nations Environments Assembly in Kenya as part of a Global Voices delegation, which further sparked her interest in sustainability in healthcare and policy making. In the future, she hopes to combine both travel and medicine by volunteering and working overseas.
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