Allyship in Action: Bridging Divides For Sustainable Healthcare in Kibera, Kenya
Noor-Ul-Ain Quresh
Masters of Health Science in Global Health Systems
“Don’t question what you’re stepping on” said my co-worker Collin as we maneuvered through a tight alley made of mud in Kibera, the second-largest informal settlement in the world located in the outskirts of Nairobi, Kenya.
This past summer, I had the opportunity to work as a Quality Assurance and Paediatric Research intern at Aga Khan University Hospital in Nairobi, Kenya. This experience marked my inaugural visit to Africa, where my responsibilities involved curating and supporting health systems assessments across 51 outreach clinics in Kenya and Uganda. These clinics were established with the goal of providing accessible healthcare, even in the most remote villages near Mount Kenya.
As I walked through the narrow alleys of Kibera, Collin led me to an apparently deserted clinic. I initially thought it had been abandoned until he informed me that it was the product of recent initiatives by a British non-governmental organization (NGO) to involve the community in health promotion As we entered the reception area, the sole receptionist informed us that we were the first visitors to the fully operational clinic that day. It became clear that the community was not embracing the healthcare services provided by the clinic.
The sight of numerous vacant health clinics in Kibera shocked me, given the high prevalence of chronic diseases and alarmingly high maternal mortality rates in the area. This stark paradox made me realize that healthcare services, no matter how well-intentioned, were useless if they remained inaccessible to the communities they were meant to serve.
Kibera is home to over 250,000 individuals, representing 60% of Nairobi's population while covering only 6% of its land area (Desgroppes & Taupin, 2011). The houses in Kibera are typically small, measuring 12ft by 12ft, and constructed with mud walls and concrete floors. Rent costs approximately $6.36 Canadian dollars per month (Desgroppes & Taupin, 2011).
Due to the population density, inadequate sanitation, and limited access to contraceptives, 12% of adults in Kibera have HIV (J. Madise et al., 2012). The lack of a well-established sewage system resulting in 50 homes sharing a single latrine hole, and the absence of reliable access to clean water are key factors contributing to the occurrence of diseases like diarrhea, dysentery, and typhoid in 17% of Kibera's children (J. Madise et al., 2012).
Drawing upon the resources and database of Aga Khan University Hospital, along with insights from the directors of the 51 outreach clinics, I endeavoured to understand this paradox.
The presence of numerous charities and not-for-profit organizations in Kibera is notable, with 500 of them operating within the 2.538-square-kilometer region (Farrell, 2015). In 2016, Kenya received $2.4 billion in official development assistance, $801 million of which came from the USA, making it one of the world's largest recipients of international aid (Oweno, 2023).
However, there has been a failure of these NGOs to effectively engage with the local community. The coordination board in Kenya reported that there are around 12,000 expatriate NGO workers in Kenya, working on various issues, but they often fail to transfer jobs to local workers and remain in Kenya as "career ex-pats" (Vo, 2019).
Furthermore, Kenya's healthcare system relies on health insurance, specifically through the National Health Insurance Fund (NHIF), which was established to provide coverage for those in the low socioeconomic class across the country (Kabia et al., 2019). This coverage allows for access to basic primary healthcare needs and medications free of cost for those who cannot afford it.
Regrettably, the majority of NHIF-accredited facilities are concentrated in urban areas, leaving individuals in informal settlements and rural regions without access to basic primary healthcare services (Kabia et al., 2019).
In Kibera, only one healthcare clinic, the Kibera Amref Health Centre, holds NHIF accreditation. Consequently, this necessitates patients to cover their healthcare expenses out of their own pockets. With an average monthly income of approximately $22 USD per individual in Kibera, healthcare facilities are underutilized due to the high cost of services (Desgroppes & Taupin, 2011).
The lack of integration of programs and services offered by the NGOs with the local community highlights a disconnect between the allyship that the Global North and Global South aspire to foster and the practical actions on the ground. This has led Kibera residents to express sentiments towards the NGOs such as "Kindness is killing us" and "We are being commercialized rather than being helped." (Vo, 2019).
This dynamic, characterized by organizations and researchers from the Global North coming to "assist" the Global South without recognizing the vital role of local infrastructure, expertise, and capacity building, is known as "Parachute" or "parasitic science." This issue is frequently observed in scientific research that forms the basis for treatments and interventions employed by NGOs in the Global South. Scientists from high-income countries, who frequently have greater access to funding, tend to dictate the research agenda, often neglecting the disease priorities of the countries where field research is conducted (Odeny & Bosurgi, 2022).
This unequal power dynamic perpetuates the notion that communities in the Global South are incapable of preventing and preparing for disease outbreaks, reinforcing the idea that the Global North is "superior." Consequently, it hinders the establishment of productive and substantive partnerships between health, community, and governmental entities from the Global North and South. It further accentuates a hierarchical and saviour complex, rather than fostering a reciprocal relationship built on knowledge sharing and the integration of local communities.
Furthermore, the presence of numerous NGOs often comes with certain conditions. Typically, donors from the Global North who fund healthcare projects in the Global South have specific agendas and objectives that may not necessarily align with the community's actual needs.
For instance, the Rockefeller Foundation, founded by John D. Rockefeller, was guided by managerial and business principles that stressed the importance of addressing tangible, root causes of public health issues through strategic investments (Eckl, 2014). This philosophy prioritized one-time investments that promised to address the core problems over solutions that merely tackled the symptoms. Consequently, it often led to the neglect of chronic issues for which cost-effective solutions were limited, as well as disciplines like cultural activities that did not neatly fit into a problem-solving framework (Eckl, 2014).
The charitable approach demonstrates its unsustainability and irresponsibility within the framework of global allyship, as it does not offer a reliable and lasting solution to persistent community challenges, nor does it deliver solutions tailored to the cultural context. For example, the Gates Foundation played a pivotal role in shaping treatment plans and policies for addressing Malaria. However, in their 1919 Annual Report, the foundation's president made it explicit that their ultimate goal was for the public sector in the Global South to eventually assume responsibility for these projects (Eckl, 2014). This time-limited engagement resulted in a sudden discontinuity of care, contributing to mistrust among citizens of the Global South not only towards their own governments, which had not committed to carrying on the Gates Foundation's projects from the outset but also towards the larger healthcare system and the partnerships established by nations in the Global North (Eckl, 2014).
To establish a significant alliance between academics, governments, and communities in both the Global North and South, it is imperative to incorporate the local social, economic, and cultural aspects of the intervention locations. Equally important is the development of capacity and systems within these regions to ensure the sustainability and trustworthiness of healthcare facilities.
Failing to incorporate nationwide health insurance schemes or enlist local professionals from within the community of Kibera, the health initiatives pushed by non-profit organizations, primarily led by individuals from the Global North, will not only drain valuable resources but also exacerbate the existing mistrust for international allyship.
Moving forward, non-profit organizations from the Global North, along with donors, volunteers, researchers, and students, should advocate for a comprehensive community-oriented approach, moving away from a purely charitable model. Consequently, this will strengthen allyship between nations and organizations while also building capacity in local infrastructures to sustain community-led programs.
References
Desgroppes, A., & Taupin, S. (2011). Kibera: The Biggest Slum in Africa? Les Cahiers d’Afrique de LEst, 44, 23–33. https://doi.org/10.4000/eastafrica.521
Eckl, J. (2014). The power of private foundations: Rockefeller and Gates in the struggle against malaria. Global Social Policy, 14(1), 91–116. https://doi.org/10.1177/1468018113515978
Farrell, L. D. (2015). Hustling NGOs: Coming of age in Kibera slum, Nairobi, Kenya (Order No. 3734023). Available from ProQuest Dissertations & Theses Global. (1746693137). https://www.lib.uwo.ca/cgi-bin/ezpauthn.cgi?url=http://search.proquest.com/dissertations-theses/hustling-ngos-coming-age-kibera-slum-nairobi/docview/1746693137/se-2
- Madise, N., Ziraba, A. K., Inungu, J., Khamadi, S. A., Ezeh, A., Zulu, E. M., Kebaso, J., Okoth, V., & Mwau, M. (2012). Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. Health & Place, 18(5), 1144–1152. https://doi.org/10.1016/j.healthplace.2012.04.003
Kabia, E., Mbau, R., Oyando, R., Oduor, C., Bigogo, G., Khagayi, S., & Barasa, E. (2019). “We are called the et cetera”: Experiences of the poor with health financing reforms that target them in Kenya. International Journal for Equity in Health, 18(1), 98. https://doi.org/10.1186/s12939-019-1006-2
Odeny, B., & Bosurgi, R. (2022). Time to end parachute science. PLOS Medicine, 19(9), e1004099. https://doi.org/10.1371/journal.pmed.1004099
Owino, E. (2023, June 8). Trends in Traditional and Non-Traditional Aid Flows to Kenya, Uganda, and Ethiopia.
Vo, L. (2019, July 18). Kibera Slum: When Kindness Kills Development. https://rotarypeacecenternc.org/kibera-slum/
Photo by Damian Patkowski on Unsplash
