by Mariana Costa Checa (MPA-DP ‘13)
Julia is the owner of Kisumu Eastlands Community Medical Center– a one-bedroom adobe house with an old HIV prevention poster hanging on its unpainted walls. By U.S. standards, it could be anything but a medical facility. In Manyatta, the biggest slum in Kisumu, it is just one of the many small private clinics providing basic healthcare to the inhabitants of these dust-covered streets.
As part of our internship with Millennium Cities Initiative this summer, fellow MPA in Development Practice student Paloma Ruiz and I, are collaborating with Kenya’s Ministry of Health to do a mapping of all health facilities in one of Kisumu’s districts. Despite being the third largest city in Kenya, Kisumu has traditionally performed poorly in terms of health, with an HIV prevalence rate that doubles the Kenyan national average. Precise information on where and how are people being treated is key to change this reality, and although the government has a comprehensive database of health facilities in the city, this excludes the dozens of informal clinics populating the slums, which is why we have decided to focus our work there.
Julia is a retired nurse. She worked for more than 30 years at the Nyanza Provincial Hospital, the biggest public hospital in this region of Kenya. This is, at least, a guarantee that she knows her profession, and that despite the frequent lack of supplies and medicines to actually treat patients, she can guide them on what to do when it comes to common illnesses such as malaria, typhoid, or HIV-AIDS.
Considering how small Julia’s clinic and most of the others we visited are, and given that usually there are two or three people employed and rarely any patients in sight, I have been wondering how these clinics keep up their business. Seeing one or two patients per day, Julia probably earns no more than 200 or 300 shillings (around $3), from which she still has to pay her assistant.
A trained retired nurse earning less than $2 a day is the reflection of an economic system with almost non-existent business opportunities. Slum economies like Manyatta’s are overcrowded with (far from efficient) businesses, providing the few services some people are trained in, and those that others must buy, such as health. In part, it is this lack of opportunity for other businesses to arise in Manyatta that has made small clinics like Julia’s flourish despite their minimal economic benefits.
This is the same reason why there are usually 10 piki piki (motorbikes that serve as taxis) waiting for one occasional client on every corner; why street vendors sell more shoes than Kisumu citizens and their unborn children could ever possibly wear; or why three people work in a matatu (small transport bus) that could do with just the driver.
In Manyatta and Nyalenda, the main slums in Kisumu, many businesses are providing services where probably just one provider would do. The reasons behind this are clear and common in most poor settings. The same dynamics operate in many parts of my own country, Peru. It is a way of sharing minimal business opportunities and securing more employment, even if it is underemployment.
When it comes to health, however, this system also entails risks that go beyond economics. Almost anyone can sell shoes or learn how to drive a motorbike, but can anyone treat malaria adequately? Certainly not. Although, from what we have seen in Kisumu’s slums, the presence of a certified health professional, like Julia, is not necessarily a requisite for an institution to be called a “clinic”.
We hope that more information on who is providing health services in the most vulnerable communities of the city, and how are these being provided, will contribute to the current efforts undertaken by the government to improve the delivery of public health in Kisumu and as such, the living conditions of those who most desperately need it.
Mariana Costa Checa
MPA in Development Practice Candidate, 2013
School of International and Public Affairs | Earth Institute