Ms Ann Owiso is a middle-aged mother of two from Mashimoni Village in Nairobi’s Kibera slums. When you enter her house, you can’t help but notice how neat the single room on the first floor of a corrugated iron sheet building is. She has gone to great lengths to decorate it; there is a woollen carpet while the sofa set has flowery seat covers that match the curtains.
She is confident and happy to welcome us. But she confesses that it has not always been like this. Ms Owiso admits to not having been particularly bothered about neatness and hygiene.
For instance, when Ms Margaret Kilonzo, a community health volunteer, first suggested that she boils or treats drinking water, Ms Owiso dismissed the idea as absurd.
“I had this notion shared by many people that water is harmless. In fact, there is a saying: ‘Maji hayana roho mbaya, hayawezi dhuru’ (Water can do no harm’),” says Ms Owiso.
“I believed all you had to do was get some straight from the tap to quench your thirst. That’s what I used to do because the water looked clean.”
Ms Owiso’s life, and indeed that of her family, has changed drastically, thanks to Ms Kilonzo’s determination to educate her and the neighbourhood on hygiene.
But it wasn’t easy. To convince Ms Owiso to start using boiled or treated water, Ms Kilonzo had to take her to the streets and show her where the pipes that supply the water she considered safe for drinking are laid.
Because of the dense population and lack of basic infrastructure such as proper sewer, raw sewage flows freely on storm water drainage by the road. And this is where the pipes are laid.
That is what convinced Ms Owiso to treat her water. She realised that germs could be finding their way into the water when pipes burst or through loose joints. It was an eye-opener. She admits that after she began using boiled water, the frequent stomach aches she used to experience fizzled away.
This sunny Thursday morning, we are here for what has become a regular health check-up and educative forum. After a hearty exchange, Ms Kilonzo begins by asking Ms Owiso if she has ever heard of cholera.
“Is it the disease that makes people pass watery faeces?” Ms Owiso enquires, to which Ms Kilonzo answers in the affirmative and goes on to outline the symptoms of the disease and the preventive measures.
What follows is a 30-minute candid talk interrupted by occasional peals of laughter, a clear indication of their close relationship. Among the issues they discuss is immunisation and treating water.
Ms Owiso says her youngest child, who is only three, has received the recommended vaccines.
Ms Kilonzo escalates the discussion to the importance of polio vaccination, HIV/Aids testing and family planning.
When they get to proper washing of hands, Ms Kilonzo asks Ms Owiso to demonstrate. This exercise is repeated at Ms Francisca Ndinda’s home, Ms Kilonzo’s third stopover this day.
Ms Owiso has mastered the technique and ensured her family gets the hang of it. She has placed a container of clean water and soap next to the toilet so that those answering the call of nature can wash their hands.
Of importance, she says, is to ensure that people wash their hands under running water instead of in a container.
Walking on the narrow streets of Kibera, Ms Kilonzo shakes hands with residents.
Her next stop is just a few metres away, where Ms Jane Mmboga, who lives in Transformer Mashimoni, is waiting for her.
Ms Kilonzo has been a health volunteer in Kibera for 20 years but Ms Mmboga has known her for half the period.
They have a close relationship, and Ms Mmboga calls her Daktari wa Mtaa (estate doctor).
While she initially took Ms Kilonzo’s advice with a pinch of salt, Ms Mmboga says ‘daktari’ these days is the first person the community looks for when any member has a health problem.
“Recently, a neighbour came complaining that her child had been bewitched because she had wounds in her mouth. When we called Ms Kilonzo, she examined the baby and told us to take her to the health centre. It turned out that the baby was just sick. She was treated,” Ms Mmboga says.
She adds that community health workers like Ms Kilonzo are what the residents need and pleads with the government to recognise their efforts.
Looking back, Ms Mmboga says, the health volunteers’ greatest achievement is helping the community abandon the infamous flying toilets.
“Through their education on hygiene and caring for our environment, they gave us the power to demand that landlords build toilets. The flying toilets existed because there were no proper places for residents to relieve themselves,” she says.
While most people would look down on Kibera residents as poverty-stricken and disease-ravaged, nothing could be further from the truth.
Listening to these women talk, one realises that this is actually a very empowered community, especially on health matters.
This is something that gives Ms Mmboga a sense of pride.
“People say that Kibera is known for lawlessness and violence but when I visit my friends in Kawangware and ask if the area has visiting ‘doctors’, they say it does not. It makes me proud for I know we are way ahead of others in certain respects,” Ms Mmboga says.
With the help of health volunteers, Kibera women have not only managed to improve their well-being and raised hygienic standards at home, but they have also got their husbands to participate in family health matters.
Ms Mmboga says pregnant women who are accompanied by their husbands to the nearby Amref Health Centre are given first priority during antenatal and postnatal care, encouraging men to be more active in their wives’ and children’s health.
During the recent cholera outbreaks in different parts of the country, including a premier hotel in the city, with some reporting deaths, “there was not a single case reported in Kibra”, Ms Kilonzo says.
Meanwhile, Mr David Kitavi, the director of Youth Development Forum, a community-based organisation, says behavioural change among the residents has been one of most notable impacts of continued health volunteers-community engagement.
“More and more people are willing to seek treatment in hospital. Also, women who would otherwise have opted to give birth under the care of traditional birth attendants now go to hospitals,” he says.
Today, childhood diseases that saw many locals visit hospitals for diarrhoea and stomach aches, among other illness, have been dramatically reduced, thanks to simple things like proper hand washing.
“I use a jug and basin to clean everyone’s hands before meals. Then I wash my hands last so that I am safe from germs,” says Ms Mmboga.
“I grew up in a village where such practices were not common. There, you pick a fruit and just eat it but here, things are different. We have been taught to clean our hands after visiting the toilet, changing diapers, before cooking and before eating.”
This has translated to incredible school attendance, good grades and good transition to the next level of education.
“I remember a story about a child who asked her mother to buy her a mango on their way home from school. She became adamant when her mother told her to pick one and just eat it. The child refused to eat the mango unless it was washed. So when that parent shared the story with me, I was very happy to learn that the children are transferring that behaviour to everyone at home,” Mr Kitavi says.
Ideally, a community health volunteer is assigned a group of households to serve. It is known as a community health unit. Ms Kilonzo, for instance, serves 100 households with a population of more than 500.
She has to visit every household at least once a month and file a report.
Since children are highly vulnerable, Ms Kilonzo reports if there is a sick child at home, whether the family is sleeping under treated mosquito nets, the general health status of the family, and children’s immunisation status, just to highlight a few.
Interestingly, on the day DN2 joins Ms Kilonzo for a round of visits, she does not write anything down.
Asked why, she responds: “Sometimes information on someone’s health is very confidential. If a client sees you recording what he or she considers private, chances are the client will become evasive. The goal is to integrate with the community and become part of the residents’ lives. You have to be sharp and carry some of this information in your memory for documentation later,” she says.
But for their efforts, all a health volunteer get is a pat on the back from the government.
“It is unfortunate that there been little effort by the government to support community health volunteers, yet they play a very important role in places like Kibera,” Mr Kitavi says.
“We give the 80 volunteers we work with Sh2,000 every month as a token of appreciation. Their leaders get Sh3,000. This is very little, judging by the work they do.”
Besides Mr Kitavi’s organisation, Amref Health Africa also gives them Sh2,000 every month. Experts DN2 spoke to said if the government is to achieve universal health coverage, one of pillars of its “Big Four” agenda, the role of volunteers should be mainstreamed.
According to the Ministry of Health, the country has 5,309 community health units, each served by two volunteers. This is way below the 9,700 units Kenya needs.
The “lucky” volunteers like Ms Kilonzo, who work in hotspots like Kibera which has a heavy NGO presence, get to take home a stipend. The rest go home empty-handed after years, even decades, of selfless service.
THE LINK BETWEEN THE COMMUNITY, HEALTH SYSTEMS AND VOLUNTEERS
Although the community appreciates the health volunteers’ service, no one understands their importance better than David Kitavi, the director of the Youth Development Forum, a community-based organisation.
Born and raised in Kibera, Mr Kitavi wakes up with one goal in mind: to ensure the 5,620 children under his care in 40 primary schools remain in school.
To achieve this, he has to ensure that these children’s families are stable and healthy.
That is why he works closely with 80 community health workers to strengthen families.
“When people work together, families are strong and government structures are working, it is possible for people to become self-reliant,” he says.
“Volunteers are selected by the community. Some of them have basic training in health and sanitation. Besides, the community looks up to them for guidance and advice. So they are a very important cadre of health providers in this society.”
Among the roles community health volunteers play are collecting information on individual families and the community’s health situation, making referrals and conducting sensitisation campaigns, for instance during disease outbreaks.
They also help the community conserve the environment to minimise the likelihood of disease outbreaks and raise the community’s sanitation standards.