For the residents of western Kenya’s Manyatta slums, Phelgone Atieno is no ordinary community health worker. Universally revered as “Sister Phelgone” she is greeted by nearly every community member with an obligatory Erokamano, the Luo word for “thank you.”
Ms. Atieno has come a long way from her life in 2002, when she was diagnosed with the Human Immunodeficiency Virus, weighed less than 90 pounds, and stood on the brink of death. After losing her job as a teacher at the Aga Khan pre-primary school, she began working odd jobs near her home in Manyatta, the largest informal settlement in the city of Kisumu. In 2004, Ms. Atieno and four other residents started a community-based organization called Pal Omega dedicated to empowering peers affected by HIV.
Over the years, the organization’s reach has expanded considerably, and today, Pal Omega’s initiatives combat HIV-related stigma, support victims of gender-based violence, and offer comprehensive family planning education. But while members dedicate themselves to expanding accessible health care and increasing awareness of available resources, they face the challenge of a bloated and austere international development complex.
The Forgotten Shadows of Development
While the United Nations has referred to its Millennium Development Goals initiative as “the most successful anti-poverty movement in history,” more Africans live in extreme poverty today than did in 1990. Much of the progress made in global development since the UN set its benchmarks stems from rapid growth in China and Latin America, leaving behind the most vulnerable residents of Sub-Saharan Africa.
As it faces significant poverty and health gaps, Kenya is an archetypal case of the shortcomings and failures of modern development in Sub-Saharan Africa. In particular, the city of Kisumu, despite its designation as a Millennium City by the UN, maintains a poverty rate of nearly 40 percent. Throughout Kenya, extreme poverty and poor health engender a vicious cycle entrenching communities in poor living conditions, low life expectancy, and high child mortality.
Despite an influx of international aid and NGO investment directed at health care, Kenya’s infant mortality rate remains high and its life expectancy low. Malaria, AIDS, and TB are still highly prevalent killers even after numerous global efforts to distribute treatment and increase awareness.
Article 43 of the Kenyan constitution guarantees citizens the right to “the highest attainable standard of health care,” a truly progressive declaration. But the lack of affordable and accessible health care continues to produce unfavorable metrics in Kenya.
According to research conducted by World Bank economist Edwine Barasa, 83 percent of citizens remain uninsured, forcing the vast majority of Kenyan families to make exorbitant out-of-pocket payments for treatments and procedures. This phenomenon is clearly reflected in health expenditure data: the Ministry of Health reported in 2013 that 32 percent of health financing came directly from household payments, overwhelming even government expenditures on health care. Health care accessibility is further skewed for Kenya’s poorest quintile, which receives about half as many government health care funds as the richest quintile despite nearly twice the need.
A History of Neglect
Why is it that in spite of yearly infusions of around $2.6 billion in official international assistance, the vast majority of Kenyans are consistently deprived of accessible health care?
Part of the problem can be attributed to consistent government neglect of health care needs over the last few decades. The current iteration of the Kenyan health system, initiated in 1994 with the Kenya Health Policy Framework Paper, devolved most health care authority to local administrations. Today, the lowest, most accessible level involves village dispensaries, followed by district clinics and provisional hospitals. Nairobi’s Kenyatta National Hospital represents the most significant federal involvement in the Kenyan health system. But most health care provision and management occurs at local dispensaries and private centers operated by NGOs and domestic organizations.
While recent administrations have significantly hiked health care spending, a legacy of federal neglect continues to haunt the system. In 1970, the Kenyan government nationalized health care and eliminated user fees for all treatment. The results were tremendous—by 1980, Kenya had quadrupled the number of health facilities open to treat patients, and the population experienced a rapid increase in life expectancy.
The progress of the 1970s coincided with a global movement for health improvements. UNICEF’s 1978 Alma Ata conference produced a simple goal of universally accessible health care by 2020, and the conference produced a series of recommendations for governments and donors to hike funding for community health programs.
At the start of the 1980s, though, a distinct ideological mantra of “structural adjustment” took hold, encouraging privatization, user fees, deregulation, and austerity. The World Bank and International Monetary Fund became influential players in international development, and both offered loans contingent on the slashing of social services spending and privatization of public programs. The World Bank encouraged nations like Kenya to institute user fees, decentralize management, and jumpstart the privatization of social services.
International health metrics indicated an immediate and devastating blow. Developing nations in Sub-Saharan Africa, South Asia, and Latin America became attractive targets for international investment but simultaneously witnessed the weakening of their primary health systems. In Kenya, the initiation of out-of-pocket payments for health clinics in 1989 was followed by a decade-long period of declining life expectancy.
In June 2016, the International Monetary Fund published a report reviewing the economic implications of its once-heralded agenda. The report concluded that while short-term effects of deregulation and privatization appeared favorable, those policies entrenched widespread inequality and gutted critical social services, undermining the foundation of long-term economic expansion and development.
An Unwieldy Development Industry
Nations like Kenya have recently reversed course, and as health challenges have attracted international attention, aid has also flowed freely into global health efforts, sparking an intense academic debate about aid’s effectiveness. Advocates like Columbia economics professor Jeffrey Sachs, an architect of the Millennium Development Goals, laud the successes of countless interventions, like the role of bed net distributions in reducing malaria deaths in Sub-Saharan Africa. On the other hand, economists William Easterly and Dambisa Moyo contend that development aid props up corrupt regimes and fosters dependence. The free distribution of bed nets, they respond, crowds out cheap local sellers of bed nets, driving out a sustainable indigenous solution and leaving a vacuum in the market after the end of the distribution efforts.
Regardless of the merits of these academic perspectives, there is no denying that in the West, “we now have a development-industrial complex,” argued Dr. Thomas Burke, Chief of Mass General Hospital’s Global Health and Human Rights Division, in an interview with the HPR. “It requires tremendous resources just to feed that giant animal, and it’s entrenched in its responsibilities to feed the salaries of Westerners.”
Indicators throughout Sub-Saharan Africa suggest that this “development-industrial complex” has failed significant portions of this region’s population. Those aid dollars have been so ineffective, explained Dr. Burke, because they have not addressed underlying factors, like governance issues and the lack of legal and regulatory institutions. Most importantly, though, international interventions often augment the very structure of inequality that produces negative health outcomes.
Consider the following thought experiment: a health-related NGO sets up shop in Western Kenya, starting a clinic with the goal of providing quality health services. Even before the clinic starts seeing patients, prices in the immediate surrounding spike as sellers take advantage of the affluent, money-waving wazungu, Swahili for foreigners. Prices for ugali, a local staple starch, rise exponentially and home prices skyrocket, entrenching families in a cycle of poverty. When the clinic finally opens its doors, only the richest can afford the fees of seeking the high-quality treatment. Supported by dollars from the West, though, the NGO attracts the most qualified and skilled doctors in the area, depriving public facilities of needed human resources.
This thought experiment has played out on a large scale in Kenya. The country faces an acute shortage of physicians, with only one doctor for every 10,000 citizens. The United States, for the sake of comparison, has 26 doctors for every 10,000 people. To compound this problem, internationally supported non-profit clinics poach much of the available medical talent. Despite making up more than 40 percent of total health centers, government-funded clinics house only 22 percent of Kenya’s medical professionals. This discrepancy significantly impacts Kenya’s rural population that has limited access to international financing, considering that 50 percent of Kenya’s doctors serve Nairobi, which makes up seven percent of the national population.
As Dr. Burke argued, “we actually have the incentives all wrong.” International support, he suggests, has the potential to be successful when framed through the lens of innovation and entrepreneurship. But, he says, the “biggest obstacle to innovation and entrepreneurship” remains “us shooting ourselves in the leg through our own human wish for power and for money.” This tendency has produced in Sub-Saharan Africa a widening gap between the expected and actual outcomes of copious sums of money in development aid.
Emerging Solutions from Community-Based Strategies
This gap is where Ms. Atieno and her Pal Omega team members come in. Today, twelve years after its inception, the organization operates several initiatives to financially and socially support other Manyatta-dwellers affected by HIV. The two-room early childhood development center represents the fulcrum of the whole operation, serving nearly 60 children aged three to seven, many of them infected with HIV. In addition to anti-stigma initiatives, support groups, and community health fairs, Pal Omega runs a group savings and loan program to alleviate the widespread poverty of HIV-infected residents of Kisumu.
Collectively, the organization attempts to fill the gaps between the expected health outcomes posited by the Ministry of Health and its NGO partners and the reality of rampant poverty, consistent HIV transmission rates, and unacceptably high infant mortality. International organizations often overlook the very real and largely effective efforts of community-based organizations like Pal Omega when they evaluate health care interventions. But despite the lack of robust financial support, Ms. Atieno and her fellow members work tenaciously, arranging regular health fairs and home visits to offer testing, referrals, sexual health education, and counseling.
This commitment to continued progress has not wavered in spite of a shrinking budget. The latest project being developed by Ms. Atieno’s team is a planned initiative to comprehensively combat stigma surrounding HIV and family planning in the local community. In addition to holding local dialogues, community health events, and family planning clinics, the group has recruited student groups from the nearby Maseno and Kisumu Polytechnic Universities to regularly put on educational performances for students and parents. Pal Omega’s leaders firmly believe that health literacy and stigma reduction can bridge the gap between patients and the available health resources.
Perhaps most impressive, though, is the clear universal support for Pal Omega’s operations in the community. In spite of the stigma associated with the organization’s objectives, its regular involvement with community health fairs and home visits has made the organization more trusted than any international NGO ever could be. In combination with the group’s clearly evident tenacity, these community roots offer a real opportunity for community health improvements and poverty reduction.
The model of Pal Omega, a community-based organization, offers a significantly more effective outlet for the copious amounts of increasingly available international development funds. For NGOs hoping to maximize their positive impact, contributing to already existing efforts founded upon grassroots approaches can truly serve the needs of the poor. Dr. Burke agrees, declaring that “for the poorest of the poor, local CBOs are the best opportunity for success or for lifting out of poverty.”
The daunting challenges facing Kenya and the rest of Sub-Saharan Africa will not disappear, though, as long as inequality remains the norm. “At the end of the day,” Dr. Burke contends, “there’s a real problem with equity and … it will be an unending task to lift populations out of poverty.” For Pal Omega, though, the fight against poverty and disease in Manyatta will rage on.
Image Source: Good Free Photos