Bringing health services to Kibera's poor

During her average 12-hour day at the Senye Medical Clinic in Nairobi’s Kibera slum, Dorah Nyanja wears many hats alongside her stethoscope. Not only is she Senye’s only nurse, pharmacist, midwife and occasional therapist, she also owns it.

"After nursing school I did not want to go into the hospital set-up," she explains in her three-room clinic near Soweto Market. "I wanted to go into the community." After spending eight months canvassing Kibera in search of a location that would not only provide reliable access to water and electricity but also security and enough visibility to attract clients, she set up Senye.

The next challenge for this mother of three saddled with a student loan debt was to find three months’ advance rent. She approached the Sustainable Healthcare Enterprise Foundation (SHEF), a franchise network with 64 clinic/pharmacies in Kenya.

She was initially taken aback when SHEF officials suggested she took out another loan, but later agreed. "Basically, they wanted to test my commitment," she explained. "You know the nature of human beings; if you give them something for free they are bound to take advantage of it."

Helping the poorest

SHEF endeavours to bring healthcare services to poor communities through development schemes that experiment with market-driven approaches. Working with CARE International, it tries to turn nurses such as Nyanja into entrepreneurs instead of merely employing them.

Since taking out the loan, Nyanja has seen the business grow. But it has also created new challenges, including an impression among some of her clients that she offers free services.

"If my clients cannot pay there is really nothing I can do," she explains, adding that giving something for free is sometimes the cost of doing business when most of your clientele live on about US$1 a day.

"They think that because I am working with NGOs, I do not have to pay for the drugs I dispense. In the end I am forced to show the patients my receipts," Nyanja says.

To help the poorest, Nyanja waives the 30 shilling (US 44 cents) consultation fee for those unable to pay, while sticking to the fixed rate for the medicine and hygiene products she dispenses.

And the approach seems to be working. Since the clinic opened its doors in May 2006, the average number of monthly clients has increased from 350 to more than 1300, and Nyanja’s monthly turnover has gone from $879 to $1,500 per month.

You know the nature of human beings; if you give them something for free they are bound to take advantage of it

More services

As the numbers have grown, so have the services offered. Though she still tests for TB and HIV/AIDS, there is a desperate need for more comprehensive mother and child healthcare in urban slum settings like Kibera.

Located 7km southwest of Nairobi, Kibera is the largest and most densely populated informal settlement in sub-Saharan Africa, covering about 250 hectares. What began as an unregulated settlement in World War I for Nubian (Sudanese) soldiers from the King’s African Rifles, the slum is now home to about one million people.

"Initially SHEF did not want us to do deliveries at the clinic but I realised that many mothers were having unsafe deliveries at home," Nyanja said.

Now each week Senye delivers three to five babies into a slum with a population density of 82,000 residents per square kilometre. More startling than the birth rate is the fact that an average of one woman per day visits the clinic after complications from a botched abortion.

Athough there is a need - and a market - for more health clinics in urban slums such as Kibera, for SHEF and CARE, Senye is the urban exception in a village-focused development world.

Currently three-quarters of CARE’s small-enterprise portfolio is focused on rural agribusiness, and of SHEF Kenyan outlets, the four Kibera clinics are its only urban franchises.

"It is more difficult to integrate programmes into urban areas because they are more dense and you have a lot more complex networks to work with," said Helene Gayle, chief executive of CARE International, adding that on the flip side of the urban coin is a more skilled workforce, higher population flows, and the kind of opportunities for positive growth nor necessarily found in rural areas.

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