Success Story

Kenya

An Awakening for African Health Care
By Jeannine Kenney

On the night Awinja went into labor with her sixth child, her female birth attendant rushed to her side to help her deliver the baby. The home was barren of food and Awinja's husband had not been seen since morning. After a long night, but a successful delivery, her birth attendant urged Awinja to visit the local health clinic for vaccinations for the baby and family planning counseling. Awinja promised the attendant that she would adopt modern birth control methods in six weeks. But four months later, she was pregnant again.

Awinja, just 29 years old, dropped out of school at the age of 15 to get married. She and her husband are peasant farmers in Butere, Kenya and suffer from the all too common poverty in Kenyan villages. Awinja is unfortunately typical of many women in the country who lack education on, and authority to adopt, even basic family planning methods. And she's exactly who the AMKENI project implementers hope to reach through their ambitious and innovative project to increase demand for, and the quality of, family planning, reproductive health and child survival services in Kenya. Awinja is not alone. Only 32 percent of Kenyans use modern family planning.

An Awakening
Amkeni means "awakening" in KiSwahili, one of the primary languages of Kenya. And an awakening, particularly of women, is what it will take if community health services are to improve in Kenya. Healthy life expectancy at birth—the number of years one can expect to live in full health—is just 41 and 40 years for men and women respectively. Only 45 percent of births have a skilled attendant at delivery, and child mortality rates are worsening. The country faces a rapidly growing childbearing population. On top of that, 14 percent of the adult population has HIV/AIDS with infection rates as high as 30 percent in some urban areas.

To make a difference, the AMKENI implementers, including the National Cooperative Business Association (NCBA), have built an extensive community-based network of local health care decision-makers, field coordinators, and volunteer educators who will work to improve the knowledge and decision-making ability of village women.

According to AMKENI leaders, in the past, family planning decisions—whether to have children, when to have them, and how many to have—were made by men in Kenya who have traditionally been biased against birth control. Until women like Awinja are empowered to make their own decisions and play an active role in community-based health care, project leaders say, efforts to improve women's reproductive health, lower HIV infection rates and reverse infant mortality trends will never be sustainable.

Co-op Principles for Better Health
The AMKENI project reflects a growing trend towards decentralized health care in Africa, as resource-stressed governments recognize that to meet their health care challenges, local communities must be directly involved in priority-setting, decision-making, management, income generation, cost recovery and outreach to villagers.

That model is one that NCBA pioneered nearly 10 years ago in the West African country of Burkina Faso. It lies on a tiered network of democratically elected, regional and village-based committees, field coordinators, and a well-organized network of local outreach volunteers at villagers trust. It replicates what has become known the CLUSA approach—the process of involving communities in every aspect of business development, down the hiring of local staff. The model, used by NCBA throughout its 50-years of international development work, is based on the co-op principles of democratic control, autonomy and independence, and education and training at the village level.

Without active, democratically organized community participation, says Alex Serrano, NCBA's program manager for Africa, newly created institutions will fail.

Overcoming the Barriers
On issues as sensitive as sexual and reproductive health, active community involvement is even more important. "These are difficult issues to discuss in any culture," Serrano says, "and they are even more problematic in many African countries where women play a subjugated role in their communities." Myths and misconceptions about sexual and reproductive health abound in Africa. NCBA's Project Coordinator for Kenya Joyce Wafula says even basic understanding of the causes of HIV/AIDs is lacking. In some cases, villagers believe infection is caused by witchcraft—a curse put upon a villager by an enemy.

To overcome these myths through education and greater women's decision-making ability, NCBA manages the community mobilization and women's agency components of the USAID-funded AMKENI Project.Working with project partners EngenderHealth, Program for Appropriate Technology in Health, and other international health organizations, NCBA provides training and technical assistance to communities and health information trainers in the west and coastal provinces of the country. NCBA's Wafula, a native Kenyan, works to establish democratically elected, viable Village Health Committees and regional Health Coordination Committees and trains and manages local field facilitators. Based on principles of democratic participation, the committees set and control the agenda for their community's heath needs, raise money to provide local services and, perhaps most importantly, are accountable to their communities. No longer does the village chief determine who serves on committees; now, the entire village decides.

A substantial barrier to democratic participation, though, is the intense poverty and more pressing health issues in many of the villages. When people do not have enough to eat and lack access to clean water that will prevent diarrhea, Wafula says, it can be difficult to engage them in long-term planning for better local health care and a more educated approach to reproductive health. Overcoming those barriers takes intensive education and outreach, helping villagers to understand that to overcome the immediate, they must focus on the long term.

Enhancing the Role of Women
To that end, Wafula also works with other project coordinators to hire and train local "women's agency" field facilitators who bring women into the project as active participants. The involvement of the local women, like Awinja's birth attendant, as a first point of contact is a critical part of gaining the trust of female villagers who are reluctant to speak out on their reproductive health needs. To date, NCBA has helped form 158 locally elected village health committees (VHCs) and 177 health advocacy groups in the districts of Kakamega, Bungoma and Butere. Nearly 40 percent of the VHC members are women-an accomplishment in a country where Wafula says the prevailing community attitude is that the opinions of youth and women are irrelevant. "There is an apprehensiveness by men about women participating equally," she says.

Health education has been conducted for 320 women's groups and networks to facilitate greater "agency" for women. And the project is working. Wafula says demand for family planning, reproductive health, health education and disease prevention is on the rise as more women are getting the information and services they need to make their own reproductive decisions. And demand for child immunizations exceeds local clinics ability to supply it. Now, where there used to be apathy, Wafula says, women are more engaged. Next year, NCBA will expand its activities into an additional 160 villages.

The Burkina Faso Model
The Kenya project builds on NCBA's experience in the West African country of Burkina Faso. In 1993, NCBA's CLUSA International Program adapted its well established model for direct and active community involvement in building successful agricultural co-ops in the developing world to the health care system. By 1995, the Burkina Faso program had involved 62,000 villagers—one-third of them women—in an analysis of their village health care services. They formed 738 democratically elected village health committees and established 67 regional health management committees. Today, all 67 health management committees are still operating and each has its own profitable pharmacy, administrative capability, technical competency, cost recovery programs, and revenue generating activities. They are, in short, sustainable.

It's Not About Money and Power
And in Benin, together with University Research Co., (URC) a for-profit development organization, NCBA is helping improve the sustainability of local health care in that country using a similar model. The program focuses on the Borgou and Alibori departments in northeast Benin where health statistics on family planning, HIV/AIDS and infant mortality are most dismal. There, NCBA works to develop locally elected health committees, called COGECs, which are made up of community members and representatives from the nearest public health facility.

The challenge, says Debbie Gueye, URC project coordinator, is to change the community's notion of what it means to be on a committee or to serve in an elected position. In the past, Gueye says, there was a corrupt "air" about serving on committees or being appointed or elected to a local governmental position. "Traditionally, someone gets elected, and they're in for life," Gueye says. "That's not a great way to introduce change. We're trying to reverse that."

A key goal is to help the villagers understand that the health management committees are "theirs" and that everyone should be involved. "These committees are not about money and power. And if villagers see that they can be involved in these committees, they're more likely to be engaged."

In Benin, NCBA staffer Telesphore Kabore, who also worked on the Burkina Faso project, provides the COGECs with logistical, financial, management, and organizational training. The goal is to make these committees as self-sufficient as those he helped develop in Burkina Faso.

Kabore also coordinates a network of field facilitators and volunteers that do community healthcare outreach. Together they serve as a first line of communication between the 300,000 villagers and the COGECs.

In all of these projects, and others like them, the core cooperative principle of democracy—implemented at all community levels—appears to be the key to success. Only with active involvement of local men, women and youth in local healthcare solutions will many small African countries begin to reverse the devastating trends on infant mortality and HIV/AIDs.

"When you know the decisions you make will directly affect your wife or husband, your sons, daughters and neighbors," NCBA's Alex Serrano says, "that's when healthcare begins to improve."