Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Friday, December 7, 2007

The Failure Of Donors To Account For Geography, Local Practices And Need When Creating A Kenyan Health Clinic – Stacy Coronis

In the southern part of Kenya, near the Tanzanian border, is Amboseli National Park and just outside of the park is a health clinic built with money from an oil company as funneled through an Italian Catholic church. The clinic is perhaps one of the most beautiful and modern buildings in the Loitokitok District of Kenya and one of the most poorly utilized. The clinic is a woefully under-thought, failed public health intervention because the donors did not account for geographical considerations, the clash between local customs and Western medicine and the necessity of the clinic itself.

Failure To Consider The Importance of Geography

Of all places to build a beautiful, well-stocked and relatively high tech health clinic, the area around Amboseli National Park is an unlikely candidate. As a result of both the size of the park and the grim living conditions, not many people live in the area surrounding it. The park is 392 km2 of vast spaces, thousands of animals and few people. There are some guest lodges and staff quarters on the grounds, but overall, the population inside the park is very small. The population outside the park is not much bigger because the environment can be so harsh that few can make a life out there. In the two yearly dry seasons, this area of Kenya is parched and almost free of vegetation, making it difficult for the local Maasai population to feed themselves or their livestock. Even during the rainy season, resources are limited.

The small population around Amboseli seems even smaller due to the vast distances between the bomas (villages). The bomas are spaced very far apart from each other as well as from the health clinic. Many bomas are over an hour’s walk from the nearest one and the walk to the health clinic can take half a day or more for many people. Data suggests that there is an inverse relationship between the distance to health care and the use of health care (1). This relationship is in full effect outside Amboseli because the distance to the clinic makes it prohibitive for the local population to use its services. As a result, the staff has resorted to providing mobile clinics for the area, but the mobile clinics offer limited services and are not always available to the local population.

The Clash of Local Practices and Western Medicine

Another major reason this health clinic is failing is the clash between the local Maasai health practices and the Western medicine practiced at the clinic. Traditionally, the Maasai use local medicine men and plants to treat ailments (2). A medicine man lives within a community and the local people know this man their whole lives, so they often feel safer seeking treatment from him than from a stranger. The medicine man uses treatments made from local products that the Maasai are familiar with and feel at ease using (2). Many Maasai are far more comfortable with this approach than Western practices because they have grown up with these traditional approaches. The Maasai also prefer the Medicine Man’s methods because they are proven methods that the community has been using for generations. Much of Western medicine, however, is an unknown commodity for many of the Maasai. Payment options are another benefit of visiting the medicine man as opposed to traveling to a dispensary, health clinic or hospital. A medicine man is free to accept non-monetary payments, such as chickens and vegetables. He can also let a client defer until he or she can comfortably pay him for his services (2). As a result, most of the drugs available at this health clinic near Amboseli are going to remain unused because the local Maasai population goes to their medicine man either by choice or because they cannot afford to pay health clinic fees.

The Medicine Man is not the only health care provider in the Maasai culture. Maasai women overwhelmingly use local midwives and female family members to assist in at-home birth due to cultural practices, monetary considerations and geography. Even though the clinic near Amboseli has a well-equipped birthing room as well as incubators, women still choose to give birth at home. In a summer 2007 baseline health survey of Loitokitok District rural areas, which includes Amboseli National Park, 955 children were surveyed and of those, only 52 were born at a health clinic or hospital (3). This data indicates that home births are the standard for Maasai women, meaning that such a large maternity ward is unnecessary at the Amboseli clinic, though other options for prenatal care and safe delivery should be offered. The women not only feel more comfortable in their own homes, surrounded by family, but few can afford to pay for a hospital or clinic birth (2). Also, once labor starts, there is rarely enough time for a woman to walk to the closest facility or find some sort of transportation to take her there. Using a health clinic for giving birth is often not practical, especially in such a sparsely populated area as that surrounding Amboseli.

It is not just the maternity ward that sits unused; the pharmacy at the clinic also remains virtually untouched. It is well-stocked, but too expensive and not set up in a way that the Maasai find easy and comfortable to use. The expense of Western medicine, particularly prescriptions, can be too great for many Maasai to handle. In Maasai culture, a man’s wealth is his cattle and children, not paper notes, so even if a man is considered traditionally wealthy he may not be able to pay for medical services at the district hospital or the local clinic (2). Even when charges are nominal, as at the Loitokitok District Hospital, the cost can be a month or more of wages for a Maasai, as they are subsistence farmers and herders, not merchants (2). For rural Maasai, going to seek treatment at a clinic or hospital can involve serious economic consequences such as spending a high proportion of the household budget and selling assets, which can push a family further into poverty (1). There is also the issue of leaving income generating activities to take time traveling to and spending time at a health facility, which can be prohibitive (1).

In addition to the burden of paying for medical services and prescriptions, instructions that can accompany Western medicine can be a problem because many of the Maasai, especially the women, are illiterate as they stay home to help the family instead of attending school. Most aspects of the pharmacy do not take into consideration the needs and culture of the local population.

A Non-Existent Needs Assessment Leads To An Unused Facility

The geography of Amboseli and the uneasy relationship between traditional Maasai health practices and Western medicine are major. The real issue, though, is that it does not appear the donors performed an accurate needs assessment before building the clinic. The best approach to setting up a new clinic would have been to go to many areas in Kenya and see which populations could most use a health clinic based on numbers and need. The area near Amboseli clearly has a need for medical care, but not the numbers to support such a large clinic. It is necessary to find and use reliable measures and estimates of the local needs for health care, and if the donors had paid attention to the population numbers, they would have seen that the area needed a much smaller dispensary or maybe only mobile clinics to meet health needs (4). A legitimate way to assess health services is to compare them to the health needs of the target population and the donors either did not do this or did not care about the results of their assessment (4).

As the clinic stands, nearly every aspect of it is excessive, especially the operating theater. The theater has not been used once since it was added nine years ago because no one thought to install a generator to power the lights and equipment. Even with a generator, however, there just isn’t a large enough population in the area to warrant this large complex. Despite the vivid example of waste the operating theater sets, a new wing was recently added to the clinic, but has never opened its doors.

The clinic also houses a maternity ward and incubators (but, again, no electricity to run them), but no willing or able population to use them. On the other hand, Loitokitok District Hospital, which uses space heaters near cribs to warm babies, serves a larger and more diverse population that would take more advantage of this technology were it available. Instead, the Amboseli clinic’s maternity ward sits empty and the incubators are not where they are most needed. The donors simply did not pay attention to the needs and wants of the local population when setting up this clinic.

Another problem with the clinic is that the Kenyan government has very distinct guidelines about the differences between a dispensary, a clinic and a hospital. To open their new wing, the health clinic would have to be reclassified as a hospital, meaning government officials would have to come to the clinic and declare it necessary that a hospital be in the area. If an accurate needs assessment had been completed before construction began, donors would have known that the new ward would push the clinic into hospital territory. The reclassification of the clinic as a hospital is unlikely to happen for many reasons, not the least of which is that the area outside of Amboseli does not need a hospital because it does not have the population to support it.

It does not appear that a needs assessment of the local population or the staff has been done since the clinic was constructed either, considering the new, unopened wing. If the donors were to conduct regular assessments, then they might realize that the staff at the clinic only needs to work part-time or that the staff’s time would be better spent at mobile clinics instead of idling the day way inside the clinic. Even if the donors will never conduct a needs assessment themselves, the clinic staff should do it themselves and report their findings. If the staff did this, they could have some input on how the money could be best spent instead of watching it get wasted on unnecessary construction and technology. The total lack of interest in figuring out what the local population needs and wants leaves this health clinic empty and useless.

Conclusion

It is heartbreaking to see so much effort go into creating a health clinic that few people use simply because donors failed to consider the geography and population of the area, the Maasai’s reluctance to use Western medicine for many ailments and the necessity of the clinic to exist at all. With even a cursory needs assessment, donors could have come up with a better solution to local health needs. Instead, one gets the answer to the question, “What does a failed public health intervention look like?” Visit Amboseli National Park in Kenya and find the most beautiful, clean health clinic in the country and you’ve found the perfect example.

References

1. Peters, David H., Anu Garg, Gerry Bloom, Damian G. Walker, William R. Brieger, M. Hafizur Rahman. “Poverty and Access to Health Care in Developing Countries.” Annals of the New York Academy of Sciences. September 2007; 9.

2. Timayio, Senewa Maasai Culture and Practices lecture. SFS Camp, Kenya. 6.3.2007.

3. SFS/NIDRA Baseline Health Survey. Loitokitok District, Kenya. June 2007.

4. Gibson, A., S. Asthana, P. Brigham, G. Moon, J. Dicker. Geographies of need and the new NHS: methodological issues in the definition and measurement of the health needs of local populations. Health & Place Volume 8. Issue 1, March 2002; 47-60.

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3 Comments:

  • At December 9, 2007 at 12:20 PM , Anonymous Anonymous said...

    Who is writing this stuff??? Why don't you want to identify yourself/ves?

     
  • At December 15, 2007 at 5:18 PM , Anonymous Anonymous said...

    Stacy --

    An interesting paper, about something I previously knew nothing about, but I've lost you on the question of "so what?" Specifically, this is a clinic built, as I understand it from your description, with private money. It's halfway around the world. I didn't donate to the Italian church, nor am I a shareholder in the oil company that donated money to build it. Why is this important for me to think about?

     
  • At December 17, 2007 at 6:53 PM , Anonymous Libby said...

    Why is it important?

    1. With such limited resources in most countries, there is nothing worse than waste. There is a need for so many health interventions throughout the world that a beautiful yet useless clinic makes me cringe. And sadly this is not an isolated incident. There are hospitals and clinics all over that were poorly planned and now useless.

    2. Maybe you didn't pay for it this time, but if you make charitable donations, do you know how they are actually spent? I would like to know that my money is being used effectively and efficiently.

    and 3. Does it really matter if its "halfway around the world"? Do they not deserve appropriate medical care as well?

    Stacy - I enjoyed your paper and I think it is the perfect example of a failed public health intervention, despite good intentions.

     

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