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Mental Health In Kenya: A Place For Traditional Medicine?

by Access Afya

Mental health is an often under-reported and under-recognized health issue in our world today. Much of the problem is our society’s failure to acknowledge mental health problems in loved ones and seek proper treatment for them. However, in places of the world such as Kenya, health care innovators are pursuing the unique blend of traditional and Western medicine to better serve people with mental health issues in a healthier and more culturally appropriate way than approaches of the past.

Kenya’s Mental Health Issue

The World Health Organization (WHO) estimates that the leading cause of ill health and disability on a global scale are mental and neurological disorders. However, because of cultural taboos and stigma, many mental health cases go untreated. WHO asserts that mental health issues should in fact be part of a larger development plan since they have a big effect on a country’s economy by adversely affecting people’s abilities to care for themselves and their families.

Part of the issue surrounding mental health is the lack of medical professionals trained to help, especially in poor and under-served areas of the world. In East Africa specifically, the problem is dire. There are only 79 working psychiatrists in the East African nation – one for every 500,000 people! In 2013, there were only 25 licensed psychiatrists in Kenya.

In developing countries, seventy to eighty percent of people with a mental health problem in developing countries receive either no treatment at all, or ineffective treatment, such as treatment given by waganga, or traditional African healers.

It has been recognized in Kenya that while some waganga approach healing with well intentions and have been trained to perform customs passed down for decades in the traditional medicine community, many are in the healing business for the ulterior motive of taking advantage of Kenyan’s who will pay large amounts to have their ailments cured the traditional way.

Private psychiatrist offices that many people in the Western world are used to are just not feasible in the urban areas and informal settlements in Kenya, where most of the country’s population is concentrated, the same types of communities that our programs and clinics at Access Afya serve. Trying to imitate Western psychiatric systems is problematic, as specialists and hospitals are in such short supply. So how do we get mental health services to people who need them, especially in a country where the stigma and taboo surrounding mental health issues are resounding?

One of Access Afya's clinicians listens intently as a patient chats with him.

One of Access Afya’s clinicians listens intently as a patient chats with him. Might clinicians be able to work in harmony with traditional healers to help their patients?

A Creative Solution

One outstanding organization has begun to tackle this question by incorporating traditional medical beliefs into long-standing Western practices. They are attempting to utilize waganga to reach populations that may not wish to try Western approaches to mental health at first. Basic Needs, an international development charity focused on mental health issues, has been working with a group of Kenyan traditional medicine and faith healers for the past five years to educate them in patient protection and human rights.

Basic Needs recognizes that their approach needs to be a two-way street. They are training traditional healers how to identify mental health problems and refer patients to licensed psychiatrists, and psychiatrists in Kenya have recently begun to recognize the need for some of their patients to seek traditional help. Each party must accept that the other has a presence and necessary position in the mental health treatment of many Kenyans.

Dr. Monique Mutheru is one of Kenya’s few psychiatrists. She believes that traditional medicine is an appropriate route for some types of mental distress. Cultural beliefs surrounding mental illnesses, such as possession by spirits, can often cause psychological distress that traditional healing may best alleviate.

However, Dr. Mutheru emphasizes cooperation between Western medical practitioners and waganga. She says, “The idea is to work together, to work as a team.”

Dr. Daphne Ngunjiri, Access Afya’s Medical Director, recalls a case at one of Access Afya’s micro-clinics during which the patient, a young girl, had been suffering from a septic (severely infected) leg wound, and Access Afya’s clinicians found out about her case when her brother visited the Access Afya pharmacy looking for pain medication. The family was having her leg wound treated using herbal medications for months with no signs of improvement. At Access Afya, clinicians recognized the problem was serious and referred her to a government hospital where she was diagnosed with cancer.

This unfortunate incident, Dr. Ngunjiri says, highlights that “patients need to feel comfortable to share all additional measures they are taking…[to] help doctors assess the benefits and risks and ensure patients are making informed decisions.” If doctors and health care workers do not acknowledge that traditional healers are still very active in our communities today, patients may not feel comfortable reporting any traditional healing techniques they may be simultaneously using.

International psychiatrists and experts on cultural psychiatry are agreeing that the most effective approach to health issues, especially mental health issues, may be to incorporate cultural beliefs and traditional medicine. Dr. Miscol Ascoli, cultural psychiatrist at the Newham Centre for Mental Health in East London, says, “I think we have to consider that in a globalized world explanatory models are sometimes multiple. It’s not like you either believe in spirits or you believe in mental illness. Sometimes you believe in both.”

This past Monday, August 31st, was African Traditional Medicine Day, and what better way to celebrate long-standing medical traditions in Africa than acknowledging that proper training of traditional healer may be able to bridge the needs gap for mental health in Kenya?

Sources:
http://www.bbc.com/news/health-23189069
http://www.pri.org/stories/2015-03-03/fighting-funk-how-one-kenyan-battles-her-mental-health-problems-helping-others

Access Afya’s Dental Partnership: Healthy Schools, Healthy Smiles

by Access Afya

Access Afya is partnering with the St. Francis Community Hospital to make dental care more accessible to our community. We started in March, targeting our Healthy Schools children.

The need for dental care

According to World Health ‘Organization (WHO) statistics, tooth decay is the single most chronic condition-affecting children today, especially with 60–90% of school children having dental cavities or decaying teeth.  With fewer than 1,000 dentists serving the 44 million people of Kenya, this is an important medical issue that needs attention.

The gap in dental care became evident to us when over 20% of the children screened in our Healthy Schools programs were found to have dental issues.

“Tooth decay is the most common chronic disease of childhood and a harbinger of health woes in later years”, says Karen Sokal-Gutierrez, a physician trained in pediatrics, preventive medicine, and public health with the Joint Medical Program of the University of California, Berkeley, and the University of California, San Francisco. “We worry about AIDS and malaria and TB among the world’s poor, but tooth decay is so much more common, ” she says. “Unfortunately, it’s always been neglected,” even as processed and sugared foods proliferate in developing nations.

A dental inspection is underway during Access Afya's Dental Day!

A dental inspection is underway during Access Afya’s Dental Day!

“In most rural areas, people have to travel long distances to see a dentist,” says Stephen Irungu, chief dental officer at Kenya’s Ministry of Health and past president of the Rotary Club of Murang’a. “Most of the patients will go to the dental clinic only because they have pain.” Cultural norms suggest “it’s OK if your teeth fall out, if your teeth are broken. They think people are not going to die from it,” says Past District Governor Geeta Manek.

Tooth decay, and other dental problems, often stem from improper dental care. Higher awareness of dental hygiene and care may thus discourage such habits, resulting in better overall well-being.

In the informal settlements of Mukuru where we work, this is certainly something we have found to be true.  Young children’s teeth decay and rot because of poor dental health and nutrition, leading to further dental and health issues.  Our clients frequently ask us to integrate dental. “Customer experience and feedback is key to our model,” said Maggie Kiplagat, Head of HR and Talent at Access Afya,  “we listen to our patients’ needs.”

A Walk Through Mukuru

by Access Afya

70% of urban residents in Kenya live in informal settlements, where unsanitary living conditions and overpopulation lead to a high prevalence of communicable disease. Often, health care is unreliable in these areas due to inconvenience, cost, weak supply chains, unprofessionalism, and inconsistencies. We at Access Afya realize the need for first class, personalized, and dependable health care in these communities. Through our micro-clinics and other programs, we are committed to making sure our patients know what they are getting, feel noticed, and feel genuinely cared for.

Recently, some of our Access Afya team members made a short video clip while walking through Mukuru Village to explore location, directions, and place in informal spaces with no addresses. For Access Afya, it is important to have many signs throughout the twists, turns, and complicated layout of the informal settlement pointing to one of our micro-clinics, Kisii Clinic so that everyone that hears about our services knows where to get them. We invite you take a walk with us through Mukuru and get a glimpse of one of the communities that we serve!

Cashless Clinics

by Melissa Menke
Cashless Clinic Flyer featuring Access Afya staff member, Dhahabu Galma

M-PESA, Kenya’s most popular form of mobile banking, has a long way to go on usefulness and usability before being a truly common method for retail purchases for the mass market. Enterprises such as Access Afya, who serve the mass market, have a lot to gain from going cashless, such as lowering financial risks and costs of handling cash at scale. We are interested in continuing to work with partners to address challenges we have identified testing full use of mobile money for primary healthcare payments in low-income areas.


 

Access Afya runs healthcare programs in Nairobi’s informal settlements that are designed for sustainability and scale. We run a chain of quality assured primary healthcare micro-clinics that we build, stock, and run directly in these communities. Mobile money integration would make it easier to scale by cutting administrative costs and the risks that come with handling cash. Additionally as Access Afya increases the number of health membership plans it offers, mobile money becomes a more attractive option to offer clients as it can be done from any location. We recently ran a cashless clinic pilot with PharmAccess Foundation and Dodore to incentivize the use of mobile money payments at our Sinai Clinic.

During the trial, over half of our patients paid via M-PESA when prompted by our team. But it became clear that there are several barriers to using Lipa Na M-PESA. We learnt a lot about our patients’ experience of Lipa Na M-PESA as a mode of payment for health services.

Cashless Clinic Flyer featuring Access Afya staff member, Dhahabu Galma

Cashless Clinic Flyer featuring Access Afya staff member, Dhahabu Galma

 

The Pilot: A Completely Cashless Clinic

All patients that visited our Sinai clinic during the pilot were asked to make payments using Lipa Na M-PESA (LNM). Mobile money use and specifically M-PESA (a product of Safaricom, the largest telecommunications provider) market studies repeatedly find to be widely used. People that use Access Afya clinics are mostly informally working or self-employed, and uninsured. They use Access Afya for a wide range of primary care needs from consultations to family planning to first aid and more, and most people pay cash for the services they use and medicine and hygiene products that they buy.

We anticipated that this change from cash to mobile money could be potentially frustrating to some clients. We did a few things to ease the transition. First, a PharmAccess team member stayed in the clinic at all times serving as an M-PESA agent. Clients could deposit funds into their account if they had mobile money but no balance. Second, we created excitement around mobile money by running a lottery where patients could win airtime for paying via M-PESA directly. Third, we worked on education and awareness, including posters and flyers explaining why we were running this program (to make our clinics more secure for us and for them, and to collect exact amounts without having to deal with change) and also working with another PharmAccess agent to explain mobile money and LNM to any of our clients with questions.

 

Payment Patterns

Our clients fell into three groups:

  1. Clients that were registered with M-PESA and had a positive balance: These clients paid us directly.
  2. Clients that were registered with M-PESA and had no M-PESA balance, but did want to pay with mobile money: These clients used the PharmAccess agent and then paid us via M-PESA.
  3. Clients that were not registered with M-PESA, did not have a phone, or who insisted on paying cash: In these cases, the PharmAccess agent accepted their cash and then paid us from the agent phone

Cashless Clinics-results graph

 

We found that during our six weeks of being cashless, about one-fourth of our clients paid us directly via M-PESA.

Half of our clients were willing to use mobile money but needed the agent to assist them. Even with the airtime lottery, an in-clinic agent, and a positive encouragement from our team, one-third of our clients refused to pay via M-PESA. This is not too surprising. The Financial Diaries Kenya finds that while 90% of study participants used mobile money, the average closing balance was only 6 shillings.

Of those that used Lipa Na M-PESA, one-third reported challenges.

One of the most frequent complaints we received were that the system was confusing: there are two options for LNM payments, “Pay Bill” or “Buy Goods,” and patients were confused about which to select. Other common complaints included long transaction times due to the network speed and challenges understanding the system due to no or low literacy.

Some clients, within the two-thirds that did not face challenges, saw the value of M-PESA payments.

Here is what a few of our airtime lottery winners had to say:

“M-PESA payment is awesome as there are no additional charges. If you want to pay fifty shillings that is the exact amount deducted from your M-PESA account.”

“…it is not secure to use cash in the kijiji* as there are many thieves around and thus it is risky and prone to theft but M-PESA is safe.”

Claire, one of our lucky lottery winners

Claire, one of our lucky lottery winners

 

Looking Forward

M-PESA is a success because of the need to move money through an individual’s network. However, it is not yet a widely used retail mode of payment in low-income markets. While most of our clients had mobile money, 61% had never used the Lipa Na M-Pesa service before. There are differences in user needs and experiences for using mobile money for large transfers versus small daily transactions, and if we want to increase the use of mobile money at retail spaces like ours we need to acknowledge and address these issues.

We surveyed a sample of the patients that chose not to use M-PESA and saw eight themes emerge, the top four were mentioned by 70% of patients.

  • 21% of our patients found LNM too time consuming.
  • 18% did not bring a phone to the clinic.
  • 18% did not want to use LNM for a “little” transaction.
  • 13% did not use Safaricom (the mobile network provider that operates M-PESA).

LNM asks a lot of its user: the service interface consists of a menu to navigate, asks users to then enter numbers and verifications, and generally demands a lot more time than reaching into one’s pocket for a shilling note. Could the system be faster and easier for small, retail transactions? This is directly related to people not wanting to use LNM for “little” transactions: it is not worth the time.

The percentage of users not on a Safaricom line was a surprising but interesting finding. While still owning the market, it is not always the active SIM in a patients’ phone, meaning mobile money strategies need to be multi-network.

We had around 8% of our (unsatisfied, surveyed) patients fall into each the following four categories: They simply preferred cash, they were “too elderly, sick, or intoxicated to use the service”, they wanted to wait until next time, or they experienced a network delay. These four reasons, which made up one-third of clients’ complaints, highlight a few important trends.

First, we can and should find and design ways to make mobile money more accessible for those who are elderly, disabled, and illiterate.

Second, network delays are still too common, reducing trust in the M-PESA system. The longest LNM transaction time was 32 minutes, when the M-PESA system was down. This not only harmed that patient’s experience but may have also spread through their networks through word of mouth.

Finally, we will see a natural trend of early, mainstream, and late adopters take up LNM and mobile money for retail use. Right now, Access Afya is the only spot advertising the acceptance of LNM anywhere near our clinic! There will be a natural network effect when there are more places to spend mobile money, and we will see people carrying their phones more and balances increasing.

 

Summary

We are not able to keep our clinics cashless: we want to get there but cannot be turning clients away in the meantime. We still offer LNM as one payment option at both of our clinics, and we do see some patients choosing it even after the cashless pilot ended. More people pay via LNM at our Sinai Clinic (where we ran this pilot) than at our other clinic meaning the encouragement and education did something to change behaivor.

This was an exciting and unique look at the retail use of M-PESA at the “base of the pyramid.” At Access Afya, we are still committed to looking at mobile payments for our clinic and field programs and hope to see the industry work towards a better experience for users to make small, regular payments more common.


Interested in mobile money, social enterprise and Access Afya? We would love to hear what you think of this post. Get in touch: melissa@accessafya.com.

*kijiji = informal settlement

 

Access Afya Update: Growing, Innovating and Looking Ahead

by Access Afya

We recently sent out an update to our network about our growth in footfall, revenue, and range of services. We are also excited about the launch of our custom developed patient records app, and a mobile money pilot we ran that made our clinics completely cashless for 6 weeks. Recently our organization landed some big new partnerships and recognition for our work and we share some details and videos.

Check out our full update here!