Some of the youth in Mukuru were trained by French and German NGO programs that used to hold artist workshops in the slums. Others picked arts and handicrafts up in search of livelihoods. Others create with their youth groups.

The first postcard: women washing clothes, children playing “tire” and double-decker corrugated iron houses.

Mongololoh is one of our community artists who stops by the clinic occasionally and knows our workers. Access Afya commissioned him to draw postcards of the Mukuru slums in the streets and path surrounding the clinic for donors to our crowdfunding campaign. We want our supporters to see the world we work in. $1.25 of each donation of at least $25 goes to supporting this artist. Each postcard we mail to supporters is signed by him.

Mukuru after dark; the Masaai painted here patrol the streets in the evenings.

I asked him if he had ever drawn his neighborhood before, and he said no. Usually, he draws Masaai warriors and lions and things that he can sell to tourists passing through Nairobi on their way to safaris. He told me he liked having a job where he was able to sit and draw his life.

He named the series “Mist in the Ghetto”, by Mongololoh.

Title of the series scrawled on the side of the book.

Help Access Afya expand our reach and receive your own original watercolor postcard of the vibrant Mukuru slums.

Domianah, or Dommy as she is often called, grew up in the Mukuru slums.

Domianah Smiling

I first met her at an outreach event Access Afya organized for young mothers. After the event I was talking with her about this slum and the community there- something about her made me sure I wanted to work with her. While we were talking I complemented her bracelets- simple amber rings that ran up her wrist.

“They are the female condoms. The expired ones.” She replied.

Domianah volunteers with the Sex Worker Outreach Program, or SWOP, so she is an expert on the subject. She teaches commercial sex workers and other high-risk groups about their options for protection and refers them to clinics for routine sexual health checks. One of the challenges, she tells me, of working with sex workers is shipments come in bulk for female condoms, and workers stock up because they do not know when they will get them again. The women store them in their crowded homes; there is not sophisticated inventory management. Expiration dates come and go and women do not always notice.

When Domianah sees packages of female condoms where the expiration date had passed, she takes them from the workers, opens them, removes the inner plastic ring, washes it, dyes it, and hands them out to health workers as bracelets to raise awareness in the community.

I laughed out loud. I was impressed by her creativity and inspired by her commitment to work with some of the toughest challenges faced by this community and have a little fun while doing it. I asked her to get me some bracelets.

Domianah now has her first full time job, paid with benefits, as a Community Outreach Coordinator with Access Afya.

Global Health Bracelets

We are raising money to open a second mini-clinic in a different neighborhood within the Mukuru slums. Our top-level supporters will receive their own set of three Global Health Bracelets. We encourage these supporters to take photographs of themselves wearing their bracelets around the world, send them to us, and we will add them to our blog, showcasing our global network of individuals supporting Access Afya and raising awareness about safe sex! Please consider supporting our Start Some Good campaign and sharing the information with your networks.

The fourth and final customer profile is of a mother who came from a surrounding public outpatient clinic, where the model is a low-cost 20 shilling all-in fee for consultation and medication, although they had run out of most medications including all three things they had prescribed for the child. While illuminating one of the frequent challenges in “accessing” care through existing facilities, this story also raises another ethical issue in social enterprise.

We had everything on her prescription in stock. The child had diarrhea and was fussing. The treatment was zinc tablets, antibiotics, and a cough syrup. The mother looked at the list, the prices, and asked if we could lower the cost for her.

We certainly don’t do free medication or discounts, but we do know that antibiotics are consistently over-prescribed in Kenya – and probably in most of the world. The World Health Organization and the Kenya National Standards for the treatment and prevention of diarrhea both recommend oral rehydration salts and zinc are given immediately, but that antibiotics add no practical value unless the case is severe and dysentery suspected.

We recommended she use ORS salts, buy the zinc, and forgo the rest. People are used to buying antibiotics in response to almost every visit, but we make sure we recommend it only when necessary.

This lowered the cost of the treatment for her. This lowered our revenue. This action was in line with global and national best practices. We believe in the long-run, what is good for the customer is good for business, and the lifetime value of this family will be greater for us if they trust us and know we are looking out for their health and their wallets.

Resilient children of Mukuru

This man did not lead with talk of malaria; rather he started asking to buy some over the counter painkillers. Then, be began to inquire which brands of malaria treatments we stocked. Why was he concerned with our brands? He had bought some malaria medication from a nearby chemist, but they were not making him feel better. So he was thinking of trying a new brand.

Rather than recommending our brand, we recommended he think about letting us do a consultation with him and running a rapid test to see if he did in fact have malaria. A more likely reason for his medication not working was that he was treating the wrong thing, not taking the wrong brand.

Many people living in the slums still travel frequently to rural areas, so it is not impossible that some would pick up the disease. However, actual instances of malaria in Nairobi are uncommon, although most people with fever still assume that it is the cause.

He was excited that we had on-site testing capability. He told us he would be back, and spread the word that there was a place to get a malaria test nearby. This is one advantage we have with our location- from the outside, looking like a chemist. People stop in for a familiar interaction, and we are able to give them new information.

Our second profile is of a woman who was feeling dizzy. She walked up to the counter, told this to Carolyne, and asked what medication she should buy. Carolyne is a registered nurse (although she runs clinical operations for Access Afya) and at this point she asked the woman to come back and have a consultation for 100 Kenyan shillings (around $1.25) to find out what was causing that dizziness.

“You can’t just sell me something here?” The woman asked.

“No,” said Carolyn, who went on to explain why we wanted to collect a full background, that dizziness could be caused by a number of issues, and some of the issues with over the counter medication that our previous post raised.

The woman listened and said she would go to find some money and come back later. We hear this a lot. Sometimes people do come back, and sometimes it is just a polite excuse to go and buy drugs from another chemist.

But this woman actually came back. She spent 100 shillings on that consultation, and also purchased a lab test to confirm diagnosis. We ran the rapid diagnostic test on site and collected an additional 100 for that, plus for medication prescribed.

While the previous post tells a story of us “losing” a sale, but sticking to our principals and giving out valuable information, just hours later the opposite happened. Here, we made a medication sale but also consultation and lab. We are certainly optimistic that in the long run, “what is good for the customer is good for business” can work for us.

Inside the Access Afya consultation room.

We made the decision as an organization to sell medication according to diagnoses and prescriptions, with only a small list of items such as aspirin and condoms that can go over the counter. Explaining this to our potential customers has been a challenge, because it represents a stark difference from the status quo. The conversations we have with them vary widely. In one day while updating inventory, Carolyne recorded four very different interactions.

A big part of our nurse’s work is convincing people to use consultations and lab tests.

Person one walked up to the window and asked for four flagyl tablets, an antibiotic that we only sell through prescriptions. Our staff explained that this treats a variety of infections, and that we would like to do a consultation to get to the root of her symptoms. Carolyne explained to her that four tablets did not meet any of the low dose requirements, and that she needed to purchase more for an effective treatment.

The woman was confused. She knew her symptoms, and that last time she went to a chemist she bought a few flagyl pills. She accused us of just wanting to make a bigger sale, with more drugs and the consultation fee.

Our response was that absolutely no sale size was too small from us- but we had some legitimate concerns here. We wanted to understand her symptoms so that she gets the right drug. Four tables is not a full dose. Taking less than a full dose is dangerous- it can cause a relapse of the infection and start to build up resistance over time.

She was genuinely confused – why other chemists had never asked her these questions, or talked with her about dosages before? She seemed even a little upset. She told us we were commendable for following regulations and upholding a high standard of care.

She was then honest about having only twenty shillings on her, told us she was going to a neighboring chemist, but would keep us in mind for next time.

Despite the fact that we did not make a sale here, this is a huge win. Our nurse took the moral high ground and we stuck to our principles. We spread valuable information in the process, and got this woman thinking and asking questions. The Access Afya team is thinking a lot about how to work with even women like this one- poorest of the poor who will require serious behavior change. We have some creative ideas, and would welcome anyone with suggestion for us to get in touch through info@accessafya.com.

Just six short weeks after signing a lease on our site, which looked exactly like every other rusted, corrugated iron structure in the slums, we opened doors for patients. In Kenya, this was no small feat. The 12 x 15 foot plot is now a consultation room, dispensary, lab, and waiting area, all with tiled floors, painted walls, and medical equipment stocked. Look out for our next post, which will be dedicated to describing the process of transforming this space.

Our clinical officer standing in front of the site.

We brought on a great clinical team to work in the pilot site. When Access Afya is open, there will always be a registered nurse or clinical officer on-site providing services. We also have one full-time community health worker at the front window, holding conversations about our services, making sales, and scheduling appointments.

One thing we did to show our dedication to our clients was open morning hours on Christmas Day and the day after. Both are public holidays, and most health facilities and shops are closed. We saw a few patients in the days leading up that helped us make this decision. One had been in a recent road accident and needed his wound dressing changed every other day. Another had an antibiotic from a public hospital that needed to be injected daily, and a third was on a daily anti-malarial injection that he wanted us to administer. Our phenomenal clinical manager showed up for morning hours on public holidays to get these people the care they needed.

It was worth it- the feedback we have been getting from these three patients, along with many others, has been overwhelmingly positive so far.

Celebrating the unit graduation

On Friday, the Kayaba Crescent Community Health Workers graduated. This was a really big deal- it was the first graduation held since the roll-out of the community strategy.

The Community Strategy was launched in 2006 by the Ministry of Health. It rests on networks of “community health workers” (CHWs)- individuals selected from their community and trained in basic health provision and referrals. In urban areas, a community health unit is made up of around 5,000 households, which are then divided between 50 CHWs who check-in on each household each month.

Afya Yetu Song

There are 23 units in the district Access Afya is piloting in. At least six still need training, and they are concentrated in the Mukuru area where we are. While much of our initial work was with the Kayaba unit, our site is now in Kisii Village and our unit is still in need of training for the strategy roll-out.

Following training, the CHWs conducted an extensive baseline survey on community health, recording 26 indicators for each member of each of their households. Despite expected challenges in gathering this, the data coming out of the baseline survey was already powerful. Key indicators were recorded on a large whiteboard at the front of the ceremony.

Less than half of all households were treating their drinking water

Half were using sanitary latrines

2,553 out of 4,007 had some hand-washing facility
One of the most exciting things about the day for me was that through this strategy, we can start to formalize the informal settlements. There is regular counting and visiting of people, information collected on facilities. It was very powerful being there at an event attended by public officials talking about work being done in a place that is not officially recognized as existing. This is why it is so important to continue to train the remaining groups in Mukuru- the slum we operate in- a place with no formal recognition and notoriously weak land rights.

We had to say a goodbye last month to Kelly, summer fellow with Access Afya, who was a regular writer for this blog among many other things. The good news is that the team is growing and we now have a full-time Pilot Manager working on all things related to pushing to get our first “health kiosk” ready to open.

Carolyne is a clinical nurse with a passion for improving healthcare for vulnerable populations. Her community work includes working with street women on the coast and caring for patents in the psychiatric ward in another slum here in Nairobi. She also holds a Masters in Public Health and brings experience from various nurse postings in addition to experience managing clinics and coordinating care in the private healthcare sector.

In her first week, she already screened and selected an impressive and passionate group of nurses who attended first interviews, which we conducted last week. People were genuinely excited about what we are doing, but we are waiting until after practical assessments next week to make offers. She has also quickly integrated into all the networks I have introduced her too- from the village elders and community health workers in Mukuru to our fellows in our new office space.

We’re lucky to have someone smart and as committed to Access Afya’s mission as we are. Look out for an upcoming post on our next milestone: starting construction on our site!

As we speak the first pilot manager interviews are underway and we hope to have this talented group narrowed down quite quickly.  We are still sorting through the nurse practitioners and will hopefully be conducting preliminary interviews early next week!