By Gift Briton
The morning sunlight casts a golden glow over the rocky landscape of Lake Victoria’s Mfangano Island in Homabay County as Siprine Wanjoro walks purposefully towards a community medical centre with her six-week-old baby cradled in her arms like a delicate treasure.
As she enters the hospital, she is greeted by the staff’s warm smiles. Today, Wanjoro brings her fifth-born son for vaccination. Her face depicts a mother determined to give her son the best start in life.
Wanjoro’s heart pulses with joy and gratitude as the nurse administers the vaccine. She knows that her child is protected. Demoralized by mishandling and long waits elsewhere, Wanjoro resolved to receive her family’s care needs here. She is one of the mothers whose lives have been transformed since this facility opened in 2017, a testament to the inspiration and hope it brings to the community.
Located near Sena Beach on the 65-square-kilometer Mfangano Island, this center has undeniably enhanced access to primary healthcare, including maternal and newborn care services.
Popularly known as Ubuntu-Afya Kiosks, these community hospitals, including the one in Mfangano, have made it possible to attain the World Health Organization’s (WHO) five-kilometer average distance requirement for every inhabitant to the nearest healthcare service.
Wanjoro praises the exemplary care and professionalism of the nurses in this facility, a testament to the respect and value they bring to their work: “Since I learned about the community hospital, I no longer have to travel long distances, pay extra transport costs, and wait for hours to receive care from rude nurses. Ubuntu provides quality services, and you can rely on them when you need care.”
Before the establishment of this facility, mothers faced arduous journeys and challenges in accessing essential maternal care services.
The island’s geographical isolation, situated over an hour’s boat ride away from the mainland, posed significant barriers to primary healthcare, especially for expectant women and newborns in need of urgent medical attention.
In several instances, expectant mothers had to endure hours of travel by boat to seek care on the mainland, with the fare often exceeding the cost of the healthcare services they sought. Sometimes, the harsh conditions of the lake did not warrant traveling.
Care by skilled workers before, during, and after childbirth, according to WHO, can save the lives of women and newborns. However, Wanjoro’s childbirth experience without adequate support from the medical staff, which almost cost her life, is etched deeply in her memory.
In 2016, before the discovery of the Ubuntu Kiosk, Wanjoro found herself abandoned by nurses at a critical time. Pregnant with her second child, as labor pains intensified, her pleas for help echoed through the halls of the hospital. Her cries were answered only by distant voices of unseen guards who promised aid that came too late.
Miraculously, she brought her second child into the world without support. The nurses arrived only after the birth. The same situation had happened to her previously during her firstborn’s delivery.
Everything changed when Wanjoro discovered the community health Kiosks. She now relies on this facility for almost all her healthcare needs, and her subsequent deliveries have been smooth.
Unlike the previous hospitals she had visited, Wanjoro found an oasis of warmth, quality care, and nurturing support at this community hospital. Here, Wanjoro says that compassion is plentiful.
“Ubuntu Afya Kiosks have brought services closer to people. They have contributed to enhancing maternal and newborn health access in Homabay County. We believe that the Ubuntu Kiosks played a significant role in putting Homabay on a positive maternal health access indicators trajectory, as outlined in the 2022 Kenya Demographic Health Survey (KDHS). Before, in 2014, the percentage of women with at least four antenatal care (ANC) visits in Homabay was 59 percent. It improved to 69 percent in 2022. Because of these centers, there are some sub-counties, including Mfangano Island, which are now meeting the WHO’s five kilometers radius standards,” reveals James Otiato, County Reproductive Health Coordinator in Homabay County.
Compared to other regions in Kenya, maternal deaths in Homabay County remain high mainly due to delays in accessing care during childbirth and inadequate utilization of antenatal and post-natal care. Homabay had about 516 deaths per 100,000 live births in 2022. This indicates a slight decline from the 583 deaths per 100,000 live births recorded in 2014.
“The rate of under-five mortality in Homabay County stands at 62 percent, unmet need for family planning at 17 percent, teenage pregnancy at 23 percent, skilled care delivery at 95 percent, and fertility rate at 3.6 percent,” adds Otiato.
The KDHS 2022 report revealed a glaring disparity in access to primary healthcare services between rural and urban areas. For instance, urban regions have a higher percentage of women receiving at least four ANC visits for their last live birth (74%) than rural areas (62%).
Otiato attributes this stark contrast to the inadequate ratio of skilled health workers in rural settings, resulting in overwhelmed staff and long waiting times. Moreover, rural facilities often face shortages of essential supplies and equipment.
These challenges are compounded by rural residents’ limited livelihoods, making it challenging to seek care. The scant availability of health facilities, often staffed with few skilled workers, further adds to the barriers.
Dr. Samson Gwer, a Paediatric Neurologist and Executive Director of Afya Research Africa (ARA), identified these healthcare disparities as a motivation for establishing community hospitals (Ubuntu-Afya Kiosks).
Ubuntu-Afya Kiosks are a network of rural healthcare centers founded by ARA to bring essential healthcare services closer to Kenyan communities. Ubuntu means ‘you for me and me for you.’ ARA is a non-profit organization that accelerates access to quality healthcare in Kenya.
“As a junior medical doctor, many times I visited my parents in rural Western Kenya, I would be crowded out of my parents’ house by community members seeking care, having gotten wind of my visit.
“Daktari nitie” (the doctor is around) – the message would be passed around the village quickly. I was ill-equipped to offer service during these visits, but I started carrying my stethoscope, a blood pressure machine, and a patellar hammer during subsequent visits. Many times, I sent my patients for investigations or with prescriptions to the nearest town. They would cover the costs of travel and get back to me with the results or procure the drugs,” Dr. Gwer recounts his personal experiences.
He continues: “The nearest public health facility was a distance away, frequently lacked medicines, and was often staffed by a clinician who might not report to work regularly or would be rude and intoxicated during working hours. They had no alternatives.”
Driven by the vision to provide care to his community and others in a similar setting, Dr. Gwer established ARA with an inspiration to formulate a healthcare delivery model tailored to underserved rural communities. ARA embarked on a journey to introduce sustainable and community-centric healthcare solutions.
Starting with a center in Malindi, Kilifi County, and expanding to some areas in Nairobi, the organization encountered initial setbacks but remained dedicated to refining its rural healthcare delivery model.
“Initially, we assumed that if we provided subsidized care, people would pay and access care, but we failed miserably. The poor communities are susceptible to price. They would rather go to government facilities where everything was free than to pay any little amount for care even if it meant going to that government facility using transport,” narrates Dr. Gwer.
Reflecting on these challenges, Dr. Gwer and his team reconsidered their approach. “We realized success lay in involving the community in the process. We also acknowledged that cost would always be an issue for the community at the bottom of the pyramid. So, we brainstormed models that could enable us to provide care to this community, and that is when we conceived the idea of cross-subsidy with supplementary enterprise.”
Using this model, setting up an Ubuntu-Afya Kiosk involved identifying a community with significant challenges in accessing primary healthcare. This community also needed an active self-help group engaged in savings and credit enterprises like table banking. Through this group, the community shares the cost of setting up the center with ARA.
According to Dr. Gwer, communities often provided idle land, supervision, and free labor to construct the hospital. ARA provided the necessary resources: medical supplies, staff, oversight, quality control, and a digital health management system. Once established, the hospital began operations.
Additionally, ARA supported the community group’s savings and credit enterprise by injecting funds based on their needs. For instance, if a group has a table banking kitty of Shs. 100,000 and needs an additional Shs. 100,000 for all group members to get a loan; ARA provides this amount. Part of the interest accrued from this enterprise is reinvested into running the Ubuntu Kiosk.
ARA seeks partnerships with the county government to sustain operations as the hospital grows. They approach county authorities to support human resources and supplies. However, ARA maintains its oversight, quality control checks, and digital health systems even when the county government takes over the running of the centers. Dr. Gwer says that most County Governments they have approached support this initiative.
ARA maintains quality care in the Ubuntu centers through several components. They promote good record-keeping, ensure staff are suitably trained, and support essential medical supplies and oversight mechanisms that involve regular inspections to provide quality customer service, clear communication, cleanliness, adequate supplies, and accountability to health workers.
“We have a network of 25 Ubuntu-Afya Kiosks across Homabay, Siaya, Nandi, Kilifi, and Kwale counties. The centers operate 24 hours a day, providing maternal health services, postnatal care, skilled deliveries, newborn assessments, vaccinations, occupational therapy for people with disabilities, and treatment for infectious and common childhood diseases. We also address non-communicable diseases like hypertension, epilepsy, and mental illness,” notes Dr. Gwer.
Most primary health services at Ubuntu centers are free where there is a public-private partnership with the County Government. ARA works with the community group to set subsidized pricing where such partnerships do not exist. Homabay County, in particular, has provided care to over 300,000 individuals, 67 percent of whom are women and children under five. In 2017, ARA received the County Innovation Challenge Fund (CICF), a program funded by the Foreign, Commonwealth & Development Office, to scale up the innovative community hospital nationwide.
The community medical centre on Mfangano Island has garnered praise from local women. Maurine Ongaro, a 32-year-old mother of two, chose to deliver her youngest child at the Mfangano community center in 2021 after hearing glowing reviews from friends.
Impressed by the compassionate and patient care provided by the nurses, Ongaro emphasized the importance of a supportive and respectful environment during labor. “During labor, you need peace of mind, not a nurse who yells at you. Here, nurses handle you carefully and support you through every step.”
Ogweno Evelyne, the Nurse in Charge, believes treating patients with dignity is critical. “It is all about how you talk to a client. If you are a passionate nurse, talking to patients the right way and handling them with dignity comes naturally,” says Evelyne, who has worked here for over five years. The hospital has been a lifeline for many mothers, especially during doctors’ strikes, often serving as their only option for care.
Leah Wambita, 29, gave birth to her first child at the community medical center. With her three-year-old daughter, she still favors the same center for future births.
However, Leah emphasizes the need to enhance the hospital’s capacity to perform Caesarean sections and manage complications. Currently, no hospital on Mfangano Island is equipped for such procedures.
Instead, C-sections must be conducted on the mainland, over an hour’s boat ride away, posing a significant challenge for expectant mothers needing urgent care.
Wambita also urges the hospital to incorporate the new Social Health Insurance Fund (SHIF) to facilitate payment for services when necessary.
“Initial challenges included misaligned expectations, with communities assuming ARA had abundant funds to offer free services. Communicating that ARA was a non-profit with limitless resources took time.
Additionally, there were instances where the community-contributed land was reclaimed, forcing ARA to relocate developed sites,” Dr. Gwer adds.
