Posted on Friday, Dec 12, 2008 at 6:58 pm by Lissy Desantis
Following the Second Annual Right to Health Conference, my colleague Amanda Cary and I have been on the ground searching for innovative approaches to comprehensive women’s health care; models for service provision that move away from the “vertical approach” and integrate critical services such as family planning and HIV&AIDS counseling and testing. This integration helps to break down the many barriers women face when accessing health care. It’s a new way of thinking about health and about the systems that are designed to promote it — imagining every patient as a holistic person, with legitimate demands upon the health system and fundamental rights within it that must be respected, protected and promoted.
In order to examine these models further, we’re visiting NGO outreach sites in rural areas, government facilities in the heart of Nairobi, faith-based organizations in the capital’s slum areas and holding interviews with a wide array of service providers. Here’s a brief glimpse into what we’ve discovered… so far: the story of Emma and Eunice.
Eunice lives on the outskirts of Nairobi, along the dusty, crowded industrial road linking Kenya’s capital to the coastal port of Mombasa. Every six weeks she goes with her newborn daughter, Stella, to the health center for their regular check-ups. It isn’t easy to access health care in Kenya – health facilities are often far away and transport is expensive. Even when a woman does manage to reach the facility, the medicines, services and even health workers may not be there. Eunice is one of the lucky ones – she lives nearby to a government health facility in the Industrial Area. But she chooses another facility for her care. She chooses to pay extra fare, to take extra time and to travel into the heart of Nairobi to visit Nurse Emma Kariuki at Loco Health Center.
Loco Health Center is at the very end of a tarmac road falling slowly into disrepair. The pavement eventually turns into dust, and cars become fewer and fewer as the road narrows towards a small footbridge leading over the railway tracks. Under this footbridge, next to the old railway supplies warehouse is Loco Health Center. The facility is made up of only a few buildings – one larger concrete building for general consultations, and several smaller trailers housing the child welfare clinic, antenatal care clinic and tuberculosis clinic and laboratory, as well as space for a support group for people living with HIV&AIDS.
Emma Kariuki has been a nurse at this small, bare bones facility for years. And it was Emma who pioneered the integration of services for women who visited the facility – matching up the services she offered with her own, holistic view of the clients who came to seek her advice and support. In Emma’s words, “I asked myself, if I’m genuine about HIV, the women who are coming for family planning are telling me they’re sexually active, and if they’re sexually active, then I’m denying them an opportunity to get to know their status.” One of her first clients was a woman whom she had tested for HIV as part of prevention of mother-to-child transmission. The client was HIV negative. The next time she was tested, three years later, she was HIV positive. According to Emma, “That gave me the energy to continue.” Emma was determined to take advantage of future opportunities for all her clients, no matter what services or needs brought them to the health center.
So Emma sought out training on HIV counseling and testing, and began to integrate it into her own family planning services. Initially, her colleagues felt that offering HIV testing to people in the family planning clinic would deteriorate the demand for family planning services. But Emma persisted, and proved them wrong. “It was the opposite. Clients began to come to us from other clinics. Those that I tested would go and tell others in the community, and they’d come to me and tell me ‘Sister, I hear you’re offering VCT and family planning. I’m not your family planning client, but I’ve come for VCT.’ Instead of the numbers going down, they started to go up.”
This is why Eunice comes to Loco, instead of her own, closer health facility. When she arrives here with Stella, she can get a full package of care. She has her reproductive health needs met, and she can feel confident that her other needs, such as HIV counseling and testing, will be met. Another client at Loco, Felista, feels the same way. She tells other women to come to Loco because “here they can be free, just as I am free.” At Loco, women are viewed holistically – they are viewed as rights holders and as partners in health service provision, not simply as beneficiaries. Both Eunice and Felista, through regular visits for family planning, have been counseled and receive regular HIV tests. Now, they both want to bring their husbands to be tested at the facility as well. This type of comprehensive care has ripple effects – by skipping a small stone across the pond, the waves have eventually reached the farthest shores.
In the eyes of providers such as Emma and women such as Eunice and Felista, providing comprehensive services for women is by no means impossible. Women want to receive the services, health providers want to give them, and yet the system just simply isn’t designed for it. Major challenges exist: health workers must be trained in counseling and testing for HIV, and there must be enough health workers in the facility to handle the influx of clients that will follow and spend the necessary time with each. Furthermore, health facilities must have enough commodities to instill faith in clients that when they do manage to make a visit, they won’t go home empty-handed and uninformed, and there must be enough space to ensure privacy and confidentiality. Yes, there are major gaps and major needs; however, health workers such as Emma are changing the paradigm and demanding more from the system within which they work, looking for the simplest, most cost-effective way to provide the needed services. Indeed, they are blazing a trail for the rest of us to follow.
Emma sought out extra training on HIV counseling and testing, as well as community and home-based care, and paid for it herself. The Clinton Foundation provided Loco Health Center with the 2 extra trailers necessary to create the space needed for confidential counseling and testing. With simple interventions such as this, Emma was finally able to provide the care that she felt respected the integrity of the women who sought her services. Women do not simply receive information and services, they demand them as well. We should all follow Emma’s lead, advocating for health systems that allow health workers to encourage, engage with, and respond to these demands.
Eunice, Felista and Emma have begun this process, and service integration is simply one method with which we can begin to meet the needs of both health workers and the communities they serve. Let us support Emma and Eunice in this journey – let us recognize their challenges and acknowledge that they should not be fighting this battle on their own. Let us follow Eunice’s lead, and seek out models that promote both women’s rights and women’s good health. Let us look to the end of the road and under the bridge, to small, simple, unassuming models such as Loco Health Center. Here, a woman is more than a body in need, a health worker is more than a stop along the way, and the right to health is looking more and more like a reality every day.