Here’s how northwest Kenya gets nomadic families to health services.
It’s 11am at a water point in the parched, windy bush of Kibish, in northwest Kenya’s Turkana county, and a tiny, makeshift city is taking shape. The just-add-water metropolis, which is being assembled from supplies loaded on the back of a small fleet of Land Cruisers, has its own small clinic.
The patients arrive at the Kimormor in dribs and drabs. Many have walked for hours to reach the clinic because they live so far away.
It’s June and the sun sits high.
There are women trailing waddling toddlers and carrying babies strapped to their backs. They’re here for health check-ups, immunisation and birth control. But there are also men with long sticks, coaxing small herds of goats and cows toward the watering point to be vaccinated and checked for disease. The men are here because, next to the health clinic, there’s a small veterinary clinic.
In Turkana county, a large portion of the population are nomadic pastoralists, following massive herds of goats and cattle across the Savannah literally in search of greener pastures. This lifestyle often takes a toll on families’ health.
Children here are twice as likely to die before their fifth birthday compared with the national average, government data shows. And the rates of acute malnutrition in children — the kind that can permanently stunt mental and physical development — were around 30% as of July 2017.
To get men to health facilities, however, is often a challenge. It’s crucial that they visit — not only to provide security to women and children as they walk the long distances to clinics, but also for their own health.
Around the world, research has shown that men are far less likely to visit health facilities for check-ups than women. A 2015 study in the journal AIDS, for instance, found that in East and Southern African countries, men are significantly less likely than women to have been tested for HIV.
As a result, fewer men are on antiretroviral therapy and many who receive treatment get it at a later stage of HIV infection than women, when the virus has had a significant amount of time to deplete their immune systems.
But studies show that men’s low utilisation of services is not just the consequence of their poor health-seeking behaviours or attitudes about manhood. Health services are often not designed to attract men.
Here in Turkana, however, health workers have figured out a way to get men and their families to clinics: offer them crucial services for their livelihood — their animals — in addition to healthcare. Welcome to the Kimormor, north-west Kenya’s answer to a problem that has long baffled public health officials and other service providers.
John Lomulen arrived at the Kimormor with a herd of about 40 goats and 10 cattle in tow.
“The most important [reason why I came today] is the fact that my livestock would get vaccinated and be checked if I attended the Kimormor. This then motivated me to think about bringing my wives and children too for the health services,” he says.
“My cows have never been vaccinated and it is good they are receiving this for the first time. Now I am sure they are free of diseases.”
When someone comes in for one service, organisers say, it can often coax them to stay for others. The Kimormor also offers ID registration.
Llipsini Ekuwam, a 28-year-old mother of three, is here with her two-year-old son. She walked for three hours from their village so that the toddler can receive a check-up and vaccinations. It’s the first time, she says, that she has ever brought one of her children to a clinic.
“I have never heard of it or seen other women doing that,” she explains.
“I came here because the [community health volunteers] talked to my husband about it and he asked me to come with this baby. The other two children are at home taking care of the goats.”
As her little boy is passed between health workers, they also begin to chat with Llipsini about options for hormonal birth control. “Have you ever tried it?” they want to know.
“No”, she tells them. “All you are supposed to do is wait until God gives you another baby.”
For organisers, that’s a typical answer here. Only one out of every 10 women uses a birth control method, government data reveals. The health workers quickly run through the benefits of contraception and explain that, with birth control, Llipsini can choose how far apart she wants to have her children.
“You — and your body — can have time to rest between deliveries,” the nurse says.
Llipsini listens attentively and promises she’ll think about it, and discuss it with her husband before the next Kimormor.
“Acceptance to family planning here is still a challenge because men believe that children are wealth,” says Daniel Echor, a public health nurse who works on Kimormor outreaches in Turkana.
“But projects like Kimormor are starting to bear fruits. We are seeing women slowly starting to accept long-term family planning services and delivering in hospitals.”
Bringing basic healthcare to nomadic populations like those in Turkana, however, presents enormous logistical challenges. For one thing, it’s difficult just getting to them.
That’s in large part because there are no roads in or out of most of the communities the Kimormors service. Travelling there requires a fleet of hardy four-wheel-drive bakkies, but even they are often no match for the harsh elements. When it rains, vehicles are frequently marooned in sandy lagers. And when it is particularly dry, the stony terrain batters the cars and punctures tyres.
Without roads, organisers must rely solely on natural landmarks such as mountains and the direction of the sun to chart their path to reach communities. Those communities sometimes change their own migration routes without warning to avoid cattle raids from neighbouring communities, and therefore simply don’t show up at a planned Kimormor site.
For this particular Kimormor, like many before it, things didn’t exactly go according to plan. On the original day the outreach was slated for, it rained. On the day it was rescheduled for, it rained again. Local government offices struggled to rustle up supplies and staff.
But finally, early one morning in late June, teams got under-way. At 4am, a convoy of eight vehicles and 35 people set out from Lodwar, the county headquarters. It took about 12 hours over teeth-rattling rocky terrain to reach the water point described by local scouts, who advise Kimormor officials on where to meet communities along their migratory routes. And, if getting health workers and government officials to Kimormor sites is half the challenge, the other half is informing communities about a visit.
In the days before a Kimormor, health workers fan out across the area, explaining what the outreach will cover. They enlist local leaders to spread the information to the community and use Digisomos, small battery-powered audio devices preloaded with recordings that explain the Kimormor’s services in local languages.
“Traditional leaders known as emurons play a big role in mobilising the community members to attend the Kimormor,” says Echor, the nurse.
“They are more respected by men in the community and their word is taken seriously. So days before the Kimormor outreach day, they go around the village informing people about the outreach and why they should attend. This has helped so much in getting more people to come for the health services.”
Around 5pm, the services at the Kimormor begin to wind down. Organisers dismantle tents and pack leftover vaccines and medicines into the backs of their bakkies. The last remaining community members pick up their children and prod their cattle to begin the long walk back to their settlement.
Everyone, organisers and community members alike, wants to get home before the sun sets into an inky, unbroken black over the bush. Community members especially don’t want to stay put too long — it could invite the unwelcome attention of cattle rustlers. Kimormor team members, meanwhile, will head to a local health centre to stay the night before driving on to their next location.
So they all say their goodbyes quickly and head off. In three months, after all, they’ll all be back to do this over again.