Rethink Health Care provision for nomadic pastoralists
It is late morning, yet the sun is almost melting the earth away. It has certainly boiled the river into inexistence. Deep in the remote outback of Samburu county, a team of health care workers is on a mission. They drive fast on the desiccated riverbed. They are determined to reach a small settlement of pastoralists somewhere just beyond the horizon, far into the dancing mirage.
After enduring the heat, surviving the dust devils and the frequent jolts over unforgiving terrain, they reach the small settlement where a Samburu woman is breastfeeding her two-week-old baby. They examine them and vaccinate the baby. This baby and the mother are in good health. It is not the case in the other manyatta where they find a young woman lying on a makeshift framework with an assemblage of herbal concoctions besides her. She is recuperating after suffering severe bleeding in a complicated delivery during which the baby died. The nurse talks to her, her attention shifting from the unpromising display of concoctions to the frail woman whose chances she knows are slim. She is severely anemic and can barely sit up. Her mother and other older women mill around, seemingly resigned to a dreadful fate. They’ve seen this play out much too often. One of the older women adopted her son’s children after his wife died in during childbirth. The other one lost some of her grandchildren to starvation before they left the previous settlement several hundred kilometers away.
The health workers move from manyatta to manyatta, doing what they can with their meager supplies. The heat worsens, and the struggle against fatigue and dehydration gets worse. The demand for their services is higher than they can muster. They keep their eyes on the clock, wanting no part of a dangerous drive back to Maralal town in the dark.
The outreach team is the closest this nomadic community ever gets to health care. But it is a tiny drop in the vast expanses occupied by pastoralists in Kenya. It is a mission made no easier by the constant mobility of the nomads and the harsh environment. Yet it is one that is necessary as demonstrated by the needs of the people they found.
Kenya’s pastoralist communities live in the arid and semi-arid areas. They are considered marginalized due to the lack of basic infrastructure. Investing in infrastructure in such regions is not only difficult and expensive due to their vastness but also lacks any social or economic sense. The constant movement of the people means any hospital buildings, roads, electricity grid, etc. become dead investment when they are abandoned as the pastoralist move deeper into the wilderness in search of pasture. It is a lifestyle that lacks the certainty and predictability necessary for fiscal planning.
This is a difficult thing with regards to healthcare. Nomads need health care services as much as anyone. They are the cultural groups with the greatest unmet health needs. Think of the least vaccination coverage, the highest infant and maternal mortality, the lowest life expectancy, etc. Every health indicator reveals a depressing trend and the need for urgent action. This action cannot be the construction of new hospitals or roads as it would be in ‘settled counties such as Kisii or Kirinyaga. The lack of permanence in their lifestyle means permanent structures such as these are not an option. But leaving them without healthcare coverage is a violation of their rights. The government has an obligation to provide health care services to every citizen. What do you do when these citizens are in constant mobility and cannot come to the facilities you build?
You cannot force them to depart from their age-old way of life. Any such demand would be unproductive at best. A scenario where those in government are adamant that only the conventional health care system can work creates a chasm between them and the pastoralists. They have to defend their way of life against any domineering force. Such a patronizing stance evokes serious resistance, perhaps even violence. It is a natural reaction to the intrusion of one’s culture. The domineering demand for a change cannot endear anyone to them, let alone foster a relationship that promotes health. Pastoralists will not abandon their way of life, and should not have to. The leaders will not abscond their duty to provide health care and should be ashamed of themselves if they do.
What this leaves us with is to go to the nomads not to impose change on them but as equals who adapt service provision to their way of life in order to meet their right to health care. It would be a win-win both ways. The nomadic pastoralist stays healthy while maintaining their culture, and those responsible are not caught out in dereliction of duty. The requirement is to overcome our own “settled” mindset and the demand for certainty and predictability.
This is exactly what devolution exists for. It was created to take resources and services to the people; whoever they are, wherever they might be. If people were to be required to go to where resources are and settle there and change their way of life to fit in, then counties should not exist in the first place. Continuing this pattern means a failure of this expensive devolved experiment. Many Kenyans believe that the devolution of health care is fundamentally flawed because there is no place where any significant change has occurred. Health care in “settled” counties such as Nakuru, Kiambu, etc. is the same old style of brick & mortar hospitals and health centers. In ‘nomadic’ counties such as Turkana, Samburu, Marsabit, etc., this cannot work. In this case, devolved healthcare services must adapt to the age-old mobility of the people. What may have been difficult for the national government to do should be the strategy adopted by the devolved governments to provide health care services to the people?
Mobile health care services are already provided to some extent by non-governmental organizations. No organization can make a significant impact in such vast areas under such severe conditions and where settlements are in constant flux. This calls for the county governments to take up the responsibility. They should already have made significant inroads in this regard. Such counties such as Marsabit and Samburu should not have the same health care priorities as Nairobi or Nyandarua. Where the latter need larger hospitals, the “nomadic” counties need to invest in mobile health care services. It is justified to use tax-payers to build large hospitals in the settled counties. Indeed, it is an obligation. It is also sane for them to expect that people will come to these hospitals since they have permanent settlements within the proximity. The same cannot be said of counties populated by nomadic pastoralist. A large hospital, even a small health center, is an unjustifiable waste of resources if built somewhere in Samburu county where the only certainty is that those living there today will be gone tomorrow.