The paradoxical role of families in women and girls health in slums


Pauline OosterhoffPauline profile

One of the things that strikes one most clearly in working in the slums in Kenya is that, as in many developing countries, the state is barely present in most people’s lives. For the women my colleague Emily Kahega Igonya and I encountered in Nairobi’s slums last week, the government was inactive while they were sold by their sisters or brothers-in-law, tricked into unpaid work with false promises of education, and kicked out of their parental homes as orphans.

Yet Kenya’s recent constitutional reforms are based on the idea that devolution, handing off central government responsibilities to municipalities, can solve people’s problems by bringing government closer to their lives. This seems doubtful, given that for most of the women in slums we talked to, it is family and friends, not the state, that provides them with support. It made us wonder how and to what extent state policies can interfere in dysfunctional families, when it is the family that provides for the services that dysfunctional states fail to provide.

The impact of the new Kenyan constitution on health outcomes

According to the new Kenyan constitution introduced in May 2010, all Kenyans have the right to the highest attainable standard of health. To realise access to health, the constitutional reforms prescribe “devolution”, a transfer of responsibility from the national government to the counties. Devolution should bring the government closer to the people.

Last week Emily and I examined the effects of Kenya’s constitutional reforms on access to HIV and AIDS services for women and girls in Nairobi slums. We worked with HIV-positive women, all young mothers, on digital storytelling to inform policy makers of the effects of these national policies on their health. All women described betrayal in their families –often by other women- that exposed them to HIV, violence, and destitution. Yet it is their sense of family –even if it is just their own children – that allows them to survive in the absence of a functioning state.

When Larissa, a widow with two children, completed primary school in a village, her mother was no longer able to pay for her school fees. She called her elder sister in Nairobi, who offered to pay for her education. Upon arrival in Nairobi, however, her sister told her that she would only pay for school fees if Larissa agreed to marry her husband as his second wife. When she refused, her sister’s husband presented Larissa with a widower with two children who would marry her and pay her school fees if she were to take care of him and his children. She ran away and met a man with a job in a restaurant who paid her school fees and married her. Shortly after the delivery of her second child, he fell ill with AIDS. He encouraged her to seek treatment from international donors but he denied that he was HIV positive to her until the very end. She has now been inherited by his younger brother. He takes good care of her, and she is pregnant with his child. Who is failing women like her?

The implementation of the devolution of health services began last year, with the election of governors and county principals, but it has barely affected these women. For sex workers -some of whom have been involved in sex work since their early teens – the effect on their health has been clearly negative. Municipalities interpret and enforce laws on sex work more harshly than the central authorities did, chasing women off the streets and detaining them. Police detention makes it harder for them to take their AIDS medicines. Sex workers reported having to stop their medication completely, or change to herbal medication. In their perception, devolution means that “law enforcement can now use their cars freely to extort more bribes from us later at night.”

Sex work, the family and state support

For sex workers, other sex workers and community-based organizations are the main form of support after their own family failed. Rose, a young mother, was taken in by older sex workers when she was orphaned at the age of 15 and rejected by her family. She has worked as a sex worker ever since. Sarah’s mother decided that her job was done after her daughter finished primary school. Sarah decided to go to Nairobi to live with her aunt, who could not pay for all her expenses. She had to look for money herself, and at the age of fourteen she found herself on the streets as a sex worker. When her aunt guessed how she made her money, she threw her out, leaving her at the mercy of different men who took her in until they were bored or she became pregnant. Linda finished high school and went to college, hoping to become a secretary. She came to Nairobi to look for work and live with her uncle. He had no money to pay for her. The only people who were willing to help her find a job and a home were bargirls who moonlighted as sex workers.

Women we spoke with –no matter how poor- had done their best to avoid the state health services for years. As Lucy, a young widowed mother of two, explains, “there is no confidentiality, the lines are long and the hours are short, and everyone can see you.” Instead, they obtain AIDS medicines through internationally funded and managed services like MSF and CDC. Kenyan community-based organizations, like HAKI and COTANET, help women to organise themselves and establish their own peer support systems. But for housing, food and other essentials, it is their own family they rely on first. And when that system fails- without any safety net offered by the state, charities or INGO’s – women are exposed to many risks, including HIV. Policies that aim to support the right to health of women and girls in slums need to recognize the central roles of families in responding to governmental irresponsibility.

All names in this article are fictional to protect the identity of the women.

Pauline Oosterhoff is a Research Fellow for the Participation, Power and Social Change (PPSC) team at IDS. She can be found on Twitter as: @PPJOosterhoff

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Participatory visual processes in Nairobi’s margins


Thea ShakrokhThea Shakrokh

I recently spent a week in Nairobi with community researchers from The Seed Institute and Spatial Collective (two of the research group members within Participate []) who were learning about participatory video as an action and research strategy within their participatory research initiatives. Participatory visual processes provide creative possibilities for the very real issues affecting people’s lives to be captured. Jackie Shaw from Real Time facilitated a journey through which the researchers gained hands on experience of facilitating a participatory video process, and looked at how the approach could be used to amplify the voices of the most marginalised in their communities, and generate dialogue with decision-makers.

Community researchers in Kasarani, Kenya learning about facilitating participatory video processes.

Community researchers in Kasarani, Kenya learning about facilitating participatory video processes.

The potential of participatory video to visually communicate the context specific issues, concerns and aspirations of community members resonated strongly with the community researchers. As participatory video is a creative process there is flexibility in its use. This meant that in learning about the approach researchers were able to think about ways to connect it to their own visions for action research; it was interesting for example to hear the nuances in the way that the purpose of participatory video was interpreted:

“Participatory video is a tool for highlighting issues on the ground that do not yet have a strong presence in public debate, for example disability issues.”

“It is a group process that enables issues to come out as people have conversations through working together.”

“Participatory video will enable more people in the community to be reached and in an interactive way which will provide community ownership over the issues generated.”

“Censoring of the narrative, which traditionally happens in survey work is removed, the story coming through is true to the detail of what the community members were sharing. Also the authenticity of the voices will remain, for example the language of the youth will be what is heard.”

What came across clearly in the conversations that took place over this week, was the importance the groups placed on the empowering nature of participatory video – in particular, the way that the exploration of community stories is placed at the centre of the process as opposed to starting with the external policy context which is so often the case. By creating a space for issues to be deliberated and communicated collectively, there was a feeling of increased power behind the message articulated.

For me what is really powerful about participatory video is that it provides a space for communities and policy-makers to make connections that are grounded in the reality people’s lives, and their physical spaces. Importantly, in the context of Participate, the digital nature of video makes the perspectives and voices of people living in poverty accessible at the local, national, and international levels; from cross-community dialogues to global policy debates, with strong possibilities of dialogue between the two.


Spatial Collective community researchers sharing the participatory video process with their peers in Mathare settlement, Kenya

The next steps in Nairobi will be to take participatory video to the communities that Spatial Collective and The Seed Institute work which they hope will bring a new dynamic to their work. The Seed Institute are planning to use participatory video to provide new opportunities for children with disabilities to participate in and lead the learning and action activities that they facilitate. The Spatial Collective moved very quickly to share the method across their team of youth leaders who coordinate community-led mapping in Mathare settlement. They are planning how to make their inquiries into community issues deeper by creating spaces for wider community interactions through forums and debates around the films that are made.

Participatory visual processes can reveal and communicate powerfully about experiences from the margins by providing contextualised examples of the complex and subjective aspects and consequences of development. It will be really interesting to see how the use of video develops in both organisations and across the initiative, and also how the various actors in this post-2015 debate respond to making a very real, very human connection with people living in poverty.

Thea Shahrokh is a Research Officer in the Participation, Power and Social Change research team at IDS.

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