Interviewing the Urban Poor of Nairobi’s slums

IMG_20130206_175622Last week we ran our first prototype design challenge in Nairobi, in collaboration with various local civil society activists and the iHub.  Our objective was to test applying design thinking to a governance problem in the field.  We composed a design team from heterogeneous individuals and selected problems outside the day to day focus of participants (see our summary and high level takeaways from the experience here and here).  Their challenge was to “design ways to enable residents of Nairobi slums to access higher quality health care in an environment in which governments services are inaccessible, private clinics are run by unlicensed operators, and counterfeit medicines are rife.”

For our empathy work, we took participants into Mathare, one of Nairobi’s slums.  Critically, we arranged facilitators to help teams navigate the area, first approaching residents to assess willingness to talk.  The two hours we spent there was universally the highlight of the three day experience for our participants.  Those I spoke to wished we could have spent more time doing interviews, visiting different areas of Mathare and other slums in Nairobi to build a fuller picture of the slum health care situation.

As our buses first pulled into Mathare, however, the general sentiment couldn’t have been more different.  Participants felt an hour and a half was far too long.  Many were concerned for their safety, uncomfortable walking through the slums with their ethnic identities written clearly across their faces during such a politically charged time.

Very few team members had ever ventured into Nairobi’s slums, let alone engaged deeply in conversation with residents.  It proved to be an eye opening experience for them.  A few assumptions in particular were debunked through our discussions: that unlicensed physicians are solely out to make a buck at the expense of the health of residents, that people were receiving counterfeit or expired medicines without knowing it, and that government health services were preferred but inaccessible.

Often when you’re doing empathy work, someone who is initially hostile to the idea of communicating with you won’t stop talking once they get going.  That was the case for an unlicensed physician with whom Mark and Vivian spoke in Mathare.  The “doctor” prided himself on the services he offered to slum residents, often free of charge, and had an array of clinics to refer people to for issues he could not address himself.  He didn’t have formal training or a license because he couldn’t afford it.  He obviously lacked a fuller set of medical skills that formal training would afford.  But, he was also ill equipped to manage the psychological burden that comes with a sense of responsibility for the health of others in an environment with high morbidity and mortality rates.  Whereas at first blush one might jump to shutting down unlicensed medical providers, such as this program in Uganda does, Mark and Vivian’s conversation indicated an opportunity to support and train individuals like this man in order to improve health in urban slums.

We also spoke to a young mother who knew exactly who sold counterfeit drugs and where she could get legitimate ones.  Most of the people our participants spoke to did access government services, though they often walked up to 40 minutes to reach such services.  Furthermore, most were happy with the care they received from private clinics nearby in the slums.  One of the biggest barriers we uncovered to health was one we hadn’t anticipated at all: crime.  One mother told us that if her son is sick at night it’s too unsafe to venture out of their home, so she does the only thing she can — pray and wait until daybreak.  It was also clear that the issue of poor quality care and improper medication might be more important for mothers than for children.  Many of the mothers described how they carefully selected the right health provider when their kids were sick, but paid little attention when it came to their health, even self-medicating if necessary.

One can imagine how different an intervention to improve health care in Nairobi’s slums would look, even if conceived by Kenya’s best and brightest, had we not first taken the time to talk to the people we were designing for.  Our afternoon in Mathare was our first real indication that we’re onto something.