Nikumbuke-Health by Motorbike

The Problem

Health care for women is often conditioned by multiple factors, such as the feminization of poverty, gender norms and values that place women at a disadvantage for societal resources, and certain cultural meanings associated with illness that may negatively influence prevention, early diagnosis of disease, and treatment. Women across Kenya suffer from preventable illnesses that pose an enormous health burden on them, their families, their communities, and their country. In rural communities, these problems are exacerbated due to lack of health education, difficult access to medical care, and community mistrust towards the government medical system.

A 2009 health needs assessment for women in four rural communities in South-East Kenya, conducted by Dr. Ishmael Mwangi, of the Lunga Lunga Health Center District of Kwale, and Dr. Araceli Alonso, of the University of Wisconsin-Madison (UW-Madison) in the United States, identified six major health concerns. 1) Life expectancy of women had dropped from 60.1 years in 1990 to around 45.6 years in 2009, primarily because of the HIV/AIDS pandemic and lack of information and health care to treat it. 2) Early marriage and teenage pregnancy had contributed to high infant mortality and maternal death rates, as well as serious health complications such as severe vaginal perforation. 3) Pregnancy, especially in adolescents, put women at higher risk of malaria infection than any other adult group. Because pregnancy reduces immunity to malaria, it makes women more susceptible to malaria infection, increasing the risk of illness, severe anemia and death. For the unborn child, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery and low birth weight. 4) Female genital cutting put young women at risk of acute health problems such as hemorrhage, shock, bacterial infection and failure to heal, tetanus, trauma to adjacent tissues, urinary retention, and HIV infection. 5) Cultural myths and misconceptions had serious preventable health consequences. For example, some women claim that malaria is a disease caused by supernatural evil forces that produce degedege or severe convulsions in a child, which must be treated by a witchdoctor. These cases are medically diagnosed as cerebral malaria, and they are often too advanced for any form of anti-malarial therapy. 6) Basic medications such as multivitamins were out of the reach of women; most pregnant women chew on soft stones or pieces of dry mud to satisfy their craving for iron. The stones, however, caused kidney and liver damage when not taken with enough fluids; dry mud contributed to intestinal parasite infections since it often contains live larvae.

Before N-HbM, women had to travel long distances, often by foot or bicycle, to access the one government clinic. In addition, two thirds of the population live below Kenya’s poverty line and cannot afford the government medical fee. Preconceived cultural habits and ideas often preclude women from even considering reaching out to existing government facilities. As a result, preventable diseases spread easily and treatable illnesses often become endemic, particularly among women and children.

Solution and Key Benefits

 What is the initiative about? (the solution)
Since 2009, N-HbM has reached approximately 60,000 people through the following: 1) A health post turned into a large newly built Community Health Center for women and girls in Lunga Lunga. 2) The Mama-Toto Mobile Clinic—one of its most successful programs—to reach the most isolated communities. 3) A three-year anti-malaria campaign that distributed 1000 Insecticide Treated Nets (ITNs), with anti-malaria health training workshops. 4) A formal train-the-trainers program of health promoters (community health workers). 5) Celebration of “health parties,” or community meetings organized by newly trained health promoters to identify health issues and concerns; approximately 16,000 people have been reached. 6) Summer health camps for women and adolescent girls. 7) Various culturally sensitive health promotion initiatives, such as the creation of a Street Health Theater Company that has trained a group of women to perform skits on disease prevention, diagnosis and treatment. Performances take place every month in each target community with an average audience of approximately 1500 people per year; at the end of 2014 it would have reached around than 5000 people. 8) Direct interventions for disease prevention, such as the installation of rain-water tanks in strategic locations, and the training of women to build solar lights made of recycled soda bottles, to prevent respiratory infections from kerosene lamps. 9) Income generating activities run by local women such as small poultry, tailoring and bakery industries, in order to afford healthcare related fees. 10) A pilot system of scholarships to secondary schools for girls, because education and health issues are intimately related.

All programs are evaluated at the end of each year by the local government representative and the staff of N-HbM. An external evaluation will be conducted at the end of the fifth year of service, in 2014.

Evaluation strategies have been:

Formative Evaluation - Primarily qualitative in nature, through interviews and open-ended questionnaires with the health promoters. Each year health promoters are asked to evaluate the effectiveness of the health curriculum, and to provide feedback for the ongoing improvements of project operations. They are also asked to identify challenges they face during their learning period and later, throughout their practice as trainers and in the communities. Interviews and open-ended questionnaires are also distributed to most beneficiaries and stakeholders: eg. families who receive ITNs and anti-malaria health training, students doing service-learning, and representatives of the local government.

Summative Evaluation - Primarily quantitative in nature, focuses on pre/post tests of knowledge gained by trained health promoters. N-HbM documents attendance at health parties as well as the information collected in those meetings. For the malaria campaign, N-HbM documents the number of families that received ITNs; most families complete surveys after the first and second year of using the net and of receiving the anti-malaria training.

Yearly evaluations have been taken very seriously to improve programs and to overcome unexpected challenges, even those that may appear insignificant, such as changing the color of ITNs after finding out that white nets were considered by some women as “demonic.”

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
In the first place, Dr. Alonso had a leading role in engaging government support for the original women’s health needs assessment. After the preliminary results of the assessment, in 2010 N-HbM was created and spearheaded the research, envisioned the goals and objectives for the various programs, and designed and implemented them.

The N-HbM model uses a comprehensive and collaborative approach. The successful implementation of its programs is due to well-planned public-private, local and transnational efforts, including very active participation of target groups.

Even though N-HbM lacks a complex administrative structure, it has been able to carry out impressive programs by strategically engaging diverse stakeholders. Its success on the field is due to joint efforts by local governments in Kenya, the local branch of the Ministry of Health, and the contributions of N-HbM. N-HbM headquarters are located in Lunga Lunga, although the founder and director’s main office is in Madison, Wisconsin, in the United States. Its programs are developed collaboratively and transnationally through all stages, directed by Dr. Araceli Alonso, a professor at the University of Wisconsin, and coordinated at the local level by Ms. Bendettah Muthina Thomas.

The University of Wisconsin-Madison in the United States provided the academic knowledge and human resources of various groups of trained students who have translated their health knowledge into action through a service-learning program. Each year, a group of students are selected among many applicants to accompany Dr. Alonso to participate in the N-HbM training and disease prevention programs on the ground.

The Davis Foundation for Projects for Peace, Rotary Club Madison-West, Ira and Ineva Baldwin Wisconsin Idea Grant, and Undergraduate Wisconsin Idea Grants provided funds for the health prevention programs and travel costs of students for service-learning. At UW-Madison, the Global Health Institute and the Department of Gender and Women’s Studies have offered crucial support for Dr. Alonso’s visionary project, and have taken part in the selection of students. The Madison Undergraduate Initiative Grants also has provided assistance to implement the projects.

The role of highly dedicated local women leaders who were selected and trained to supervise and coordinate N-HbM programs cannot be underestimated. Ms. Bendettah Muthina Thomas and public nurse Ms. Josephine Matini have been crucial in recruiting and engaging health promoters, and in creating a synergy that has turned health promoters into local village leaders. The same synergy has facilitated the committed involvement of many other women and the collaboration of men, thus multiplying the impact of the programs.

Finally, approximately five hundred private individuals have also contributed to the success of these health initiatives, supporting sustainable projects such as the installation of rain-water tanks, the construction of the Nikumbuke Community Health Center for women, the creation of a business incubator for women, and the scholarships for local girls to enter secondary education.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The strategies developed by N-HbM made it possible to simultaneously spread health and women’s rights knowledge for disease prevention, and provide health services to isolated communities to complement or make public services more accessible.

The initiative got off the ground with the needs assessment conducted by Dr. Alonso and Dr. Mwangi. Once the main health concerns were identified, the following goals and objectives were set by N-HbM in close collaboration with the local government of the Kwale District:


• Create a sustainable model of comprehensive health initiatives for women and girls at a relatively low cost and transferable to other regions. Replication in other African countries is a mid-term goal.
• Assist the government in developing disease prevention and health promotion programs to reach those who do not have resources or live in isolated and remote areas.
• Overcome stereotypes and prejudices in order to bring health policies and services to those who can afford transportation and government fees but are resistant to them.


1. Provide basic health services through the Mama-Toto Mobile Clinic that would outreach the most isolated communities with preventive care such as childhood immunization and ITNs, disease diagnose such as rapid malaria tests, and treatment for non-communicable and communicable diseases.

2. Develop health awareness and information campaigns—summer health camps, health parties, street theater, etc. in order to familiarize women and adolescent girls from rural communities with female anatomy and body changes throughout a woman’s life span; explore concepts of health and disease; address issues of hygiene, nutrition, water and sanitation; and deal with infectious diseases, and neo-natal and maternal health.

3. Create a train-the-trainers program for health promoters. Selection of potential health promoters would be based on women’s potential leadership and communication skills. The trained health promoters would spread their newly acquired knowledge around their own communities holding health parties. At the end of the fourth year (2014) it is expected that health promoters would have reached around 38,000 people; approximately 16,000 in two years.

4. Implement a service-learning program with UW-Madison. Program would be a human resource development initiative, and an affordable method of health promotion with a total of 20 students per year.

All goals and objectives have achieved greater success than expected. N-HbM had to create waiting lists and increase the number of health promoters per training session. The launching of Mama-Toto Mobile Clinic in 2010, the opening of a small permanent health post in Lunga Lunga in 2011, the building of the Nikumbuke Community Health Center for women in 2012, the installation of rain-water tanks, and the numerous students who request to do service-learning, have dramatically accelerated the fulfillment of our goals and objectives.

Initial results confirm that a comprehensive health approach is indispensable: without an adequate delivery of basic health services and information on women’s rights, health promotion campaigns would not have fully succeeded. The need for information and awareness is interlinked with basic health services and referrals, and vice-versa.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
In 2009, the health needs assessment for women took place in four communities: Lunga-Lunga, Godo, Perani and Mpakani. Major health concerns were identified, a gender approach adopted, and a strategic plan designed for prevention, early diagnosis, and treatment of disease.

In 2010, the first summer health camps for women and girls began, reaching a total of 300 women and 100 adolescent girls among three villages. The anti-malaria campaign was also implemented, with the distribution of 1000 ITNs at different stages and in-depth education regarding malaria prevention, detection, and treatment.

In 2011, the pilot training program of community health promoters was launched. Due to the success of the health services and health promotion, the same year a Maasai village known as Maasailand and located in an even more remote area requested the same services for its women.

In 2012, the training program for community health promoters was fully implemented. A total of 12 rain-water tanks were installed in strategic locations to facilitate sharing by several at risk families. N-HbM launched the Street Health Theater Company, and trained 34 women to perform skits about issues of concern to the communities, such as HIV/AIDS, malaria prevention, detection and treatment, pre-natal and post-natal check-ups, delivery at the government clinic, safer home deliveries, infectious diseases, etc. Also in 2012, up to 12 women were trained to build solar lights made of recycled soda bottles in order to spread this knowledge among other women who are prone to respiratory infections due to the use of kerosene lamps and charcoal for cooking in small dark areas.

The health promotion programs will continue in 2013 with the training of community health workers, the installation of more rain-water tanks in other strategic locations, an expansion of the Street Health Theater Company performances to reach at least two new communities, and the construction of a water well in Godo, one of the most isolated communities. N-HbM has also developed a plan to expand its services to women and children with a preventive medicine and vaccination program in partnership with the local government and the local branch of the Ministry of Health. In addition, in 2013, N-HbM will integrate complementary programs such as the planting of autochthonous trees as a long-term measure to preserve natural water sources, and the training of women in the construction of rocket stoves that are easy to build and use, highly efficient, need small quantities of fuel, and may help prevent respiratory illnesses.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Gender norms and values have been an obstacle. Although caring for the sick is predominantly a woman’s domain, it is very difficult for women to make a decision about where and when to seek treatment for disease. When their husbands are around, women need their permission to attend the health care facility; when they are not around, the permission must come from another male relative in the village or from the mother-in-law. In order to overcome this obstacle, N-HbM is working closely with husbands so they can see that women’s health does not only benefit women, but their whole family and the entire community. Also, the summer health camps for women and adolescent girls and the training of community health workers have taken a gender approach to family relations as a basis to understand disease, health, healing and well-being.

Traditions and myths that attempt to make sense of disease have been an obstacle. People often delay seeking treatment and disregard disease symptoms. Some refer to disease as caused by witchcraft or as God’s will; hence death is perceived as inevitable and even expected. The training of community health workers, and their diligent work in their communities, has been a great asset. They are always local women with tremendous leadership skills who are trusted in their communities. This trust enables them to transmit their knowledge in a culturally sensitive manner. Several Street Health Theater Company performances have also dealt with the nuances of cultural perceptions of health and disease in each community.

A related obstacle is the tradition of seeking the help of a witch doctor or healer for disease treatment instead of consulting with a health professional. The difficulty of accessing a far away clinic, the cost of health services, and the mistrust towards official health facilities have barred women from accessing preventive medicine, accurate diagnosis and adequate treatment. Although the tradition of the witch doctor is still present as part of the communities’ cultural heritage, the role of N-HbM has been of utmost importance. Its affordable health services and comprehensive health promotion campaigns have helped to overcome economic constraints as well as to combat fear and mistrust towards government health facilities.

The lack of transportation for most of the members of these communities has been another obstacle, partially overcome by the Mama-Toto Mobile Clinic. N-HbM is aware of the need to expand its mobile services with additional emergency transportation provided by motorcycle-ambulances, a project planned for 2014.

The lack of clean water continues to be a big impediment for the advancement of all health programs dealing with illness prevention. It is an arduous task to fight intestinal parasites and contagious diseases when the water that people drink is heavily contaminated. This challenge has been partially overcome with the installation of rain-water tanks in strategic locations to serve several families at a time. More tanks are needed, however, and the construction of a water well is a crucial measure planned for 2013.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Local governments provided the infrastructure for N-HbM to operate in the area. It also authorized the purchase of a plot of land for the Nikumbuke Community Health Center in Lunga Lunga.

In 2010, the Davis Foundation for Projects for Peace granted the first financial support to conduct three summer health camps for women and girls, launch a permanent health post in Lunga Lunga and hire a local public nurse to work with the projects during the year ($10,000). The Morgridge Center from UW-Madison, granted a fellowship ($7000) to Dr. Alonso to start the first anti-malaria campaign, and to partially cover the expenses of three student assistants. The local government and N-HbM reached out to the Rotary Club in Kenya and Madison, and it gave $900 to purchase a refrigerator for medications and two cooler bags to carry them. Individual donors financed most medications for the Permanent Health Post and the Mobile Clinic for the entire year, with $4000 mostly collected by UW-Madison students

In 2011, the Institute for Global Health at UW-Madison granted $ 10,000 to partially finance the trip and expenses of 12 students to assist with the first pilot training program. The Rotary Club provided $1200 to purchase a motorcycle for the Mama-Toto Mobile Clinic. The Mama-Toto expanded its service to the most remote village of the border with Tanzania—Maasailand. The Mobile Clinic became sustainable by renting the motorcycle out the days it does not go to the villages. Rent money is currently used to purchase the medications. The medical services provided by N-HbM are not totally free for the public, but the fee is symbolic and affordable, and it helps to build trust and to buy the fuel for the Mobile Clinic. The Ira and Ineva Baldwin Wisconsin Idea Grant granted Dr. Alonso $45,000 for three years (2012-2014), to implement the health promotion program and train 36 community health workers in three years. This money covers travel costs for 12 students each summer, to assist the local government with the health promotion programs. The Rotary Club granted $1900 to N-HbM to purchase the first five rain-water tanks. The Morgridge Center made a second grant to the anti-malaria campaign, this time to survey the population about the effectiveness of the first year’s campaign and to purchase malaria-rapid-tests to diagnose malaria in-situ.

In 2012, the Global Health Institute awarded N–HbM a Field Experience Grant to cover the rest of the expenses for the students from UW-Madison to travel and conduct the health training. In May 2012, individual donors provided a total amount of $7000 that was used to purchase the land and build the Community Health Center. Also, another seven rain-water tanks were purchased and installed. The Morgridge Center granted two scholarships, one to advance the anti-malaria campaign with the creation of the Street Health Theater Company, and the other to train 12 local women to make solar lights out of recycled soda bottles.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
All N-HbM programs are self-sustaining. For example, after the first investment of $1200 to purchase the motorcycle, the Mama-Toto Mobile Clinic started renting it out to third parties when it was not being used. The income generated thus allows N-HbM to purchase medications, pay for fuel and even keep some savings for mechanical repairs.

The training programs are sustained through a formal collaboration agreement with UW-Madison, since N-HbM deploys the human potential of students in service learning programs. University students completing their academic programs on public health and gender issues are very willing to share their knowledge and acquire teaching experience by training others. In fact, most of these students need teaching experience before they enter the job market after graduating from college. Students see this service-learning experience as a unique opportunity to learn firsthand from women in the communities, advance their career, grow, mature, and most importantly to give back to society and to make the world a healthier place for women and girls.

This health promotion model is in demand by other nearby communities, such as Mgombezi and Jirani. Similarly, model replication is being planned for a rural area of Rwanda, in the Matyazo sector (Gashonyi village), in order to increase the quality of health care for 27,000 residents. These requests show that this health initiative is transferable at a relatively low cost and easily replicable, not only in other parts of Kenya but also in other countries. With a culturally sensitive approach adapted to other settings, this model could be easily transferable to any other rural community where medical services are out of the reach of women.

Five main elements are essential for replication:

1) A flexible and functional circular coordination system to design and develop the programs for research and fieldwork to be translated into action and practice: Start with target women’s feedback and information as well as with local government input. Add academic knowledge, and contrast with health promoters’ input on the practical execution of programs. Go back to target women’s feedback and local government input, and go over this loop of empirical and academic knowledge until each program is implemented and consolidated. 2) Strong leadership synergy created by local women who motivate and engage other women, and coordinate and supervise programs locally. 3) Human resources such as university students with academic training in public health and gender studies. 4) A passionate, highly knowledgeable and empathic conductor to orchestrate each instrumental part and to create harmony and cohesion. 5) Institutional support by the local government and by the Ministry of Health.

The N-HbM model is exportable and highly adaptable for other culturally divergent countries in the African continent, and at a global level. A keystone of its effectiveness is the lack of complicated infrastructures, or convoluted logistic and administrative structures. This simplicity makes possible direct door-to-door community work.

This model can be replicated and applied to other sustainable development programs, such as alphabetization and professional training.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
According to government estimates, the indirect impact of the N-HbM services touches more than 50,000 individuals, approximately two thirds of the rural population of the Kwale District. In addition, more than 3000 families per year have directly benefited from the health services of the Mama-Toto Mobile Clinic (9000 in 3 years); making up a total of approximately 60,000 beneficiaries.

According to Dr. Mwangi, maternal health has greatly improved by encouraging pre-natal visits and the delivery of babies at the government Health Center for those who can afford the transportation and fee, and by providing knowledge and tools for safe home deliveries for those who do not. He also asserts there has been a decrease on cerebral malaria, related to several factors directly linked to N-HbM initiatives, such as the distribution of more than 1000 ITNs, malaria rapid tests used by the Mama-Toto Mobile Clinic, and the disease prevention work of the Street Health Theater Company.

The first and most important lesson has been the ripple effect of working with a health determinant to achieve sustainable development with a gender focus. Health initiatives often result on a chain cause-effect of a much larger scope in people’s lives. Concrete measures like installing rain-water tanks may initially appear as service related exclusively—providing clean water for several families, preventing disease, and alleviating women’s daily lives—but additional unexpected beneficial outcomes often come up. For instance, water-tanks indirectly allow families to send their daughters to school, since there is extra money that can be invested in school fees.

The second lesson is that engaging all stakeholders and target groups in the decision-making process and in every step of the preparation and implementation stages is paramount to create sustainable programs. Learning directly from/with people and developing trust from within and inside-out, communities become a tremendous source of information for the adjustments of implementation of all N-HbM programs. It has been vital to have the communities’ input as they felt ownership and control over the programs. In addition, this approach has facilitated local inter-community communication, multiplying and expanding the positive effect of N-HbM programs. This has been the case with Maasailand, a village previously ostracized by other neighboring communities.

The third lesson is that a small budget need not be an obstacle for the success and sustainability of development programs. Institutional partnership and collaboration have been more critical than financial resources, even though without financial accountability, it would have not been possible to carry out the work.

To summarize: the five key elements for the success of N-HbM transnational, comprehensive and humanist approach to health, development and gender are: 1) Flexible and functional circular coordination and information system. 2) Strong leadership synergy created by local women. 3) Well trained students, culturally and academically, as a human resource. 4) A program director with academic knowledge and access to rigorous research and fieldwork. 5) Institutional support, including local government support.

Contact Information

Institution Name:   Nikumbuke-Health by Motorbike
Institution Type:   Non-Governmental Organization  
Contact Person:   Araceli Alonso
Title:   Founder and Director  
Telephone/ Fax:   +254727174802
Institution's / Project's Website:
Address:   P.O. Box 32
Postal Code:   80402
City:   Lunga Lunga
State/Province:   Mombasa
Country:   Kenya

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