9 July 2014

Africa: The Paradoxical Role of Families in Women and Girls Health in Slums

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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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