Earlier this month, All Africa reported that hospitals across Nairobi have been systematically and illegally detaining hundreds of women for failing to pay their bills. But it would be wrong to assume that these women are receiving quality healthcare in return. In fact, the article tells the story of Margaret Anyoso, who was detained at Pumwani Maternity Hospital in Nairobi for a few weeks; during that time, doctors discovered that a surgeon had forgotten a pair of scissors inside her body during a caesarean section operation. Further north in the Ethiopian capital, urban health isn’t much better. According to a report by the World Atlas in January 2016, Ethiopia ranks fourth among 25 countries with very limited access to healthcare, with 22 doctors for every one million people.

With 3.5 million residents, Nairobi’s population is growing at an annual rate of 3.8 percent. The city’s population density is 4,850 people per square kilometer (12,600 per square mile). A growing 60 percent of the population is settled in slums, most of them suffering from the inadequate provision of public services. Similarly, Addis Ababa has a population of more than three million residents, growing at an annual rate of 3.8 percent. Increased by nearly three times since 1970, the city’s population density is a little more than 5,000 people per square kilometer (about 13,400 per square mile).

Urban Health in Addis Ababa, Ethiopia

Children below the age of five are the most vulnerable to urban health in Addis Ababa

Slum in Ethiopia. CC: Biedermann

Slum inhabitants in Ethiopia comprise 80 percent of the country’s urban population. The World Health Organization estimates that more than half the population lives more than 10 kilometers (6.2 miles) away from the nearest health facility, usually in regions with poor transportation infrastructure.

Before she rushes to a joint cardiac committee to present cases for surgery, Helen Befekadu, a cardiac intensivist at the Addis Ababa University’s Cardiac Center Ethiopia, explains the major urban health issues suffered by slum residents in Addis Ababa, which are mainly related to lack of basic needs. For example, she says, there’s a variety of communicable diseases due to the lack of water coverage, like acute febrile illness (AFI), typhoid, cholera, diarrheal diseases, meningitis, and less commonly, malaria.

Sanitation and poor waste management result in a wide spectrum of diseases, ranging from the common cold to complex respiratory and gastrointestinal diseases. Shortage of food and malnutrition, especially for children under the age of five, often cause health problems like anemia. Other urban health factors include overcrowding, which is largely due to rapid rural-urban migration. Population growth in urban centers tends to be faster than the national average (4.1 percent versus 2.7 percent, respectively), with the 1.4 percent difference thought to be the result of net migration to urban areas, rather than increased fertility.

Befekadu is on a Paediatric Cardiology Fellowship at the Aswan Heart Center in Egypt, using this opportunity to aid her community. The main elements pulling Addis Ababa’s health sector back are ignorance and poor management, she tells progrss. Befekadu adds that the public health sector needs to work on initiatives to understand the real urban health problems according to real-time data. She suggests that they prepare a well-structured plan based on the identified challenges, create a feasible action plan and engage the community and responsible parties in order to begin to address these challenges. Another thing she believes is important in the enhancement strategy of the public health sector is monitoring and releasing periodical evaluation for subsequent improvement.

Befekadu strongly recommends that the government work on building awareness and educating the community to take part in these activities and community-based movements. She also calls on collaborative projects in the city municipality, health governmental offices and partners to provide better health and nutritional services throughout the year in an organized fashion.

Urban Health in Nairobi, Kenya

Urban health in Kibera, slum in Kenya.

Africa’s largest slum, Kibera, is in Nairobi. CC: Ninara

Kenya, on the other hand, has almost 20 million people (41 percent of the Kenyan population) living in poverty, and access to the most basic of needs like clean water, education, sanitation, and especially healthcare, is considered a luxury.

In light of the gap left by formal healthcare systems and in an effort to cater to the largely underserved population of Nairobi’s informal areas, Access Afya is a chain of three clinics located in the capital’s largest slums. “Free healthcare in Kenyan slums is typically very poor quality, while quality healthcare is too expensive,” founder of Access Afya, Melissa Menke, tells progrss. “These Kenyans are faced with a choice – get poor quality, free healthcare; do nothing at all; or wait for long periods to get subsidized healthcare. No one should have to make this choice.”

According to Menke, the National Health Accounts found that up to 30 percent of Kenyans will not seek medical care when they are sick, citing the high cost and no access to the needed care as their key reasons. “Child mortality rates are three times that of high income areas, many times due to treatable conditions,” she says. “Poor health creates a poverty trap keeping people in slums.”

The poor and inconvenient health options in Nairobi’s public hospitals force patients to resort to informal chemists as primary care options. These are often unregistered health facilities and are rarely staffed by trained medical professionals. “They make money selling pills to people without any attention to medical protocols,” Menke says. “In fact, 83 percent of chemists in Kenya are not registered with the Pharmacy and Poisons Board, and an estimated one-third of medication in the market is substandard. Sick people cannot recover without quality medication.” 

Menke founded Access Afya in 2012. Before doing so, she had spent time in Kenya, Jordan and the U.S. working in sustainable economic development. In Nairobi, she felt a need, and saw a market for, better healthcare. “While the gap in reliable health was tangible, and the solutions are emerging, they were not being systematically applied to low-income populations,” she says. “I started Access Afya to correct this and ensure that patient-centered, outcomes-oriented, digitally-driven primary care could be accessible to even the poorest populations.”

Access Afya’s model makes a difference by getting essential health products and services to a population that is ill-served by the current health system, Menke explains. They also teach patients in Nairobi slums to set the bar higher in terms of their own expectations when they seek healthcare. “Patients pay to use Access Afya clinics because they are convenient, fast and reliable,” she says. “This has led over 15,000 unique patients to us, each one paying a small fee that is used to cover the lean costs at our clinics.” One-third of the Access Afya team is hired from the slums themselves, which puts them in a position to best understand the patients’ health needs, but also allows them to better relate to patients’ struggles. Even after they leave the clinics, Afya’s team follows up with their patients by phone or via SMS.

Access Afya clinics are networked and data flows digitally from the registration desk and triage area to consultation, through to lab and back up to pharmacy. Using digital health software and devices is essential to operate in the small environments where Access Afya works, while keeping costs down and enhancing their ability to monitor quality and operations at a larger scale. Access Afya also works with the government and accepts national health insurance. Moreover, they partner with schools and factories to pay for care in their mobile health programs.

“At scale, it is individuals, businesses and governments that will invest in health and continue to finance our business and growth,” she reflects. Menke could be right.

Access Afya isn’t the only startup looking to fill the gap in urban health services in the Kenyan capital. Nairobi-based startup Flare for example, works to connect patients with ambulance services. The company has been up and running since March 2017, mediating between patients in emergencies and hospitals in a city where emergency calls rarely go through.

In Addis Ababa, on the other hand, policy makers and health enthusiasts seek help on a more institutional level. Earlier this month, the Ethiopian capital sealed a $230,000 deal with a Chinese company, Afei Holding Co., to build the largest general public hospital in the country. The hospital will be managed by Addis Ababa University, and will be treated as a training center for undergraduate and postgraduate medical students. Other initiatives include Sir Magdi Yaacoub’s medical convoys, which operate on patients and offer training for physicians.



CORRECTION: An earlier version of this article stated that Kathryn Weichel is Access Afya’s founder. However, Melissa Menke is the founder and Weichel is the director of marketing in Access Afya.