In the past couple of weeks since Kenya confirmed its first COVID 19 positive case,the government has rolled out guidelines and directives to stem the spread of thevirus. With the number of cases rising daily, more efforts are needed to protectthose who are in environments that make it challenging to implement thecontainment measures. These include urban slums that are characterized byovercrowding, inaccessibility of basic services such as running water and abjectpoverty.The government of Kenya, like many other countries, took decisive steps tocontain the virus soon after the first positive case was confirmed. Citizens were urged to adhere to social distancing, frequent handwashing, use ofhand-sanitizers and to avoid huge gatherings. These measures were accompaniedby a nationwide night time curfew, closure of non-essential services, learninginstitutions and places of worship, a stricter regulation of the public transportsector and cessation of movement in areas with a high number of positive cases. While these containment measures have been touted as the basis of infectionprevention, their implementation, especially in urban slums has been a challenge.This is owing to the deficiencies highlighted above that are the normalcharacteristic of informal settlements . The stay- at- home directive has made itdifficult for many to maintain social distance and the loss of jobs means thatincomes for many households have either shrunk considerably or been lostaltogether.

JUNE 2020

COVID19 and Community HealthcarePerspectives from Nairobi’s informal settlements

Introduction

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COVID19 containmentmeasures practices in the slum

communities

Moreover, having many people at home forconsecutive periods of time puts increasedpressure on already-strained sanitationfacilities and water supply causing achallenge in frequent handwashing as apreventive measure. Residents are trying their best to

practise personal protectivemeasures especially handwashing.Local shops and small traders haveset up simple handwashingstations next to their businessesfor their customers. The local leadership has helped tomobilize partners to set uphandwashing stations in busyareas such as local markets andboda boda (motorcycle) terminus.The main challenges withhandwashing are the inconsistentsupply of water due to rationingand lack of soap.

ApproachAs part of an African Population and HealthResearch Center (APHRC) project onimproving health in slums, we conducted athree-week cycle of telephone interviewswith residents, local healthcare providers,religious leaders and key decision makers intwo of Nairobi’s slums. The main aim of theinterviews was to explore the overallpractices and impact of the COVID19mitigation measures on the lives ofNairobi’s urban poor.  The project onimproving health in slums study is aimed atdeveloping feasible health delivery modelsfor urban slums and has been conductingstakeholder engagements since 2018. Our engagement targets differentstakeholders including key decision makersinvolved in health service delivery in  twoslum communities with the aim oftriangulating data collected fromhousehold surveys, spatial mapping ofhealth facilities and health facility surveysand observations to assess health facilitycapacity in delivering services to the slumresidents.. With the onset of the pandemic,a shift in the engagement strategy wasrequired; one that allowed continuedengagement but adhered to thegovernment’s directives. Through the weekly phone calls we soughtto understand the emerging issues inimplementing the COVID19 measures inthe slums by exploring the impact ofimplementation of COVID19 measures forthe slum residents.

Hand washing

“Many people are adhering to the hand washingguidelines. Some hand washing points have beenprovided by organizations but most people have

created their own “Do-it-Yourself” hand washingpoints at the entry of their homes and at the local

shops. The community gets piped water two times aweek and tanked water once a week from the city

council. On other days people are forced to buywater from vendors.”

~Community Worker

“...Some organizations have donated handwashing points and soap within the community.

This has made it easier for people to wash theirhands regularly but we still need more soap.”

~Community Worker

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Use of face masksAs per public health regulations,residents are wearing masks while inpublic spaces. However, consideringthe difficult economic situation,many complain that the cost ofmasks is too high (KES 20 to 50). Theyare forced to make sacrifices tofollow this directive. The biggest concern from a publichealth perspective is the improperuse and disposal of masks.

even more vulnerable and are unable toafford food and to pay rent.

“The number of meals people consume has decreased

drastically. Many people are now only having one meal aday. Those who would buy food especially in the evening

from the street vendors are no longer able to do so. There isan organization that donated food enough for 100 peoplebut that is obviously not enough with more than 40,000

people in the community.” ~Youth Representative

“People are getting evicted from their homes every other

day. When they leave one place, they look for otherhousing within the community, but many times since

they are still not able to afford the housing they are evictedagain.”

~Community Worker

“Many people have the masks but they use theminappropriately. Some keep them in their pocket while

others are hanging them on their necks, otherscovering the chin while others are holding them in

their hands. I think they only have them because it isnow illegal not to have masks in public places.”

~Health Representative

“People have been forced to buy masks, but manycannot afford them.”

~Youth Representative

Social distancing

Adhering to social distancing has beena major challenge among the slumcommunities. This can be attributed tocongestion within homes and housesbeing very close to each other. Slumsare also more communal and there islittle private space. The situation isworse now because most of the peopleare no longer going to work andschools are also closed.

“Observation of social distance amongst residents isnot easily applicable in the slum especially now that

schools have closed and children are not going toschool. There is no space for social distance, houses areso close together making it difficult to maintain social

distance.” ~Religious Leader

Social disorder is on the rise as a result ofthe frustrations from the COVID19measures. Cases of risky social behavior inthe community such as theft and violencehave been reported. This comes with theincreased anxiety from the economicshocks of COVID19 and the uncertaintyfrom the seemingly dark days ahead. Theslums social fabric which has for a longtime been considered an opportunity forkey interventions in slums is at the risk ofdisintegrating.

“Some youths recently tried stealing food that was meantfor the elderly in the community and was being donated by

some benefactors in the Indian community..” ~Religious Leader

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Impact of COVID 19 measures in

the community

The COVID19 containment measureshave led to massive closure ofcompanies and other businessesleading to far reaching effectsespecially for low income daily wageearners. The loss of income has alsoaffected the small scale traders in theslums due to low purchasing power asa result of the surge in the number ofunemployed persons in the slums.Many households which were alreadypoverty stricken have been rendered

Increased cases of domestic violence andsexual assault have been reported duringthis period. This surge could be attributedto women and young girls being trappedinwith their abusers by the stay- at- homemeasures. The victims remain in closecontact with their abusers and may notget help easily due to the disruption ofservices. “Cases of domestic violence have been on the rise. Reports ofyoung girls being sexually abused are becoming common.

The perpetrators of these heinous crimes are people they livewith either in the same household or in the neighborhood,”

~Health worker

Social protections and food security: Coordinated efforts to ensure that allhouseholds within the slums are cushioned against food insecurity and thatpeople are safe from hunger and related harms. Food distribution should targetall the slum dwellers and should involve community leaders to allow thecommunity to own the interventions. Stakeholders should further ensure thatslum residents are safe from other risks emanating from the measures such aseviction orders and mental frustration leading to social ills. Cash transfers havebeen recommended as an effective way of protecting communities duringCOVID19.

Protection against domestic violence: Stakeholders need to step up means tokeep potential victims safe. Hotline responses and quick action by authoritiesduring the stay home period should be activated to ensure that victims havechannels of seeking help.

Strengthening response at Level One (community level: Increase efforts tosupport Community Health Volunteers to continue with their routine duties byproviding appropriate protective wear. Their link to health facilities is importantto make sure that people still receive the care that they need, especially for non-covid related illnesses. With more support they can also keep sensitizing thecommunity on the importance of adhering to guidelines.

Call to Action

There is a need for positive reinforcement on what they are doing well. However,there are serious glaring concerns that if not addressed early are likely to counterall the efforts and drain the progress in COVID19 prevention measures.Government and partners should therefore consolidate their efforts fast and firmlyto implement the following measures:

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References

1. Bird, J., Montebruno, P., & Regan, T. (2017). Life in a slum: understanding livingconditions in Nairobi’s slums across time and space. Oxford Review of EconomicPolicy, 33(3), 496-520. 2. A Protocol for a multi-site, spatially-referenced household survey in slum settings:methods for access, sampling frame construction, sampling, and field datacollection." BMC Medical Research Methodology. 19 (2019): 1-8. 3. UNICEF (2020) Social Protection Response to COVID-19. Available at:https://www.unicef.org/documents/social-protection-response-covid-19 4. Ministry of Health- Kenya (2020). COVID-19. Available at: https://www.health.go.ke/

This research was funded by the National Institute for Health Research (NIHR) Global Health Research Unit onImproving Health in Slums using UK aid from the UK Government to support global health research. The viewsexpressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Departmentof Health and Social Care.

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Authored by: Peter Kibe, Lyagamula Kisia and Dr. Pauline Bakibinga