Lauren Roop is a second year IU School of Medicine student who spent the summer of 2023 in Elodret, Kenya, as a Slemenda Scholar working with the AMPATH partnership.
This past summer, I was lucky enough to live and work in Eldoret, Kenya, as a Slemenda Scholar doing research with the AMPATH partnership. This summer in Eldoret was one of immeasurable learning through global health research. However, the experiences that have stuck with me most are the ones I encountered outside of the hospital or classroom, and many of these have changed how I view global health and healthcare in general.
Before coming to Eldoret, I saw global health initiatives as an attempt to solve a “problem” in a healthcare system or community. My only exposure to global health efforts was from the perspective of high-income countries (HICs), and this is the perspective with which I expected healthcare to be approached. However, this experience has shown me that tackling these complex issues begins by first understanding the needs of the community you enter, and no one knows the needs of a community better than community members themselves. An example of this I encountered during my short time in Kenya was a culturally appropriate, community-based approach to improving maternal and child health: the Chamas for Change program.
To understand Chamas for Change, it’s important to first understand the challenges faced by Kenyan women and mothers. Maternal mortality is the leading cause of death in Kenyan women of childbearing age; and after birth, 1 in 19 infants in Kenya don’t live to see their first birthday.¹ Much of this has been attributed to healthcare barriers, particularly access to and quality of prenatal care, labor, and delivery postnatal; access to vaccines for mothers and their children; and access to contraception and family planning. Predictably, lower-income and rural communities are disproportionately affected by these challenges. Poor maternal and child health outcomes are a pressing matter in Kenya —one that is affecting countless lives— but the question of how to combat such systemic issues is daunting. In my short experience with the program, I believe Chamas for Change serves as a great example of locally-led work and can have incredible impacts on the health and livelihood of entire communities.
The Chama is a long-standing cultural practice in Kenya where a group of people meet regularly to pool their resources for mutual financial advancement. In 2012, AMPATH began the Chamas for Change initiative, which connects mothers within communities to form groups early in their pregnancy. Led by a local Community Health Volunteer (CHV) trained to lead each meeting, the Chama meets twice a month to learn health, social and financial literacy.² Together, the women provide mutual support to ensure that each member can achieve the Chama goals: 1) attend four prenatal care visits, 2) deliver their baby in a healthcare facility, 3) breastfeed exclusively for the first six months, 4) obtain long-term family planning, and 5) ensure their children receive all routine childhood vaccines. All of these goals were created based on strong evidence that they can reduce health risks for both mothers and their children.
The Slemenda Scholars were lucky enough to travel to Bunyala with AMPATH’s Population Health team to observe Chamas meetings. In learning about Chamas for Change before visiting, I had a specific picture in my mind of members sitting at desks, listening to long lectures, carefully taking notes, etc. When we arrived at our first Chamas meeting, we were greeted by the mothers and their children who sang a call-and-response song to welcome us; taking each other’s hands, dancing together and their children dancing along with them. The women then sat in a circle to discuss the week’s topic: common illnesses in infants. The CHV kicked off the session by going through some reference pictures and posters, but the discussion quickly found a life of its own as women shared personal stories, asked questions and contributed helpful tips (a member of the AMPATH Population Health team was kind enough to translate for us). Without knowing the content of the conversation, I would have guessed that this was just a meeting of friends enjoying each other’s company.
The discussion ran the gamut of topics, many of which were light and had the women joking and laughing (Your son does that too? I thought mine was the only one!). Other times, the conversation took on a more serious nature (When my baby is sick, how do I know it’s time to go to the hospital?). Through it all, the women listened, shared, and supported one another until every voice was heard and every question answered.
The Chama connection doesn’t end after the birth of a child either. Each Chama meets for a total of three years, continuing to be a source of learning and social support as their children grow from infants to toddlers. In the first and second years, as the group members have developed trust between each other, they have the opportunity to begin their microfinance process. In other meetings of Chamas in their second and third year, we saw women contributing money to the group’s total assets, pitching their business ideas to request a microloan, and sharing the success of their business ventures made possible by the group’s resource pool. This provides women with the opportunity to use the financial literacy tools learned in Chamas meetings to earn their own income and propel their autonomy further, creating opportunities for themselves and their families.
The effectiveness of Chamas for Change is clear when looking at the statistics on maternal and child health outcomes: In 2018, women in the Chamas program were 1.5 times more likely to deliver in a healthcare facility, 3 times more likely to attend a postnatal visit with a CHV, and 1.5 times more likely to use contraception for future family planning.³ They also had lower rates of maternal morbidity, stillbirth and infant morbidity.³
The Chamas for Change groups are now led by 18 employees of the Kenyan Ministry of Health facilitating 398 groups across Kenya. Through this facilitation at the local level, it’s the Chamas members themselves who propel each other’s knowledge and success, which results in better outcomes for themselves, their families, and their community. AMPATH assists with organization, training and data collection.
The vast improvement in maternal and child health services and outcomes in these communities didn’t result from a massive influx of money or supplies. Rather, incorporating education and local expertise into an existing social system gives mothers the opportunity to reduce their health risks and achieve their long-term goals.
The question of how to improve maternal-child health is one that experts have probed since the beginning of global health initiatives, and one that many in HICs have sought to answer through fundraising, equipment donation, and foreign intervention, to name a few. While these methods can accelerate the process to improving healthcare in underserved communities, the Chamas for Change program serves as an example that, in many cases, facilitation is just as important as donation, and creating opportunity is just as important as creating funds. I was exposed to many locally-led health innovations in Kenya, all of which helped me reframe my thinking and understand how to engage in global health efforts more ethically and effectively.
The solutions we seek in pursuing more equitable healthcare globally are not all found in large donations or the application of external systems, but in the homes, city centers, and backyards of each community and its members. As we continue to pursue more equitable healthcare globally, our most important resource is the people affected by these global health interventions. In doing this, we may find that some solutions are much closer than we think.
Chamas References:
- Ruhl LJ, Christoffersen-Deb A, Songok JJ. Chamas for Change: Validating the effect of a community-based women’s health education program on facility-based delivery and other maternal, newborn, and child health outcomes. BMJ, 10 Jan 2018.
- Chamas for Change: Strengthening Maternal and Child Health. AMPATH News, 1 Apr 2017.
- Maldonado LY, Bone J, Scanlon ML, et al. Improving maternal, newborn and child health outcomes through a community-based women’s health education program: a cluster randomised controlled trial in Western Kenya. BMJ Global Health, 2020.
