Cartel or chemist?

Could tapping into the informal services in Nairobi’s Mukuru slum be the answer to better health, schools and water provision?

Jack Makau's picture
Insight by 
Jack Makau
Jack Makau is director of Slum Dwellers International Kenya
27 February 2020
A woman behind a counter arranges her vegetable produce

Traders keen to grow their businesses have few options in the Mukuru slum in Nairobi (Photo: copyright Know Your City TV)

John Njuguna is a butcher in the Mukuru slum in Nairobi. He sets up on a wide table on the side of a normally muddy road that enters the settlement from the adjacent industrial area. Many others trade alongside Njuguna, selling a grand selection of second-hand jeans, colourful Chinese flip-flops, plastic utensils, on and on and on. A continuous flow of customers come and go. 

Njuguna arranges his meats, including cow and goat hoofs, and various heads. He has two bowls, one with cow tongues and the other with different sized intestines. The wonderful smell of roasting meat drifts from a nearby charcoal grill. A customer stops by, points at a stuffed intestine. Njuguna picks it up and places it on a newspaper page, salts it and passes it over in exchange for 20 shillings. The customer nibbles on the meat and stands aside to allow the next customer to be served.

“Trade is fine, but there is no opportunity to grow my meat business beyond this table,” Njuguna says to me. “I’m training a young fella to tend to the table; this will allow me to build another business." 

“What business are you thinking about?” I venture. He replies: “If you look at this street, you’ll notice there is no pharmacy. The nearest is in Jamaica.” Jamaica is a section of Mukuru, some streets away. 

I’m startled: “A pharmacy? To sell medicines, you mean?” “Yes,” he responds. “There is money in medicine.” 

Setting up a pharmacy in Mukuru is easy – take a notebook to another pharmacy and copy what they do: the drugs they’re selling, and what drugs they give for which symptoms.

Quack clinics

Njuguna will be in good company. There are 206 healthcare providers in the slum. But only 14 are registered with the National Health Insurance Fund – the government state corporation that provides Kenyans with health insurance. Most of the others are not even registered as businesses; many do not have any trained personnel.

Mukuru’s residents recognise the dangers in the sort of healthcare Njuguna proposes. But the prohibitive cost of accessing proper healthcare, coupled with the widely available and entrenched health quack system, often leaves them with no choice. 

A rethink on healthcare…

Urban planning processes have never attempted to provide slum residents with proper healthcare – until now. This is a first, among several other firsts, that the Mukuru Special Planning Area (SPA) process is achieving.

In August 2017, the Nairobi County government designated Mukuru slum as an SPA, identifying it as an area needing substantial redevelopment. This legislative tool allows out-of-the-ordinary planning and innovative strategies to upgrade infrastructure and services. 

The SPA law was typically applied for quite different purposes, such as military activities or building hydroelectric dams. But after declaring Mukuru an SPA, it has become Kenya’s largest single slum upgrading project.

So tightly packed are the shacks in Mukuru that building hospitals to replace the quack health providers would significantly displace residents from their homes. This wasn’t an option. The community needed another solution and looked to Mukuru’s community health volunteers (CHVs).

A man behind a counter chops meat

Trade as a butcher is fine, but offers little opportunity to expand (Photo: copyright Know Your City TV)

With a little training, the CHVs – of which there are over 300 in total – were able to link Mukuru’s population with the formal healthcare system. They began running campaigns such as safe water treatment and even acted as midwives. The SPA health plan supports legislation that provides training and remuneration for the CHVs and creates better opportunities for would-be quack pharmacists. 

…and informal schools

As with healthcare provision, so with education: Mukuru has over 42,000 children and youngsters attending 193 educational institutions, most of which are informal.

To illustrate the challenge of the informal schools, only 20% have functioning toilets. Yet, Mukuru’s entire land area would be taken up if schools, of the prescribed planning standard, were built to serve the school-going population. 

So plans to improve education within the slum took a different approach – involving the informal school owners. This had not been done before. Now, working with Mukuru’s informal service providers is included in many proposals coming out of the planning process. 

Tapping into informality

For any basic service not delivered to Mukuru, there is money to be made. Most toilets in Mukuru are pay per use; water is sold in 20-litre jerrycans and so on.

Providers often fight any attempts to replace these informal services, earning them the label of slum ‘cartels.’ These providers previously hampered efforts to formalise household electricity connections, so that residents stopped paying Kenya Power and Lighting Company (KPLC).

Mukuru’s work to design systems that delegate service provision to local, informal providers, as well as making investments to regularise them, is a valuable contribution to the urbanisation discourse. It’s a bold departure from typical solutions that seek to shift slum populations on to formal systems, which often end up being too expensive or inaccessible to slum populations.

Njuguna, it turns out, will not sell medicine using a notebook of symptoms and drugs. “I don’t want to kill people”, he says. “I will sell only from prescriptions. And my service will be more affordable. Unlike the quacks, I will sell in single doses. If a customer can only manage to buy one capsule at a time, that’s what I’ll sell them”.

The long-vilified slum service provider may have the key to the intractable challenges of slum upgrading.

About the author

Jack Makau is director of Slum Dwellers International Kenya

Jack Makau's picture