An innovative solution: standardized Bluebox approach to health services delivery
According to the 2008 Kenya Demographic and Health Survey, mobile populations, such as truck drivers and sex workers are among the key drivers of the HIV epidemic in Kenya. The reasons behind the transmission of HIV among these high-risks groups are due to a complex mix of economic, social, and cultural factors.
Since 2009, North Star Alliance has been operating in East Africa to bring quality health services to mobile populations in a BlueBox. The organization uses converted shipping containers (painted blue) to house clinics that deliver public health programmes for people with increased health risks, such as truck drivers and sex workers, and primary health care to communities with limited or no access to medical services. North Star has eight Roadside Wellness Centres in Kenya. Each Roadside Wellness Centre is staffed by a clinical officer, HIV Testing Service (HTS) provider and outreach coordinator, all of whom carry out outreach activities to build awareness among truck drivers and sex workers about HIV transmission, infection, prevention and protection.
In Kenya, North Star Alliance is working closely with the Ministry of Health and the National AIDS & STI Control Programme (NASCOP) to strengthen implementation of the government’s strategic plan to bolster HIV prevention programmes for mobile populations working along the country’s transport corridors.
Building strong client relationships: conducting outreach activities
While North Star’s containers are located at strategic destinations such as border posts or truck stops, where mobile populations tend to gather, the realities of the lives of truck drivers and sex workers can make it difficult for them to access the containers. A key component of North Star’s strategy in health services delivery involves conducting outreach activities at “hotspots” where truck drivers and sex workers congregate, such as at bars or lodges.
North Star’s operations are informed by a deep understanding of the health seeking behaviour and socio-economic conditions of its target populations. HIV Testing Service Providers play a crucial role in outreach and deploying needed health services to truck drivers and sex workers. Timothy Rotich an HTS Provider in Salgaa observes, “For truck drivers, for the time I have worked in the RWC, I have observed that most drivers don’t visit the RWC unless they are critically ill. Most of them complain that they are tired and they don’t wish to walk from where they have packed their trucks to the RWC.” A truck driver in Namanga explains, “if we leave our truck, within one minute our fuel is stolen or some of our cargo is taken.”
Timothy Rotich notes, “The best way to offer services to truck drivers is to take the services to them through outreaches.” Timothy further notes that the role of “Balozis” - male peer educators who are also truck drivers - is essential for encouraging and empowering truck drivers to visit the RWCs to get tested for HIV and to receive basic primary care services.
In Burnt Forest, the Roadside Wellness Centre staff including the clinical officer, outreach coordinator and HTS provider have been effective in building strong relationships with truck drivers and sex workers. The team proactively calls truck drivers who will be passing through Burnt Forest to ensure that they receive follow-up treatment and care. Naomi Jepkemei, the HTS provider in Burnt Forest notes that calling truck drivers before they actually reach the container has significantly increased the number of truck drivers seeking care.
Confronting challenges on the ground
HIV treatment is life-long, yet many truck driver and sex workers travel or migrate for their livelihoods, risking treatment interruption. The RWCs follow the guidelines set by NASCOP, which stipulate that high-risk populations are to be tested for HIV every three months. Loss to follow-up of clients, however, is a major challenge for North Star’s Roadside Wellness Centres. Joan Nyaga, a HTS Provider in Jomvu notes that delivery of services at the actual hotspots works well, whereas facilitating return visits to the RWC for follow-up is a critical challenge. Joan notes, “[truck drivers] complain the RWC is far from the hotspots.”Access to electricity and power is not always constant at the RWCs and attempting to reach truck drivers via SMS can be difficult.
Several HTS providers spoke about the challenge of stigma and how it impacts the care-seeking behaviour of HIV positive clients. Charles Kilundo, an HTS provider in Emali, notes that many truck drivers and sex workers that are HIV positive sometimes withdraw from or leave their communities due to stigma.
Scaling up to advance the 90-90-90 strategy
Despite confronting formidable challenges on a daily basis, North Star’s HTS providers play a critical role in advancing the UNAIDS 90-90-90 strategy, which aims to provide quality health care for HIV positive people and limit new infections and the further spread of the HIV pandemic. North Star Kenya aims to have 50 RWCs in the country by 2030. North Star Alliance is striving for scale up not only through replication of its RWCs in more locations, but also by expanding its depth of services. The RWCs in Salgaa and Maai Mahu, for example, are now offering antiretroviral therapy to HIV positive clients. Soon, all RWCs will be providing ART to clients. A key strategy for advancing health care in low-and-middle income countries involves the provision of integrated care that transcends a narrow focus on vertical interventions such as HIV, TB and malaria. By providing more services under one roof, North Star Alliance offers comprehensive services that include not only HIV and STI testing and screening, but also basic primary care.
Raman Sohal is a PhD Candidate at the Institute of Health Policy Management and Evaluation at the University of Toronto. John Mochoma is a Partner Relations Officer at the North Star Alliance East Africa Office in Nairobi, Kenya.