By Edwin Ambani Ameso
As a student, doing fieldwork at home is one of the most puzzling yet gratifying undertakings. From an outsider’s perspective, your identity and sense of belonging presents unadulterated access to local knowledge sources. For insiders, the notion of ethnographic research by one of their own; sons, brother, uncle and/or cousin, is mind-boggling. Claims of identity and belonging presumes that, what you are looking into is obvious; can you not see? Have you not heard? Do you really need to interact at different levels yet all this is common knowledge? Are you a stranger to the prevailing circumstances of the locals? These questions and many more emerge as one tries to gain access to the field at home.
The project of global health coverage in Kenya
Meanwhile, different local knowledge hubs exist at home that make access to field-sites an endless game of positioning and repositioning for the local researcher. In that spirit, what is local and familiar in a given context becomes unfamiliar and peculiar in another context and access persists as an endless game of networking entry and re-entry.
As a doctoral candidate in Aarhus University, 2019, I was provided a chance to go back home and conduct a year-long multi-sited study. Kenya provided the grounds for this ethnographic venture. In late 2018 infrastructural governance efforts, backed by World Bank funding, pushed for Universal health coverage. This initiative aimed at pushing the formerly uninsured into the health insurance portfolio and strengthening existing safety net programmes. Generally, society’s welfare systems are deemed key to unlocking quality, affordable and available health care for all. With decentralization in Kenya, the two-tier system of governance, which was promulgated through the 2010 constitution, allowed regional governments commonly referred to as counties and the national government to work on improving health outcomes for the citizens at state and county levels.
Access to health services in rural Kenya is a challenge for the many who have to make long journeys to the nearest health facilities that are in most cases ill-equipped and understaffed. One of my many cases was an undiagnosed tumor patient in the vast county of Kitui that proved fatal. This women in her eighties had developed a tumor the size of a newborn’s head and the nearest health facility capable of handling her case was over 80 kilometers away. With limited income options and overreliance on state-led erratic welfare assistance, typically cash transfers, when the woman learned that the tumor was cancerous in its late stages, access to palliative and hospice care were not even an option.
Thus, my desire to address this issue grew, where access to health is largely a priviliedge of the wealthy. I pose the question whether in deed ‘health for all’ is a realistic or unrealistic dream meant for political gains.
The neglected discourse
From my beginnings as a bachelors’ student in anthropology, I have learned that most of the society’s academic fabric in Kenya have yet to recognize that anthropology has something to offer in academia and in development. This is true from politicians, who feel anthropology should be scrapped as a discipline to employers, who question the value addition of anthropology. I therefore knew that the research in health, I was about to undertake, would be daunting for a local researcher as much as it is for foreign researchers. First and foremost, bureaucratic obstacles meant I had to navigate through the two tier systems of governance meeting politically inclined individuals, some with rudimentary understanding of anthropology and its position in health research. Others, with zero understanding of how anthropological inquests into health matters would add value to health and health systems. To crown it all, conducting ethnographic research through qualitative techniques contrasts usual ideals of productive operational research in the global south. In this part of the world, quantitative research has become the modus operandi for renowned demographers and others, who are key to programming and policymaking. As such, fieldwork customarily relies on quantitative tools like questionnaires and outsourcing local labour. This includes but is not exclusive to research assistants for doctoral students, non-governmental organizations, and government programmes. In the rural settings, I was going to be the nosy young man, moving around without a questionnaire, to observe, participate and understand my ‘people’s’ daily lives rather than evaluate their health options.
Expectations of a doctoral student
In the field, status and studentship expectations emerged that had a way of skewing access to interlocutors and repositioning me. The expectation of a doctoral student was to outsource labor and then retreat to town settings in a luxurious fully equipped apartment and wait for data to trickle in. On one hand, in the unstable health care system in Kenya, where consultation services are at a premium, the sick and vulnerable, my main interlocutors, conflated my studentship with the capability to medicalize them through diagnosing, prescribing and imparting medical know-how to them. On the other hand, for health workers, my other set of interlocutors, the idea of a researcher as a land-cruiser-riding, city loving visitor with access to infrastructures of governance was quite inherent. For instance, I had informal meetings with one nursing officer in-charge of a health facility, who exhibited this expectation. I got to the meeting venue on a (piki piki) motorbike, and he stood in shock. After a few sips of his Tusker he simply asked, ‘daktari (Swahili for doctor) where is your land cruiser, you know your big machine. You doctoral guys are not ‘students’. You have lots of money, and the ones I have often seen around even come in their red-plated United Nations white land cruisers and land rovers to conduct research?’
As a researcher, the people I worked with thought of me as privy to the established forms of governance generating politics in and of health. The same forms of governance that undermines and ignore the needs of the oppressed, overworked, underpaid, and discouraged health workers. Thus, I epitomized a voice for the voiceless in a health system inconsiderate of their demands for better health and health systems. To politicians’ and technocrats, I embodied a means through which they could voice their opinions and from their well-kept drawers they enthusiastically drew out paper plans, well documented but shelved away. As you could perhaps imagine, navigating these very different, sometimes contradictory, expectations were near impossible at times. On heath worker told me:
‘Please, I hope these difficulties we are facing the governors and the ministry of health can understand that, this idea of universal health coverage is nothing but a dream. If we do not get staff and medicines to serve the people, we will not be able to meet the needs of the people. Besides, we are also human beings, we need to be paid, its been over three months without pay, and we are constantly being asked to come and report to work. Using intimidation will not help anyone, because if we are demoralised we will simply engage in our own businesses and forget this as we have mouths to feed’.
Navigating the ethnic divide
Adding to this, working in multiple field-sites meant I was navigating multi-ethnic settings. Regional governments embrace ethnic diversity through politics privileging majority ethnic-groups in line with former British colonial indirect rule to control their respective territories. As a country, Kenya has over forty-three ethnic groups occupying different regions, which form ancestral lands to them. Doing research in these settings, ethnic identities, and the intricate relations between those, work to inhibit or promote access.
‘So, what is your name? posed one interlocutor. “My name is Edwin Ambani,” I answered. “Ooh, you are our (shemeji) in-law, welcome. My wife, is your mother, she comes from your community in the neighbouring county”.
This an identity that, shows the intermarriage relations that have co-existed with the communities around lake Victoria in the western part of Kenya.
Doing fieldwork at home presents these and more ethical dilemmas that constantly position and reposition the researcher. In an ill-equipped health system in Kenya, the need to define and emphasize the scientific nature of anthropological inquest into health matters becomes key. Furthermore, studentship requires careful networking through elitist lenses and status that position and reposition the researcher. This has the capability to skew access to interlocutors at the community, health facilities, and administrative levels.