To what extent have the efforts of the Lions Club of Mombasa Pwani as an NGO been successful in enhancing easier access to quality healthcare for the residents of Mombasa?

Healthcare is a right that improves citizens' overall quality of life many are unable to access. Healthcare impacts most sectors of a country, as good health increases productivity and enlarges the labour force. Consequently, many Non-Governmental Organizations (NGOs) alleviate the government's duty of ensuring citizens have access to quality healthcare, one being the Lions Club, an international NGO promoting social welfare, with the Pwani Club focusing on free and quality healthcare, especially eye care.

I find myself asking how Non-State Actors manage to provide a plethora of services, and how they use their power to meet goals. It is well known that NGOs have power, which is then used to promote societal well-being. However, how they use and attain their power to do so can be unclear, and many powerful NGOs have been known to misuse it or fail to achieve objectives due to factors such as restrictions by states, underfunding, lack of support from citizens etc. In fact, it can be challenging for an NGO to be successful and provide services, which is why I aim to investigate how power is manipulated, increased and used to overcome any obstacles in order to provide services.

This political issue relates to course content such as power, sovereignty, interdependence and legitimacy. The significant link to power, specifically the usage of soft power aids my understanding of how they gain social acceptance and its potential impact on governing bodies. It delves into the use and maintenance of legitimacy for gaining power and providing services without government intervention. As NGOs work under a governing body, the concept of interdependence demonstrates how NGOs form relations with governments to act. This will lead to the exploration of the challenges to the sovereignty of the two states, if any. The Social Development and Liberalism theories explain why the state and NGOs act as they do and the benefits of doing so.

This exploration focuses on the local level of analysis of Mombasa. For my engagements, I interviewed the president of the Lions Club, Mr Mora¹. His knowledge regarding the club's history, goals, and missions, informed me of strategies to improve access to healthcare so I could evaluate their success. Knowing how the club worked led me to their clinic, so I interviewed the Secretary, Ms Mary, who has held that position for 20 years. She organizes bi-monthly eye camps around Mombasa and neighbouring areas. Medication and eye checkups are offered to patients, some of whom travel from neighbouring countries to attend. This data aids me in assessing the extent of the club's impact. Her knowledge of patients, and experience working in the clinic, with donors and county officials, provide invaluable information regarding the demographic of people who have been served. I gained insights into the club's funding strategies and its relationship with the county government, facilitating an in-depth analysis of the NGO-county interdependence and the economic dimension of their services. To see the other side of the coin, I volunteered for a day in the clinic, talking to workers, doctors, and patients to see how they think the club has promoted quality healthcare through its services. I learnt about their strong reputation with citizens, awareness strategies, and patients' reasons for choosing Lions. I deduced how they garnered legitimacy, helping me analyze the role legitimacy plays in gaining power, which consequently helps me see how it has been used to continue their practice. To avoid bias from one party, I interviewed a County officer, Mr David, who managed hospitals and explained the challenges that public hospitals face, like underfunding, and lack of resources and training, which helps in exploring interdependence between the two parties and why they support the Clubs cause, which I connected to increases in their power.

In my interview with the Secretary, she emphasized the 'good name' and 'reputation' of the club in Mombasa since 1994. I realized that the club has garnered strong legitimacy through action and service. She also revealed the crucial role of donors that sustained their mission, meaning that their status increased their fundraising capability. According to the president, the club has attained their 'reputation', through consistent community care and the quality of services it offers, which I deduced was sustaining its legitimacy and gaining power through action. To see if this perspective is shared by citizens, I talked to a first-time patient while volunteering in the clinic and questioned why she came to Lions. She said it was because her 'community members advised her to go there because of their excellent service at low prices', which I believed to be gaining power and legitimacy from the citizens. Mr David expanded on how working together maintains healthy relationships between the two entities and is a way for the citizens to get quality healthcare which the government itself may not be able to provide consistently. Clearly, the county government depends on NGOs and has shown full support to the NGOs which they can help grow due to their lack of ability, allowing them to gain soft power over them and act freely. However, he also spoke of the county hospitals such as Coast General taking a step further and offering vaccinations, disease prevention, and restorative care, which Lions does not.

To begin with, the Lions Club has strong legitimacy in the coastal region so the county government of Mombasa supports their efforts and includes more services in its outreach program, which consists of eye checkups and general care. Legitimacy can be defined as the consent of the governed to be ruled by a government according to John Locke (Prof. Awadhesh Kr. Singh, n.d.). Sociologist Max Weber breaks these into 3: Traditional, which stems from long-withstanding customs, Rational-Legal, based on a system of laws established and accepted by society, and Charismatic, based on the personal qualities of a leader (Matheson, 1987, p. xx). I connected information from the Secretary and President's interview, and deduced that they have garnered legitimacy through the quality services provided in the same area for an extended period of time. Evidently, they have implemented Traditional legitimacy in order to gain power. For NGO's, traditional legitimacy accumulates the strong trust of the public, alleviating their legitimate status, which increases their power over the government as they have the citizen's support. The information from my volunteering proves that their idea of legitimacy is shared with them, as they have a strong reputation for commendable service and action. Many patients I spoke to relayed the positive reputation Lions holds for good and quality service. This falls in line with Seymour Martin Lipset's contribution, which states that 'legitimacy involves the capacity of a political system to engender and maintain the belief that existing political institutions are the most appropriate and proper ones for the society'(Kamalnath Nayak, n.d., p. xx). the County Government has often supported their camps and helped by providing services such as screening for pregnant women, adding medication and the labour force. In the past year (from June 2022-July 2023), they have assisted around \( 14/28 \), as seen from official records. However, why would the county government depend on and assist the NGO without feeling their sovereignty is threatened, given the NGO's critical healthcare role? According to the Mombasa County Health Quality Management policy and the Kwale County Government website, health financing has many threats, including poor cash flow, delayed payments from NHIF, high levels of poverty, and more, proving that health financing plays a significant role in the lack of quality healthcare. The club's legitimacy invites generous donors which results in services being free, or cheaper than most due to their nature as an NGO. As a result, the county saves money on healthcare. This support can be analyzed through the liberalist principle of limited government intervention. The County Government will accept help from legitimate NGOs as they sometimes lack the financial means to provide healthcare. It is clear from both primary and secondary research that the use of legitimacy gained through the provision of quality services for years is key for Lions Club and NGOs to maintain the support from the government, consequently increasing the services provided and access to healthcare in Mombasa.

Secondly, Lions Club has constant funding in large quantities while the County Government does not. Mr. Mora and Ms. Mary have explicitly stated that they have sufficient funding to sustain their services, with a monthly income of approximately 1 million Ksh. Without them, cataract surgeries, outreach programs, maintenance, and a good standard of service won't be possible, limiting access to quality healthcare, as emphasized by Ms Mary. Furthermore, due to their nature as an NGO, they do not make a profit but enough to cover costs. For example, while volunteering at the eye pharmacy in the clinic, I noticed that the medicines sold were cost-to-cost. I wanted to investigate more about the economic factor in providing healthcare, and I found out that according to the Kwale County Government, some challenges faced by the county's health sector are inadequate health facilities, shortage of medicines, medical supplies and equipment (Kwale County Government, 2023), which can all be traced back to poor funding, similar to Mombasa. Challenges to health financing include poor access to allocated funds to cater for the QI budget needs, poor cash flow, and delayed payments from NHIF. This forces the county to depend on the NGO for assistance, giving them soft power over the County (Mombasa County Department of Health, 2022, p. xx). According to Nye, soft power can be defined as the ability of an entity to persuade others to do what it wants without force or coercion. By alleviating the pressure of funding that the county faces, they are dependent on NGOs and private donors to continue providing services that need them. It is clear from both primary and secondary research that the county government is dependent on NGOs like the club to assist with the provision of healthcare. This dependence gives them soft power that not only increases government support but adds to its legitimacy, giving them leeway to extend their services however they please.

However, from my observations, the club puts emphasis on eyecare, limiting the services offered. During my clinic volunteer work, I observed a strong focus on eye care, with dedicated outreach programs. While they do provide other services like dental care, blood testing, and ENT Clinic, the emphasis on eye care might lead patients to think other services aren't available. Healthcare should encompass a broad range, including hospital care, prescriptions, maternity, mental health, and more. Mr. David's interview confirmed public hospitals offer most services. As the club's clinic does not offer these, the county government offers better services that actually aid patients. This aligns with the theoretical framework of Social Democracy. The Club operates as they please because they are free to do so, but the public sector has to operate in the favour of the public. The NGO has their own interests and goals in line and can choose whether it want to expand its services, by funding more sectors and focusing on the general need of the public which brings out the limitations of NGOs when using power to provide services. Therefore, from both primary and secondary research, it is evident that the Lions Club, like other NGOs, only use their power to provide certain services, which limits its ability to provide quality healthcare.

To conclude, my findings have informed me that NGOs gain traditional legitimacy through services provided over a long period of time, gaining them approval and recognition from citizens which increases their soft power over the government. However, the dependence that some states may have on NGOs threatens their sovereignty and legitimacy. Furthermore, NGOs aim to work with governing bodies in order to increase the quality and extent of healthcare provided. However, aligning with the Social Democracy theory, most NGOs work however they please, while the government is required to bend to the citizen's wishes. In regards to the economic aspect of it, NGOs usually have large amounts of funding constantly from donors, giving them means of carrying out as many services as they wish. Some states, on the other hand, are unable to receive or spend large sums of money, impacting the quality, management, services, infrastructure and labour force of local hospitals. This makes me question why the two actors don't collaborate extensively to improve healthcare systems for the benefit of citizens.

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