Community health workers push for sustainability

On a given workday, Martha Masawa might administer antimalarials against the disease that has long devastated the Nyanza region, killing over 10,000 people in the country each year.

She has routinely checked vitals, referred patients to health facilities, and administered antidiarrheal and dewormers to her community in Suna West, Migori County. She has also identified highly transmittable infections like measles and helped snuff them out.

She works eight hours, five days a week. In recognition of her efforts and those of many others like her, the national government has started paying community health promoters (CHPs) – also known as Community Health Workers (CHWs).

According to Martha, the payment is well received but could be more. "But this is a calling. We work to better our community."

In the spirit of universal healthcare, President Ruto turned the tide with the decision to include CHPs in the government's payroll, making Kenya's CHPs the small minority that is actually paid anything at all out of more than three million community health workers globally. Research from the Center for Global Development revealed that up to eighty-six per cent of community health workers in Africa go completely unpaid.

The World Health Organisation estimates a global shortfall of up to 10 million health workers by 2030. CHPs are poised to fill this gap if they are respected as a professional health workforce that is salaried, supervised, skilled and supplied.

Each community health volunteer in Kenya is supposed to receive a monthly salary of sh5,000. The national government contributes half of that, and the county governments must cover the remaining half.

Before the move by the government, CHPs depended on donors for supplies and stipends. For years, a community-led health organisation, Lwala Community Alliance, supported the CHWs in Migori with a monthly stipend of sh2,300.

Despite these wins, challenges still abound, affecting CHPs’ output.

Last year, the government supplied resources, including smartphones and special kits equipped with an electronic community health information system (eCHIS) for efficient data collection. Stakeholders agree that this was a commendable step, and that the government should build on this success by ensuring continued supply of these kits and empowering health workers to be able to digitally record stocks and use technology to replenish them when they run out.

Timothy Oduor, the nurse in charge of the local dispensary, says he must physically fetch medical supplies from the sub-county hospital over 30 kilometres away. "We rely on manual records, which causes lots of delay and wastage."

The dispensary is also quite small, so storing the supplies is also challenging. "We often have to go home with these items. As you can imagine, our homes are not that spacious. We store the supplies under the bed or on a rack in the ceiling. This is risky because we have children, and some of these medicines are sweet. We run the risk of accidental poisoning."

Further, community health promoters are not yet equipped to handle the medical waste. "As for now, we have halted the blood sugar and malaria tests because these require the use of sharp items. We don't have proper disposal mechanisms," says Martha, adding: "The medical supplies were not here for years. Now that they're here, we are not sure they will be here after we run out," says Martha.

Despite the challenges, much is being done to address supply chain constraints.

"There was no clear way how the CHWs could get commodities from facilities," says Helen Achieng, a pharmacist and supply chain expert at Lwala. "Through our recommendations, there is now a clear policy in Migori County on the reporting structure, reordering structure and waste management structure."

Carla Blauvelt, Senior Director for Global Programs at VillageReach, calls on "continued radical collaboration" from the government, private sector and other stakeholders to help improve responsive primary healthcare systems. "We must ensure the ongoing supplies will be there when they're needed, at the places where they're needed, so that communities are routinely strengthened."

Lwala and VillageReach have also partnered with the Ministry of Health to identify gaps in primary healthcare delivery, giving recommendations that are then scaled up and embedded for sustainability. For instance, they designed and piloted a training curriculum for CHWs, which the ministry adopted.

The curriculum imparted skills such as patient assessment, risk factors, communication and interpersonal skills, advocacy skills, health promotion, disease prevention and management, data collection and much more.

"Community health workers are doing huge feats of promotive, curative and preventive care," says Achieng. "Their pivotal role in preventive health care and their unique rapport with communities can only be effective if they have the necessary resources, support, commodities and tools to serve their communities."