COMMUNITY HEALTH WORK IN SUB-SAHARAN AFRICA: The
Kenyan experience
The role of CHWs in sub-Saharan Africa has evolved over time and
place in response to changing health care priorities, disease
burdens, and shortages of human resources for health. CHW
programmes play a crucial role in the support and delivery of
services in sub-Saharan Africa and are critical in efforts to tackle the
existing health worker crisis. However, they need support,
supervision and financial and non-financial incentives if they are to
carry out their work effectively.
This session will look at how one such CHW programme in a South
Kenyan district at the foot of Mt.Kilimanjaro informs the above
issues.
Presented by:
Dr. Edwin Lutomia Mangala
MSc. Public health-health promotion student
Leeds Metropolitan University.
Objectives
•To analyse, through a practical example, the role of CHWs in public
health in Sub-Saharan Africa
•To identify some of the key challenges that face CHW programs
•To explore possible solutions to identified challenges
Scope

Background information
◦ Social, political, economic
◦ The healthcare system

The CHW program in Loitokitok district
◦
◦
◦
◦
Design and implementation
Early challenges and intervening measures
Successes and failures
Key issues arising
Background

Sub-Saharan Africa & Kenya
Country Profile
•Geography
•580,367sq.km
•Capital – Nairobi
•Other cities – Mombasa, Kisumu
•People
•Population – 39m
•Religion – Christian 82.6%,
Muslim 11.2%, Traditional 5%
•Languages
•Official – English, Swahili
•Others – 40 from Bantu (67%),
Nilotic (30%) and cushitic (3%)
•Government
•President
•Prime Minister
•Economy
•Largest in Eastern Africa
•Services – 59.5%
•Agriculture – 23.8%
•Industry and commerce – 16.7%
•Political
•Multiparty state in 1992
•New constitution 2010
•Over 40 political parties
Kenya health care system

Ministry of Health
◦ Ministry of Medical Services
◦ Ministry of Public Health and Sanitation

Two broad divisions
◦ Public (government owned)
◦ Private
Kenya Healthcare system

Traditional pyramidal structure
◦
◦
◦
◦
◦
◦
Dispensaries and private clinics
Health centres
Sub-district hospitals and nursing homes
District hospitals and private hospitals
Provincial hospitals (8)
National hospitals (2)
Important Institutions







Medical practitioners and dentists board
Clinical officers council
Nursing council of Kenya
Kenya medical supplies agency (KEMSA)
Pharmacy and Poisons Board
National hospital insurance fund (NHIF)
Kenya Medical Research Institute (KEMRI)
Source: WHO (2009)
•Budgetary allocation to health fell from 7% (2009/2010) to 6.5%; Target 15%
Some key health/Development Indicators
Kenya Africa UK
Global
Total population (millions)
39
Population living in urban areas (%)
22
38
90
50
Gross national per capita (PPP int. $)
1,570
2,561
35,860
10,599
Life expectancy at birth (years)
60
54
80
68
Adult mortality rate (per 1,000 adults 15 – 59 years)
319
383
77
176
Under 5 mortality rate (1,000 live births)
84
127
5
60
Maternal mortality ratio (per 100,000 live births
530
620
12
260
HIV prevalence rate % ( adults 15-49)
6.3
4.7
0.2
8.0
Literacy rate (%)
73
62
99
Source: WHO (2009)
61, 565
Healthcare workers
Specialist doctors
 Medical Officers
 Clinical Officers
 Nurses
 Public Health Officers

Major causes of morbidity
HIV/AIDS
 Tuberculosis
 Malaria
 Pneumonia
 Respiratory tract infections
 Road accidents
 Factory accidents
 Gastroenteritis
 Diabetes mellitus

Key Issues
A largely rural and poor population that
has limited access to the formal
healthcare system
 Inadequate expenditure on health
 No universal health financing scheme
 Limited health workers; mostly urban
based

CHW program in Loitokitok
district
Location

Kuku Group ranch – 1,500 sq.km
◦ Semi-arid
◦ Average Temp- 30 0 Celsius

12,000 inhabitants - Maasai Community
◦ Nomadic herders
◦ Traditional
Implementing agencies/Institutions
•Ministry of public health and sanitation
•Maasai Trust
•Christian Children’s Fund
•African Medical Research Foundation (AMREF)
Health workers
Public health Officer (1)
 Medical Officer (1)
 Nurses (6)
 Support staff (10)

Structure
CHW selection by community
 Training (3 months)
 Allocation

◦ 1CHW per 2-3 homesteads (20-30 households)
◦ Duties – Water, sanitation, ITNs, Immunization,
Antenatal care, Delivery, nutrition, communicable
diseases, health education
◦ Resources – Bicycle, CHW bag, Stationery

Reporting/supervision
◦ Monthly to health centre
Early challenges
Too much workload for CHWs
 Motivation
 Failure to translate theory into
practice ? literacy
 Large coverage area

Emergency measures
Reduce number of CHWs
 Narrow focus
 Closer supervision
 Incentives

Notable successes
Increased immunization coverage
 Home management of diarrhoea using
Oral Rehydration Salts
 Surveillance system

Failures
Water and Sanitation
 Reproductive health
 ITNs

Key Issues

Resource limited setting
◦ Does it increase access?
◦ Does it address health workers shortage?

Cost-effectiveness
◦ Is it really cheap?

Empowering
◦ Who decides?
◦ Who acts?

How is success evaluated
Excerpts from Kenya budget
2011/2012
•£10m – Recruitment of 3,150 nurses and 1,050 public health officers
for rural areas
•£2.7m – 1,050 motorcycles and 2,100 CHWs in rural areas
Solutions?