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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.

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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

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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

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Background Sub-Saharan Africa & Kenya

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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

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Kenya health care system Ministry of Health Ministry of Medical Services Ministry of Public Health and Sanitation Two broad divisions Public (government owned) Private

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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)

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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)

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Source: WHO (2009) Budgetary allocation to health fell from 7% (2009/2010) to 6.5%; Target 15%

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KenyaAfricaUKGlobal Total population (millions)3961, 565 Population living in urban areas (%)22389050 Gross national per capita (PPP int. $)1,5702,56135,86010,599 Life expectancy at birth (years)60548068 Adult mortality rate (per 1,000 adults 15 59 years)31938377176 Under 5 mortality rate (1,000 live births)84127560 Maternal mortality ratio (per 100,000 live births53062012260 HIV prevalence rate % ( adults 15-49)6.34.70.28.0 Literacy rate (%)736299 Source: WHO (2009) Some key health/Development Indicators

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Healthcare workers Specialist doctors Medical Officers Clinical Officers Nurses Public Health Officers

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Major causes of morbidity HIV/AIDS Tuberculosis Malaria Pneumonia Respiratory tract infections Road accidents Factory accidents Gastroenteritis Diabetes mellitus

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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

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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

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Implementing agencies/Institutions Ministry of public health and sanitation Maasai Trust Christian Childrens Fund African Medical Research Foundation (AMREF)

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Health workers Public health Officer (1) Medical Officer (1) Nurses (6) Support staff (10)

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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

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Early challenges Too much workload for CHWs Motivation Failure to translate theory into practice ? literacy Large coverage area

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Emergency measures Reduce number of CHWs Narrow focus Closer supervision Incentives

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Notable successes Increased immunization coverage Home management of diarrhoea using Oral Rehydration Salts Surveillance system

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Failures Water and Sanitation Reproductive health ITNs

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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

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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

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Solutions?