1. 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.

2. 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

3. 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

4. Background Sub-Saharan Africa & Kenya

5. 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

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

7. 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)

8. 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)

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

10. 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

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

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

16. 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

17. 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

21. Implementing agencies/Institutions Ministry of public health and sanitation Maasai Trust Christian Children’s Fund African Medical Research Foundation (AMREF)

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

23. 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

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

25. Emergency measures Reduce number of CHWs Narrow focus Closer supervision Incentives

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

27. Failures Water and Sanitation Reproductive health ITNs

28. 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

29. 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

30. Solutions?