Community Health Units (CHUs) serve as the first level of health service delivery in the Kenya health structure. Within these units, there exists a Community Health Workforce that consists of Community Health Volunteers (CHVs) that are governed by Community Health Committees (CHCs) and supervised by Community Health Assistants (CHAs). The Makueni Community Health Policy prescribes that each Community Health Unit should have an average of 20 Community Health Volunteers and 2 Community Health Assistants.
Kilome sub-county, one of the 6 sub-counties in Makueni county, has an approximate population of 103,928 and 26,901 households. Of the 26 community health units in the sub-county, Mercy supervises 3community health units and 90 community health volunteers. Mercy’s engagement and passion for community health caught our attention while facilitating a capacity-building session for the CHAs. We spoke about her experiences in offering supervision services to community health volunteers.
What motivated you to become a Community Health Assistant?
I am a Diploma Holder in Community Health from Mount Kenya University. A single moment didn’t inspire my journey to community work but rather a series of life events that made me realize I cared deeply about people and their well-being.
My motivation to be a community health worker resulted from my personal experience. The birth of a child represents a new journey that parents are eager to embrace. However, this was quite different for my parents as I suffered mild cerebral palsy at birth which affected my speech and movement of both upper and lower limbs.
Some journeys can lead us in directions we never imagined; when a parent receives their child’s diagnosis of cerebral palsy, their vision of the future changes. They must learn to cope with circumstances they were unprepared for. Sometimes, not knowing where the path may lead can be intimidating. Battling this condition was an uphill battle filled with frustrations, but it also had a basket of rewards and accomplishments. My parents and siblings, who form my strong social support system, keep me going by constantly reminding me that “it does not matter how slowly you go as long as you do not stop.”
How has your journey been, and do you think the government is doing enough for people living with cerebral palsy?
The cerebral palsy diagnosis opened a new chapter for my family. This was a new journey for my parents to go in loops over the situation.
Health care workers recommended daily physiotherapy services. However, my parents could only afford to take me for physiotherapy services monthly. I appreciate that this was a great sacrifice and commitment, given the distance, poor road infrastructure, and the high cost of health services exposed to patients then. Physiotherapy services are now a bit more accessible since Kenya adopted a devolved system of government in 2013; however, they are still offered at level 4 and 5 health facilities (only 9 out of 235 in the county). The government needs to improve on this. Also, strengthening community home-based care will relieve households’ economic and psychological burdens.
I appreciate that devolution has made health services more accessible in Makueni County. My mother was unfortunate as she traveled more than 200 kilometers to Machakos county referral hospital for my birth delivery. She was admitted for delivery four days prior and had a successful normal delivery after prolonged labor. Facilities were understaffed, and health care workers had a negative attitude, with no specialized doctor on duty to perform a caesarian section.
Currently, my village has a health facility less than 5 kilometers away (as recommended by the World Health Organization) that offers comprehensive emergency obstetric care, among other services. If this was the case, my situation could have been different if this was the case because cerebral palsy is preventable. I have accepted myself and desire to help the community mitigate preventable disabilities and deaths. I know my little contribution can avert some of the disabilities which impose a socioeconomic burden on households.
My journey as a community health assistant began in June 2020. I was recruited through the national government Universal Health Coverage program. The selection was a pivotal moment in my life. I desired to invest in breaking down the stigma surrounding disability. I believed that it was imperative, and my career would be a catalyst towards achieving my goals. The opportunity would enable me to contribute to rebuilding health systems to help historically oppressed communities.
I take solace in the statement “Don’t compare someone else’s chapter 20 to your chapter 1” in my low moments. The statement has always been my seed for transformation.
Who are your support systems, and do you think the government is doing enough to support people with disability?
The government is very efficient in formulating policies. I appreciate that people living with disabilities are engaged in policy formulation. However, most of the time, prominent people living with disabilities talk on behalf of the rest who are less privileged. I find their challenges very different. If someone has a severe disability, the caregivers remain their right voice, so they should be considered in decision making. Further, the policies need to be disseminated. Some people living with disability and their caregivers do not even know the policies exist.
I appreciate my family for their unending love and support. As a grown woman, they are still always there for me. Parental support is not always the case for everyone. Parents with children or even people living with disability tend to keep them off from the community. This could be attributed to myths and misconceptions and the stigma surrounding disability. For example, some disabled children usually don’t go to school (despite being a constitutional right); they are left behind doing house chores. This violates children’s rights because special schools are available.
“No one can make you feel inferior without your consent.”
What is your role as a Community Health Assistant?
The success of community health volunteer programs hinges on regular and reliable supportive supervision. The greatest supervision need exists in the most remote areas where health services are the most overstretched and facilities ill-equipped, for instance, where I work. In the worst-case scenario, the community health volunteers don’t know who their supervisors are and what they expect of them. Optimal supervision outcomes are determined by carefully selecting appropriate training and mentorship, selection and deployment, training, and continuous capacity building of the workforce.
As a community health assistant, I offer support supervision to community health volunteers as defined in the policy. I appreciate the draft Makueni Community Health Policy document that considers people living with disability and home-based care as part of the community health service package. Still, I look forward to a future where policies will be responsive to community health service providers living with disabilities, even if they are few. The stigma of a disability has barred people with great potential from exploring different career paths.
Delayed milestones are one of the indicators community health volunteers track for child health and development. One of the community health units has already identified four children with disabilities who can benefit from physiotherapy services; however, the guardians cannot raise funds for transport. I know many in the community are yet to be identified.
I am already aware of the increasing burden of non-communicable diseases. Long-term complications of non-communicable can be attributed to late diagnosis and non-adherence to medication. If their capacity is built and increased, the community health workforce shall relieve households’ socio-economic burden of managing these complications, contributing to disability.
What is your typical day like?
The community health assistant position entails health service delivery at the household level. Working at the household level throughout is a challenge for me; however, I have developed strategies to reach out to high-priority households with the help of community health volunteers and my public health colleagues. I usually leverage on home visits, and leverage focused dialogue and action days to disseminate key messages to the target audience. Unfortunately, I do not support community health volunteers as expected because I was not oriented or trained since deployment.
The Basic Module training is meant to build the capacity of community health volunteers in terms of disease prevention, health promotion, and simple curative care to lead and help their communities in health improvement interventions. It is the initial training for all community health workforce in Kenya. I appreciate that the county government has funded the co-facilitated training by the Financing Alliance for Health. The training was an eye-opener. I have learned the importance of comprehensive planning before executing community health activities and the importance of quality data. I will do a consolidated work plan with the community health volunteers for more focused community service delivery.
What changes have you seen in your community since you began your role as a Community Health Assistant?
I appreciate the county government of Makueni has set aside a budget in the current financial year and trained community health assistants on the basic module, which is the backbone of community health strategy. I think this training reflects the commitment of the county government to support community health services. The training will enable me to offer more structured support to the community health volunteers.
The three community health units I am supporting are reporting for duty consistently, and we are in the process of structuring community dialogue and action days.
What challenges do you face while delivering community health services?
Governments aspire and assume that individuals are willing to conduct voluntary social service in rural and informal settlements. However, the reality is different, probably acknowledging that community health volunteers are poor people living in poor communities who require an income. This assumption has led to significant attrition leaving only the CHVs who are enthusiastic and reliable to become overloaded with tasks.
I also think that national and county governments have not thought through how to accommodate people with disability who are passionate about serving their community. For instance, I am a slow writer, and my handwriting is not legible, but I can type very fast. I would be efficient with an electronic system, but currently, we are using a manual reporting system.
I currently supervise three CHUs and 90 community health volunteers against the recommended community health assistant to community health volunteer ratio of 1:10. The workload is heavy. To offer supportive supervision to these units, I require a reliable means of transport, which is currently unavailable.
The community health volunteers are also demotivated. I do not expect much from them. I desire to build their capacity, but the time and bandwidth are limited.
What do you do to support community health units to be sustainable?
The county has already initiated income-generating activities (IGAs) in some units, with community health volunteers doing table banking. I look forward to supporting resource mobilization, even if it advocates for community contribution.
What have you done to increase the coverage of COVID -19 vaccination in your community?
I know that Makueni county’s coverage of COVID-19 vaccination is lagging compared to other counties. I have learned how to segregate my audience from the communication component of the basic module training. I think it will go a long way in improving this indicator.
What are you most proud of as a Community Health Assistant?
This career focuses on the inherent worth of all people. It considers an individual’s life in context without belittling or demeaning their choices. To address the challenges and barriers in society that make it difficult for an individual to be empowered. I feel that my personal experiences and challenges have served as a basis for growth and preparation for a life of helping others. Working with vulnerable people has been an absolute privilege.
“Believe you can, and you’re halfway there.”
In our communities, many families face different struggles every day. They don’t have support or don’t know how to access or navigate the various health issues. Community health workers go above and beyond to provide the necessary support. I appreciate everyone who has allowed me to enter their realm, trusting me to journey with them as we overcome challenges. It is an indescribable experience and feeling when you can help a person in need.
I once visited a grandmother who was a caretaker to a neonate whose mother died post-delivery. I desired to help the household members with information on how to take care of the newborn. The child is now fully immunized, has never contracted diarrhea, and the growth monitoring curve is normal. For me, there is nothing more fulfilling than touching the life of somebody.
“There is no greater disability in society than the inability to see a person as more.”