Globally, 70% of community health workers (CHWs) are women. They deliver essential health services for their communities but they are often unpaid or underpaid for their work. In September this year, the Kenyan government took ambitious steps towards reversing decades of health system reliance on women’s unpaid labor by launching a new initiative to pay, equip and digitize 100,000 CHWs and formally integrate them into the country’s health system.
“When I heard that the government is going to pay CHWs across Kenya, I was very happy because we have a lot of financial responsibility to our families,” says Millicent Miruka, who has been working as a CHW in Kenya’s Rongo subcounty for the past 11 years. “This will really help sustain many more families throughout the country. Additionally, the kits we received, which have the commodities we need, have made caring for patients at community level easier. The kits enable us to do initial health screening for things like blood pressure and blood glucose levels, and to refer patients where necessary.”
Professionalization does not only advance CHWs’ ability to care for their families and to provide quality care for patients. It also creates opportunity for increased female leadership and employment in health systems, and it places CHWs in a unique position to improve women and girls’ agency and power by equipping them with knowledge and tools to own their health.
“Women play an important role in their communities and are often the glue that keeps these communities and families together,” explains Miruka. “Many women and young girls come to me for advice. I educate them on family planning methods to prevent unplanned pregnancies and HIV infection, and I encourage them to complete their schooling and to do everything they can to achieve their goals. I want them to achieve even more in life than I have.”
To drive a community health agenda forward that is more responsive to the needs of women and girls, Lwala Community Alliance, with support from Johnson & Johnson Foundation, works through the Community Health Units for Universal Health Coverage (CHU4UHC) platform to help accelerate policy and systems change, strengthen community governance, and achieve CHW professionalization.
Miruka was among the first CHWs to receive training from Lwala and the Ministry of Health in Rongo subcounty. Training ranged from basic introductory modules focused on the role of CHWs, to more in-depth technical training, community case management training, and training on nutrition screening, contraception, and malaria and HIV prevention and management.
Another key component of the program was advocacy training alongside CHWs around the world, developed by Community Health Impact Coalition. “This helped us make our voices heard globally. We learnt how to speak on behalf of other CHWs, and by extension other women, to raise awareness on issues that affect us,” shares Miruka.
The training she received, she says, has equipped her to be a pillar for her community and for patients seeking care. Miruka typically spends her day conducting around 10 to 15 home visits, educating her community on maternal and child health, screening for illness, providing basic treatments, referring at-risk pregnant women and other clients to the local facility, and following up with recently treated patients.
Miruka continues to seek out opportunities to advance her capacity as a health professional and to grow her knowledge and skills. She aspires to return to school someday to study nursing and perhaps even teaching. “I’d like the opportunity to learn more about best health practices in other countries and how we can potentially implement these in our own communities in Kenya,” says Miruka. “I have achieved a lot as a CHW. I have a lot of knowledge to share with members of my community, especially women and girls, and I have earned their respect as a result. I am very grateful and proud of that.”
A recent study by Lwala demonstrates that training and experience are more reliable indicators of CHW knowledge and performance than literacy and formal education. As CHWs are professionalized, Lwala works to break down barriers to entry for women, especially those with decades of experience in delivering care. Traditional birth attendants (TBAs), for instance, have provided community health services for generations, but are often excluded from CHW cadres by discriminatory literacy and education requirements. In the development of the National Certification Guidelines for CHWs, Lwala worked to reverse these requirements and collaborated with Migori County’s Ministry of Health to identify existing TBAs, integrate them as CHWs, and add them to the CHW registry.
Kenya's Vision 2030 emphasizes the importance of CHWs in improving healthcare, shifting focus from curative to preventative measures, and advancing Universal Health Coverage. “Adopting a systems thinking approach and systematic policy plan is needed for recruitment, utilization and retention of CHWs, enabling sub-national governments to achieve health care for all,” says Julius Mbeya, Co-CEO at Lwala Community Alliance.