Nearly 17 years ago, a village in Western Kenya was grieving the deaths of two beloved leaders, Margaret and Erastus Ochieng’. They were kind and generous neighbors who helped orphaned children with school fees, invited hungry families to share a meal, and seeded a vision for a hospital in their village–all while raising six children of their own. Tragically, they died of HIV because of a broken health system that wasn’t designed to reach them. Out of this grief, their community–alongside two of their sons, Milton and Fred–created something new, a way to ensure that all of their neighbors could access health care.
Through this community-led movement, the relationship between Lwala communities and the health system is changing. We have seen community committees advocate for funds to build new maternity wards and new laboratories at their local health facilities. We have seen villages launch campaigns to build latrines, declare their villages open defecation free, and construct safe wells for clean water. We have seen community health workers organize and advocate for more government funding of health commodities, equipment, and services. We have seen neighbors encouraging each other to deliver at health facilities, seek HIV care, and get a COVID-19 vaccine. As trust and accountability build, health outcomes improve.
We believe that this community-led change is uniquely positioned to transform the health system in Kenya and beyond. The status quo of concentrating resources on top-down technical solutions to specific illnesses misses the root cause of poor health. We can create powerful technologies and innovations, but without justice, participation, and accountability, their impact is limited. As our Co- Founder, Fred Ochieng’ stated, “Inequity is a disease, and empowering communities is an integral ingredient in the cure.”
In this review of the year, we invite you to discover what is possible when communities lead. Together, we are breaking cycles of inequity to advance health for all.
Lwala bridges the gap between communities and policymakers, ensuring that local solutions are translated into policies and systems at the county, national, and global levels. This year, we strengthened the health system across all four pillars of community-led health.
Lwala worked in coalition to develop a National Community Scorecard, which will be used by community committees throughout Kenya to assess the quality of health services and advocate for change.
At the national level and in Migori County, Lwala informed Community Health Services Legislation, which provides a framework for community health worker (CHW) recruitment, training, accreditation, payment, and supervision.
After scaling the Obstetric Hemorrhage Initiative to 167 facilities, Lwala advocated for the inclusion of these lifesaving approaches into two national training tools, which will prepare health workers to provide emergency obstetric care.
Working with government, we are developing and piloting a national system for collecting and using community health data—the Electronic Community Health Information System (eCHIS). It will create a reliable flow of CHW data between community, county, and national levels.
Community health workers (CHWs) are the backbone of the health system. Yet CHWs are often under-equipped and under-supported, and only 14% of CHWs in Africa are salaried. At the same time, traditional birth attendants (TBAs), have been providing health services to communities for generations, but they are often blocked out of CHW cadres by discriminatory literacy and education requirements. Lwala’s research demonstrates that education credentials are not a predictor of a CHW’s work-related knowledge, and well-supported CHW cadres, inclusive of TBAs, can improve health outcomes. Lwala maps all active TBAs in a community, incorporates them into existing government CHW cadres, and ensures they are all paid, trained, supervised, digitally empowered, and connected to community committees.
1. Read the full study here. 2. Lwala Household Survey, 2021.
Professionalized CHWs–inclusive of transformed TBAs–track children’s growth, ensure on-time immunization, diagnose and treat the most deadly childhood conditions, and connect children and families to local health clinics. Lwala works with community committees and government to support local clinics to have the resources, training, and systems to provide quality care–ensuring that no child slips through the cracks.
A peer-reviewed study examined the health seeking behaviors of households in Lwala-supported communities and comparison communities. It found:
Lwala supports community groups to lead the planning, execution, and evaluation of local initiatives. The focus of these groups is varied–they work to improve health services at the community level and at health facilities, they improve schools for their children, they ensure access to clean water, and they elevate the rights of women and girls. With leadership from community members, change is equitable and lasting.
“At Lwala, we work every day to shift the status quo of development. Rather than having politicians, donors, and technical experts determine what a community needs, we want to see that power transferred to communities—our role is to support them to chart their own path.”
- Hellen Gwaro, Director of Programs at Lwala
At Kochola Dispensary, the number of patients had outgrown the facility. Labor and delivery was sharing a space with antenatal and postnatal care, and many women felt there was no privacy.
Hearing these concerns, the Health Facility Management Committee–a community committee that oversees health services at Kochola–set out to change this. They used skills from Lwala’s training on leadership, resource mobilization, and accountability, and they worked closely with the head of the health facility to draft a budget.
As a result, they secured $40,000 from the county government to build a new maternity wing, which opened this year. To provide a full range of maternal health services, they also set up laboratory space to conduct antenatal testing. This will ensure that high-quality, dignified care is available to every woman who visits Kochola.
Severe bleeding during childbirth–known as obstetric hemorrhage–is the leading cause of maternal death in Kenya. Though this condition is treatable, health providers often lack the training, equipment, medicines, and blood required to save lives.
In response, Lwala partners with the Ministry of Health to advance the Obstetric Hemorrhage Initiative (OHI), which is a bundle of protocols and tools that can treat obstetric hemorrhage and prevent maternal death. The bundle includes: misoprostol, the uterine balloon tamponade, and the non-pneumatic anti-shock garment (NASG). The NASG is a simple, reusable tool that gives hemorrhaging women an additional 72 hours to get further treatment, and it has been shown to reduce mortalities related to obstetric hemorrhage by 67%.
Women and girls have unique health needs at every stage of their life—from family planning, pregnancy, and childbirth, to ensuring the health and wellbeing of themselves and their families. Lwala improves the health of women and girls across the life course, and we strengthen their representation in decision-making so that they receive the health care they want.
The COVID-19 pandemic had an outsized effect on women and girls, limiting access to health facilities, closing schools, and reducing access to preventative care. In response, Lwala launched a qualitative evaluation to learn more about the barriers women were facing in accessing maternal health services. Through a community-led design process, community committees launched new transportation systems for laboring women, CHWs designed new tactics to identify pregnant women and follow-up after delivery, and facilities opened new maternity wards. Lwala also supported supply chain solutions to ensure facilities could conduct comprehensive testing and screening at antenatal care visits, and we greatly expanded access to free ultrasound services.
To address the unique challenges of young women, Lwala provided mentorship, family counseling, and financial support to 240 adolescent girls who had dropped out of school during pregnancy, enabling them to return to the classroom. We also doubled down on community-based sexual and reproductive health services, running open-air outreaches at the village level and delivering contraceptives directly to homes. As a result, more women than ever in our communities accessed contraceptives, despite the pandemic.
And in a time when women’s health has been deprioritized, Lwala expanded its fight against cervical cancer–a leading cause of cancer-related death for women in Kenya–through mass HPV vaccination campaigns and routine screening at health facilities.
The second year of the COVID-19 pandemic brought new challenges— like more acute illness associated with the Delta variant, the need to rapidly deploy vaccines, and an exhausted workforce constantly asked to do more.
Throughout the pandemic response, Lwala has been unwaveringly focused on protecting health workers, reducing the spread of the virus, maintaining essential services, and providing the best treatment to community members who fall ill.
INEQUITY IS A DISEASE,
COMMUNITIES ARE THE CURE.