At Lwala, our strategy for systems change isn’t simply about reaching more people. It’s about learning from every partnership, adapting our approach to each context, and building the evidence for community-led health at national scale. In 2024, we put our community-led health model to the test in new geographies, expanding our reach from 600,000 to 2.85 million people across Migori, Homa Bay, and Baringo Counties. Now, we’re using this evidence and experience to shape our next chapter of growth: bringing community-led health to Siaya and Nyamira Counties, reaching 5 million people across 5 counties by 2028.
Introducing Siaya and Nyamira
Siaya County sits just north of Homa Bay, along Lake Victoria’s eastern shore. More than 1.2 million residents live across rolling hills and remote island communities, sustained by fishing and farming. The geography reflects both the beauty and complexity of life along the lake: Siaya has some of the highest HIV and malaria rates in Kenya, while seasonal flooding and long distances often make it difficult to access health care. Even amid these challenges, Siaya County government has been laying a strong foundation for change. As one of the first counties in Kenya to pay community health workers (CHWs), this bold investment paved the way for national policy change and remains a testament to Siaya’s political commitment to improving health care for all.
Nyamira County: In Kenya’s western highlands, Nyamira County’s fertile soils, cool climate, and lush agriculture support thriving smallholder farms producing tea, bananas, dairy, and other crops. However, Nyamira’s growing population, exceeding 750,000 people, is outpacing the county’s health infrastructure. Overburdened facilities, transportation barriers, seasonal incomes, and pressure on water and sanitation systems continue to shape health challenges across the county. Nyamira County has taken strides to address these challenges, strengthening coordination and turning plans into action. With Lwala as a trusted partner, Nyamira is bringing together government, communities, and stakeholders to achieve a shared vision for better health.
Where opportunity meets commitment
In February of 2026, Lwala officially signed Memorandum of Understandings with Nyamira and Siaya, formalizing our commitment to work together and use data to drive decision-making. We also developed joint work plans and cost-sharing agreements that set shared priorities, clarify responsibilities, and increase government investment over time.
“Our government has committed to achieving universal health coverage. This is not possible, unless we start at the communitylevel. That’s where our greatest opportunities with Lwala lie—strengthening prevention and shifting care closer to communities. ”
- Dr. Donald Mogoi, County Executive Committee Member for Health, Nyamira
Lwala sought partnership with counties with high disease burdens and committed leadership who demonstrate domestic investments and a willingness to learn, adapt, and co-lead alongside communities. Beyond need, it was clear Siaya and Nyamira had established strong legislative frameworks, a paid community health workforce, and a shared vision for better health.
Building from the baseline
Building on lessons from previous expansions, we conducted comprehensive baseline assessments to better understand what is working, where gaps remain, and how resources can be directed where they will have the greatest impact.
On paper, Siaya and Nyamira share many of the same health challenges. Maternal deaths in both counties are nearly five times higher than global targets, and newborn and infant deaths are above Kenya’s national average. But behind these numbers are two very different health systems.
While evaluating CHWs in Siaya, we found that 68% had received updated training, but only 11% of households were visited by a CHW in early 2026. When we dug deeper into this gap between knowledge and practice, we discovered uneven workloads, digital reporting barriers, and the need for refresher training—57% of these trained CHWs were last trained more than two years ago. In Nyamira, household visitation was higher at 58%. Their assessment pointed toward a different need—capacity building for CHW supervisors through mentorship and coaching. To address this, Lwala will support training for CHW supervisors, strengthening the coaching and mentorship CHWs receive on the job. Alongside these efforts, Lwala will also help train CHW advocates and grow CHW networks in both counties, giving CHWs a stronger voice in the policies, financing, and decisions that shape their work.
Our assessment also found that less than 10% of community health committees are fully functional in both counties. This means one of the greatest opportunities for systems change is strengthening community accountability—a core area of Lwala's expertise. By working hand-in-hand with county government to institutionalize these structures, we can ensure that communities are not just beneficiaries of the health system, but active partners in shaping how it is planned, delivered, and improved. We're already working with county government to rebuild these committees in every community, beginning with local election of the representatives who will be trained to champion local health priorities and accountability.
Understanding differences like these allows us to be more targeted in our approach rather than applying a one-size-fits-all solution. This data informs the strategy behind our joint work planning with county government, prioritizing our investments for better community health, supply chains, and monitoring and evaluation.
Prepared for care, built for trust
At the facility level, baseline assessments identified stock outs of essential medicines as a recurring challenge across both counties. In Nyamira, stock availability varied widely across facilities, suggesting a distribution and maintenance challenge rather than an overall shortage. In Siaya, nearly 9 in 10 facilities reported stock outs despite strong inventory management, pointing instead to gaps in procurement and commodity supply. Lwala’s technical support is helping counties ringfence funding for more reliable procurement, while simultaneously training facilities to build stronger systems to plan, order, and safely manage essential medicines and health supplies.
Quality improvement initiatives like these are a priority in the first steps of our new county partnerships. We learned from our past expansion that as CHWs connect more families to care, health facilities must be ready to meet that increased demand. That’s why we invest early to ensure facilities are stocked, data is reliable, and health workers can confidently provide care. When families are referred to a facility and receive the medicines, providers, and services they expect, it builds trust in the health system—making them more likely to seek care again when they need it.
Curiosity, evidence and partnership
Our vision is a Kenya where every community is served by a strong, government-owned health system shaped by the people it serves. We're expanding into these two new counties not with a blueprint, but with curiosity, evidence, and partnership—because lasting change begins with listening. Over the next two years, we will strengthen health systems where communities have a voice, CHWs receive the support they need, facilities are prepared to deliver quality care, and leaders use evidence to make better decisions.
“We don’t have a Lwala team and a County Government team ,us and them, we are one team. We are doing this work together, with research giving us direction to achieve our shared goals.”
Moses Omondi, Nyamira County Program Coordinator
