For the past 15 years, Lwala has worked with communities to innovate, test, and adapt our community-led health model. Over time, we brought more communities into the fold, and our roots in Lwala Village grew to all of Rongo Subcounty, where we have been delivering health services to 125,000 people. In 2022, we expanded to two more subcounties in Migori County, Nyatike and Awendo, where we are now working with new communities, across a population of 420,000. This scale-up is part of our larger strategy to reach all of Migori County, a population of 1.1 million by 2025.
Awendo neighbors Rongo and is similar in geography, population size, climate, and economic activities. Like Rongo, Awendo is mostly rural with an urban center. Conversely, Nyatike is located on the coast of Lake Victoria and covers a wider geographical area, so communities are further spread out. It has a semi-arid climate and rough terrain that is prone to flooding when it rains. The mobility of the fishers who occupy the shores of the lake and its terrain pose a challenge in providing consistent health services in Nyatike.
In the last year, we built deep partnerships with these local governments, developed joint work plans, and conducted a baseline household survey to understand the unique health challenges in Nyatike and Awendo and measure change over time. Alongside government, we trained 868 CHWs who registered households and began providing services, and we mobilized 55 youth peer providers (YPPs) in Awendo to increase access to sexual and reproductive health for their peers. We also began work with 51 new public facilities to advance initiatives that improve quality of care.
These activities unlocked new learnings, as we established different ways of working with government, adapted our community health services to the needs of new populations, and uncovered new challenges and opportunities faced by health facilities.
Adapting our model for government support
With this expansion, we are using a different approach to government partnership. In Rongo, Lwala directly delivers many services with the support and direction of local government. In Awendo and Nyatike, however, we are making a further shift toward co-implementation. This means we develop work plans together, but the government leads all service delivery–like training and mentorship for CHWs, for example–while Lwala supports activities, offers thought partnership, develops tools, and provides supplemental resources. “We usually convene forums with Lwala where we brainstorm and explore the best possible solutions tailored to the needs of our community members,” says George Magolo, the Public Health Officer and Subcounty Focal Person in Awendo. “Then we work together in implementing and monitoring activities to achieve common objectives in our communities and health facilities. I am happy that we are already seeing improvements in service delivery.”
“One of the most rewarding parts of our partnership with Lwala is the co-creation and co-implementation of activities. I see a bright future for Nyatike Subcounty with improved health services and outcomes.”
- Evans Abonyo, Public Health Officer, Nyatike Subcounty
Because this approach rests heavily on collaboration and joint activity planning, it can often take more time than direct implementation. It also requires more nimbleness and flexibility on our part to support government, aligned with their plans and priorities. Though we may have less control over timelines, we know that ceding power to government is the path to sustainability in the long run.
Equipping the community health workforce
As an early joint activity, we worked with the governments in Nyatike and Awendo to ensure that CHWs were trained, supervised, digitally empowered, paid, and connected to health facilities. We also partnered with communities to identify 59 women serving as traditional birth attendants, who have now been incorporated as CHWs. One challenge that emerged during training was the high caseload of CHWs in Nyatike–some CHWs had been assigned as many as 100 households. We worked with government to map households and recruit more CHWs to reduce and standardize caseload. Additionally, we began to institute monthly review meetings, a critical venue for CHWs to meet regularly to discuss challenges and validate data.
Once trained, CHWs began to register households, provide services during routine visits, and organize outreach events and open maternity days. We found that in Awendo, which borders Rongo, many community members were already familiar with Lwala, so community acceptance was high and household registration went smoothly. In Nyatike, which is further from Rongo, we had to spend more time building buy-in through community dialogues, hosted with government early in our entry process. Because Nyatike is so vast and has higher rates of poverty, we found that once we engaged with communities, the desire for more community-level health care was high. The result in both subcounties is that the majority of households have been registered–meaning they are included in a CHW’s digital tool to ensure that no family slips through the cracks.
CHW household visits, health outreach events, and open maternity days are already increasing visits to health facilities as more patients are referred–according to facility data, postnatal care visits have increased by 17% in Awendo compared to early 2022. We have not seen the same increases in Nyatike, a more challenging environment where it may take longer to shift health outcomes. We also expect it is an issue with data. In 2022, Lwala partnered closely with Awendo’s Subcounty Health Management Team (SCHMT) to ensure that community health data was being included in facility registries–we will do the same with Nyatike’s SCHMT this year, which will yield a clearer picture of health improvements.
This work is supported by digitizing CHWs through the electronic Community Health Information System (eCHIS), a digital platform owned by the national government to advance Universal Health Coverage (UHC). Lwala supported the development and rollout of eCHIS nationally, and at the county level, Lwala was part of the team that developed Migori County’s digitization strategy to ensure a reliable flow of CHW data between the community, county, and national levels. We rolled out the platform in Awendo and Nyatike, and trained 868 CHWs on eCHIS.
We learned that many CHWs need ongoing support and mentorship to use the platform, so we also trained community health assistants (CHAs)–who already provide ongoing support supervision for CHWs–to increase use of the platform and help solve problems. These activities were always done in partnership with government so that CHWs and CHAs buy into eCHIS as a government-owned platform that will be used in the long run–and not a partner-driven solution that might phase out in a couple of years. We have already started seeing improvements in CHW data quality, reporting, supervision, and commodity management.
Improving quality of care at health facilities
Alongside our expansion, we established partnerships with 51 new public facilities to advance quality improvement initiatives (16 in Awendo and 35 in Nyatike). We conducted baseline health facility assessments, which identify strengths and areas for improvement in service provision. The assessment found gaps in governance, supply chain, service delivery, and finance, and facility teams developed improvement plans tailored to these gaps.
Across facilities in Awendo and Nyatike, we saw the need to strengthen channels for community oversight. In response, we are working with the government to reconstitute and strengthen the Health Facility Management Committees, which are responsible for resource mobilization, oversight, and management of health facilities. This also connects to Lwala’s work with community health committees, which are government mandated bodies that provide oversight in community health. Just 28% of facilities across both subcounties had a fully formed and active CHC. These community accountability mechanisms are important for ensuring that health facilities provide high-quality care that meets the needs of the community, and Lwala will support their strengthening.
Secondly, the assessment found that commodity stockouts were undermining service delivery and patient satisfaction at the facilities. This challenge was reflected in facility data for antenatal care visits, which declined by 3% in Awendo since early 2022–when government facilities lack the reagents for ANC profiling, patients here are more likely to seek care at private facilities, or they may forgo ANC altogether.
“When patients are referred by CHWs, only to visit the facilities and find that the services are not available and quality is poor, this affects the effectiveness of our overall CHW program, and the credibility of CHWs is compromised.”
- Roseline Juma, Lwala Quality Improvement Officer, Nyatike Subcounty
To mitigate stockouts, we are working with the government and the facilities to redistribute commodities and improve inventory management processes, including disposing of expired drugs. Additionally, we are partnering with Village Reach in conducting a study that will assess the supply chain status in Migori County and ultimately lead to an improvement plan for commodity supply chain management that will be driven by the county.
Finally, we worked with Health Facility Management Committees to select and train quality improvement coaches in every facility. The leadership of these committees in this process is central to success, as they know the staff who are best placed to drive this work forward. Together, we are strengthening the capacity of quality improvement coaches and empowering them to sustainably champion initiatives in their facilities that improve service delivery.
“It’s times like this that I feel especially proud to be a public health officer because I can truly see the impact we are making in the lives of our community members.”
- George Magolo, Public Health Officer and Focal Person, Awendo Subcounty
As we forge ahead with our plans to bring lasting change and impact to 1.1 million people in Migori County, these lessons will inform our expansion to Migori’s remaining subcounties. We will continue to partner with government to strengthen support for CHWs and co-create models that are flexible and responsive enough to deliver meaningful impact to the communities that we serve.