Community health workers (CHWs) are the caregivers of their communities. They reach every household in their village with essential health services, they make referrals to facilities, and they are a trusted source of information for their communities. Yet CHWs are often under-equipped and under-supported, and only 14% of CHWs in Africa are salaried. Lwala is committed to professionalizing CHWs, ensuring they are paid, trained, supervised, equipped, and digitally enabled. We advance the professionalization of CHWs through policy and systems change nationally, and we partner with the Migori County government to strengthen service delivery through the county’s 2,751 CHWs.
Professionalization unlocks the door for more accessible, higher quality health services. With the right training and tools, professional CHWs visit more than 3 times as many households as under-supported cadres. This is aided by payment–when CHWs are paid, they can spend more time delivering health services and less time finding other ways to financially support their family. Additionally, a recent study from Lwala found that when visited by professionalized CHWs, children were 15% more likely to be fully immunized, and pregnant women were 14% more likely to attend 4 or more antenatal care visits. Professionalization is also an issue of gender equity–more than 70% of CHWs worldwide are women, meaning that health systems are built on the backs of unpaid women’s labor.
Through Lwala’s recent expansion into Nyatike and Awendo Subcounties, we are now directly supporting 1,414 CHWs. Paris Odhiambo is one of those CHWs, and she has been serving her community in Awendo for nearly six years. “I worked 5 years without payment,” she says. “We carried around heavy books with information about our patients. It was really difficult because I didn’t know if anyone was aware of the work I was doing.” Now, Paris and her peers have been trained and equipped with commodities and digital tools to track their patients. She is also getting paid.
Lwala is part of a global movement through Community Health Impact Coalition (CHIC) committed to change the status quo for CHWs like Paris. We don’t just advocate for change–we offer solutions based on programmatic experience, joint research, and most importantly, the voices of CHWs themselves. Consolidating these lessons, members of CHIC and the World Health Organization (WHO) developed a tool called the CHW Assessment and Improvement Matrix (CHW-AIM), which supports governments and donors to build and sustain strong CHWs cadres. When government policies and systems align with these 10 proCHW principles (see text box), both communities and CHWs reap the rewards.
An investment that saves lives and improves gender equity
The status quo in health care is that hard-to-reach and vulnerable populations must spend precious money and time–hours or days–to receive services. Meanwhile, many governments and donors seek to fill the gap with the unpaid labor of CHWs, often women stepping up to help their communities because they see the deathly impact of inaccessible care. Lwala combats this status quo by ensuring that every CHW we support is paid. This improves health outcomes and livelihoods: “Payment motivates us,” says Paris. It enables me to be independent. I am capable of supporting myself, my family, and my community.”
Lwala is working to make this a norm across Kenya, ensuring that governments own the payment of CHWs. In 2021, we supported Migori County to establish its first CHW Registry, a key step toward getting CHWs paid and supported. Last year, Migori County passed a milestone Community Health Services (CHS) Act, which solidifies the county’s commitment to professionalizing and paying CHWs. In addition to supporting the development of this legislation, we have partnered with the government to align other county policies and priorities with proCHW principles. Recently, for example, Migori County developed a new County Integrated Development Plan, which will drive priorities and budget for the next 5 years–and it includes indicators around CHW payment as a result of Lwala’s inputs.
“Being paid has given me dignity in doing my work. The training has equipped me to serve and teach my community well, and now that we have mobile phones to collect data, we no longer have to carry heavy books. It helps me feel recognized for my work and supported by the community.”
- Paris Odhiambo, Community Health Worker, Awendo Subcounty
At the national level, we have worked through Community Health Units for Universal Health Coverage (CHU4UHC), a coalition co-founded by Lwala, to elevate community health and CHW payment as a requirement for reaching bold UHC goals. We advocated for CHW payment to be included in party manifestos during last year’s election, and we met with the new administration post-election to develop a way forward. As a result of this momentum, the government has made a commitment to pay stipends to all 1oo,000 CHWs in Kenya, and the President and county governors have agreed to a cost-sharing arrangement. Coupled with national CHS legislation that will be re-introduced this year, we are supporting Kenya in fostering a proCHW ecosystem that values community voice and women’s labor.
Power in a defined role
“I was chosen by my community as someone who could serve their health needs,” Paris says, explaining how she became a CHW. This reflects a key tenant of professionalization: CHWs should be recruited from their community by their community. This increases acceptance, ownership, and sustainability. Additionally, government guidelines should clearly define the role of CHWs, as well as the knowledge and experience necessary to fulfill the role. In many cases, however, these guidelines don’t exist–without clearly defined roles and selection criteria, it’s impossible to build a professionalized community health workforce. To change this in Kenya, Lwala worked with the Ministry of Health to develop National Certification Guidelines for CHWs, which outline the role of CHWs and set standards for their accreditation.
As governments more clearly define selection criteria for CHWs, Lwala believes they must not introduce or reinforce barriers to entry for women, especially those already providing care. Traditional birth attendants (TBAs), for example, have provided health services to communities for generations, but they are often blocked out of CHW cadres by discriminatory literacy and education requirements.
Lwala’s research, however, shows that professionalization and experience are more reliable predictors of CHW knowledge and performance than formal education and literacy. So in the development of the National Certification Guidelines for CHWs, we worked to reverse exclusionary eligibility requirements. We also developed a tool alongside the Migori County Ministry of Health to identify existing TBAs, incorporate them as CHWs, and add them to the CHW registry–149 TBAs in total. Together, we are committed to honoring the work of women who have decades of experience in providing care.
Creating a movement, with CHW voices at the center
Too often, CHWs’ voices are excluded from decision-making that impacts their work and the communities they serve. In 2021, Lwala joined CHIC and CHWs around the world to develop an advocacy training for CHWs. So far, 300 Lwala-supported CHWs have been trained. Additionally, in Migori County we helped initiate a CHW Network as a platform for CHWs to engage in advocacy–within one year, it’s already grown to 900 members. They are working to secure official recognition from the county government, which will add legitimacy and open doors for engagement and advocacy.
At the global level, many of our CHWs are making their voices heard, demanding recognition, payment, training, and opportunities for career advancement. In March, Maureen Wasodi from Awendo traveled to Kigali, Rwanda for the Africa Health Agenda International Conference (AHAIC), and Millicent Miruka from Rongo spoke at a USAID-hosted meeting on maternal and child survival, both sharing their stories while advocating for the professionalization of CHWs.
“There is power in speaking out and telling our stories so that we can take the lead in fighting for CHWs’ rights and for our communities.”
- Lawrence Onyango, Community Health Worker
An investment in CHWs is an investment in communities–in their health, their wellbeing, and in undoing structural inequities that bar them from high-quality health care. Together, we will ensure that CHWs in Kenya and around the world are paid and supported to keep their communities healthy.