Kwale Kenya - Thoughts on Community Health Strategy, Sustainability and Universal Health Coverage

As our project with the Ministry of Health in Kwale, Kenya comes to a close it is a good time to reflect on the impact we have had. A large part of our work has been in supporting the county’s Community Health Strategy and we are currently evaluating the impact of that strategy with questionnaires and Focused Group Discussions with Community members, Community Volunteers, Community Health Assistants and Facility in Charges in the facilities connected to the Community Units we have supported.

During the project, we supported 24 community units, with 240 Community Health Volunteers, supporting them with bicycles, smart phone, wifi hot spots and solar power banks, along with training programmes and review meetings. We initiated a pilot study using smart phones to collect health data and also supplied government log books to collect data both digitally and in analogue form. We supported trainings for CHAs and Health Records Officers in DHIS2 tracker data collection, looking at how data collected can be made more useful and relevant at a local level.

But in our current discussions with the community, we again appreciated the impact and importance of establishing the community unit itself and how by supporting the Community Health Volunteers, including a small monthly stipend of $20.00. This small but significant economic contribution maintained a greater level of commitment to the voluntary work being done, even when this voluntary work was more than 20 hours a week.

Kenya is now embracing the challenge of Universal Health Coverage and has embarked on a pilot study in 4 counties, spending 3.1 billion Kenyan shillings (30 million dollars) in the process. The government intends to roll out the program in all 44 counties in the country. However, the economic challenges loom large in their capacity to do this.

According to an editorial in the Kenyan newspaper The Nation on Sunday January 12, 2020, “Sh1.8 billion has been released for the procurement of required health products and technologies as part of the Sh3.1 billion programme.” “70% of the amount so far will be spent to buy drugs and basic medical equipment and the rest to strengthen health systems in the counties.”

A question can be asked if spending up to 70% of the allotted amount on drugs and supplies is the right focus or should more money be spend on developing and supporting the Community Health Strategy in the country. At this point, most counties rely on donor organizations to support the Community Strategy and don’t allocate any funds to support Community Volunteers and the establishment and maintenance of the Community Strategy. This creates challenges in the long-term sustainability of the Community Strategy, which given its potential impact in supporting the goal of Universal Health Coverage, may make this more difficult to achieve. 

The whole vision of the Community Health Strategy is to create a link between the community and the healthcare system and by training volunteer workers, to intercede in the community and help facilitate better health seeking behaviour. This can help prevent more serious sickness and allow better healthcare take place. With the growing threat of non-communicable diseases in the whole world, and the serious economic challenges this can bring, preventative interventions would seem more important than ever and the community volunteers are in a unique position to do this.

However, research on Kenya’s Community Strategy shows that without giving stipends and other support, volunteers become more disenchanted and the tendency to drop out becomes more of an issue.

(Exploring perceptions of community health policy in Kenya and identifying implications for policy change – Health and Policy Planning 31 – 2016)

Also, an increasing body of research shows that one of the most obvious but misunderstood factors leading to ill health is economic challenges. A lack of money in communities encourages poor health seeking behaviour, which then in the long run can cost countries more money in healthcare and social costs than in addressing the root problems of poverty and general economic challenges.

One book, called “Utopia for Realists” by Dutch writer Rutger Bregman, explores these issues, even making the argument for a “Universal Basic Income”, which he says that in many countries shows a markedly positive impact in changing behaviour and often leading to better health and less strain on social services. He quotes “In 2008, the Ugandan government distributed almost $400 to some 12,000 16-35 year olds. All they had to do was submit a business plan. Five years later, the effects were staggering. Having invested in their own education and business ventures, their income has gone up nearly 50%. And their odds of getting hired had increased over 60%. Another Ugandan programme distributed $150 to over 1,800 poor women in the north of the country. Incomes increased nearly 100%. Cash handouts in Namibia decreased malnutrition from 42 to 10% and in Malawi, school attendance increased 40%.”

Supporting Community Health Units can be one way of supporting better economic opportunities and helping raise the standard of living in poorer communities. At the moment, the government is focusing more on building the health infrastructure and supplying more medicines, and while that is necessary, a question can be made that by focusing more investment in Community Strategy and also paying stipends to volunteers, and also training a new cadre of Community Health Extension Workers, that investment may pay better dividends in raising the standard of living and by preventing illnesses such as diabetes and hypertension. Not only would that save a lot of money in the long run it can make the goal of Universal Health Coverage that much closer to fruition.