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Kenya can no longer afford to ignore community health workers

As Kenya launches the Universal Health Coverage (UHC) pilot project Lilian Kaivilu spoke to Githinji Gitahi, co-chair of the UHC 2030 Steering Committee, on the important role community health workers will play in UHC.

QUESTION: In the recent years, Kenya has experienced shortage of health workers at all levels. Should this be a concern as the country launches UHC?

ANSWER: No country can say they have enough health workers for UHC. The latter is a continuous thing because populations are changing and there is a demographic shift of diseases. So the question is what can we offer with the health workers we have as a starting point.

We have to launch UHC and then start building the journey. We cannot wait until we have enough health workers. We need to recognise that we do not have enough human resource then put in place measures to ensure we have adequate numbers as we continue implementing UHC.

Q: Having joined other lower middle class economies after rebasing her gross domestic product in 2015, Kenya is likely to see reduced donor funding in the health sector. How should the country prepare for this by 2030?

A: The country currently receives about $900 million (Sh92.2 billion) from donors. The rest of the money comes from the government and people paying from their pockets. Therefore, the country needs t find ways to convert the out-of-pocket expenditure into premiums through the National Hospital Insurance Fund (NHIF) so that people can access health without worry.  We should aim to reach a minimum of 15 per cent of total budget being allocated to health by 2030.

Q: What will be the role of community health workers (CHWs) in the envisaged dispensation?

A: CHWs are the foundation of a good health system and if we do not build a good foundation, then everything else is going to be weak. This is because these are the people who ensure that households have toilets, dispose of rubbish in the right manner, have hand washing facilities, trace tuberculosis patients and maintain their data base.

Q: Currently, many CHWs offer their services voluntarily at the community level. Should their remuneration be a point of attention?

A: The challenge we have, is that for a long time we have failed to recognise and put them on the payroll. This is because the partners have continued to support them. As Amref Health Africa, we are trying to put a bill in parliament to ensure that CHWs are integrated, regulated and remunerated as part of the health system.

We, however, have not reached the tabling stage of the Bill. But eventually the solution will be to formalise CHWs, know who they are, train, regulate and pay them. There is no other way out.

Q: So what should be the solution in the meantime?

A: If we do not integrate the CHWs in the four plot counties, we shall fail. Out of the Sh3.9 billion set aside for the UHC pilot programme, there is some money that has been allocated to ensure that we have community health services fully integrated.

We do not have enough community health units that are operational in these four units. One of the key things is to operationalise these units in the four counties.

Part of the money will also be used to train community health extension workers (CHEWs) who will lead the community health units.

Q: Who pays for this training? The CHEWs are going to be trained through the medical training colleges. There is a curriculum that has been developed on the same. We are therefore asking counties to pay for this training. The average cost of training one CHEW is Sh50,000 to Sh80,000 for  a period of six to eight months.

A: What lessons that Kenya can learn from other countries in Africa that have embraced use the UHC model?

Rwanda is a good example. They have a system where about 90 of the people have a functional health card. The country has also formalised their community health services through cooperative societies and this way, they have achieved commendable progress in maternal health and child mortality.  We need to learn from Ghana’s failed system.

Initially, the country provided a very generous list of essential services. They, however, got to a place where they could not afford it and, therefore, they had to take several steps backwards. If we promise more than we can offer as we launch our UHC, we may end this way. Let us start modest and then build up. We must not start by being over optimistic.

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