By Duncan Mboya
Community Health Volunteers (CHVs) are community-based workers who supplement formal health system in promoting disease prevention in rural Homa Bay County.
Initially known as Traditional Health Attendants, the change of name to CHVs has brought about behavior change in the broader healthcare sector.
“The concept was adopted by the Kenya government and made a policy after a study conducted by a Kisumu City-based Great Lakes University. The university researchers discovered that CHVs could be useful in the delivery of essential health services at the community level,” Dr. Richard Muga, Executive Committee Member of Health Services in Homa Bay County, says.
According to Dr. Muga the University found out that CHVs have the potential to supplement the formal health system, especially today when infectious, nutritional and non-communicable diseases have become common.
Dr. Muga says that the CHVs who are nominated by the community members are taken through a rigorous interview and training before being enlisted to start helping to tackle the health challenges.
He says, the CHVs have been found to be leading facilitators of success as they help find solutions in fixing hitherto intractable health problems.
The CHVs, he adds, are trusted enough to be allowed to enter households in their villages to check how communities live and report back to the government officers for a timely action to deal with any issue of concern.
According to Mr. Mathews Ajwala, a Community Health Officer in Homa Bay County, CHVs are well educated and each is currently serving over 100 villagers.
Mr. Ajwala notes that the CHVs’ main role is to follow up on ARVs defaulters, COVID-19 follow ups, distribution of mosquito nets to needy cases, ensuring that mothers seek maternal health and following up on sanitation issues, besides other health challenges.
He disclosed that Homa Bay County has 2,936 CHVs, monitoring and preventing cholera outbreaks, malaria and increasing number of HIV cases.
CHVs, he says, are guided by the Community Health Act, Section 12 of which spells out the functions of CHVs.
“Each CHV is expected to visit members of the community under her/his care daily, attending to their daily health needs and reports back to the Community Health Assistant (CHA) for immediate action,” he adds.
The official reveals that all the households are linked to a health facility within their locality where they report for treatment and those on regular medication access their medicine.
Rapid Diagnostic Tests for Malaria
“Together with the local village administrators, CHVs have a quarterly meeting where they discuss new challenges and develop new work plan in addressing reported cases of disease outbreak, those defaulting from taking routine prescribed medicine and others,” he adds.
He reveals that all the discussions are then transferred to a chalk board where communities are summoned to see the findings thereafter solution – action – targets are agreed upon.
“The dates for immunization, sanitation clean up operations, or any other health threatening findings, are set and the CHVs move into action,” he adds.
After three months, they dialogue again and see how the exercise was executed and move to action again in helping fill the gaps if there is any.
Ajwala reveals that CHVs are the first medic to attend to sick people since they carry out referrals to health facilities from households.
“They are trained on immunization, water and sanitation, importance of latrines, HIV Aids, promotion of family planning methods, and nutrition matters,” he notes.
He says that they are however allowed to carry basic medicine like pain killers in their medical kits but not antibiotics.
The CHVs also conduct Rapid Diagnostic Test (RDT) for malaria and recommend for patients transfer to a medical facility.
“They have been very useful in identifying people suffering from pneumonia, tuberculosis, COVID-19,” he adds.
Ajwala said that it’s the CHVs continuous work during the outbreak of COVID-19 pandemic that has led to the closure of the two quarantine health facilities that were opened to cater for COVID-19 infected people.
He reveals that this became possible having realized that majority of the cases were asymptomatic hence did not require quarantine but home based care.
“They followed all COVID-19 cases and ensured that hand washing hygiene, wearing of masks and keeping distance in public places are adhered to by communities,” he adds.
Making Homa Bay an Open Defecation Free County
Ajwala narrates how CHVs have helped in reducing Open Defecation (OD) that has been a big problem in the country.
According to 2009 national census, 45 percent of villages were still helping themselves in open spaces, with some recorded cases of diarrhea.
“We had major cholera outbreak in 2007 and by 2019 we have recorded 90 percent Open Defecation Free (ODF) category up from 45 percent in 2009,” he adds.
He says that the success that leaves only 10 percent of villages still openly defecating is fully attributed to the work done by CHVs in educating and mobilizing communities to sink latrines.
He adds that the cholera pattern in the county that was prevalence along Lake Victoria beaches, with Mbita town serving as the hot spot every year has reduced.
“The CHVs have succeeded in making162 villages ODF out of 3,323 villages in the entire county. A number of villages are also soon joining the list,” Ajwala adds.
Rose Makori, a resident of Shauri Yako estate in the outskirts of Homa Bay town says that they have a three days program of keeping their estate clean, a move that has saved the residents from contracting cholera and other waterborne diseases.
“We are taken through the cleanliness exercise that starts at 7 am after we have released children to go to school by our CHV Jael Onditi,” Makori says.
She says that since she was appointed to serve amongst them, Onditi has saved the village with prompt action to medical emergencies.
“She ensure that everyone in the village uses the toilets correctly, ensure that children wastes are properly disposed off, keeps their food wastes, removes stagnant water and keeps cleanliness within the corridors,” she adds.
On their role in managing HHIVAIDS, Ajwala says that CHVs are the success behind the reduction of HIV prevalence to 19 percent currently in the county from 43 percent in 2016.
Ajwala notes that through CHVs, HIV defaulters are followed up and asked to report back to accessing their medicine and those with known signs are also encouraged to report for medical tests.
Moses Okelo is one such person who went back to receiving his antiretroviral drugs after defaulting for three months.
“I defaulted having felt tired of taking daily medication but our local CHV came to my home and sweet-talked me back into the program,” Okelo, a resident of Lwala village in Central Karachuonyo reveals.
Okelo who was diagnosed with HIV/ AIDS in the year 2000, continues to receive his medicines from Simbi Kogembo Dispensary without fail.
“I was cautioned that I will never be allowed back into the program again in case I default,” Okelo, the father of three says.
Improved TB management and Infant Immunization
Ajwala says that besides HIV Aids, CHVs have also helped improve safe delivery of babies, antenatal care and immunization.
He said that tuberculosis management in Homa Bay is currently the best overall in the whole country. “Tuberculosis management is excellent as they keep tab of those on medication and visit them to inquire on reactions from the medicine if there is any apart from following on defaulters,” he adds.
“I monitor coughing people within my area of operation and with the help of neighbors, I refer them to hospital seek medical attention when the cough persists for one week,” Peter Odero, CHV in Maguti village in North Rachunyo sub county says.
Odero notes that the program is a success save for a few fishermen within the beaches who run away once they started developing strange coughs.
Mr. Jacob Aduda, sub county health strategy focal person for Rachuonyo North Sub County says that by incorporating the CHVS, the government shifted from top – bottom – approach to bottom – up – approach strategy, that brought on board a participatory action in collaboration with community members in healthcare management.
Aduda who is in charge of 61 CHV that are spread in 58 administrative locations, says that the CHVs are serving under the supervision of community health unit that forms a population of 5,000 community members.
“They have MOH 5013, a chalk board where they register all names of community members, reporting tools and MOH 5914, daily service logbook where they record what they do daily,” he adds.
He notes that the assistant then enters all reports from 10 CHVs into MOH5015 and forward it to the sub county health strategy focal person.
Aduda says that all CHVs meet at the nearest health facility that they report to every 28th day of every month to hand over reports and also discuss the way forward including challenges they went through.
The reports are therefore handed over to the Sub County officials and then sent to District Health Information Service (DHIS) by 15th of every month.
The Community Health Council, a governing body that is charged with the responsibility of overseeing CHVs at sub location level, is also a source for resources in support of the CHVs work within the villages.
“They follow up on HIV defaulters and talk them back to taking their medicine, ensure all expectant mothers deliver at health facilities and look at sanitation within the localities,” Aduda notes.
He says that CHVs has helped reduce the rate of TB patients defaulting by tracing them and bringing them back to starting taking medication a fresh.
“We are provided with malaria Rapid Diagnostic Kits (RDK) that includes a thermometer for testing suspected malaria cases,” Odero says.
He adds that they also carry with them antimalarial medicine, pain killers, ARS and amoxilline that they dispense to sick people.
Magdalene Odede, a CHVs from Wi Milanya village in Rachuonyo North sub-county, notes that majority of defaulters and those unwilling to attend clinics sessions are newly married women who fear visiting health facilities.
“We apply interpersonal communication that we are taught in convincing populations to see the benefits of being healthy,” she adds.
Jane Achieng, a resident of Kolonde village in Central Karachunyo location, confirms that she was afraid to attend clinics at the local Simbi Kogembo dispensary.
“I was a newly married woman and I did not see why I should go to the clinic for fear that everyone will come to know my pregnancy status,” Achieng reveals.
But upon being talked to, Achieng says she made it a habit of visiting the facility as directed until she gave birth to her six years old son.
According to Philgona Owino, a CHV in Kolonde village, Achieng has since become like the leader of young women of her age.
“She keeps encouraging them to visit health facilities in good time and also advise them to stick to their appointment dates,” Owino adds.
Achieng commends Owino for giving her mosquito bed net that has been of great help to her family.
“I live within Kimira Oluch Irrigation Scheme that is economically viable project but also home to mosquitoes,” Achieng notes.
Besides playing an important role health care service delivery, CHVs are increasingly involved in behavior change interventions, including for hygiene-related behavior change.
And on a daily basis, they continue to survey their jurisdiction, sending routine reports to their superiors and advising community members with no fail.
All said and done, there are limitations that should be addressed to make CHVs more effective. These borders on community misperceptions, poor remuneration, long working ours and lack of necessary tools.
“Even though we give our best to communities whom we serve, they think that we are paid well hence they are unwilling to give us detailed information,” Peter Odero says.
He says that members of the community are mistaken by their commitment to duty that starts at dawn and sometimes ends late in the night.
Odero notes that to date CHVs are only paid a stipend of Kenya Shillings 2,000 (U.S. dollars 20) every month unfortunately the money is rarely paid in time.
“We are working without prompt pay as we are owed several months of salaries,” he notes.
“We are forced to give priority to the community over our family since most of the time we are woken up early in the morning, sometimes in the middle of the night depending with the emergency,” Jael Onditi says.
CHVs also lack necessary equipment such as torches and gum boots that could make their work at night easier.