Community health workers, the missing link in health care carew slows down task shifting

BERNARD MUTHAKA explores how delay in policy review has slowed down shifting tasksMajor indicators are showing that Kenya will miss out on the health-related millennium development goals. Among the concerns is that the current approaches to health service provision need major re-thinking.Figures from a recent demographic and health survey, indicate that about half of children under five years, do not go to hospital for major illnesses like malaria, diarrhoea and pneumonia. Yet they are the leading causes of death in that age group.Medics contend that such children are getting services at home, which means, it is crucial to start empowering the community to render certain basic health services.Presently, the health sector faces a crisis with many facets including a dissatisfied workforce. In such a context, the strategy now widely referred to as "task-shifting" — where some tasks are delegated to the lower categories — can make a big difference in access to basic health services.While neighbouring countries like Uganda and Ethiopia have already begun implementing aspects of the strategy, Kenya’s progress has been consigned to policy proposals. "We have already designed a curriculum for training of community health workers (CHW) which would enable them to carry out curative duties such as giving of antibiotics for major childhood illnesses," confirms Dr Khadija Abdullah of the Division of Child Health, Public Health ministry.It is not clear why the necessary steps towards making changes to the policy have been delayed. This is despite the presence of robust evidence that show CHW can implement interventions that can lead to improved health outcomes. Such evidence includes an award-winning project called Sauri millennium village which is being implemented in Western Kenya. The project delivers a free minimum package of primary health care services at the village level. It has involved the use of about 800 professional and paid CHW who deliver health care services to underserved communities.The workers have clear performance indicators and regular supervision, in addition to financial and non-financial incentives.The Sauri project coordinator Jackline Oluoch, explains that the project has led to the reduction in malaria prevalence, malnutrition and increased the number of immunised children in the targeted communities."The project has also facilitated the collection of timely health care data in areas where previously no such data existed," she explains.According to Gertrude’s Children’s Hospital chief executive officer Gordon Odundo, task shifting is a strategy that can be especially handy in management of paediatric HIV.Working with the Regional Aids Training Network, the hospital recently completed an advocacy training pilot project calling for greater human resource mobilisation for paediatric HIV."There are some basic services currently being provided by nurses and doctors that can safely be delegated to the community workers. ART adherence for example is a big issue in paediatric HIV and community health workers can effectively monitor and enforce adherence," says Odundo.For CHWs to make an effective contribution there is need for clear guidelines such as the procedures for selection, appropriate training and continuous supervision.At the moment, most CHW operate as volunteers, with unclear structures on recruitment or compensation for their labour. WHO argues that there is little evidence showing that volunteerism can be sustained for long periods, especially among community health workers who are poor and require an income."Although in many programmes they are expected to spend only a small amount of time on their health-related duties, leaving time for other breadwinning activities, community demand often requires full-time performance," says WHO. CHW programmes are not a cheap or easy, but they remain a good investment since the alternative in reality is no care at all for the poor living in geographically peripheral areas.

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