Strengthening community health volunteer programmes: lessons from Meru County, Kenya

Community health volunteer (CHV) programs are foundational to robust health systems. Evidence suggests that CHV programs can lead to a citizenry that is more engaged in care decisions and reduce the financial burden on care within the health sector.¹ In Kenya, CHVs are typically selected by the communities in which they live and serve an assigned set of ~100- 500 individuals through household visits each month, depending on the county’s population density.² CHVs share health promotion messages, monitor chronic health conditions, refer community members to health centers/hospitals, participate in community health events, and more.

The COVID-19 pandemic has emphasised the important role CHVs play to ensure community health. As part of Kenya’s COVID-19 Response Strategy, CHVs have been recognised as potential agents of behaviour change specifically supporting the government to: ensure that correct information reaches households; demystify myths and misconceptions, and support in health promotion by demonstrating good hygiene practices such as hand washing.³ They also can play a vital role in active case-finding and contact tracing within local communities⁴.

The Government of Kenya has officially placed CHVs as the first level of the health system and recognise their role in achieving their health goals articulated in the country’s Vision 2030.⁵⁶ In order to align to national-level strategies, Meru Vision 2040 outlines specific projects to be implemented, several of which involve the County’s CHV cadre. The County Government has also prioritised the strengthening of Community Health Service Provision within its County Integrated Development Plan (2018-2022).

IDinsight partnered with the County Government of Meru to survey Meru County CHVs with the goal of providing the County with data that could better direct efforts and resources towards a stronger CHV program. We held several early conversations with the public health unit in Meru to understand what evidence would support decision-making about the CHV program. We then conducted a phone survey of ~25% of Meru County CHVs, drawing samples from different sub-counties, over the course of 2.5 weeks in September 2021 with a team of trained enumerators. We ultimately spoke to 743 of Meru’s 2,944 CHVs.⁷ We found that it is paramount for counties to provide avenues to receive feedback from CHVs on the support they require to ensure success of the CHV program and delivery of better health care to citizens. While the majority of CHVs are satisfied with their role, counties could benefit from investing in digital equipment (such as smartphones) and provide additional training to empower CHVs to serve their communities. We detail our findings and recommendations for Meru County in this blog post.

CHV Cadre

The Meru County government was interested in understanding more about the demographics and income-generating activities of CHVs in order to best target support and recruitment efforts moving forward.  We found that the majority of CHVs were female, middle-aged and had at least a primary school education. On average, CHVs had been in their role for 6.5 years. While we recommend promoting recruitment of youth into the CHV role – especially when considering the needs of other youth, and sexual/reproductive health issues – we are cognisant of the unique challenges counties face in recruiting and retaining younger CHVs. For example, county officials described that younger CHVs often leave their communities in order to seek economic, marriage and/or educational opportunities elsewhere. It was also apparent that implementing the Kenya national guideline’s requirement that CHVs should have at least a secondary education was a challenge, as the communities choose their own CHVs based on whom they trust and educational attainment in some sub-counties was low. The majority of CHVs undertake varying income-generating activities – an expected outcome as the CHV role is voluntary and does not draw compensation. About two-thirds of Meru County CHVs engage in farming as their primary income-generating activity.

CHV training and toolkit use

In order to optimise training and resource allocation, the Meru County government wanted to assess the level of confidence CHVs felt in their role following recent trainings, as well as how toolkits provided by the county or partners supported their work. About half of the CHVs were confident in their overall skills and knowledge to succeed in the role, but confidence levels vary across priority knowledge areas. CHVs were most confident in their knowledge of the referral process. Only about half felt fully conversant with topics like child health, communicable and non-communicable diseases (NCDs). Training on NCDs and COVID-19 were the most requested topics even though 90% of CHVs had attended at least 1 training on these very topics within the previous year. Together with the County, we hypothesised that this was related to the evolving nature of health practices and that these remain relevant for CHVs in their communities,  and thus recommended continuing to focus on these topics during training sessions.

The vast majority of CHVs (90%) reported receiving at least one tool from the County Government, but they reported using some pieces of equipment more than others. The most utilised tools were blood pressure monitors, mobile phones and stationery – including referral forms. Less than half of those provided with COVID-19 PPEs reported utilising them. We recommend that counties continue to provide PPEs to curb the spread of the pandemic, and also focus on tools that have high utilisation, and are most relevant for the management of NCDs – the most common conditions within the community – specifically, blood pressure machines and glucometers, in addition to mobile phones for more efficient reporting and referrals. Another recommendation was to establish a revolving fund⁸ for such items, contributed to by government, donors, and community members to support in the purchasing and restocking of toolkit items.

CHV digital readiness and perceptions towards the use of digital technology in their work

As Meru County considers how to scale-up digital tools throughout its health programs, they wanted to understand the current use and perceptions of digital tools amongst CHVs. Over 90% of CHVs prefer transitioning from current paper forms to digital reporting, but fewer than half had access to smartphones. This impaired CHVs ability to use smartphones for both e-learning and reporting platforms, such as Mobile-Jamii Afya Link (M-Jali).⁹ The majority of CHVs who had a smartphone had received it as part of the toolkit provided by the County Government. As the county continues to mobilise resources to transition to paperless forms of reporting, it seems that the short-term priority can be to ensure there are SMS or USSD-based options available for learning and reporting, since all CHVs surveyed had at least a feature phone. The long-term priority remains, however, increasing resource mobilisation efforts to diversify the set of donors and strategic partners supporting the expansion of access to smartphones among all CHVs. 

CHV perceptions of the health facility referral process

Referring community members to health facilities for access to medical services is a key role of CHVs and addressing issues in these processes can have a significant impact in communities’ health-seeking behaviour. The majority of CHVs were satisfied with the current referral process and linkage to health facilities, though a few areas were identified for improvement. Most CHVs had referred patients to a health facility within the County within the prior six months. The current referral process in Meru County is two-way and entails CHVs referring patients to the health facility and health workers referring patients to CHVs in their local communities for subsequent observation. The key areas that CHVs identified for improvement in this process were related to wait times and medical supplies at local facilities.  To support in streamlining the referral process for CHVs and cut down on wait times, the County Government – through the Public Health Office –- has recently launched Community Health linkage desks at health facilities. Since this was rolled out, the County Government has observed a decrease in complaints from the community. 

CHV knowledge and attitudes towards their roles and responsibilities

Understanding CHV’s motivation and satisfaction can help the county government better predict attrition and identify opportunities for targeted support. The survey found that most CHVs were both satisfied with the role and motivated to continue serving their communities as CHVs. They reported being either highly or very highly motivated to be a health volunteer for the County. While the role currently has no remuneration, CHVs reported the role having other non-monetary benefits. The largest benefit of the role to CHVs was the impact they had on the wellbeing of the community. The primary challenge they identified was the lack of remuneration/financial support. Meru County has already budgeted to address this concern through a quarterly stipend, but is seeking partners to make it accessible to the entire cadre. 

The community health approach has been recognised as an effective way for making improvements in health care delivery and Community Health Volunteers are a key pillar of this approach. The devolution of healthcare put county governments at the centre of delivering on health outcomes for Kenyans. Data and evidence on the support necessary for the success of community health programs should be at the centre of healthcare policies and decisions at the county level.