How communities can support resilient health systems: Lessons from a family planning project in rural Kenya
Heading east from the city of Isiolo, Kenya, the landscape almost immediately changes from a lush green to a dry tan, amplified by the beating sun. Vehicles become scarce, replaced by occasional herds of camels, goats, cows, and their owners, along dusty roads dotted with acacia trees and dry riverbeds.
This is Garba Tulla, a sub-county in Isiolo County, and home to just over 50,000 people spread across 6,500 square miles — about seven people per square mile. Communities are scattered, connected by a network of dirt roads and paths in gravelly sand.
Through a grant by the USAID-funded Advancing Partners & Communities (APC) project, World Vision Kenya seeks to improve voluntary family planning and maternal, newborn, and child health in Garba Tulla. JSI Research & Training Institute, Inc., implements the APC project in partnership with FHI 360. Since 2014, the project has worked in close collaboration with the county and sub-county Ministry of Health offices in four Garba Tulla communities. In 2017, the project expanded to a community called Barambate.
Hussein Ture is a nurse who worked at a public dispensary in the community of Barambate between 2015 and 2018. Hailing from the region himself, he understands the people who live here and their health challenges. Many are pastoral and travel with their herds, which makes it difficult for them to get to a dispensary for basic health services. Receiving complex or emergency health care requires traveling for hours by vehicle, and few people have funds for this purpose. Ambulances are far, and people have lost their lives waiting for them to arrive.
In addition to its remoteness, Garba Tulla is on the frontline of climate change. In the past few years, Barambate has faced severe drought, which is especially hard on pastoralists, who depend on crops and livestock to live. The famine that follows drought contributes to upsurges in malnutrition and diarrhea, particularly among young children and pregnant women. Food and water insecurity intensifies conflict among local groups.
Remote communities are disproportionately hit by health workforce shortages
For three years, Mr. Ture was the sole formal health worker in Barambate. Despite his smile and dedication, he was overwhelmed and overworked. He attended patients, managed stock, collected and reported data, and identified and contacted patients for follow-up care. Although his dispensary only served about 1,400 people, the remoteness of the area made it difficult to ensure that everyone received the care they needed. Mobile phone service in the area is sporadic and unreliable, so when Mr. Ture could not call his patients, he went to their homes. Because there is no maternity unit at the Barambate dispensary, Mr. Ture delivered babies in the community, leaving the facility unstaffed.
This staffing shortage is not unique to Barambate. Currently, there are only ten public health officers and four community health extension workers to support nurses who run Garba Tulla’s sixteen public health centers. In 2013, Kenya established a mid-level community health worker cadre called community health assistants, but it took nearly two years to renew their contracts after they lapsed in December 2016. A 100-day national doctors’ strike in early 2017, followed by a five-month nurses’ strike, exacerbated staffing gaps.
Community health volunteers and leaders can improve health coverage
In the face of these difficulties, Mr. Ture had help serving this community. World Vision Kenya trains, supervises and supports community health volunteers (CHVs) and faith leaders in Garba Tulla communities to help improve access to and demand for voluntary family planning and maternal, newborn, and child health services in Barambate.
CHVs educate their fellow community members about practices such as healthy timing and spacing of pregnancies, and about the care they can receive at the dispensary. They also provide condoms and pills, referrals for other health services, conduct follow-up visits, and convene communities for health campaigns. In Barambate, CHVs reported to Mr. Ture, and some helped him with day-to-day dispensary services.
In the face of formal staffing shortages, the project also engages faith leaders to improve demand for health services. Through APC, World Vision trained over 80 imams and sheikhs on healthy timing and spacing of pregnancies through Quran-based teachings that align with health messages. Leaders pass these messages to community members during weekly sermons, religious forums, and community discussions. By talking about these issues openly, community leaders help demystify and destigmatize reproductive health concepts.
Together, faith leaders and CHVs have had a tremendously positive impact. In 2018 alone, imams and sheikhs reached nearly 1,000 people with messages about healthy timing and spacing of pregnancies during 48 public discussions. Thirty CHVs reached an additional 9,853 people with related information and made 1,875 referrals for voluntary family planning services. CHVs and facility staff provided contraceptive methods to approximately 6,300 people.
In 2019, World Vision’s work continues. With the Ministry of Health, the project is training and supporting CHVs to provide injectable contraceptives, Kenya’s most popular family planning method. While national policy permits CHVs to provide injectables in certain contexts, this has yet to happen in Isiolo County.
How health and development partners can support resilient health systems in last-mile communities
In recent years, Kenya has committed to achieving ambitious goals such as universal health coverage and the Sustainable Development Goals. Reaching remote and vulnerable communities such as Barambate with high-quality health services is imperative to attaining these goals, but will require significant planning, time, and resources. So how can health and development partners help countries build resilience in such contexts? World Vision’s work in Garba Tulla highlights some lessons:
- Ensure that national policies trickle down. In decentralized contexts such as Kenya, national policies can take months or years to roll out at the sub-national levels. As a result, people living in the hardest-to-access areas have little exposure to new approaches and innovations. Development partners, particularly those that are part of national policy conversations, can familiarize sub-national health teams with these policies and help them adapt and roll them out. In places such as Garba Tulla, task-sharing strategies are especially relevant, because when sufficiently supported, they can redistribute the burden of services among health providers while improving coverage.
- Cultivate relationships with sub-national actors, especially county health teams. Health and development partners have a crucial role in supporting countries’ journeys to self-reliance, including at the sub-national level, where capacity is often lower. World Vision’s long-standing presence in Kenya and collaborative approach paved the way for a fruitful relationship with sub-national health actors in Garba Tulla that has strengthened over the course of the project. Working with county and sub-county health teams, World Vision conducts joint strategic planning, identifies and applies creative approaches to building skills, enhances learning about community health (e.g., through study tours), and coordinates with other local projects and individuals to improve alignment and efficiency. The project demonstrates how close partnerships with local health authorities mitigate health system shocks, such as famine.
- Engage with a range of community leaders to diffuse messages and facilitate dialogue to reinforce healthy behaviors. Community leaders, such as male and female religious leaders, teachers, women’s groups, elected officials, and CHVs, have a considerable influence on societal attitudes and norms. World Vision works with an array of these leaders to support health behavior change through different but complementary approaches to reach various segments of the population. These mutually reinforcing messages foster a supportive environment for practicing certain behaviors, such as birth spacing.
- Continue to advocate for frontline health worker investments.
Frontline health workers in areas such as Garba Tulla function with few resources, poor infrastructure, weak supply chains, and endemic security issues. Such hardships reduce motivation, resulting in frequent staff turnover and poor continuity of services for the community. At all levels, it is crucial to advocate for approaches and resources that support health workers, particularly in places that adopt task-shifting approaches to strengthen service coverage and quality. Partners may encourage motivation packages commensurate with the health workers’ scope of work and the local context; provide regular and sufficient supervision and training to ensure quality control; and adopt measures to ensure health worker safety.
Mr. Ture has recently moved to another health facility in Garba Tulla, and two new nurses now staff the Barambate dispensary, working in shifts to better distribute the workload. They look forward to providing families in Barambate with the information and services they need to be healthy.
About the Author
Kristen Devlin is a technical advisor for community health working on the Advancing Partners & Communities project.