The ‘family doctors’ who stay on call for no pay

Wednesday April 10 2019

Mothers at the Kabuga Health Centre in Gasabo district of Kigali. Community-based health programme covers 90 per cent of Rwandans. PHOTO | BILL & MELINDA GATES FOUNDATION


For her effort in ensuring expectant mothers in Tigray, Ethiopia deliver in health facilities, access contraceptives, and that children get vaccinated on time, Senait Fiseha Alemu is known by the moniker, “doctor.”

But Ms Alemu, who sometimes walks for close to two hours—or even 20 kilometres—to reach a single family, is not a doctor.

She is one of 40,000 community health extension workers, commonly referred to as community health workers (CHWs).

Now skilled in reproductive, maternal and children’s health, Ms Alemu started off as a volunteer and went on to gain a diploma from the Health Extension Programme.

Ms Alemu and her “kebeles” (smallest administrative unit in Ethiopia) were feted by the government as models of community health.


Senait Fiseha Alemu ( second left) receives an award for her work as a community health volunteer in Ethiopia, at the recent Africa Health Agenda International Conference in Kigali, Rwanda. PHOTO | COURTESY


They have embraced locally tailored health practices—their children are vaccinated, they use latrines, and families sleep under mosquito nets.

CHWs are a crucial link to healthcare at the household level. They facilitate access to health services largely in rural areas where health centres are few and far between.

They have medical knowledge and are trained to treat common illnesses in children under five, support maternal health including family planning, link their community to HIV/Aids and TB care, and most recently tackle mental health, diabetes, hypertension and other non-communicable diseases.

Wholesome model

Prof Miriam Were, a renowned Kenyan researcher with close to four decades studying CHWs, describes this as a “way to help people look after themselves.”

“This is a wholesome model of health. These are people that the community knows and trusts and it is through these relationships that they are able to prevent diseases and promote health,” she said.

According to Prof Were, CHWs embody local solutions to health challenges.

“It is a cost-effective method as they need training for about two weeks and you have a frontline of health workers who can treat dehydration in children, ensure mothers make nutritious meals for their families and in the event that they encounter a complicated case, these can be referred to hospitals,” she says.

According to the World Health Organisation, CHWs are a vital link for countries to achieve Universal Health Coverage.

Research by the global health body shows that for every dollar spent on a CHWs, the return on investment is at least $10.

Prof Were believes there is an urgent need to sustainably integrate CHWs into the national health system. Across the region, the status of community health workers is not uniform.

In Ethiopia, they are institutionalised. They access training and get a salary. In Uganda and Tanzania, according to the Tropical Health and Education Trust, there is a transition from informal volunteers to formally trained, appointed and compensated community health workers.

There are about 180,000 in total across the country. They are trained and deployed by different funders, and subsidise what they earn with side businesses.

Among them is Namaganda Joweria from Nabitovu B Village in Iganga District, about 40 kilometres away from Jinja town in eastern Uganda.

In spite of not being compensated for training expectant mothers on their health and that of their infants, she says she will continue doing the work she has done for a decade now.

“I am a farmer full time but when someone is sick in my village, I am there for them. I chose to be a community health volunteer and I am proud of what I do. Once in a while we get training and I am excited when this happens as I become better at helping my neighbours,” she said.

Performance stipend

In Rwanda, CHWs do not receive a salary but a pay-for-performance stipend. It is pegged on laid-out deliverables such as the number of women who were referred to hospital by a CHW following post-partum bleeding or how many visits they have made in a quarter.

The community-based health programme has since covered close to 90 per cent of Rwandans.

The Minister for Health Dr Diane Gashumba said: “Our programme is based on volunteerism. I agree that you cannot ask someone to work from morning to evening without pay yet they have families. They spend hours in serving their neighbours and other people. We have a performance-based financing.”

Rwanda has close to 50,000 CHWs available 24 hours a day.

“A survey conducted two years ago targeting CHWs asked them what they would do if they failed to meet the threshold for the performance-based incentive. More than 90 per cent said they would still continue to work for their community.

“They said there was nothing more rewarding than the trust the community has in them, and that is meaningful for us in Rwanda,” said Dr Gashumba.

Ms Alemu, Prof Were and Dr Gashumba spoke at the Africa Health Agenda International Conference (AHAIC 2019) that was held in Kigali, Rwanda from March 5-7. The theme was Universal Health Coverage.

In Kenya, CHWs are not paid as the Ministry of Health does not consider them formal health workers.

“It is immoral to have people work and not be paid. I know of a CHW in Kibera [an informal settlement in Nairobi] who has worked for 20 years without compensation. We need to address the recruitment, training, motivation and supervision of CHWs. I however, laud some counties such as Siaya, Homa Bay and Makueni for the work they do with CHWs,” said Prof Were.

Policy approach

Jean Kagubare, the deputy director of Global Primary Health Care at the Bill and Melinda Gates Foundation, said it was commendable that African countries are exploring a policy approach to recognise CHWs as a cadre in human resources, and that it was vital to integrate technology in primary healthcare.

“CHWs are not only a vehicle to the realisation of UHC, but they also offer an opportunity to leverage on innovation and technology to further improve the reach and access to health services,” said Dr Kagubare, adding that the benefits include cutting hospitalisation costs for preventable diseases as well as transport to health facilities both for the patient and the care giver.

In Rwanda, the CHWs have a phone and a SIM card provided by the Ministry of Health where they can submit information that is sent to health facilities in the area, ambulances on standby and to a central system.

The rapid SMS system allows for real time interventions for ambulatory services, for instance, when an emergency arises.

Another technological advance that supports CHWs in the region especially in Kenya and Ethiopia, is a backpack developed by Philips, an international health technology company.

The bag has basic testing equipment to detect infections such as pneumonia. A solar panel is attached to the front and charges as the community health worker is working in the field. It can thus charge mini lanterns in the backpack and a phone.

Alice Tarus, a research scientist at Philips, demonstrated the components of the bag. It includes the Children’s Respiration Monitor (also known as ChARM), which tracks respiratory rates in children under five, and can tell whether a child has pneumonia.

It is strapped around a child’s chest, without requiring direct skin contact. It picks up the child’s breathing rate by interpreting the chest movements.

Pneumonia causes more than 900,000 deaths annually among children under five.

The bag also has a digital thermometer, a flexible plastic colour-scale to measure the circumference of a child’s arm to pick out malnutrition; a finger-pulse oximeter that measures the oxygen in the blood as well as a pulse simultaneously; and a blood pressure monitor.