Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Sunday, December 9, 2007

Creating Sustainable Health Systems: Why Health Services Cannot be Dependent on Community Health Workers – Waceke Wambaa

Globally, Sub-Saharan Africa (SSA) faces the greatest challenges regarding healthcare delivery. With 11 percent of the world’s population and 24 percent of the global burden of disease, SSA is served by only 3 percent of the world’s health workers (1). There are not enough trained healthcare providers in place to run the basic health services, let alone disease specific programs like HIV/AIDS, which has greatly impacted families, villages and entire districts (2). Within the region, more than 75 percent of doctors and over 60 percent of nurses live and practice in urban areas, leaving the other half of the population, located in rural communities, without licensed and trained healthcare personnel to serve them (3).

In Kenya, the health worker crisis in the country has resulted from the combined effects on high attrition rates from the impact of HIV/AIDS, poor working conditions and low salaries. Kenyan healthcare falls into this category, where Community Health Workers (CHWs) are increasingly been burdened with the task of serving these healthcare needs, leading to the estimated 1200 skilled workers leaving Kenya’s health workforce every year (2). As such, health services in Kenya are unable to provide quality healthcare because they are dependent on CHWs.

Just who is a Community Health Worker?
The official international origin and role of the title CHWs goes back to the World Health Organization’s (WHO) Alma-Alta Declaration of 1978, even though traditional healers and community health activities existed well before this time (4). CHWs, as defined by the WHO, are individuals who are trained to carry out various functions in the healthcare arena. They have limited training and do not have the educational background of a nurse, paramedic, or doctor. As such, CHWs are individuals who are invested in the communities where they work and “..should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers” (5).

CHWs include traditional doctors, community midwives, traditional birth attendants, and health education workers to name but a few (6). Over the years, CHW’s roles have expanded to include not only their role as health care providers, but also community advocates who are involved in greater technical aspects of community healthcare and delivery (5).

What is the link to CHWs and the Kenyan healthcare system?
The “Brain Drain” phenomenon

From 1960-1975, the UN Economic Commission for Africa and the International Organization for Migration estimated 27,000 Africans migrated to developed countries. During 1975 – 1984, the figure rose to 40,000 and estimates now report at least 20,000 Africans migrate annually (7, 8). Between 25 – 50 percent of Kenyan nationals with a university education are projected to live in a foreign country (9). Other estimates in 2000 placed as much as 51 percent of Kenyan born physicians and 8 percent of nurses out of the country (10). The WHO currently recommends that the minimum number of physicians to every 100,000 individuals at 20. Yet between 1990 and 2004, Kenya only had 13 physicians or less for every 100,000 people (11 - 13). These statistics reflect the fact that “brain drain” is a problem in Kenya. Thus, health services in Kenya are unable to provide quality healthcare because they are dependent on CHWs for the provision of healthcare in the country, to supplement the impact of brain drain on the healthcare sector. This absence of trained healthcare personnel including doctors and nurses has caused an increased burden on CHWs. AIDS has also ravaged and decimated Kenyan healthcare providers, contributing to the health worker crisis present in the country today (14, 15).

The demands for healthcare services adding fuel to the fire
Health services in Kenya are increasingly unable to provide quality healthcare because they are dependent on CHWs as the primary method of healthcare delivery. With the social expectations theory, there are governing patters set in place within a society where certain norms, roles, rankings and sanctions are in place for the society to function (16). With very few trained healthcare providers, CHWs have been forced to fill this role, despite the fact that they lack the formal and complete education to function in this capacity and thus, are ill prepared to deliver quality healthcare to all Kenyans. Consequently, the Kenyan health care system is in a vicious cycle where CHWs are forced to fill the urgent need for health care workers and inadvertently become the normative standard of healthcare delivery, perpetuating the problem of lack of skilled healthcare personnel within the system. Though societal structure demands the availability of healthcare providers in the event of illness in a community, many rural communities in Kenya have had to deal with unprecedented death and disease especially from HIV/AIDS. CHW have been forced to take the role of primary healthcare providers especially in regions of the country where there are no other options for health providers (15). CHWs thus become socially accepted by communities as healthcare providers as they are better than nothing, adding credence to the supposition that health services in Kenya are unable to provide quality healthcare because they are dependent on CHWs.

HIV/AIDS has had a negative impact on CHWs and the provision of quality healthcare in the country. The numbers do not lie. In 2005, nearly 40 percent of health workers in the country had an immediate family member who was HIV-positive or who had died of AIDS (14). Nyanza province, one of the 7 Administrative regions in Kenya, had the highest proportion reported with greater than 60 percent of health workers reporting a death in the family as a result of HIV/AIDS and 50 percent reported that they were caring for an immediate infected relative (14). In addition to this psychosocial burden of HIV/AIDS on health workers, up to 60 percent of all medical hospital beds in Kenya are thought to be occupied by HIV-infected patients (14). Adding to this crisis are the high attrition rates reported within the healthcare system as a result of increased morbidity and mortality rate of health care workers with HIV/AIDS, social stigma from the disease causing an increased reluctance to care for people living with HIV/AIDS and absenteeism from work in order to care for sick family members and or attend funeral services (17). This has reduced the number of skilled healthcare professionals and the quality of services provided, resulting in increased health related expenditure due to replacement and training of new employees (14, 15). Consequently, the burden of health care delivery has fallen on CHWs to provide medical care to many AIDS patients as there is limited provision of higher trained medical personnel to provide this care across the country, creating a health service system in Kenya that is unable to provide quality healthcare because of the increased dependence on CHWs.

Show me the money!
Economically, Kenya continues to be hampered by corruption and political wrangling, limiting the extent of development within the healthcare industry. The country’s external debt has continued to rise, and in 2006 accounted for 48.5 percent of GDP (18). As a result of debt repayment commitments, many key healthcare and social service industries have suffered through lack of public budget allocation (19). This in turn has had a direct negative impact on targeted goals as stipulated in the first National Health Sector strategic Plan (1999-2004) (20). As a result, decreased standards of healthcare provision and delivery have become the norm. In addition, development of the country’s health infrastructure has lagged behind Kenya’s population growth rate, which stood at 3.3 to 3.9 percent during 1977 - 1990 (21). Concomitantly, many health facilities have lacked the necessary healthcare resources whether in terms of trained healthcare personnel, medical equipment or medical supplies to deliver quality health care to the ever expanding Kenyan population (19). This has forced the ever increasing use of CHWs to fill in gaps in service delivery within the context of an overwhelmed healthcare industry. This does not alleviate the burden of Kenya’s high unemployment rate of 40 percent (2001) or the estimated 50 percent of the country’s population living below the poverty line (18). Being a CHW does not mean an end to poverty. Contrary to this, often CHWs work as volunteers with little or no financial or material compensation. As such, they often find themselves as part of the lowest socioeconomic grouping within the society, unlike skilled medical workers like doctors and nurses, who are able to obtain wages above the poverty line. Thus, though CHWs lack formal medical training and adequate financial remuneration, they may still find themselves functioning in the role of nurses and other medical personnel because of a healthcare system dependent on CHWs for healthcare delivery (5).

This increased use of CHWs in the provision of basic health services has arisen as a result of the acute health worker shortages in the country (22). These shortages have been exacerbated by both “push” and “pull” factors including inadequate health systems with unsatisfactory working conditions, poor career opportunities and low salaries, encouraging the mass exodus of trained health professionals out of Kenya. As these skilled health professionals migrate to developed countries, considerable strain is placed on Kenya’s health system, which is already suffering the effects of years of neglect, economic stagnation and poorly managed health care reforms (1). As a result, CHWs are used within the healthcare system to provide services that they have not been adequately trained for. Thus, health services in Kenya are unable to provide quality healthcare because they are dependent on CHWs for healthcare delivery. Of importance is the fact that in 2006, the WHO identified a threshold in doctor, nurse and midwife workforce density below which high coverage of essential medical interventions, including those necessary to meet the health-related Millennium Development Goals is very unlikely. Kenya, with its critical skilled health worker shortage, is one of 57 countries that falls below the WHO stated threshold (1).

Media is just compounding the problem?
Healthcare services in Kenya cannot provide quality healthcare when media portrayals are skewed, showing CHWs as sources of social expectations of what healthcare should be. Where are the portrayals of doctors, and nurses, inspiring young minds for future generations? Media outlets in Kenya take the form of TV, radio and billboard advertisements to name but a few. The media portrays a system so dependent on CHWs that who can believe otherwise? HIV/AIDS campaigns, advertising posters, and so forth, are all heavily marketed with the use of CHWs. Public health has failed to broaden the scope of healthcare roles to the community. A young Kenyan watching television will see CHWs as the face of healthcare. Where are the doctors and nurses on TV? Media has not shed an attractive light on possible roles that a young Kenyan can aspire towards as a career choice. There are few if any role models on TV that positively and continuously show pictures of physical therapists, cardiologists or otherwise. Instead, you see CHWs at the local Volunteer Counseling center. Or CHWs riding a bicycle or walking in front of a village pharmacy. This is not a role that has been glamorized by media to give it a “sexy” slant that youth clamor for it. Where is the picture of an attractive young person, dressed in high fashion, driving a high power car from an impressive mansion going for dinner at an expensive restaurant, with an attractive companion…with captions alluding to the fruits of success of this individual being a successful medical practitioner? This would be highly successful psychological warfare in the promotion of more and more young people seeking careers as healthcare workers. However, because of a failed media portrayal of what quality healthcare can look like in Kenya, the roles of healthcare providers are primarily limited to CHWs and as such, health services in Kenya are unable to provide quality healthcare because they continue to be dependent on CHWs. Thus, media has helped define social expectations reduce the role of healthcare to the CHWs.

CHWs are important but they should not be relied on to be the primary mode of healthcare delivery in the country. Health services in Kenya should be able to provide quality healthcare but cannot as they are dependent on Community Health Workers. This has to change for the growth, development and future posterity of the nation.

1. WHO World Health Report: Working Together For Health. 2006. Accessed on Dec 6, 2007.
2. USAID. The Capacity Project. Accessed on Dec 2, 2007.
3. World Health Organization. Taking Stock: Health Worker Shortages and the response to AIDS. 2006. on Dec 1, 2007.
4. World Health Organization. Declaration of Alma-Ata. September 1978. Accessed on Dec 1, 2007.
5. World Health Organization. Community Health Workers. What do we know about them? January 2007. Accessed on Dec 2, 2007.
6. World Health Organization. Human Resources for Health. Accessed on Dec 2, 2007.
7. El-Khawas MA. Brain drain: putting Africa between a rock and a hard place. Mediterranean Quarterly: Fall 2004.
8. Mutume G. Reversing African’s “Brain Drain”. Africa Recovery. July 2003 (17):2. Accessed on Dec 3, 2007.
9. Center for Global development. Kapur D. McHale J. The Global migration of talent: what does it mean for developing countries?
10. Center for Global development. Clemens MA. Medical leave: A new database of health professional emigration from Africa. August 2006. Working Paper 95.
11. Physicians for Human Rights. An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa. 2004.
12. United Nations Development Program. 2002. Accessed on Dec 6, 2007.
13. Brain Drain in Africa. Facts and Figures. Accessed on Dec 6, 2007.
14. 2005 Kenya Health Workers Survey: Preparedness for HIV/AIDS Service Delivery. National AIDS and STD Control Programme. 2006 Available from: Accessed on Dec 6, 2007.
15. Tawfik L, Kinoti SN. The Impact of HIV/AIDS on Health Systems and the Health Workforce in Sub-Saharan Africa. USAID. 2003.
16. DeFleur MR, Ball-Rokeach SJ. Theories of Mass Communication. White Plains, NY. 1989.
17. Hirschhorn LR, Oguda L, Fullem A, Dreesch N, Wilson P. Estimating Health Workforce Needs for Antiretroviral Therapy in Resource-Limited Settings. Human Resources for Health. January, 2006.
18. CIA –The World Factbook. 2007. Accessed on Dec 4, 2007.
19. World Institute for Development Economics Research, July 2002. Debt Relief and Health Care in Kenya. Accessed on Dec 4, 2007.
20. Glenngård, A H, Maina, T M. Reversing the trend of weak policy implementation in the Kenyan health sector? – a study of budget allocation and spending of health resources versus set priorities. Health Res Policy Syst. 2007; 5:3.
21. Wortham, Robert A. Population Growth and the Demographic Transition in Kenya. International Sociology. 1993; 8: No. 2, 197-214.
22. Mundi Index: Kenya Unemployment Rate. Accessed on Dec 6, 2007.

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  • At December 12, 2007 at 8:31 PM , Anonymous SL said...


    Very interesting paper you have. Health system sustainability is a very complicated topic, as countless factors contribute to the oiling of the engine. I think you hit a lot of the key points regarding the over-representation of disease and the under-representation of people to facilitate heatlhcare deliver. GDP statistics also very alarming--politics is perhaps another side of the story that is probably equally complicated (albeit more scary).

    -Steven Lin

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