Rosie Steege, Jane Wairutu and Linet Okoth report back on the passing of the Nairobi City County Community Health Services Act in June 2021 – welcome news for Nairobi’s Community Health Volunteers (CHVs) who have waited almost two years since the Bill’s inception.
The Bill sees Nairobi’s CHVs entitled to receive a monthly stipend of KSh 3,000 (approx. $30 USD) plus a further 500 ($5USD) contribution to the National Health Insurance Fund.
This payment is in exchange for eight days work in a month and is contingent on CHVs successfully achieving an 80% performance target. CHV performance is assessed by Community Health Assistants using a checklist. The checklist includes ten indicators, among them are the number of household visits, total number of referrals (e.g. referring children for immunisation or pregnant women for antenatal care), participation in community mobilisation and general reporting. The CHVs should perform in at least eight out of ten indicators to receive their payment.
Implications of the Bill
The passing of the Bill is an important milestone. CHVs form a key part of the health workforce, linking communities with the health system. Nairobi’s CHVs live and work in complex urban environments, many face particular challenges. Informal settlements lack basic public services – such as clean water and sanitation, waste management and health facilities – as well as proper governance and often face high levels of unemployment, crime and insecure tenure. Further, profiling of 386 CHVs in Mukuru S.P.A. in 2019 by SDI Kenya and Muungano wa Wanavijiji under ARISE found that CHVs are likely to serve over 1,000 households, far above the recommended 11-150 households for CHVs in urban areas.
Slums are also disproportionately impacted by COVID-19. The CHVs’ vital role in the ongoing COVID-19 pandemic demonstrates their agility to respond to shocks and their shifting and evolving demands. Their work recently gained them recognition from the Cabinet Secretary for Health, county governors, and the President.
CHV work is purely voluntary as stipulated in the community health services motto “our health our responsibility” this has however contributed to dissatisfaction and attrition among Nairobi CHVs. Passing of the Bill should see improved motivation among the cadre. Payment also provides a welcome opportunity to work towards Sustainable Development Goal (SDG) 8 – decent work and economic growth.
Payment of CHVs may also reap rewards for gender equity and SDG 5. SDI Kenya’s profiling under ARISE, found that 82% of Mukuru’s CHVs were women; the predomination of women in roles with the least pay and the least power is echoed globally. Fair remuneration for women’s work is critical as women may internalise and reproduce harmful gender norms that spill over into their interaction with their clients, damaging the broader development agenda. Therefore, Nairobi’s decision to increase payment for CHVs to 3,500Ksh may pay dividends. Evidence has shown that women’s participation in the paid health workforce results in improved health – both in the generation of wealth and also through the contribution of earnings to health promoting investments. Women have been shown to invest 90% of their earnings towards their families’ well-being compared to up to 40% invested by men.
ARISE partners LVCT Health with other community health actors at national level, provided input into the Bill and the memorandum to the proposed Bill. The memorandum advocated for expunging some components of the National Bill that were not in favour of, or excluded, the CHVs. These expungements were adopted by the health committee and included in the Bill through the National Community Health System Technical Working Group. LVCT Health were key to ensuring that the Bill spoke to the needs of CHVs working in informal settlements.
Although a great step forward, this isn’t the end of the road for fair remuneration for CHVs. For one, we need to be cognizant of the fact that the payment accounts for CHVs might not be commensurate with the effort CHVs make in offering services.
CHVs in informal settlements are assisting some of the most underserved populations, given support and remuneration to allocate fair time to their roles without relying on additional income generating activities will further contribute to health and development gains for the vulnerable in society. Muungano’s profiling also revealed that women were also more likely to volunteer more hours than men, meaning that the paid time allocation may disadvantage women if they work additional hours without payment.
Secondly, formal evaluation of payment structures and their impact on community health delivery and the CHVs experiences is needed to understand if they payments are truly fair, or whether any perverse incentives or unintended consequences from the new policy surface. For example, close attention to the 80% performance target should be paid to ensure this does not distort health care provision or disadvantage men and women differently whose gendered roles in the community influence their ability to reach the targets. Additionally, work is required to ensure that CHVs who are eligible are receiving their stipends in a timely manner. Prior to this Bill CHVs were meant to be receiving a stipend of 1,300Ksh through implementing partners however, ARISE profiling demonstrated that often CHVs were receiving only half this amount putting enormous pressure on CHVs who were unable to rely on the income.
While Nairobi is not the only county to implement payment for CHVs in Kenya, this is not yet a national policy – advocacy for all CHVs to be remunerated regardless of where they reside and work is a must. This can be supported by reflexivity and transparency – sharing both the success and failures of implementing the policy for other counties, or indeed countries who may wish to follow their example.