In Kenya, community health volunteers fight for pay and status

Millicent Miruka is doing her rounds.

In a small house in this village in western Kenya, she sits across from a young couple and their sleeping 3-month-old, Joy. As the corrugated iron roof above creaks in the late morning sun, Ms. Miruka launches into her questions.

Does Joy have a birth certificate? she asks in the family’s native Luo language. The parents nod. Are there books and toys in the house for her development? A few, yes. Does the baby sleep under a mosquito net? Again a nod.

With her authority and knowledge, Ms. Miruka could be mistaken for the baby’s pediatrician. But she is actually a local volunteer called a community health worker, or CHW, who is in charge of providing basic health care to dozens of families here. Across Kenya, there are approximately 100,000 CHWs, whose services range from doing routine medical checks to teaching about family planning and nutrition.

In Kenya and beyond, CHWs are hailed as a cost-effective way to plug gaps in overstrained and underfunded health systems. Globally, there are more than 3.8 million spread across nearly 100 countries, including the United States. Most are women.

But if the work is indispensable, the workers have often been treated as far more disposable. “Why are they so effective? Because they’re doing the jobs of nurses and clinical officers” – for little or no pay, explains Kathy Dodworth, a public health expert at the University of Edinburgh. Now, some countries, including Kenya, are making moves to standardize pay and training. But CHWs say there is still a long way to go.

CHWs should be treated as professionals “like other health care workers,” says Ms. Miruka, who is also an advocate for better working conditions and more opportunities for career advancement for CHWs in Kenya.

A transformation in care

Many areas of Kenya are health deserts. The country only has around 13.8 doctors, nurses, and midwives per 10,000 inhabitants, well below the World Health Organization minimum recommendation of about 45. Particularly in rural areas, the nearest clinic is often an unaffordable motorbike taxi ride away.

Ms. Miruka knows all too well what that means. When she was a young woman, her small daughter fell seriously ill. Community members said she was bewitched, and on their advice, Ms. Miruka treated her with local herbs. Only after her daughter died did she learn the real cause of her sickness: malnutrition.

Gioia Shah

Millicent Miruka trains fellow community health workers in the western Kenyan county of Migori, July 18, 2024.

The experience was transformative, she says, and 12 years ago, she began volunteering as a CHW for a local health charity called Lwala, where she later became a supervisor of other CHWs. By then, community health was a major interest for international donors, who saw it as a low-cost and effective way to fight major disease epidemics.

Today, the Global Fund, the world’s largest financier of HIV/AIDS, tuberculosis, and malaria care, spends hundreds of millions of dollars annually on CHWs. In Kenya, the organization, which is supported largely by the Gates Foundation, has budgeted $200 million toward community health programs between 2017 and 2027.

CHWs can be particularly effective because they have the trust of their neighbors and can speak to them in their own language. By spreading knowledge on health topics, they often help in preventing people from getting sick in the first place, lessening the burden on clinics and hospitals.

A study by Lwala, for instance, found that patients of CHWs were 15% more likely than others in the same communities to be immunized, and 14% more likely to have done four or more prenatal care visits. Another study found that in one area of central Kenya, more than twice as many women who had met CHWs delivered their babies in a clinic or hospital.

A dead end

Yet their success created challenges. Because CHWs in Kenya were deployed by a wide range of groups, often in response to particular health needs, their distribution, training, and pay were often poorly coordinated. They were also tied to the ebbs and flows of donor funding.

And even as more and more tasks were transferred to their shoulders, pay remained meager. Until 2023, many CHWs in Kenya earned between 2,000 to 5,000 Kenyan shillings a month, equivalent to $15 to $35. And in sub-Saharan Africa as a whole, less than 15% of CHWs receive any money for their work at all.

“Investments in CHWs ... are increasing at a rate faster than others in the health care system because this was found to be a cheap way to do something,” explains Catherine Kyobutungi, executive director of the African Population and Health Research Center.

Then in 2023, the Kenyan government announced it was officially taking charge of the country’s CHWs. It registered almost the entire workforce, around 103,000 people, equipping them with medical kits and smartphones to do digital data collection. Pay was standardized at 5,000 Kenyan shillings, or about $35, a month. Meanwhile, every CHW is in the process of receiving the same 10-day basic training.

CHWs like Ms. Miruka also see this as a positive sign that their work is being taken more seriously – though still not seriously enough. As she walks through her village, crossing maize fields and passing under rows of eucalyptus trees, she reflects on her career.

“Becoming a nurse, that was my dream,” Ms. Miruka recalls of her younger self. Now she’s more realistic. After all, a CHW in Kenya still has no possibility of career advancement, and no path to a salaried job.

For now, she knows, this is the end of the road.

Reporting for this story was supported by the Solutions Journalism Accelerator fund of the European Journalism Centre. That program is supported by the Gates Foundation.