By: Alex Collins (IntraHealth International) and Janet Muriuki (IntraHealth International)
What happens to women’s access to family planning when you partner nurse leaders with community health workers (CHWs)?
That’s what IntraHealth International’s USAID-funded Human Resources for Health (HRH) Kenya Mechanism sought to find out. One year into the COVID-19 pandemic, UNFPA estimated that the disruption in contraceptive services had lead to 1.4 million unintended pregnancies worldwide. And in Kenya, even before the COVID-19 pandemic, about 1 in 10 women wanted to delay or stop having children but were not using contraception. Differences in
contraceptive use among Kenyan women living in cities compared to rural areas made the need to tailor services even more pressing. Only 40% of urban women reported use of a modern method, such as an oral contraceptive pill, implant, or injectable, compared to the Kenyan national average of 58%. Fewer urban facilities in Kenya offer family planning services (73%) compared to rural (91%). These disparities are likely due to a large proportion of urban residents living in slum conditions, with limited infrastructure and where women have trouble accessing quality health care and other services.
In Kenya, 76% of nurses, 63% of community health assistants (CHAs) and 73% of community health volunteers (CHVs) are female. This type of “woman-to-woman” platform is considered a high-impact practice for increasing access to and use of family planning. As an FP2030 Commitment Maker, the Kenyan government is committed to expanding access to modern family planning methods in both rural and urban facilities.
Long-acting reversible contraception (LARC) such as intrauterine devices (IUDs) and implants reduce how often women must visit a health facility or pharmacy for a refill and they are more effective at preventing pregnancy than oral contraceptive pills, injections, or condoms. Increasing the number of LARC users could relieve some of the pressure on Kenya’s overtaxed health system because these patients would not need recurring appointments or prescriptions. Additionally, women using LARC can maintain control of their reproductive health despite disruptions caused by extenuating circumstances such as the current pandemic
Approach: Urban and Rural Reach
To reach women in both urban and rural areas, trained nurse leaders and Kenya’s growing community health assistant and volunteer cadres partnered together. Since 2016, the HRH Kenya Mechanism has worked with the government of Kenya to build stronger human resource systems, data-use methods, and training programs. It has helped institutionalize in-service training in counties to align with national universal health coverage requirements and service delivery guidelines for reproductive health and family planning, among other priority health services. The HRH Kenya Mechanism also facilitated in-service training on LARCs to over 850 health workers from 17 counties, expanding access to these birth control methods through facilities in some of Kenya’s most populous counties, like Nakuru’s Rhonda Dispensary and Maternity health facility. To ensure sustainability, the mechanism helped 13 counties develop and implement health workforce training policies and guidelines.
Health workers participating in the LARC in-service training, like Alice Boit, the nurse-in-charge of the Rhonda Dispensary and Maternity health facility, brought what they learned back to their posts and spearheaded a continuous training and mentorship program. In Alice’s facility, where she supervises 40 staff members, she taught other nurses what she had learned during her training, including insertion and removal of IUDs. In turn, she and her team worked with CHAs and CHVs linked to the facility to do household outreach visits, provide relevant information about LARC methods, dispel myths and misconceptions, and assist with referrals and links to services. Together, these trained nurses and CHVs are reaching a population of more than 27,000 people in Nakuru county, making the facility a favored destination for women seeking family planning while increasing the number of clients choosing LARCs.
Results and lessons learned: A partnership that works
The power of this partnership between nurses and CHWs is real. A two-year post-training follow-up of 274 health workers (32% of the total 850 trained) showed that the quality and quantity of LARC and other family planning services improved in the counties where trainings had occurred. From 2017 to 2019, insertions of IUDs (1,188 to 1,914) and implants (6,234 to 7,077) increased, the number of IUD removals (402 to 292) decreased, and implant removals by a local skilled provider (1,116 to 3,019) increased. Furthermore, 84% of supervisors observed positive changes in the quality of services delivered by health workers trained in LARC.
Figure 1: Findings from post-training follow up (1)
(1) Intrauterine contraceptive device (IUCD) is the same as intrauterine device (IUD)
Training nurses alone isn’t enough. Integrating trained, equipped, and supported CHWs into the health system, as done in this model, is a high-impact practice which increases access to and use of family planning, especially among women constrained by social or geographic barriers. With this partnership model in place, the number of people reached with an expanded set of contraceptive options through nurses and CHVs should only continue to grow. Nationwide, there are already over 89,000 CHVs and 3,250 CHAs in action. By 2030, these cadres are expected to expand to 100,000 and 10,000 respectively to help the government of Kenya reach its goal of 1 CHA and 10 CHVs per 5,000 Kenyans, per the country’s Community Health Policy 2020-2030 and Community Health Strategy 2020-2025. In a crucial step toward this goal, the Ministry of Health in Kenya launched Community Health Volunteers Training and Certification Guidelines in February 2022, which include a module dedicated to family planning that prepares CHVs to counsel women on all family planning methods and make appropriate referrals. In some counties, CHWs like Margaret Odera are being recognized for their important role in the health system. Margaret notes: “I have seen changes taking place, in our community and even in the facility. A CHW right now has been recognized by the government. And this is a [county-level] law that was passed in October that a CHW has to be recognized and get a monthly stipend. And this is a plus for me and for CHWs.”
Recommendations for adaptation or scale up: To improve family planning services, #CountCHWs
CHWs are key to reducing inequities in family planning access and increasing contraceptive use among women with an unmet need or barriers to use. Yet in most countries, including in Kenya, governments do not have robust data on CHW numbers, location, skills, or performance. This reality limits CHW integration into the health system where they are needed most to meet family planning and other health care goals. How can governments (and other partners) get the data on CHW they need to efficiently train, equip, and support these workers if date collection tools are inadequate?
CHW master lists and registries are integral to maximizing the engagement of CHWs in delivering family planning
and other essential health services. Acting as a single source of data on CHWs, such lists and registries can confirm whether workers meet minimum job criteria, that fair pay and supervision are in place, and that CHWs are recruited and deployed to facilities and communities most in need. Open-source information systems such as iHRIS can support the creation of CHW master lists and registries, as iHRIS meets all of the criteria outlined in the recently released Implementation Support Guide from CHAI, CHIC, Health GeoLab, Living Goods, the Global Fund, and UNICEF. iHRIS has been used successfully to support creation of health workforce master lists and registries, including for CHWs, with data collection and use shared among government and partners. As a digital global good, its use can enable future integration with other HRIS and health information systems for a broader view of the human resources for health and for tracking progress toward service delivery goals.
The HRH Kenya Mechanism partnered with the Kenya Ministry of Health to #CountCHWs by developing a community health workforce module in its iHRIS version 4.2. It subsequently trained national and county government focal persons to use the system and map 33,935 CHVs and 779 CHAs in 15 counties. Data collected were used to establish a CHW registry that could provide information on the:
- Deployment and distribution of CHVs and CHAs per the MOH recommendation
- Composition of CHVs and their skill mix at the community level for family planning and other essential health service provision
- Number of available CHVs and CHAs for planning and budgeting trainings, stipends and salaries, and other support CHWs need to perform well.
The data showed 95% of CHWs were employed by the government and 5% by non-profits, NGOs, and other partners. Nearly two-thirds of CHVs had at least a primary-level education. Data also revealed that community health services were poorly supervised, with one CHA supervising 10-27 CHVs. Of the six counties that did not meet the recommended 1 to 10 ratio of CHA to CHV, three—Nairobi, Bungoma, and Meru—are among the most populous counties in Kenya according to the 2019 census. This finding underscored the need for more CHAs for more effective supervision of family planning and other health services. The mapping also highlighted that a minority of CHVs are under 30 years old (9%), which may limit efforts to reach adolescents and young adults with family planning services.
There are three key steps to expand high-impact practices for family planning like this partnership model in Kenya:
- Train health workers, including CHWs, in LARC and other methods
- Use master lists and registries to #CountCHWs for better planning and management
- Advocate for CHWs to be recognized for their important role in service provision, with fair pay, equipment and supplies, and supervision to do their jobs well
Together, taking these steps will help us to make even greater progress in LARC and other family planning use in Kenya, with facility- and community-based health workers at the forefront of those efforts.