Community health workers in Kajiado County: an evaluation of the community health strategy in rural Kenya

Between 1980 and 2000, mortality rates of children under the age of five and maternal mortality ratios declined across sub-Saharan Africa. During the same period, Kenya's mortality rates continued to rise until 2005 when the Kenyan Ministry of Health (MOH) introduced the Kenya Essential Package for Health (KEPH) in an effort to reverse its declining health indicators. The KEPH defined six service delivery levels which included the new community level, also known as level one. The Ministry of Health's plan for delivering services at the community level, known as the Community Health Strategy (CHS), called for the creation of Community Health Workers (CHWs) which the MOH hoped would produce the expected outcomes of the CHS. CHWs would be trained volunteers that were both members of the community they would serve, and selected by their community. Their training would allow them to recognize health problems, provide basic first aid, refer patients with serious problems to health facilities, conduct surveys, maintain records, provide education, and distribute supplies. In 2010, the Division of Community Health Services released an evaluation of the relevance, efficiency, and sustainability of the community health strategy. Their results showed that CHWs could produce many of the CHS's expected outcomes. In 2013, researchers from the Boston University School of Public Health and Moi University resolved to conduct a cross-sectional study for the Kenyan Ministry of Public Health and Sanitation to assess the effectiveness of the CHWs in Kajiado County. The county faced numerous health challenges and an overburdened health system. Data collection was completed over a seven-day period in June of 2013 by fourteen teams. Data was collected from 12 communities located in the areas of Rombo, Entonet, and Central Divisions of the Loitokitok sub-county within Kajiado County in rural South Kenya. Six of the selected communities had CHWs mobilized and were the intervention communities. Six communities had no registered CHWs and served as the controls. Eligibility to participate in the study was limited to permanent members of randomly selected households that housed at least one child less than five years of age and no active CHWs. Mothers of children less than five years of age were the preferred respondents. The primary and secondary outcomes were selected to address as many of the CHS's expected outcomes as possible. In an effort to compensate for the study's cross-sectional design, results were analyzed by stratifying them by each community's proximity to a hospital, the time since the CHW's last visit, and the respondent's knowledge of their CHW's name. Data was collected from 316 households, half of which were from intervention communities, and was entered into CSPro 5.0 before being exported to EpiInfo 7.1.1 for analysis. Analysis of the results suggests that the Community Health Strategy has been largely ineffective at producing its expected outcomes in Kajiado County as communities with active community health workers typically did not fare significantly better than non-CHW communities. The CHS was not entirely unsuccessful however, as mothers in CHW communities were significantly more likely to give birth at a health facility (PR: 1.41; CI: 1.15-1.72) than in non-CHW communities. Results also indicated that a community's proximity to a hospital could be a confounder in the relationship between a community's CHW status and health outcomes. The success of CHWs may have been masked by their tendency to visit households with worse health indicators more frequently