Undressed, Maraga is elated to see Pius Bosire, a community health worker. The six-month old baby in Riana village, Kisii County knows this face all too well. Bosire walks for about three hours every day, knocking on seven to 10 doors, including Maraga’s family’s.
To his question of how “the judge” is doing, the baby’s mother Nancy Kerubo says Maraga has been coughing of late. After the pleasantries, the county government health worker takes his mobile phone out of the pocket and starts a timer.
As Kerubo holds the jovial baby, Bosire watches Maraga’s breathing.
After a minute and looking at a chart he pulled from his bag, Bosire explains to the woman that, for his age, Maraga’s coughing is not a cause for worry.
Now that it has been established “the Supreme Court president” is fine, Bosire is concerned about the lack of a hand washing point near the family pit latrine.
He lost a patient to diarrhoea two weeks before this latest visit to Maraga and his mother.
Bosire is also interested in the family’s nutrition. What follows is a battery of questions directed at Kerubo. When did you last give the children fruits? Tell me about your breakfast, lunch and supper.
How do you wash your hands, with water from the can or from a basin? I also need to see your vaccination booklet, the health worker goes on.
After a long counsel on how to wash hands and how to plan meals for her family, Bosire appeals to Kerubo’s dreams.
“If you follow the instructions, Maraga will finally grow to become a judge like his namesake,” Bosire tells the woman, referring to Chief Justice David Maraga.
Bosire once detected pneumonia in babies in the 180 households the county health department has assigned him.
Like a doctor, he wrote “referrals” to Iyabe Hospital and called medics there to inform them that patients were as on their way.
The inability to diagnose, among many other reasons given by the World Health Organisation, gives pneumonia an unchallenged spot as the number one killer disease in Kenya and many other developing countries.
In 2017, the Ministry of Health said pneumonia killed 21,584 people, accounting for more than 11 per cent of the total deaths recorded in Kenya. In Kisii County, the pneumonia deaths are due to late arrivals at hospitals.
Because of ignorance, poverty and other reasons, families seek alternative cures.
By the time the baby gets to hospital, doctors begin by detoxifying him from traditional herbs. Many children do not make it.
Kisii County director of health Geoffrey Otomu told DN2 that malaria, respiratory tract infections and diarrhoea are the other major causes of deaths.
With an acute shortage of doctors and nurses and poor medical seeking behaviour, community health workers have become an integral part of the health systems in Kenya in particular and the developing world in general.
According to the Kenya Health Workforce Report, the county has 13 physicians, nurses and midwives per every 10,000 people, a third of what is recommended. WHO says the ideal number is 44.5 medics.
This is hardly enough for curative medicine, let alone health education which informs the decision to go to hospital.
Kisii is one of the counties with a favourable human resource landscape but it is still critically burdened. For every 10,000 people in this county, there is one doctor, four nurses and eight clinical officers.
The county has embraced “task-shifting”, a model of sharing scarce human resources where medical duties that were once handled by trained technical staff have been delegated to the community health workers.
With additional training and technology, the local health workers can diagnose and occasionally prescribe medication or link patients to hospitals.
Despite concerns from certain quarters that community health workers represent lower treatment for the poor, studies show that community health results in better outcomes for mothers and children due to their cultural appropriateness in Africa.
So favourable were the results that WHO released guidelines on community health work.
Just like medicine where there is need for continuous professional development and training, the health workers are constantly shown how to take the temperature of babies, observe their breathing and identify signs of under-nutrition.
With limited medical knowledge to draw upon when judging diseases, Bosire is dependent on an application installed on his smartphone by Living Goods, a Non-Governmental Organisation.
Through this app, he registers details of the houses he is assigned such as the children’s names, those under five and their health status.
That is how he knew Maraga was well. The app prompts him to check for fever. It asks questions like ‘is the child coughing?’
When he answers in the affirmative, he is asked about the duration of the cough.
A “Yes” answer of more than four days, accompanied by an indrawn chest and the health worker’s phone prompts him to refer the baby to a hospital, a possibility of pneumonia.
According to Kisii Health executive Sarah Omache, there are 1,750 community health workers in the county. And the women trust them.
They usually have honest conversations that, they say, they would not have with the healthcare workers in hospitals. They even confess to them how a church in Getare discourages their members from seeking conventional medicine.
When 45-year-old Martha Ratemo was expectant, she began drinking heavily. Most of her time, even the one she would have spent eating, was on intoxication.
“I think the baby wanted the beer…I wanted to drink all the time and I had no appetite”, she said softly, perhaps with a tinge of regret.
The baby was severely malnourished by the time it was born.
The volunteer in charge of Egesuguri village got wind of Ms Ratemo’s predicament when talking to women as they fetched water or firewood. She visited Ms Ratemo the following morning.
The baby needed routine check-ups and medical attention as she was underweight.
At the hospital, food supplements were prescribed, which the NGO provided and Margaret Nyangarisa, the health worker, routinely visited Ms Ratemo to see if the baby had been fed. She would dutifully check the immunisation cards to confirm they were marked.
At two years, the child weighs slightly under eight kilogrammes, not promising for her age but the volunteer is optimistic.
“She was extremely thin, and weak and I am happy she can run around and play with other children,” Nyangarisa said.
The journey until a child is five — pregnancy, delivery and after — is perilous for women and children.
According to the 2014 Kenya Demographic Health Survey, there are 362 maternal deaths per 100,000 live births in the country.
Nairobi-based gynaecologist John Ong’ech says more than a third of the deaths are as a result of haemorrhage and other complications that can be arrested if the mother visits the hospital a minimum of four times as recommended by WHO.
The complications include congenital defects and pregnancy induced blood pressure. At the moment, only slightly more than half of the women in the country (57 per cent) have taken the four visits or more.
It is not a walk in the path for the volunteers as well.
“Sometimes I am called at night, when it is raining and dark. I might not even have a torch or a jacket,” Nyangarisa said. “And I will call the ambulance for them and just stay there with the woman to make sure she is not alone.”
Health still underfunded
Like many of his colleagues, Kisii Governor James Ongwae’s decisions are political as they are socio-economic. His county has 70 doctors. The health department says 206 would be sufficient.
One hundred and seventy two consultants would meet the county needs than the 27 employed by the devolved government.
The shortage is chronic and is felt across all cadres of health.
"I need more nurses but where will I get the money to pay them?", he asked during an interview with DN2.
According to an analysis of the 2016/17 health budgets, counties allocate funds in absolute terms. County health budgets, the report noted, are low and way below the recommended proportion of 35 per cent in the pre-devolution period.
Even the little that is there is still dominated by recurrent expenditure. Salaries, allowances and other emoluments take a huge chunk of the budgets.
This raises concern about efficiency in services.
Head of Community Health Development Unit at the ministry, Salim Hussein, told this publication that out of ignorance of the importance of preventive medicine, policy makers perceive health in terms of buildings, ambulances and curative drugs.
"Yet spending more on preventive medicine would reduce the money used in treating Kenyans,” he told DN2.
Dr Hussein said the government pays community health workers but even these are still very few.
Governor Ongwae has spent money on infrastructure. In 2013, there were 157 hospitals in Kisii County. Now there are 210.
This has reduced the distance locals cover to the hospital from four kilometres to 2.6, way better than the recommended five kilometres. Health accounts for 24 per cent of the county’s budget.
The governor says he would like to pay community health volunteers “but there is no money”.
The challenge of running effective preventive medicine is prevalent in all counties.
In Kisumu, community health volunteers have been instrumental in preventing defaulting on TB and HIV/Aids drugs.
Health executive Rosemary Obara told DN2 she does not know what usually happens between the health office drawing the budget and the finance department in allocation.
"We include them in the budget always and we appreciate what they do…but something happens", she said.
As at December 2017, Kisumu had about 2,200 volunteers looking after 186 community units. Every volunteer sometimes gets Sh3,000 from organisations like Living Goods and Amref.
In Busia, Health executive Melsa Lutomia said motivation, even in kind, would go a long way in improving the results that county governments get from health workers.
Turkana County’s Jane Ajele said the devolved unit has moved a bill to be giving volunteers a stipend.