In South Kamagambo, it’s not uncommon for families to travel 10 kilometers on foot to the nearest health facility. Of Lwala’s four implementation sites, communities here are the most remote. When Lwala began to work in South Kamagambo in 2019, health indicators reflected this challenge–many women gave birth at home, nearly one-third of children were not receiving immunizations, and health facilities were underutilized.
But just three years later, the data tells a different story–a story of community health workers (CHWs) reaching every household, community health committees tackling problems affecting their neighbors, and health facilities improving the quality of services. It’s a story about the community-led health model driving change.
Last month, ten Lwala-supported CHWs in South Kamagambo gathered to discuss these changes. Attached to Ongo health facility, many have served as CHWs for more than a decade and have seen a major shift in their role over time. In the 2010s, their mandated focus was issue-specific. A CHW named Daniel recounts, “At first, CHWs only had two roles–to encourage people to get tested for HIV and to educate on water, hygiene, and sanitation. We didn’t have kits or commodities, so we didn’t treat, we only referred.”
Then another organization brought different priorities–this time focused on child health. It wasn’t until Lwala entered that CHWs began to focus on health for all.
“The first thing was training, training, training. Now we are called village doctors. We have the knowledge and skills to treat people at home, but we also know when to refer them to the health facility.”
- Community health worker in South Kamagambo
Critically, Lwala ensures that increased responsibility is met with compensation, bucking a global trend–only 14% of CHWs in Africa are paid. Beyond motivation, CHWs in South Kamagambo say payment allows them to spend more time visiting households, and less time holding other jobs to make ends meet. This translates to tangible benefits–in January 2020, just 33% of households in South Kamagambo were being visited by a CHW every month. As of March 2022, household visits have increased to 79%.
And because Lwala incorporates traditional birth attendants into CHW cadres, many of them are now the most active champions of skilled delivery. “One traditional birth attendant was once delivering more babies than the facility,” a CHW named Teresa says. “But now she advises women, walks with them to the facility, and encourages them during delivery.”
Community health committees–who are responsible for overseeing and improving community health–are also an engine of change in South Kamagambo’s transformation. The Kanyawanga community health committee, which serves the same community as the CHWs above, knew that distance and lack of transportation barred many women from delivering at Ongo health facility 10 kilometers away.
They came up with a plan to hire a motorbike to provide emergency transportation for women in labor. They gained the support of the local Chief, who called a baraza meeting to secure community buy-in. Each household agreed to pay KSH20 (less than US20 cents) per month to fund the effort, and Lwala is providing a matching grant.
Since last August, CHWs and the community health committee have worked together on implementing the emergency referral system. During household visits, CHWs encourage pregnant women to develop an individual birth plan, which includes saving money for emergency transport. But it’s not affordable for everyone. Because of their community knowledge, CHWs are best placed to identify women in need and connect them with emergency transportation when the time comes. In many cases, CHWs physically accompany women to Ongo for delivery.
This effort is new, but it’s already creating change. When the Kanyawanga community health committee was asked who knows someone who has benefited, five people raised their hands–emergency transport meant a safer delivery for a sister, a daughter-in-law, a neighbor, and others.
But the work doesn’t stop there–a community referral is only as strong as the services on the other side. In 2019, Ongo health facility had low rates of immunization, antenatal care, skilled delivery, and family planning uptake. Supported by Lwala’s quality improvement initiative, Ongo’s facility committee implemented a series of changes. Through increased training of health providers, as well as supportive supervision and mentorship, staff are better able to provide respectful, high-quality care. For example, health provider knowledge on antenatal care guidelines has increased by 12 percentage points since December 2019.
Additionally, many women hesitated to go to Ongo for antenatal profiling (which assesses the mother’s health and identifies underlying conditions that put her baby at risk) because they knew they might be referred to a different facility, meaning additional travel time and costs. Now Ongo has the laboratory requirements, commodities, and staff training to conduct antenatal profiling. These improvements translate to happier clients–Ongo’s most recent patient satisfaction score was 96%, higher than all other facilities.
Ongo’s facility committee has also tackled big infrastructure projects. To improve its water supply, they wanted to collect rainwater from the roof. The old roof, however, contained asbestos and was unsafe for use. So in partnership with local government, they secured funding to replace the roof, and new water tanks were installed this year.
In South Kamagambo, community leadership has led to better health outcomes–since early 2020, childhood immunization has increased by 31%, and family planning uptake has more than doubled.
Of all these improvements, however, skilled delivery is perhaps the clearest example of the community-led model in action. At the community level, CHWs conduct home visits encouraging antenatal care and skilled delivery, traditional birth attendants champion skilled delivery, and community referral systems provide emergency transportation. At the facility level, open maternity days enable women to visit the facility and ask questions, well- trained providers build women’s confidence in high- quality care, and consistent services like antenatal profiling and ultrasounds keep women coming back. Finally, community committees consistently engage with their neighbors through dialogue to understand gaps in services and advocate for change. As a result, South Kamagambo’s skilled delivery rate is now 100%.
Stories like this reinforce Lwala’s core belief: that when communities lead, change is lasting.
For far too long, politicians, donors, and technical experts have driven a top-down approach to health care, often determining priorities for communities, not with communities. But when CHWs, community groups, and health facility teams work together, they are drivers of change who create better health for everyone around them.
