A wealth of evidence shows that the period from pregnancy to age three sets the foundation for the rest of a child’s life. Roughly 80% of a baby’s brain develops during this time period and caregiver-child interactions are critical to ensuring that a baby reaches its full potential before transitioning on to the next phase of life (WHO; 2018). Fueled by this evidence, countries have started to scale up and improve the quality of home visiting programs by strengthening and supporting the early childhood workforce that provides these services to young children and their families. One such example is Siaya County in Kenya, which started integrating nurturing care into the health system by adding responsive caregiving and child development monitoring to home visits provided by Community Health Volunteers (CHVs) and workers in health facilities in 2014. While this has been a significant development in Siaya County, the home visiting workforce (e.g. CHVs, supervisors) struggles with heavy caseloads, low pay, and limited supportive supervision opportunities which limit their ability to provide quality support to young children and their families.
To gain insight into these challenges and support policy planning, the Early Childhood Workforce Initiative (ECWI) co-convened a consultative workshop with the Government of Siaya County that was attended by Country and National officials, representatives from the County Department of Health and National Ministry of Health, representatives from civil society organizations, frontline workers, and others. The workshop was structured around the Home Visiting Workforce Needs Assessment Tool, which was designed to help government agencies and implementation partners reflect on the ways in which they can support personnel delivering home visiting across sectors for pregnant mothers and caregivers with children under 3, and has also been piloted in Bulgaria (see Box 1). In this interview, Denise Bonsu, a Senior Program Associate at R4D, chats with Dr. Elizabeth Omondi, County Coordinator for Reproductive, Maternal, Newborn, Child Health and Adolescent Health in the Department of Community Health Services in Siaya County, to learn more about her experience piloting the tool.
Q: As one of the first users of the Tool, I would love to hear more about your experience with it. What was the piloting process like for Siaya County?
A: Overall, we had a wonderful experience using the Tool. We found the Tool to be very comprehensive and appreciated how it touched on most of the factors that relate to the roles of the early childhood workforce, such as competences and standards, pre-and in-service training, and working conditions (e.g. caseloads, remuneration). The pilot workshop was also very well organized and created a collaborative space in which stakeholders across different levels (e.g. National Ministry of Health officials, Siaya County health officials, community health volunteers) could use the Tool to analyze the current status of home visiting services in Siaya County and reflect on the ways in which they can be strengthened moving forward.
Q: What did you learn from the piloting process about CHVs in Siaya County?
A: The pilot workshop taught us a number of valuable lessons that will assist us in supporting and strengthening CHVs in the County. During the workshop, we learned the importance of standardizing Nurturing Care trainings and tailoring them to different service roles to ensure that CHVs and their supervisors are well equipped to carry out their responsibilities. We also noted that there was a need to finalize supervisory tools and resources and sensitize supervisors on how to use them so that they are able to adequately support and monitor CHVs. Furthermore, we learned the importance of increasing the career development opportunities of CHVs (e.g. awarding certificates after completing trainings) to strengthen their career pathways.
Another thing we learned is the importance of reviewing caseloads to ensure that they are manageable (e.g. reducing the number of households to 50 per CHV) and taking into account each household’s unique circumstances when assigning them to CHVs, as this could influence the frequency and duration of visits. We also learned that there is a need to embed safety protocols (e.g. when conducting home visits at night) into official policy, and provide CHVs with protective gear (e.g. Muck boots for adverse weather conditions) to conduct home visits.
Q: What should others who are interested in using the tool know about the experience?
A: Countries that are interested in using the Tool should know that it is very user friendly and can be adapted to suit the needs of all cadres of the workforce across different contexts.
Additionally, when implemented during a consultative workshop, it allows stakeholders across different levels (e.g. service providers, supervisors, managers) to openly discuss the issues that affect the home visiting services in their country, and develop actionable next steps for addressing these issues in the short and long run.
Q: Could you please tell us how the Government of Siaya County has been using the outputs from the tool to support CHVs?
A: Following the workshop, the Government of Siaya County formed a committee that is responsible for implementing each of the policy recommendations that were developed. For example, in response to the need for additional protective gear, the Government started providing CHVs with tools and resources (e.g. bicycles) to assist them in conducting home visits. It also developed three home visiting tools to: 1) Assess the quality of home visits; 2) Supervise CHVs in their roles; and 3) Assess the performance of supervisors. When developing these tools, the Government of Siaya County used a similar methodology and facilitation approach to what was used during the piloting workshop, incorporating the inputs of stakeholders across multiple levels and using them to inform the design and implementation of the tools. Additionally, Siaya County is also in the process of using the outputs from the workshop to inform updates to its Reproductive Maternal Newborn Child Health (RMNCH) and Community Health Services Bills.
Q: As you reflect on the impact of the pilot workshop, I am curious to know more about your thoughts on the future adaptability of the Tool. How do you envision the Tool being adapted to other members of the workforce beyond CHVs? How do you envision it being adapted to other counties in Kenya?
A: There is currently a lot of interest in adapting Siaya County’s home visiting services model to other counties in Kenya. We have started working with other counties to conduct baseline assessments which draw on input received from key informant interviews (KIIs) and focus group discussions. We plan to use the Tool to inform these baseline assessments, as we work towards scaling up Nurturing Care in 14 lake region counties. Lastly, we plan on continuing to use and adapt the Tool and its framework to inform any research on the needs of home visitors or any other members of the workforce in Kenya.
Q: What is the status of home visiting services in Siaya County and how have they been impacted by the pandemic (e.g. any challenges faced)?
A: The emergence of COVID-19 has helped highlight the fact that CHVs are instrumental in preventing community transmission. Although they are also at risk of contracting COVID-19, they are also agents of change. In Siaya County, CHVs have the option to participate in surveillance and community education exercises. They also have the right to provide phone support to families (instead of in-person visits) or opt out of their work completely for any reason during the COVID – 19 pandemic. Any volunteer who opts out is protected from any undue consequences and continues to get their stipend throughout the crisis period. They shall however be required to inform their supervisor on their decision to opt out. Members of the Community Health Workforce with risk factors (e.g. those over the age of 60, pregnant, underlying health conditions) are given the option to opt-out of service delivery completely, or suspend in-person work and provide phone support only.
To ensure the continued provision of community-based services during COVID – 19, all participating CHVs and supervisors have been equipped with proper personal protective equipment (PPE) and infection prevention & control (IPC) supplies. If a worker does not have proper PPE, they are not permitted to work in the field or see clients under any circumstances.
The teams have also been trained on infection prevention and control skills, and provided with protocols to safely deliver essential services, delivery of COVID-related health messages, and infection control measures related to COVID – 19. They are encouraged to observe Social distancing practices and all other preventive measures.
Q: What are some of the key lessons you have learned while supporting home visiting personnel during the pandemic?
A: Covid-19 has interrupted the continuity of most of our planned activities to supporting women and children. The pandemic has shifted the focus from uptake of routine preventive services like Immunizations, antenatal care, and postnatal care including skilled delivery services. Some community members have started associating health facilities with COVID-19, and therefore they try to keep off as much as possible. Our fear is that the situation may eventually erode the gains that we have made within the health sector.
Q: What are some of the long-term implications that COVID-19 will have on supporting the workforce in the future?
A: There will be a need to build the capacity of the workforce to deliver safe and quality primary health care and ensure their welfare to continue carrying out their work. It will also be imperative to strengthen support systems and response mechanism to address any emergent issues amongst the community health workforce.
To learn more about the workshop in Siaya County, Kenya read the Workshop Report.