|Summary Booklet of Best Practices in Africa - Issue 2 (UNAIDS, 2000, 116 p.)|
Starting Year: 1986
Main Topic Area: Community mobilization
Other Topic Areas: Palliative care · Counselling · Religion
Mr Charles Thumi
Sister Gill Horsefield, MMS
Phone: +254 793 266/793 288
Kariobangi Community Health
P.O. Box 53376
The organization in charge of the project is the Medical Mission Sisters Health Programme.
The main funding for the programme comes from Memisa Medicus Mundi (Netherlands)/Cordaid. Initial help with publicity materials was received from UNICEF. The programme also receives funds from parish groups overseas and locally.
The goal is to enable the people of Korogocho to cope with AIDS physically, socially, and psychologically by:
- training community health workers to care for persons living with AIDS
- providing a backup team of medical and social services professionals to enable this to happen.
Korogocho, the slum in Kariobangi in which the programme is set, is 12 km east from the centre of Nairobi. It has a population of over 100,000 (recent unconfirmed statistics suggest it is now 130,000). Most people live in single room shanties made of plastic, tin, or mud. Sixty per cent of homes are headed by women alone. Most residents have no land and are living as squatters in the slum. As there is little opportunity for work, most try to earn a living by very small-scale trading, and by scavenging on the city dump, or by alcohol-brewing and survival prostitution.
A survey conducted in two large neighbourhoods in the Korogocho slums showed that 32 per cent of the population was HIV-positive; 14 per cent of those infected had AIDS. Due to their poverty, some 22 per cent had never sought medical attention.
The Community Health Programme was begun in 1986 by Sister Gill Horsefield, MMS, and commenced its AIDS-related activities in 1989-90.
The programme delivers many of its services through the volunteer work of community health workers (CHWs), who are all from Korogocho itself. The CHWs are supervised and supported by a professional staff of five nurses, two counsellors, a social worker who visits mothers with AIDS and helps them plan for the future of their children, and a pastoral worker who serves patients' spiritual needs. There is also a diagnostic laboratory for TB in the Deanery of the local Catholic church.
The programme has six main activities:
1. Care for the sick
The programme recognizes and attempts to build on the fact that most of the care that persons living with HIV/AIDS will receive, realistically, will be provided by relatives (not just adults, but frequently by children) and friends of the patients at their own homes. Therefore, the programme improves and supports this existing care resource through voluntary community health workers. The workers provide friendship and moral support, bring medicines, and teach home-nursing skills to the patients' relatives and friends. Where necessary, workers bring food during their visits - either a cooked meal provided once a day, or dry food to be cooked for the patient by family members. If food is provided, it is for the whole family rather than just the patient, a necessity given the difficult circumstances in which most AIDS-affected families live.
2. Referral system
The community health workers live in the slum, and they are each responsible for a small area. When someone in the area is sick, the CHW will be told by neighbours. She will visit the person to determine the seriousness of the illness. If it is a minor sickness, she will advise on home treatment or perhaps recommend a visit to the dispensary. If the sickness is serious, or the patient appears to have symptoms of AIDS, she will call the nurse, who will visit the patient with her and make a diagnosis. If the patient has the symptoms of AIDS, he or she will be registered in the programme, and the health worker will then visit regularly, and report every week to the nurse on the patient's condition. Some patients require additional care in between reporting times. In such cases, CHWs can contact the nurse in the morning when she arrives to visit the area. Once diagnosed as having AIDS, patients are prescribed their medicines by the nurses, and the medicines are delivered by the CHWs.
3. Crisis care for persons with AIDS
An aim of the programme is to help patients to stay at home until they die. When care at home is beyond the abilities of relatives or friends, there is a small hospice, run by the volunteer health workers, where patients can be looked after following a major downturn in their health. The hospice has four beds but usually has only one or two patients at a time.
4. Crisis care for children
The programme provides medical care to children living with HIV, but also runs a Child Crisis Centre where children can stay temporarily when a mother is too sick to cope, or when a mother dies suddenly. This need has emerged as adult mortality due to AIDS makes it increasingly difficult to find family members to care for orphans. The Crisis Centre is also a safe haven where children who are caring for sick parents come to learn, and where they can always come to get advice, moral support, and emotional support.
5. Children's programme
Child-headed households are becoming more common. Even when a very small child is sent to grandparents, the eldest child usually remains in the family home with the responsibility for caring for the other children. The children's programme was created for children who are healthy themselves but who will in the future be orphaned. They are invited to join in order to prepare for life without parents. They learn how to care for their sick parents and also how to bring up their younger brothers and sisters. While learning, they share a great deal together, and so form supportive groups that, it is hoped, will help them in the future.
6. Recruitment and training of community health workers
The community health workers are chosen from the small Christian communities of the neighbourhood. These communities are mutually supportive groups who expect all their members to perform some sort of service within the community. Huduma ya Afya (Service for Health) is one of the services for which members can volunteer. They are trained in community-based health care at Korogocho village school, where they have weekly classes for about five to six months. After working for a year, they receive a badge and a certificate. The CHWs are regarded with great respect in the neighbourhood, and are regarded as peers by the professional staff, who support them and help them to increase their knowledge. Some of the health workers are trained as counsellors; most of them have supplies of medicines for treatment of symptoms, and some have supplies of antibiotics. Those who work in the hospice have received training in psychological and pastoral care of the dying.
The CHWs are involved in all decision-making about the development of the programme. Their strong Christian motivation is reinforced by the gratitude and support with which they are treated by both patients and professional staff. Some of the CHWs have been working for 12 years and feel that, in spite of receiving no financial reward, they have gained a great deal in terms of increased abilities and confidence.
The programme's current patient load is 787 persons, with a cumulative total of 3,746 persons served since 1990. There were 537 new patients in 1999.
In 1998, 68 volunteer health workers provided medical care and moral support to 1,880 persons living with AIDS, including 172 babies and children.
Analysis of the programme budget for approximately 2,000 patients found an expenditure of $13.40 per patient per year (this sum includes the cost of medicines, staff salaries, transport, running a car, and administration). Of this, $2.20 represents the cost of medicine per patient per year. The cost of training per community health worker was calculated to be $7.00.
The experience in Kariobangi illustrates that a programme built largely on volunteers can make a significant difference in the lives of people living with HIV/AIDS in a very poor community. Three conditions appear to account for much of the programme's success:
- the energy and dedication of the volunteers, most of them highly motivated by religious faith, and the locally appropriate manner in which they are recruited (i.e., the fact that recruitment is based on the respect that the community holds for the candidates)
- support and supervision provided by a professional staff
- a web of local partnerships, including nearby health institutions and other NGOs working in the area.
At the same time, the programme's experience also illustrates the limitations imposed by lack of local resources. The programme is highly dependent on external financing. Without it there would be no administrative budget, no salaries for professional staff, and little money for medical supplies.
Lessons have also been learned about the difficulty of dealing with AIDS in a culture where there remains considerable stigma attached to the disease (although there appears to be somewhat more openness about the subject than even a few years ago). A staff member comments, "Often people will talk about 'this sickness' and everyone knows what they are talking about, but they don't actually call it AIDS. All the professional staff know the HIV status of all the patients, but keep the information confidential. The community health workers can only know a patient's status if the patient herself/himself shares it with them. Nonetheless, most community health workers have a very good knowledge of the signs and symptoms of AIDS, and are fully aware of any given patient's situation."
An important problem raised by continuing stigma is that of informing children about their parents' serostatus. Community health workers have been trying to persuade HIV-positive parents to share this knowledge with their children, but so far with little success. Very often the children know, or at least suspect, and the workers feel strongly that if the truth of the situation could be discussed openly within families, it would be easier for the children. However, confidentiality forbids this without the parents' consent.