Community health workers: The key to home-based Covid care?

Eleven days after the Ministry of Health launched home-based care guidelines for Covid-19 patients, Muthee wa Mwangi went on his daily morning run. Later that day, he learnt that 550 Covid-19 patients had been discharged from hospital to continue with recovery at home. 

For Muthee, June 21  was just another day and just another announcement from the Ministry of Health. He had seen a PDF of the home-based care guidelines forwarded in a WhatsApp group, but he didn’t pay much attention to it.

The next day, Muthee developed the now familiar symptoms: morning chills, fever and a slight cough. He attributed this to the cold from his morning run. After it nagged him for three days, he sought medical attention.

He was put on antibiotics for a chest infection, cough syrup and paracetamol and sent home to recover. Four days into treatment, his symptoms persisted. He returned to hospital, where the doctor recommended a Covid-19 test. It was positive.

“The doctor who called to share the Covid-19 test results told me the hospital was full and advised me to consult my employer,” he says.

His employer referred him to their company doctor, who assessed whether Muthee’s home was conducive for home-based care. 

Recommendations in the 'Home-based care guidelines for Covid-19 patients' require that those who contract Covid-19 and their household members should have no underlying health conditions. The home should also have an isolation space — preferably a room with a separate bathroom for the person infected with the virus.

The government launched home-based care guidelines as 90 per cent of patients admitted to hospitals either had mild or no symptoms, which could be managed from home. Home-based care for such patients would leave hospitals for patients with more serious symptoms or vulnerabilities. 

On June 24, the Kenya Medical Practitioners and Dentists Council CEO Daniel Yumbya said there were 113 isolation facilities with a capacity of 3,800 patients for the entire country. At the time, there 4,952 Covid-19 patients admitted to hospital.

By August 18, 161 patients were discharged from home-based care. There were 12,781 active cases. Of these, 90 per cent  — 11,502 — are deemed to be asymptomatic or have mild symptoms, which can be managed from home. So far, tallies from the daily health briefings suggest that more than 10,905 patients (out of 17,368 total recovered patients) have been discharged from home-based care. 

LEFT TO OWN DEVICES

Muthee informed his family and close contacts he had contracted Covid-19. After his doctor’s assessment of his home, he retreated to his bedroom, where he would remain for the next 22 days. He was advised how to protect his wife and two daughters, how to manage his symptoms, and assured there was additional care he would receive from hospital that he couldn’t get at home.

The next few days saw Muthee battle with a high fever and he was often drenched from night sweats. His cough worsened, his mouth and throat were dry, he lost his sense of taste and suffered from headaches. Walking the three metres to the bathroom saw him out of breath and bouts of coughing hurt his chest.

“Taking a shower was difficult. My wife had to help me. I was delirious and felt like someone was kneading my brain,” he says.

During his isolation, there was no contact from the Ministry of Health’s home-based care team he had been told would keep monitoring him. He relied on his wife, the company doctor and a psychologist paid for by his employer.

Across town, Bonnie Musambi, a KBC journalist, started feeling unwell. Suspecting  malaria, he bought anti-malaria drugs but they did not ease his symptoms: headache, fatigue and unbearable chills, a sore throat and loss of smell. 

“I didn’t suspect corona (Covid-19) because I had neither a fever nor cough,” he says. He took the Covid-19 test offered at his workplace and continued to self-medicate for what he thought was a bout of Malaria. 

“Three days later when they called and told me I had tested positive for Covid-19, I laughed. It was the last thing on my mind. I was advised to stay home and told that the Ministry of Health would be in touch,” he says. 

The next day, when nobody had reached out to him, he called 719, the Covid-19 helpline. 

“They gave me some numbers to call and when I called one of the numbers, I was advised to eat a balanced diet and a lot of fruits,” Bonnie says.

The day after that, a doctor from the Kenyatta University Teaching and Referral Hospital called and advised him to take medication based on his symptoms, to take vitamin C and to call the Covid19 helpline 719 for an ambulance if he developed breathing difficulties. 

From their experience, it is clear not many people know about the Ministry of Health system for home-based care patients. It also points to gaps in the system.

WHAT TO DO

Ministry of Health primary healthcare head Salim Hussein, who is responsible for home-based care, says those who test positive for the virus and are advised to convalesce at home should immediately register on the Jitenge MOH Kenya app available on Google Playstore.

The app allows them to keep a daily log of their symptoms and temperature during the 14-day isolation period.. Those without smartphones are required to register using *299#. 

To keep a daily log, Muthee was provided a thermometer by his company doctor, while Bonnie bought his own.

Dr Hussein acknowledged that most home-based care patients do not register on the Jitenge home-based care system. “There are about 3,000 home-based care patients registered on the Jitenge system. Most of them are in Mombasa, where home-based care was piloted, and where there has been a lot of public awareness,” he says.

“One reason why not every home-based care patient is in the system is lack of awareness. There is also fear that if one registers, he or she will be carted away to a quarantine facility.” 

Aside from self-monitoring, community health volunteers are supposed to make home visits to monitor those recovering at home.

Ruth Ngechu, the deputy country director of Living Goods, an NGO supporting community health volunteers in several counties, describes them as the link between patients at home and the health system.

“The caregivers at home monitor the patient’s vitals and offer care, while the community health worker monitors and files a report in case a patient’s situation worsens,” Ngechu says.

Community health volunteers report if a patient fails to comply with the isolation guidelines, give advice on diet and methods of transmission of the virus and also provide psychosocial support to those infected and their caregivers. The volunteers also assist in identifying possible isolation centres, especially in areas where a patient’s home may lack the space for home-based care.

Social halls, churches, mosques, temples and even stadiums have been designated as community isolation centres, Dr Hussein says. Patients in such community-based care patients can expect ‘continuous support’ from the health volunteers.

GOVERNMENT CONFUSION

Muthee received zero attention from the Ministry of Health. Two-and-a-half weeks after his first Covid-19 test and while he was well on the way to recovery, health officials called Muthee, telling him his symptoms were serious and he required hospitalisation and not home-based care.

“It was on July 18 just after my third Covid-19 test, which showed I had recovered. Someone from the Ministry of Health called. She said she had been informed that I had been exposed to Covid-19. I asked her which of the three tests she was talking about. She said the first test was done on July 1. When I told her my symptoms, she said that I should have been receiving treatment at a hospital, rather than home-based care,” Muthee says.

Later that evening, someone from Embakasi subcounty, where he lives, called, asking for the same information. He wondered why he was called after he had recovered and why different offices were asking for the same information. “Are they not consulting from the same database?” he asks.

Health officials contacted Bonnie two days after he isolated himself at home. They, however, offered him no help or guidance on home-based isolation and care. 

It is not just patients who are having difficulties with home-based care. The community health volunteers expected to offer support are ill-prepared to execute this role.

“Do you see this mask I am wearing? It is supposed to be used once, but I wear it all day for two days because we only get three masks to use for up to three weeks,” says Asha Hassan, a community health volunteer in Soweto East, an informal settlement in Langata subcounty in Nairobi. 

This was a common complaint during the training the government held countrywide for the more than 60,000 community health volunteers in preparation for the pandemic. 

“Most community health volunteers use cloth masks. They are not health workers. There is a concern about who will cater for their healthcare bills if they get infected as they do their work,” Ngechu said.

Mary Nanjoli, a community health volunteer in Kibra, Nairobi county, says she and her colleagues do not get paid for the work they do.

“We play a big role in ensuring healthy communities. We have played a big role in the fight against Covid-19. We would like the government to recognise us. Not just to pay lip service on TV, but with a stipend,” says Nanjoli, who has been a community health volunteer since 2009.

The government has been reluctant to address this complaint. Community health volunteers are supposed to receive a token payment of Sh2,000 per month. This lack of compensation is a hindrance to offering home-based care services..

“Most counties do not pay community health volunteers. They are not provided with airtime, which they need to follow up with patients and to give daily reports. Nobody is talking about how that will be catered for. How are they expected to work?” asks Ngechu.

Hassan and Nanjoli say they depend on food rations donated by well-wishers to their communities, especially now that their jobs as mama fua (washer women) and the petty businesses they were engaged in have all but collapsed due to the pandemic isolation and lockdown measures.

The two say it will be difficult for them to cope if they get home-based care patients in their communities. 

Unlike Muthee and Bonnie, who are slowly nursing themselves back to health, patients in informal settlements, such as Kibera, Mukuru and even the rural areas, depend on community health volunteers to help them recover. 

(This report was supported by the Africa Women Journalism Project (AWJP) in partnership with the International Center for Journalists (ICFJ))

A longer version of this story was published here