The BBC recently featured the “backpack midwife”— Margaret, a community health worker in Kenya who carries a backpack full of technologies that support the provision of health care within communities, particularly for women and children. Margaret makes home visits twice per week, in an area north of Nairobi with approximately 120 households. Though she says the work can be difficult, “…this is what I must do, and it makes me feel happy to be useful and known in the community.”[1] The “hi-tech gadgets” she carries in the backpack include a wind-up fetal doppler for detecting a baby’s heartbeat during prenatal care; a small light powered by solar charged batteries; a light-weight, battery powered portable ultrasound for OB/GYN or abdominal imaging; an in-ear thermometer; a blood pressure and heart monitor; a monitor which assesses respiratory rate in children; and a pulse oximeter that measures blood oxygen levels in both children and adults. All of these portable technologies are made by the company Philips Healthcare. The backpack is a key part of the Philips-supported Community Life Centers (CLCs) which seek to strengthen community health in Africa through the provision of infrastructure, power, medical technologies, training and maintenance, community outreach, information systems, and referral to other parts of the health system. More information about these CLCs can be found here.

The innovations in this backpack address real needs in communities with insufficient access to quality health services. But we would like to emphasize that it is not the technologies that reach people in these underserved, and often remote, areas. It is a person—often a community health worker (CHW) like Margaret—who transports and uses these technologies during their interactions with members of the community, considers when to employ them and how to act upon results, and decides what to do when batteries run out or maintenance is required. In many countries, national health strategies recognize that health begins at the household and community level. As such, CHWs are often best placed to perform important outreach services in communities and act as a vital link in the chain of referral to other parts of the health system. For this reason, development partners often design initiatives that either recruit a specialized cadre of CHWs or draw upon an existing national pool of CHWs. However, questions remain as to how such CHW initiatives can best be structured. What is CHW’s relationship to the wider health system? To whom are they responsible and to whom are they accountable? How are they selected, trained, retrained, and incentivized?

One key issue that has long been debated both within countries and at the global level is compensation for CHWs. This is important because in most settings, there are high attrition rates amongst CHWs who have been recruited and trained, but who do not receive financial payment. The BBC article points out that Margaret is an unpaid volunteer. This is not unusual in Kenya, or indeed many other countries in Africa, where the majority of CHWs are unpaid.

Efforts to change this are ongoing and a campaign was launched at the Africa Health Agenda International Conference in Nairobi last year that advocates for integrating and renumerating CHWs like other civil servants in the health workforce. A recent report by six organizations implementing CHW programs around the world underscores the importance of some sort of financial payment for CHWs (e.g. salaries, performance-based rewards, etc.). Based on a review of their own experiences, these implementing organizations identified eight minimum elements needed for CHW programs to succeed, one of which is that CHWs must receive financial payment, and that non-monetary incentivization is insufficient. In addition to being paid, the report argues that CHWs should be accredited, accessible, proactive, continually trained, supported by a dedicated supervisor, part of a strong health system, and part of data feedback loops.

These design principles raise important questions about CHWs in Kenya like the “backpack midwife.” How can CHWs like Margaret be trained, supervised, renumerated, and given a career path forward as part of the country’s formal health system? Who finances CHW programs—district government or national government or international agencies? How much should communities themselves contribute to CHW remuneration? How should other potential non-monetary public service incentives be handled (for example, housing, pensions, access to banking facilities)? How can such a large financial undertaking be sustained in light of existing human resources crises across primary, secondary, and tertiary health facilities?

These are critical questions for Kenya’s President Uhuru Kenyatta, as he embarks upon his strategy of affordable healthcare for all by 2022, announced in December 2017, as one of four pillars of his final term. They are also important questions for global health professionals seeking to roll out new health technologies in countries such as Kenya. A backpack (and the life saving health technologies within) is only as good as the person who carries it. And the person who carries it is only as good as the health system allows her to be. So, when rolling out new health innovations, let’s not forget that our focus should be on the systems and the people—like Margaret—whose work is essential to improving access to quality health care. A technology-centric approach will not suffice.

[1] Munford, M. (2018; January 23). Meet the ‘backpack midwife’ bringing healthcare for all. BBC News. Retrieved from www.bbc.com.