Hundreds of lay health care workers are deployed in Kenyan communities to fill the gap caused by severe staff shortages in the health sector - but could they be doing more harm than good?
Some lay health workers even dispense antiretroviral (ARV) drugs, but health experts have warned that using unqualified personnel to perform medical functions may not be such a good idea.
"Because of the burden already exerted on the available health workers by the HIV/AIDS issues, we have used lay counsellors to take up some of the roles," said Esther Kathurima, psychosocial coordinator with AIDS Population and Health Integrated Assistance (APHIA) in Kenya's Rift Valley Province, a joint initiative by the government and USAID.
"[These roles include] provision of psychotherapy counselling for groups, counselling on trauma and depression, and general provision of home-based care. They [lay counsellors] have served well because they understand the community and relate well with them."
Professional health workers are in short supply in Kenya; in the public sector there are an estimated three doctors and 49 nurses per 100,000 people; the UN World Health Organization (WHO) recommends at least 143 nurses per 100,000 people. More problematic is that over half of all health personnel and 80 percent of doctors are based in urban areas.
"Task-shifting" - in which tasks normally handled by professionals are delegated, or "shifted", to lay health workers - has been hailed as the only way Africa can keep scaling up HIV services. Ministry of Health officials said the government had so far trained and certified about 2,000 lay health workers in the public sector.
Family Health International (FHI), which works to improve reproductive health and is involved with APHIA II Rift Valley in training lay counsellors, has had generally good results.
Patients are more likely to return to the clinic and the clinic is better able to follow up those who do not, preventing loss; there is an increased adherence to ARVs, and a greater likelihood of mothers delivering their babies at health facilities rather than at home.
More training necessary
However, there are concerns. "There are limitations because they are not adequately trained to deal with severe cases, like the management of discordant couples and dealing with any side effects that might arise from the use of antiretroviral therapy," said APHIA II's Kathurima.
Sylvia Awuor enjoys working as a lay counsellor in the Gomongo slum in the Kenyan capital, Nairobi, but it is not always easy. "Sometimes I meet situations I can hardly handle ... opportunistic infections that come with HIV are a big challenge because you get ... [patients] who refuse even to go to the health facility," she said. "At times I feel we should do these rounds with a clinical officer or a nurse."
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Dr Andrew Suleh, chairman of the Kenya Medical Association, said lay counsellors should not become a long-term replacement for professional health workers.
"If you vouch for the use of lay counsellors as an alternative to the employment of health personnel, then the government would take that to mean it has solved the health worker shortage in the country," he said.
"The government must be pressured to train, employ and retain health professionals to ease the disease burden exerted on the health care workers by the twin challenges of HIV and TB - the management and care of HIV and AIDS is very labour intensive."
Most lay counsellors were volunteers employed by NGOs whose projects could end, leaving the country with even bigger shortages of health workers. "You cannot base health management on volunteerism; it is not sustainable," Suleh noted.
Kathurima agreed. "It is critical that the government invests in training and absorption of more health staff to be used as referrals."
Even in the short term, Suleh said, the government needed to ensure that proper regulation was in place for the employment and training of lay counsellors in the public sector.
Kenya's guidelines allow lay counsellors to offer testing and counselling in community settings, and refer patients to local health centres for more specialized treatment. However, there is no clear policy governing the training and minimum standards expected of lay health workers. Most NGOs apply their own standards.
"The government can opt to absorb some of these lay counsellors by training them to take over some of the tasks currently being done by mainstream health workers, but the guidelines on their use must be very clear," Suleh said.
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions