This essay considers the role that community health workers (CHWs) can play in preventing the spread, and reducing the adverse impact, of Covid-19 on Kenya’s urban informal settlements. It argues that CHWs can make a significant contribution to efforts aimed at reducing such impacts due to their proximity to the grassroots. In Kenya, the number of confirmed Covid-19 cases and deaths has risen gradually since the first case was reported on March 13, 2020.1The number of confirmed COVID-19 cases stands at 2,093, with 71 deaths as of June 2, 2020. See https://www.health.go.ke/press-releases/. The government faces a tremendous task of preventing the spread of the contagion without hurting the livelihoods of its citizens, which could have long-term implications for peace and security. Kenya’s fragile economy and weak public health-care system, marked in part by a critical shortage of health-care workers and poor governance, amplify the challenge of reining in the pandemic. The Ministry of Health (MOH) has issued several behavioral change directives following models from other countries and the World Health Organization (WHO) guidelines aimed at curbing the spread of the pandemic. These public health directives range from washing hands, wearing facemasks, and practicing social distancing. Others include the imposition of stay-at-home advisories, quarantines, curfews, and partial lockdowns.

An emerging question relates to the extent to which government would expect all people to adhere to these universal directives. For instance, how do directives founded on restrictions on movement impact people living in precarious environments such as urban informal settlements? How can these preventive measures be made more bearable and effective in settlements already made vulnerable by food insecurity, high levels of violence and conflict, and other insecurities?  Moreover, how can the government increase its capacity to identify, test, and treat people living in crowded places to prevent the spread of the virus?

Covid-19 Directives in the Context of Urban Informal Settlements

The key to curbing the spread of Covid-19 lies in adherence to public health prevention directives. However, adherence depends on awareness, capability, and the extent to which people perceive these measures as being relevant to their context.2“COVID-19 Global Survey,” initiated by the Montreal Behavioural Medicine Centre, University of Quebec at Montreal and Concordia University, https://chs.uonbi.ac.ke/latest-news/covid-19-global-survey. Kenya’s urban informal settlements have a long and complex history of structural marginalization. They lack access to basic human rights and public infrastructure such as adequate food supply, potable water, proper sanitation and waste management, employment, adequate housing, and health facilities. Residents of such settlements live in overcrowded spaces and experience myriad forms of everyday violence emanating from their living conditions. These conditions make them extremely vulnerable to the Covid-19 pandemic as they render the directives of social distancing, frequent handwashing (for twenty seconds), and proper hygiene very difficult to implement. Furthermore, most residents work in the informal sector with unstable incomes and must travel outside their homes to earn a living. Therefore, curfews, lockdowns, and stay-at-home orders threaten their livelihoods and ability to meet their basic needs. So far, many people have lost incomes due to closure of nonessential service sectors (e.g., bars, restaurants, construction sites). Given this context, total compliance with the recommended Covid-19-related directives are nearly impossible for most urban informal settlement residents. Moreover, UN-Habitat states that misinformation about the pandemic may spread quickly in such settlements because residents often mistrust government messaging and policies due to their experience with marginalization.3“Key Messages on COVID-19 and Informal Settlements,” UN-Habitat, https://unhabitat.org/key-messages-on-covid-19-and-informal-settlements. The Kenyan government has made attempts to cushion individuals and households made most vulnerable by Covid-19 related directives through its social protection program. Protective measures include cash transfers to the most vulnerable populations, enlisting youth from informal settlements in local public works (street cleaning, fumigation, garbage collection), and 100 percent tax relief for persons earning less than KSh 24,000 in monthly salary.4Alex Rees, “How Might Leaders Lead on Social Protection in Kenya? Five Insights from Practitioners,” Wasafiri, 2020, https://www.wasafirihub.com/leading-kenyas-social-protection-response/. However, there is concern over poor coordination, targeting, and unequal coverage of the program.  Accordingly, if not well thought out, responses, directives, and criminalization of nonadherence to the directives may further marginalize people who already live at the margins of society and lead to an increase in human insecurities.

How Can CHWs Best Support the Covid-19 Response in Urban Informal Settlements?

Recruiting and deploying CHWs is a strategy of the WHO for addressing the shortage of health workers, especially among low-income populations. They are men and women trained in basic health care who work within their own communities. They perform tasks that can range from treatment, outreach, community education, informal counseling, social support, and advocacy.5See https://explorehealthcareers.org/career/allied-health-professions/community-health-worker/ for more information about the duties of CHWs. As the government fights Covid-19 through behavioral change policies, directives, recruitment of health-care workers, and other responses, CHWs can contribute a lot to this effort. My earlier research on CHWs’ role in peacebuilding in Nairobi’s informal settlements (Kibera and Mathare) suggests that CHWs must respond to local sociocultural norms and practices to enhance community acceptance and ownership of their work. Moreover, their permanence in the settlements, altruism, legitimacy, accessibility, and knowledge of community norms are all important for the success of their healthcare/peace work.6Roseanne Njiru, “Peacebuilding through Health in Kenya’s Urban Informal Settlements: Insights for Policy,” APN Policy Briefing Note no. 21 (December 2018), https://www.ssrc.org/publications/view/peacebuilding-through-health-in-kenya-s-urban-informal-settlements-insights-for-policy/.

These qualities can be leveraged to enhance responses to the Covid-19 pandemic. For instance, the government might train CHWs on Covid-19 awareness and, in turn, such CHWs would deliver these messages in ways that are locally accessible and acceptable to local residents. In the context of mass information on protection and prevention, CHWs have the capacity to dispel misinformation and doubt, and deliver accurate public health protective guidelines through various community channels at the grassroots. This may require that CHWs work collaboratively with the local administration along with other organized groups in urban informal settlements. Since CHWs reside in these settlements and their work includes home visitations, they are more knowledgeable about living conditions in households and can identify individuals made vulnerable by Covid-19-related restrictions who should be included in the government’s social safety net program.

CHWs can also play a significant role in data collection on the health status of community residents and can provide the MOH with information on suspected cases of Covid-19 infection. Harnessing the capacity of CHWs may help to reduce the spread of the contagion and improve the coordination and provision of welfare assistance to those most affected communities and individuals. Because CHWs have a close understanding of the communities they serve and have already built trusting relationships with the community, this would enable them serve as connectors or bridges between health/social welfare services and the community to facilitate access to information and services and improve the quality and cultural competence of service delivery. However, CHWs will require some additional training on public health messaging, data collection on community health, identification of suspected cases of Covid-19, and referral processes. Moreover, as with all frontline workers, they also require protective clothing, materials, and monetary compensation. Their contributions would make directives aimed at reducing or stopping the spread of Covid-19 significantly more tolerable and effective, and also help reverse the adverse impacts of government restrictions, particularly on violence and crime in urban informal settlements.

References   [ + ]