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The hidden burden: The Reasons Community Health Officers (CHOs) feel more stress than Community Health Promoters (CHPs)

Community Health Officers (CHOs) supervise the CHAs inorder to ensure they fulfil their performance goals and provide high-quality healthcare services. It was clear from a recent meeting in Korogocho (which is an urban informal settlement) with both CHOs and CHPs that CHOs frequently endure higher stress levels than CHPs.

The CHOs expressed that their stress stems from the fact that their performance is directly tied to the success or failure of the CHPs. If CHPs do not meet their targets or fail to deliver as expected, it negatively impacts the CHOs’ evaluations. Additionally, CHOs are often caught between the demands of their supervisors and the challenges in the community that are managed by the CHPs, creating a high-pressure environment.

One major source of stress for CHOs is the performance-based system implemented through the electronic Community Health Information System (eCHIS). Under this system, in order for the CHPs to get their stipend they must achieve an 80% target by visiting at least 33 households and making referrals, unlike when the process was manually because the CHOs now have no control over the system-generated results. Previously, CHOs could intervene to adjust scores to ensure CHPs received their stipends, but this is no longer possible.

Sometimes CHPs achieve the required 80% but still do not receive their stipends. When this happens, CHAs must handle complaints and provide explanations, despite having no control over the system. When the stipends delay, the CHOs are usually called late at night or early morning by the CHPs seeking answers, further adding to the CHO’s stress. In many cases, CHOs are forced to give CHPs false reassurances just to prevent excessive follow-up calls, all while dealing with the uncertainty themselves.

CHPs receive a total stipend of Ksh6,000, comprising Ksh3,500 from the performance-based and Ksh2,500 from the national government. However, these payments are not made simultaneously, and the national government often delays disbursements for months. This financial uncertainty contributes to frustration among CHPs, which in turn increases the stress on CHOs who must handle their grievances.

Both CHOs and CHPs acknowledged that the pressures of their roles contribute to burnout, disagreements, and workplace tension though afterwards they laugh about them. There was a request for a structured mental well-being interventions and debriefing sessions for both CHOs and CHPs to help them cope with the demands of their work.

The role of CHOs extends beyond supervision for they are the bridge between CHPs and the healthcare system, often bearing the brunt of systemic failures. It is important to address their mental well-being for it will be impactful to effectively fulfill their critical roles in community health services.

By Faith Munyao

Through the Lens of Mercy: The Silent Struggles of a Community Health Promoter

Mercy* is a Community Health Promoter (CHP) in Viwandani, an informal settlement in Nairobi, Kenya. The name Viwandani, which means “Industries” in Kiswahili, reflects the settlement’s proximity to numerous factories. It is a place known for its bustling workforce, narrow pathways, and a maze of loosely hanging electrical wires—some dangerously exposed. Navigating these precarious conditions is a skill on its own, and for CHPs like Mercy, it’s just one of the many daily challenges they face.

The Backbone of Primary Healthcare

Globally, Community Health Workers (CHWs)—now referred to as CHPs in Kenya—are the lifeline between informal communities and formal healthcare systems. In low-resource settings, they are often the only accessible health providers for many urban and rural poor. In September 2023, the Kenyan government rebranded CHWs as CHPs, making them the key drivers of Universal Health Coverage. Each CHP is responsible for at least 100 households, visiting them to promote health awareness and prevent diseases. However, for Mercy, this number has increased to 117 households following the devastating floods of August 2024, which left many CHPs displaced and communities in turmoil.

Despite their critical role, CHPs remain overworked, underpaid, and largely unrecognized, facing immense emotional and financial strain. The mental toll of their work is often overlooked, yet emerging evidence from Africa and Asia highlights the severe stress they endure due to excessive workloads, inadequate training, and insufficient compensation.

The NHIR-SHINE Study: A Glimpse into the Lives of CHPs

Mercy is among the 14 co-researchers participating in the NHIR-SHINE study, a collaborative initiative led by LVCT Health in Kenya, APHRC, BRAC in Bangladesh, and LSTM in the UK. This study seeks to explore the strengths, challenges, and opportunities for enhancing CHPs’ mental well-being in low- and middle-income countries.

Utilizing mixed methods, including surveys and Community-Based Participatory Research (CBPR) approaches such as Photovoice, Narrative Timeline Interviews, and Body Mapping workshops, the study captures the realities of CHPs’ lived experiences. Through Photovoice, Mercy has visually documented the challenges and motivations that shape her daily work. Her images tell a story of resilience, hardship, and hope.

 

Through the Lens of Mercy: The Silent Struggles of a Community Health Promoter

“What motivated me to take this picture was the realization that, as a volunteer caregiver, I couldn’t provide a balanced diet for my own family. It hurt me a lot because I am the one who goes out to teach others about healthy eating, yet I can’t afford it for my own children. It causes me so much stress.”

Mercy’s struggle is not unique. A report by the African Cities Research Consortium (ACRC) highlights that residents of informal settlements suffer from malnutrition, stunted growth, and micronutrient deficiencies due to food insecurity. The paradox is painful—those tasked with promoting nutrition are often the ones struggling to afford it.

With meagre earnings, CHPs like Mercy are forced to take up side jobs, hoping to supplement their income. Some days they find work; other days, they don’t. The stipend they receive is barely enough to survive, yet they continue serving their communities with unwavering dedication.

In Mercy’s case, the preacher who preaches wine ends up drinking water! This causes significant stress to Mercy as she helplessly watches her young family feed an unbalanced diet due to her financial limitations. “This condition exists because, as a CHP, the income I receive is very little, so I have to push myself to find other side jobs to supplement the stipend I get. Sometimes I manage to find extra work, and sometimes I don’t, and whatever I earn from that is what I use to provide for my children at home. So, the little we earn as CHPs also contributes to this situation.” She speaks.

Living in Constant Fear: The Burden of Uncertainty
Anxiety has become a constant companion for many CHPs, exacerbated by unsafe living conditions. Studies show that chronic anxiety not only affects mental health but also has severe physical consequences. The fear of losing everything at any moment adds an emotional burden to an already overwhelming job.

Through the Lens of Mercy: The Silent Struggles of a Community Health Promoter

“…the houses got burned. [Pauses] What this represents to me is the fear that I can leave home to work, only to return and find everything I own is gone. Every time I leave, even now as I’m here, I worry if I will find my things intact when I return.”

In Mercy’s community, fires frequently break out due to poor infrastructure, illegal electrical connections, and unsafe cooking practices. The lack of proper roads makes it nearly impossible for emergency services to respond in time.
“The biggest challenge is our infrastructure. Fire engines can’t access our homes when there’s an emergency. Most power connections are illegal, done by people without proper training, making it even more dangerous.”

An Overwhelming Workload: A System Pushed to the Brink
A 2024 systematic review on CHW workload and supervision in Indonesia revealed that many felt burdened by unrealistic workloads, disproportionate responsibilities, and inadequate incentives. The situation is no different in Kenya.
Although the Primary Health Care Act (2023) outlines CHPs’ roles, many find themselves drowning in additional, unofficial tasks. Mercy’s experience is a testament to this:
“As CHPs, we’ve been given so much work, yet our pay is so little. We are told to volunteer for two hours, but that’s impossible. We have to visit 33 households per month, collecting data on everything from child nutrition to maternal health. If one household has five people, we attend to all of them. By the end of the month, we’re exhausted, unable to look for other jobs, and surviving on a stipend that barely covers a meal for our children.”
The excessive workload, coupled with financial strain, takes a heavy toll on CHPs’ mental well-being. They find themselves stretched thin, juggling between serving their communities and meeting their own basic needs.

The Way Forward: A Call for Action
Mercy’s story is not an isolated case—it is the reality for thousands of CHPs across Kenya and beyond. To safeguard their mental well-being and improve healthcare outcomes, urgent interventions are needed:

  • Realistic Workload Planning: Policymakers must ensure CHPs’ responsibilities are manageable, allowing for a proper work- life balance.
  • Fair Compensation: Adequate stipends and financial incentives should be provided to sustain CHPs and their families.
  • Supervisory Support & Mental Health Services: Structured debriefing sessions and one-on-one counselling should be integrated into CHPs’ schedules.
  • Infrastructure Improvement: Informal settlements need better roads, safer electrical connections, and accessible emergency services.
Through the Lens of Mercy: The Silent Struggles of a Community Health Promoter

“I love going to watch the sunset because it makes you reflect on how life and nature are beautiful. Yeah, despite all the challenges you may be going through in life, the sunset reminds you that even though today is ending, tomorrow will bring a new day, new opportunities.””

CHPs are the backbone of Kenya’s primary healthcare system. Investing in their well-being is not just a moral obligation but a strategic move towards strengthening healthcare for all.

*Mercy’s name has been changed to protect her identity.

Blog by Patricia V. Okoth

Supporting Mental Health in Community Health Promotion: Lessons from the SHINE Study

Working in community health is not for the faint-hearted. As one community health worker put it, “You need a heart to continue.” This simple but powerful sentiment speaks volumes about the challenges faced by community health promoters—especially when it comes to their mental well-being. Through the SHINE study, taking place in Nairobi County’s Korogocho area and Kiambu County’s Limuru, a comprehensive approach is being developed to foster resilience, well-being, and support for these crucial frontline workers.

Prioritizing People Over Pay

For community health promoters, the mission is about transformation, not targets. Their purpose is driven by the impact they see in the communities they serve. Often, they are called to action at all hours, ready to help someone get to a hospital, even if that means dipping into their own resources or taking on debt. This dedication is a powerful example of how a people-first approach lies at the heart of their work.

Yet this relentless dedication, while admirable, can be mentally taxing. The emotional weight of being continually on call, coupled with the financial strain, can be a serious drain on mental health.

The Role of People Skills and Negotiation

A community health promoter’s day often involves mobilizing support not just from within a patient’s family but also from neighbors. When a critically ill individual has no resources to get to a hospital, these workers negotiate with anyone available to secure what’s needed. Sometimes, even a few coins from neighbors or a willing boda boda driver can make a critical difference. Negotiation skills are indispensable—not only to rally local resources but also to work with hospital staff to ensure immediate care within available means.

This constant need to rally for resources or negotiate care intensifies their stress, adding another layer of strain on their mental health.

Mental Well-being: The Need for Regular Debrief Sessions

The SHINE study recognizes the mental toll of this work and has created debrief sessions to support community health promoters. Here, they can share experiences, discuss challenges, and rejuvenate their spirits for the week ahead. These sessions are essential for emotional resilience, allowing them to process the week’s hardships and renew their focus. However, these sessions need to happen more regularly to be fully effective, as the demands on their time and energy continue to rise.

Conclusion: Why Mental Health Matters for Community Health Promoters

A healthy mind produces healthy results. For community health promoters to thrive and continue their impactful work, their mental well-being must be a priority. Unfortunately, community members don’t always understand the weight or complexity of their workload, which can lead to a lack of appreciation and support. The SHINE study’s focus on mental well-being is a critical step forward, but it’s also vital that we continue raising awareness around the needs of these health promoters. Continuous counseling, regular debrief sessions, and community sensitization are essential in ensuring their mental resilience.

Investing in the mental health of community health promoters isn’t just a matter of supporting individuals—it’s about ensuring the well-being and longevity of the communities they serve. When we take care of those who care for us, everyone benefits.

For more on the SHINE study and its findings, please visit-SHINE Study Link

Wasiaya: A Community Health Promoter’s Journey from Chaos to Advocacy in Korogocho

In the densely populated urban slums of Korogocho, Nairobi, Community Health Promoters (CHPs) play a pivotal role in bridging the gap between healthcare systems and the local communities. One such remarkable individual is Wasiaya (aka Wasee), a CHP whose life story illustrates not only personal transformation but also the critical importance of mental health support, self-care, and ongoing training for CHPs.

As a Role Model Born from Chaos- Wasiaya’s journey into community health work was anything but straightforward. Before stepping into the role of a CHP, Wasee’s life was marked by turmoil and emotional distress. Growing up in Korogocho, she experienced the harsh realities of urban slum life—domestic violence, substance abuse in her community, and the constant threat of gender-based violence (GBV). The lack of support systems and mental health resources left her feeling isolated and unable to cope with the trauma she carried.

Her chaotic past manifested in anger and emotional instability, making it difficult to navigate personal relationships and community interactions. Yet, these challenges shaped her and motivated her to change. “I was chaotic,” Wasee recalls. “I didn’t know how to deal with my emotions, and I felt trapped in a cycle of pain…”

Wasee’s transformation began when she was introduced to a training program by Amnesty International, focusing on GBV and Violence Against Children (VAC) prevention. The training not only equipped her with knowledge and skills to support victims of violence but also provided her with coping mechanisms to address her own trauma.

Working in Kisumu Ndogo, an area within Korogocho notorious for high cases of GBV and VAC, Wasee began to connect with survivors and support them in accessing health services and legal aid. Through this work, she found a sense of purpose and healing. “Helping others allowed me to heal parts of myself,” she reflects.

Mental Health Gaps: A Hidden Burden- What SHINE Project aims to address!

Capturing voices: how to implement photovoice in mental health research

Imagine giving someone a camera and asking them to tell their story through images. The narrative shifts from words alone to something more powerful—visual, tangible, and deeply personal. This is the essence of Photovoice, a participatory research method that merges photography with storytelling, empowering individuals to share their lived experiences. Developed by Wang and Burris in the 1990s, Photovoice serves as a tool for community engagement, fostering dialogue, bridging gaps in understanding, and inspiring action. By enabling individuals to document their realities, it elevates marginalized voices and presents compelling visual narratives that demand attention and change (Hanna & Hanna, 2023). My life feels like this tree—tired and worn from the daily struggles of work and home. But I still have hope. Just like the tree grows new leaves after a tough season, I believe better days will come for me too (Farida_SK(Female)_Barisal).

In mental health research, Photovoice has gained prominence as an approach that uncovers deep insights into lived experiences. One study highlighted how participant-produced photographs captured the stigma, struggles, and recovery journeys of individuals with mental illness (Han & Oliffe, 2016). This demonstrates the transformative potential of Photovoice—not just in research, but as a means of advocacy and system-wide change. The SHINE Project—Strengthening Health Systems by Addressing Community Health Workers’ Mental Well-Being and Agency—integrates Photovoice to document the realities of Community Health Workers (CHWs). Through this method, CHWs become active participants rather than subjects of research, using photography to illustrate their daily experiences. A picture of an empty clinic, an overburdened health worker, or a rare moment of camaraderie among colleagues tells a story that words alone may struggle to convey. By capturing these moments, CHWs highlight their challenges, their resilience, and the systemic changes required to support their mental well-being.

This participatory approach strengthens advocacy efforts by ensuring CHWs’ voices are heard in discussions with policymakers and health system stakeholders. The images they produce serve as evidence, making the case for more supportive policies, better working conditions, and mental health resources within the healthcare system.