By Herman Opondo
NAIROBI, Kenya — Kenya’s efforts to strengthen universal health coverage (UHC) could be undermined by a largely overlooked crisis among the very workers expected to deliver healthcare at community level: poor mental health and wellbeing among Community Health Promoters (CHPs).
A new study by the SHINE Consortium has found that more than one in five CHPs surveyed in Nairobi and Kiambu counties had symptoms suggestive of depression, while nearly one in three reported anxiety. The burden was substantially higher among CHPs working in Nairobi’s informal settlements than among their counterparts in rural Kiambu.
The findings raise concerns about whether Kenya’s frontline community health system can sustainably deliver its expanding responsibilities without investing in the wellbeing of the workers at its centre.
The SHINE research involved 1,236 CHPs across Nairobi’s Viwandani and Korogocho informal settlements and rural sites in Kiambu County. Researchers also conducted interviews with 66 national and county-level decision-makers and used participatory approaches, including photovoice, life-history interviews and body mapping, to understand the pressures affecting frontline workers.
Nairobi CHPs face significantly higher mental health risks
The research found that 22.4% of CHPs across Nairobi and Kiambu had symptoms suggestive of depression, 30.6% reported anxiety and 12.7% experienced stress.
But the differences between the two settings were striking.
In Nairobi, 26.4% of CHPs recorded moderate or higher levels of depression compared with 8.2% in Kiambu. Anxiety affected 33.8% of Nairobi CHPs compared with 18.9% in Kiambu, while stress was reported by 15.4% in Nairobi compared with just 3% in Kiambu.
Overall, Nairobi CHPs experienced approximately 3.2 times the depression, 1.8 times the anxiety and 5.1 times the stress recorded among their Kiambu counterparts.
Researchers say the findings point to the need for mental health interventions that take into account the distinct pressures faced by CHPs working in densely populated informal settlements.
Financial pressure is adding to the burden
The mental health challenge is closely linked to the working conditions of CHPs.
Between 93% and 97% of CHPs surveyed said their monthly stipend was inadequate or unfair. At the same time, 92–94% reported regularly spending their own money on transport, airtime and even medical costs for community members they referred for care.
Kenya’s 107,000 CHPs began receiving a monthly stipend of KSh5,000 (about US$40) following reforms to the community health system. Each CHP is expected to serve approximately 100 households, undertaking health promotion, prevention, screening and referrals under the supervision of Community Health Assistants (CHAs).
However, the research suggests that the financial support does not always match the realities of frontline work.
CHPs described using personal resources to help patients reach health facilities, while delayed stipends and growing community expectations added to household financial pressures. Some workers also reported being assigned duties outside their official terms of reference.
Heavy workloads and weak supervision
Workload and performance demands are another source of distress.
Only 8% of Nairobi CHPs said their workload was manageable, compared with 24% in Kiambu. Just 12% of Nairobi CHPs reported completing their tasks on time, compared with 34% in Kiambu.
The study also found that 40% of Nairobi CHPs and 26% of those in Kiambu feared losing their roles.
At the supervisory level, some Community Health Assistants were reportedly responsible for supervising up to 100 CHPs, ten times the policy norm of 10 CHPs per CHA. Researchers say this undermines the supportive supervision expected to protect both performance and worker wellbeing.
The research also highlights pressures created by Kenya’s digital health transformation. CHPs reported long working days, electronic Community Health Information System (eCHIS) targets, late-night calls, unpredictable referrals and technical problems that sometimes resulted in duplicated work.
Climate shocks are creating another layer of stress
The pressures facing CHPs are not limited to the health system.
The study found that climate-related events are increasingly affecting both the communities CHPs serve and the workers themselves. During the 2024 floods, some households were displaced, sewage overflow increased risks of disease outbreaks, while damaged roads, bridges and mudslides made community visits more difficult.
CHPs were therefore simultaneously expected to support affected communities while experiencing the impacts of the crisis themselves.
The findings illustrate how climate change, poverty, gender inequalities and weaknesses in health-system design can intersect to affect the mental wellbeing of frontline health workers.
Women CHPs report safety and harassment concerns
Gender also emerged as an important dimension of the problem.
Female CHPs participating in the research reported experiences of sexual harassment by some male community members during household visits. Researchers say existing support systems do not adequately address the associated safety and mental-health risks.
Some women reported feeling unable to safely report harassment, leading them to internalise the experience.
The study found that CHPs use both positive and potentially harmful coping strategies. Peer-support groups, family and community networks, digital platforms and spiritual practices offered important sources of resilience.
However, some workers reported turning to alcohol or other substances, social isolation and excessive use of personal finances to compensate for gaps in the health system.
Researchers propose a scalable response
The SHINE Consortium says the evidence points to an opportunity to integrate CHP wellbeing into Kenya’s existing UHC and mental health frameworks.
Following validation and co-design workshops involving CHPs, CHAs, Ministry of Health officials and Nairobi and Kiambu county governments, researchers developed a four-component mental health and wellbeing package currently being piloted with 500 CHPs and 50 CHAs.
Researchers believe the approach could eventually be replicated across Kenya’s 107,000 CHPs.
Wellbeing needs to become part of UHC
The policy brief argues that CHP mental health should no longer be treated as an optional addition to primary healthcare reform.
It recommends that the Ministry of Health incorporate CHP and CHA wellbeing into the Community Health Strategy, strengthen psychological first aid and psychosocial support training, and establish clearer links between community health structures and county mental health professionals.
County governments, meanwhile, are urged to ensure timely and adequate stipend payments, strengthen supportive supervision, prevent CHPs from being assigned duties outside their mandate and establish confidential mechanisms for reporting harassment and gender-based violence.
The researchers also recommend formalising peer-support structures and connecting them with county mental health services.
For donors and implementing partners, the brief calls for investment in scaling the four-part intervention, supportive supervision and digital wellbeing tools, alongside continued research into how gender, climate and informal-settlement conditions affect frontline health workers.
A warning for Africa’s primary healthcare ambitions
As African countries expand community-based healthcare as a route to universal health coverage, Kenya’s experience offers an important lesson: the resilience of a health system depends partly on the wellbeing of the people delivering care at community level.
The SHINE evidence suggests that expanding the responsibilities of frontline workers without addressing financial insecurity, workload, supervision, safety and mental health could leave a critical weakness at the heart of primary healthcare.
For Kenya, strengthening the community health system may therefore require more than supplying CHPs with phones, data systems and stipends. It may also require ensuring that those caring for communities have systems that care for them.
The SHINE research was funded by the National Institute for Health and Care Research (NIHR) using UK aid from the UK Government. The researchers note that the views expressed are those of the authors and not necessarily those of the NIHR, UK Government or Kenya’s Ministry of Health.