community-based animal health workers in kenya

Community-based Animal Health Workers in Kenya

A Case Study of Mwingi District

African Union/Interafrican Bureau for Animal ResourcesCommunity-based Animal Health and Participatory Epidemiology Unit

Community-based Animal Health Workers in KenyaA Case Study of Mwingi District

March 2003

African Union/Interafrican Bureau for Animal ResourcesCommunity-based Animal Health and Participatory Epidemiology Unit

The views and opinions expressed in this report belong to the team and do not necessarily reflect the position of AU/IBAR or anyof the institutions represented in the study team.

The study team comprised of the following members:

Jean Claude Rubyogo, Food Security and Natural Resource Management Expert and Team Leader

Dr. Muriithi P. Muhari, District Veterinary Officer, Mwingi District

Professor Gilbert Agumbah,Kenya Veterinary Association and Professor of Reproduction and Obstetrics (Theriogenology),Department of Clinical Studies, Faculty of Veterinary Medicine, University of Nairobi

Obhai George, Monitoring, Evaluation and Data Specialist

Ibrahim Farah, Veterinary Field Officer, CAPE Unit, AU/IBAR

Franco Mwendwa, Animal Health Assistant, Kyuso Division, Mwingi District and CAHW trainer

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ContentsAcknowledgements

Acronyms

Executive Summary

1. Introduction1.1 Research needs in community-based animal

health service delivery in Kenya1.2 Research objectives

2. Overview of Mwingi District2.1 Social and physical characteristics2.2 Livelihoods2.3 Constraints to livestock rearing

3. Historical overview of community-based animal healthcare in Mwingi District

3.1 The World Neighbours project3.2 The Integrated Food Security Programme-Eastern

(IFSP-E) project3.2.1 Phase I: 1996 to 1998

a. Establishing the CAH systemb. Veterinary drug supplyc. Project review

3.2.2 Phase II: 1998 to 20003.3.3 Phase III: 2001 to 2002

4. Research methodology4.1. Data collection from CAHWs and AHAs

4.1.1 Questionnaire4.1.2 Workshop for AHAs

4.2 Data collection from livestock keepers4.2.1 Participatory methods4.2.2 Questionnaire

4.3 Secondary data

5. Study findings5.1. Age, education and animal health training of

CAHWs and AHAs5.2. Financial sustainability and drug supply in the

CAH system5.2.1. Duration of CAHW and AHA work

experience 5.2.2 Factors influencing service demand

a. Animal ownership and observed diseases

b. Willingness to pay for services5.2.3 CAHW business viability and trends

a. Time spent on veterinary activitiesb. Income from veterinary activitiesc. Uses of income d. Specific expenditure incurred by

CAHWs related to veterinary activitiese. CAHW preferences for drug suppliers

5.2.3 Business expansion and growth a. Positive changes b. Negative changesc. Suggestions for improvementd. Non payment for services and debts

5.3 Quality of CAHW services5.3.1 Assessment of the technical competence

of CAHWs and AHAs a. Knowledge on clinical signs of

diseaseb. Knowledge about reportable diseasesc. Knowledge and practices about

zoonotic diseasesd. Knowledge and practice on veterinary

drug usage, residues, withdrawal periods and veterinary equipment

e. Knowledge on ticks and tick controlf. Record keepingg. Future training to improve service

quality5.3.2 Perceptions of livestock keepers

5.4 Working relations between different animal health service providers5.4.1 Collaboration5.4.2 Competition

6. Discussion6.1 The AHA-CAHW system in Mwingi

District6.2 Technical competence of CAHWs6.3 Some reasons for success

7. Recommendations7.1 Recommendations to the Department of

Veterinary Services7.2 Recommendations to the Kenya Veterinary

Board7.3 Recommendations to the Kenya Veterinary

Association7.4 Recommendations to the African

Union/Interafrican Bureau for Animal Resources7.5 District CAHW organisations

ReferencesAnnexesAnnex 1 Agroecological zones map of Mwingi

DistrictAnnex 2 Animal health problems covered and not

covered during CAHW trainingAnnex 3 Sample of veterinary drug kit

compositionAnnex 4 List of CAHWs in Mwingi DistrictAnnex 5 Prices of veterinary drugs and equipment

in Mwingi TownAnnex 6 Caseloads of CAHWs and AHAsAnnex 7 List of fast-moving drugs via CAHWsAnnex 8 Organogram of the CAH system in

Mwingi DistrictAnnex 9 Reports, books and videos on CAH

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Acknowledgments

The study team expresses its deepest gratitude to theCommunity-based Animal Health and ParticipatoryEpidemiology (CAPE) Unit of the AfricanUnion/Interafrican Bureau for Animal Resources(AU/IBAR) for financial and technical support whileinitiating, carrying out and reporting this study. Thework was made possible by a grant to the CAPE Unitof AU/IBAR from the Department for InternationalDevelopment, United Kingdom. The team is alsograteful to staff of CAHNET and the nationalstakeholders who contributed to the design of thestudy and provided feedback on the draft report.Many thanks go to Mwingi livestock owners, CAHWsand DVO staff who diligently supported the team andprovided much valuable information, which willcertainly be instrumental in facilitating other people’slearning about community-based animal healthcarearound the world.

Acronyms

AAK Action Aid-KenyaAEZ Agroecological ZoneAHA Animal Health AssistantAHITI Animal Health and Industry Technical

InstituteAHSP Animal Health Service ProviderAU/IBAR African Union/Interafrican Bureau for

Animal ResourcesCBPP Contagious bovine pleuropneumoniaCCPP Contagious caprine pleuropneumoniaCAH Community Animal HealthCAHW Community-based Animal Health WorkerCAPE Community-based Animal Health and

Participatory Epidemiology Unit, AU/IBARCRD Chronic Respiratory DiseaseDVO District Veterinary Office(r)DVS Director of Veterinary Services FMD Foot and mouth diseaseFVM Faculty of Veterinary MedicineGoK Government of KenyaGTZ German Agency for Technical CooperationIFSP-E Integrated Food Security Programme -

EasternIL Inner LowlandJAHA Junior Animal Health AssistantKSh Kenya ShillingsKVA Kenya Veterinary AssociationKVB Kenya Veterinary BoardLM Low MidlandLSD Lumpy skin diseaseMoARD Ministry of Agriculture and Rural

Development NCD Newcastle diseaseNGO Non Governmental OrganizationPRA Participatory Rural AppraisalSHG Self-Help GroupVO Veterinary Officer

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Executive Summary

This report describes a study on the sustainability ofcommunity-based animal health (CAH) services inMwingi District, Ke nya. These services began in 1992and were supported by the District Veterinary Office( DVO) with assistance from the Integrated Fo o dSecurity Programme - Eastern (IFSP-E), a Ke nya n -German bilateral development programme. Over timeand using the process of participatory review withmultiple stakeholders, the system evo l ved into an e t work of community-based animal health wo r k e r s( CAHWs) who procured veterinary supplies andr e c e ived supervision from Animal Health A s s i s t a n t s(AHAs) at divisional level. Before the establishment ofthe CAH services, there were inadequate state andweak private veterinary services in the district. Before1992, live s t o ck owners were relying on tra d i t i o n a lveterinary practices or were using untrained people ona trial and error basis. By the end of the IFSP-E in2002, 99 CAHWs had been trained in Mwingi District.

The study was carried out between December 2002and January 2003 and focussed on financialindicators of CAHW performance, the technicalcompetence of CAHWs and the relationships betweenCAHWs and other animal health service providers. Itwas found that the CAHWs were trained, deployedand supervised by the DVO. A mutually beneficialand supportive arrangement existed between theCAHWs and AHAs, based on a private drug supplysystem, referral and backstopping support. TheCAHWs derived sufficient income from theirveterinary work to maintain their interest in thesystem, and farmers rated CAHWs very highly againstother service providers. Farmer assessment revealedthat CAHWs were accessible, affordable, offered atimely service and achieved good recovery rates.Seventy-nine out of 99 (80%) CAHWs in the districtwere active or very active, as rated by DivisionalAHAs. They were continuing to offer adequate animalhealth services three years or more after their initialtraining and the withdrawal of donor support. Ninetyfive percent of sampled CAHWs (n=40) viewed theirbusiness as successful and expanding.

Farmers’ perceptions of the good quality of the CAHservice were supported by an assessment of CAHWtechnical competence. A test was developed to assessCAHW knowledge of clinical signs of disease,notifiable diseases, zoonoses plus their ability to useveterinary drugs correctly and safely. The test resultswere very encouraging and 36/40 (90%) of the

sampled CAHWs passed the test. The mainweaknesses of the CAHWs were their record keepingand knowledge of zoonoses, but it was proposed thatthese problems could be overcome by refreshertraining. It was particularly noticeable that theCAHWs were using veterinary drugs correctly andhad good quality drugs in their kits. It was concludedthat CAHWs performed with a sufficient level oftechnical competence to limit problems such as drugresistance, particularly when compared with drug useby farmers and quacks1. The existence of a referralsystem for CAHWs and refresher training helped toensure that CAHW competence and ethical behaviourwas maintained.

With regard to the CAHWs’ working relationship withother animal health service providers, the studyrevealed very complementary links between CAHWsand government veterinary staff (AHAs and VeterinaryOfficers) in the district. The AHAs also owned Agrovetshops at divisional level and supplied CAHWs withveterinary drugs and equipment. There was somecompetition between CAHWs and informal serviceproviders such as traditional healers and quacks1, butthe general trend was increasing farmer preference forCAHWs due to the perceived higher quality of the

1The term ‘quack’ is used in Kenya to describe petty traders of veterinary and human medicines who are unlicensed, untrained and unsupervisedbut may claim to have technical knowledge of the products they sell.

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CAHWs. Considering the agroecological andsocioeconomic conditions of the district, CAH can beviewed as an initial stage in the process of extendingquality private sector veterinary services. This study supports many of the recent policy andlegislative changes proposed by the Kenya VeterinaryBoard to both regulate and strengthen linkagesbetween private veterinary practitioners and CAHWs.The study team supports moves towards a clear policyto allow more efficient utilisation of CAHWs via thelegal empowerment of veterinarians and para-professionals to trade in veterinary drugs. LicensedCAHWs could then source their drugs fromindependent and legalised private veterinary drugsuppliers. These drug suppliers would ideally beveterinary doctors but where there are no privateveterinarians, animal health assistants should beutilised. These private veterinary drug suppliers wouldbe obliged to provide direction to and haveresponsibility for the CAHWs’ work.

Recommendations to the Department ofVeterinary Services

• In Mwingi District, basic veterinary services arep r ovided by AHAs who are both gove r n m e n te m p l oyees and private sector operators. In thissituation, the DVS should review the public sectorroles of the AHAs and the potential to encoura g efull privatisation of the system. In such a system,the AHAs would no longer be employed byg overnment but, as private operators, could receivec o n t racts from government for specific publicsector tasks (under the supervision of the DVO). Itis likely that such an arrangement would be morecost efficient. In addition, savings derived fromi m p r oved efficiency could be directed towa r d senabling the DVO to fulfil monitoring andregulatory functions more effective l y

• In underserved areas the DVS should facilitateDVOs to provide direct or indirect assistance in theidentification, training and temporary supervision ofCAHWs according to district-specific needs. Ideally,the trained and licensed CAHWs should be linkedto private AHAs and vets for efficient supervisionand backstopping. If private AHAs or ve t e r i n a r i a n sdo not yet exist in some areas, every effort shouldbe made to encourage private sector deve l o p m e n tas CAHWs are trained.

• The licensing of a CAHW should be contingentupon an AHA or veterinarian being identified, onthe license, as the supervisor of that CA H W. Th es t u dy team emphasises that CAHWs should opera t ein the private sector. Government AHAs and

veterinarians should only be supplying drugs toCAHWs in areas where private veterinary pra c t i c e srun by AHAs or vets have yet to be established.

• Care and attention is required to ensure thatgovernment employees, including those who arealso engaged in private activities, do not preventthe development of fully privatised systems.Supervision and supply of CAHWs by governmentAHAs and vets should be seen as a temporarymeasure to improve the quality of veterinaryservices to underserved livestock owners, ratherthan a long-term solution.

• The establishment of CAH systems should bebased on a Memorandum of Understanding (MoU)between the DVS, DVOs and other relevantagencies in those areas where CAHWs are needed.The content of the MoU should be made availableto the veterinary regulatory body (KVB) and otherinterested stakeholders.

• The DVS should continue to inform those donorsand NGOs who support CAH initiatives of thenecessity of signing an MoU prior to thecommencement of their activities. This will help toharmonise approaches, ensure quality and enableappropriate project design according to the needfor immediate and full involvement of the privatesector. The DVS should formulate a set ofminimum standards and guiding principles thatimplementing agencies are required to follow andwhich can form the basis for the MoUs.

• The DVS should support the DVOs to sensitise andprepare the communities to ensure sustainability ofCAHW activities.

• Under current arrangements many state veterinarypersonnel are to be retired by the year 2012.Therefore, there is urgent need to maximise theuse of public sector veterinarians and resources forthe encouragement of private service delivery. It islikely that contracting out activities such asvaccination and surveillance will play a key role inenabling the private sector in marginalised areas.These contracts will have to be formulated andmonitored by the DVS and DVO.

• In collaboration with communities and the AHITIs,the DVOs should identify well performing andqualified CAHWs for certificate training. Aftertraining, former CAHWs could be licensed to workin their locations as private AHAs.

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• Where private veterinarians do exist, private AHAsshould work under their supervision. The processof licensing and monitoring is the responsibility ofthe statutory veterinary body (the KVB) in closecollaboration with the DVS. In areas where nop r ivate veterinarians are working, the KVB andDVS will need to conduct regular reviews toensure that government services and/or priva t ep a ra - veterinary professionals are not hinderingi nvo l vement of private professionals. The aimshould be for licensing arrangements to supportcomplementarity linkages and quality services.

• Veterinary investigation laboratories should, wh e r en e c e s s a r y, be facilitated to carry out confirmatorydisease diagnostic surveys to confirm local diseasedistributions. This would help in developing an e e d s - d r iven training curriculum for CAHWs inspecific areas. Simple diagnostic tests forepizootic or notifiable diseases should bep r ovided at divisional and district leve l s .

• The veterinary public health division of the DV Sshould be strengthened to carry out regular spot-ch e cking on animal food products at the marketl e vel to determine the actual levels of drugresidues and ensure the availability of wh o l e s o m efoods according to national and internationalmarket standards. It is understood that this mustbe accompanied by efforts to raise the producers’awareness on the effects of the drug usages andw i t h d rawal period on their incomes and onhuman health.

Recommendations to the Kenya VeterinaryBoard• In line with recent reports from the Office

International des Epizooties (OIE), the KVB shouldcontinue to delegate its supervisory powers to theDVS and DVOs in conjunction with its owncapacity to provide field inspection. This wouldstrengthen and widen its regulatory functionscountrywide. There is a need to further identify,define and license the various categories of para-veterinary professionals (including CAHWs)practicing in the districts and this information canbe compiled in the central KVB registry.

• Registered veterinarians should carry out alltraining in veterinary-related topics for CAHWs. InMwingi District there may be scope to increase theinitial 14 day training course to 21 days, in orderto strengthen training in those topics that werefound to be weak among CAHWs viz. recordkeeping and zoonoses. Other topics that might be

included in the initial CAHW training are minorsurgery and wound treatment, some improvedlivestock production techniques, aspects ofbusiness management and organisationaldevelopment plus exposure to other sources ofincome such as honey production or preparationof hides and skins (in order to complement incomederived from veterinary work).

• Trained CAHWs should be issued with a certificateof training and annually renewable work licenses.The latter should be subject to an annual,combined report of their supervisor and the DVO.Similarly, AHAs should also be regulated by theKVB and their appropriateness as independentprivate operators should be reviewed regularly.

• The KVB should identify and register suitabletrainers and examiners of CAHWs, who mightserve as an accreditation board on their behalf.The training of such trainers and examiners needsto be developed. The mechanisms for providinglicenses to para-professionals such as CAHWs,through DVOs and the DVS also needs todeveloped.

Recommendations to the Kenya VeterinaryAssociation

• The KVA should inform it’s members about theresults of this study, particularly with regards thetechnical competence of CAHWs, the potential touse CAHWs to improve the sustainability ofprivatised veterinary services in under-served areasand the potential to develop systems based on

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mutually supportive relationships betweenCAHWs, AHAs and veterinarians.

• The KVA should encourage those membersinterested in establishing private CAH systems toseek appropriate training in subjects related to thedesign and development of such systems, with aparticular focus on sustainability issues. There is awide range of training and information materialsavailable in written and video formats for thoseinterested (see Annex 9 for a list and sources ofrelevant materials).

• The KVA should continue to participate actively inpolicy dialogue concerning CAH systems in Kenya,and encourage the involvement of it’s membersfrom under-served areas in national-level debatesand meetings.

• The KVA should continue to participate in futurestudies on veterinary service provision, includingCAH systems.

Recommendations to the AfricanUnion/Interafrican Bureau for AnimalResources

• Based on the study findings, AU/IBAR shouldcontinue to advise its partners at policy level onthe extension of CAHWs to underserved areas.

• Through its intermediaries e.g. government, NGOs,CBOs and livestock owners’ organisations,AU/IBAR should continue to assist nationalveterinary services to gain the experience andcapacity to provide technical and organisationaladvice to relevant institutions involved in theinitiation and management of CAH systems.

• AU/IBAR should continue to work with veterinaryfaculties and veterinary policy makers to generatereliable information on CAH systems fordissemination to its partners. The involvement oflocal agencies facilitates and accelerates thelearning, attitudinal and institutional changeprocesses.

• As access to appropriate animal health services isa livestock owner’s basic right and a key factorcontributing to livestock production, AU/IBARshould seek to influence national policy makers toensure they improve the representation and activeinvolvement of livestock owners at policy levels.

District CAHW organisations

The capacity of CAHW umbrella organisations, wherethey exist, is still very weak. Enhancing their capacitywould go along with empowering the CAHWs toengage with other stakeholders such as the AHAumbrella organisation, livestock owner associationsand even the KVB. It could further encourage thedevelopment of codes of conduct and other self-regulatory mechanisms, improve linkages amongstCAHWs and with other stakeholders, includingprivate veterinarians.

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1. Introduction

1.1 Research needs in community-basedanimal health service delivery in Kenya

In Kenya, community-based approaches to animalhealth services have been evolving since the late1980s. These approaches aim to involve livestockkeepers themselves in project design andimplementation, and usually train community-basedanimal health workers (CAHWs) using short, practice-based training courses. Given the conditions inKenya’s arid and semi-arid lands, community-basedanimal health (CAH) systems have been implementedmost widely with pastoral and agro-pastoralcommunities, who may have limited access toconventional veterinary services.

Previous studies in Kenya have shown the positiveimpact of CAHWs in terms of decreased livestockmorbidity and mortality, and related livelihoodsbenefits (e.g. Holden, 1997; Odhiambo et al., 1998).However, while it seems that well-trained CAHWscan be effective in reducing livestock diseaseproblems, many projects suffer from poorsustainability. Typically, CAH projects have been setup by NGOs using subsidised systems of drug supplyand with limited involvement of the private sector(Catley et al., 2002). This situation applies to Kenya,and policy makers have questioned the viability ofCAHW systems in the absence of external financialsupport.

In Kenya, three major concerns regarding thesustainability of CAHW systems are as follows:

Financial sustainability of CAHW services.Sustainability of CAHW projects is related to thefinancial incentives received by CAHWs and in turn,linkages to a reliable supply of quality medicines.When supply chains fail or incentives are low,CAHWs are probably more likely to drop out of thesystem. This is thought to be a particular problemwhen NGO projects end and an alternative drugsupply system has not been put in place.

Quality of service. Some critics of CAHW systemsbelieve that CAHWs lack the necessary skills,knowledge and ethics to be entrusted withprescription drugs. They argue that CAHWs giveunnecessary and wasteful treatments resulting inlosses to livestock producers and antibiotic resistanceand residues in animal food products.

Relationship between animal health serviceproviders. It has been proposed that the establishmentof CAHW systems undermines the provision ofservices by more qualified service providers such ascertificate and diploma holders, or evenveterinarians. These concerns relate to the possibilitythat CAHWs may be able to provide a cheaperservice, and operate outside the supervision of morehighly trained veterinary workers.

1.2 Research objectives

In Mwingi District of Kenya, 99 CAHWs have beentrained and linked to relevant institutions andstakeholders. All the CAHWs have been active for atleast two years and some of them have been workingsince 1992. However, no systematic study has beencarried out to assess the sustainability and the qualityof services offered by CAHWs or their workingrelationship with other animal health serviceproviders in the district. In late 2002, the Community-based Animal Health and Participatory Epidemiology(CAPE) Unit of the African Union/Interafrican Bureaufor Animal Resources (AU/IBAR) designed a study toinvestigate sustainability issues in the CAHW systemin Mwingi District. It was anticipated that the studyfindings would assist AU/IBAR in its advisory role togovernment veterinary services, particularly withregards delivery options in underserved areas.

2. Overview of Mwingi District

2.1 Social and physical characteristics

Mwingi district is relatively a new district in Kenya,formed from the old Kitui District. It is one of thirteendistricts in Eastern Province. It covers an area of10,031 km2 and has a human population of 355,000inhabitants grouped in 55,000 households and anaverage population density of 37 inhabitants/km2

(Mwingi District Statistics Report, 2002). The district ismainly semi-arid, with 80% of its landmass classifiedin the Low Midlands five (LM5) agroecological zone(see Annex 1). The district is drought prone with a66% probability of crop failures (Office of the Vice-President and Ministry of Planning and NationalDevelopment, 1997).

The district population is predominantly of Kambaethnicity (95%). The remaining 5% is divided betweenthe Tharaka ethic community (4%) and a small mixedethnic minority e.g. Arabs and others. Social network,mutual support and resource sharing are embedded inKamba cultural values (Tiffen et al., 1994).

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Figure 2.1Mwingi District, Eastern Province

2.2 Livelihoods

Agro-pastoralism (crops and livestock) is the districtpopulation’ economic mainstay. Crop and livestockare subsistence (with very minimum use of off-farminputs), interdependent and equally important to thedistrict farming communities’ livelihood. Since thereis a 66% of probability of food crop failure, the ruralpopulation considerably rely on off-farm food supplyfrom the grain market by selling their animals. Athousehold level, the cash income derived fromlivestock keeping is estimated at 70% of all cashincome. Livestock are therefore used as living banksin case of cash needs (food supply, school fees, etc.).They are also used for ploughing, weeding anddraught power. In the year 2000, the district livestockpopulation was estimated at 178,000 cattle (Zebu),270,000 goats (East Africa, Galla breeds and theircrosses), 42,000 sheep (local), 570,000 birds(indigenous chicken) and 55,000 donkeys (MwingiDistrict Veterinary Office data, 2000).

2.3 Constraints to livestock rearing

While conducting community dialogue in 1994livestock production constraints listed by farmerscomprised ecological, institutional, social andeconomic factors (IFSPE, 1998). These included:

• Livestock morbidity and mortality due to diseaseand pests.

• Inadequate fodder and water accessibility duringprolonged drought periods (very frequent).

• Inadequate socio-economic infrastructures such asroads and markets.

• Inefficient and almost inaccessible agriculturalextension services to the farming communities.

• High poverty levels: 70% of the district populationlive below poverty line (living on less than oneUSD per day) and with high malnutrition levelsviz. about 48% of the under five children werestunted (Integrated Food Security Programme-Eastern, 1998).

• Inappropriate development interventions, whichhave facilitated the creation of a dependencysyndrome in the population.

• Inadequate and inefficient community basedmechanisms and institutions to handle livestockbased community development processes.

More particularly, the major constraints pertaining tothe inaccessibility of veterinary services were:

• Inadequacy of personnel and facilities to provideveterinary services to the farmers in remote areasof the district. The District Veterinary Office (DVO)had only three district-based veterinarians andnine Livestock Health Assistants (LHAs) headingthe very large divisions (each division is about1000 km2). Therefore, there were no formallytrained and employed para-veterinarians to staffthe locations and sub-locations.

• No private practitioner (LHA or veterinarian) wasreliably operating in the district.

• The rural economy was ill prepared toaccommodate veterinary professional fees since70% of the population was living below thepoverty line (as mentioned above) and notprepared to pay for professional quality services.

• No appropriate interventions to address theveterinary service delivery at the community anddistrict levels were forthcoming from the stateveterinary services.

Bearing in mind the above conditions, there was aneed to devise an appropriate, alternative andsustainable veterinary service delivery system adaptedto the local realities (social, economic, technical andecological). Therefore, a community-based animalhealth care was initiated with all relevantstakeholders.

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3. Historical overview ofcommunity-based animalhealthcare in Mwingi District

3.1 The World Neighbours projectIn 1992 an NGO called World Neighbours set up aCAHW project in Waita village. Thirty farmers wereselected, trained and equipped with a basic veterinarydrug kit, valued at Ksh. 30,000. With this kit, theCAHWs were supposed to deliver basic veterinaryservices to the targeted communities and WorldNeighbours was supposed to replenish the kits.Unfortunately, it is reported that the intervention didnot last and only two individuals are still activelyoffering services2. Some of the reasons advanced forthe failure for the World Neighbours’ initiative were: • Lack of consultation and inadequate consensus

building among the relevant stakeholders prior tothe project implementation

• Lack of exit strategy • Inadequate institutional linkages and support e.g.

the DVO was not involved• The initiative was material-input, supply driven

instead of being capacity building oriented.

3.2 The Integrated Food SecurityProgramme - Eastern (IFSP-E) In 1996 a new CAH system was established inMwingi District with the support of the IntegratedFood Security Programme-Eastern (IFSP-E), a Kenyan-German (GTZ) bilateral development cooperationprogramme. Initially, three pilot areas called Kyuso,Mumoni and Ukasi were selected although later, thescheme expanded to cover all nine divisions in thedistrict. The CAH system was implemented throughthe DVO and since 1996 has undergone anevolutionary process of participatory reviews in orderto adapt and adjust to emerging scenarios and trends.

3.2.1 Phase I: 1996 to 1998

a. Establishing the CAH system

The first phase of the project involved the selection ofproject areas, being areas where DVO staff did nothave easy access to communities and yet veterinaryservice needs had been expressed through communitydialogues. The project also identified relevantinstitutional and individual stakeholders who could

be the partners in carrying out the intervention suchas Intermediate Technology Development Group-EastAfrica (ITDG-EA), Action Aid Kenya (AAK)-Kyuso,World Neighbours and veterinary drug suppliers.

The other key events and activities during Phase Iwere as follows:

Community dialogues on livestock production, healthconstraints and solutions were carried out. It wasduring this time that the farmers identified and rankedprevalent animal diseases, pests and other livestockproduction and health related constraints. Theveterinary service delivery gaps and solutions werealso discussed.

Selection of CAHWs was done using criteria jointlydeveloped by the targeted communities and thefacilitators (DVO and GTZ staff). Some of the CAHWs’selection criteria included:• Adequate literacy level in English and Kiswahili

languages in order to adequately read andinterpret the drug labels and undertake training.Fluency in local community language was analready acquired asset and considered essential forextension purposes

• Social acceptability• Permanent resident of the area• Willingness to operate as a business for sustaining

the Animal Health Service Delivery (AHSD).

Design of CAHW training manual based on thelocally identified constraints. Generally, the trainingcurriculum covered the following topics:• Relevant stakeholders and their role in the scheme• Animal body systems• Basic veterinary pathology• Local diseases diagnosis, treatment, prevention

and control

2 This information was given to the investigation team by the DVO Mwingi, livestock owners and CAHWs (two functionaland five drop outs) from Waita Location where the project was implemented.

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• Identification and reporting of notifiable diseases• Basic pharmacology and drug label reading and

interpretation• Principles of animal husbandry, efficient

communication• Record keeping and report writing• Basic extension and communication skills.

The animal health problems covered in the CAHWtraining are listed in Annex 2.

Training of CAHWs was carried out over two weekswith a one-week break in between the two sessions.The trainers were DVO and GTZ staff. Certificateswere issued to trainees who passed a test set by thetrainers, and the certificates were to be renewedannually. Trainees who did not pass the test did notgraduate and they were not allowed to practice. Thisinformation was communicated to their respectivecommunities who were allowed to select othercandidates to be trained at a future trainingopportunity.

Provision of veterinary kits. Newly trained CAHWswere presented to their respective communities andduring this event they were issued with a basicveterinary drug kit and a bicycle on a cost-sharingbasis. At that same meeting, consensus on the modeof delivering services (cost and payment) was agreedupon by all the relevant stakeholders viz. community

members, local leaders, DVO staff and the CAHWs.The meeting was graced by all relevant stakeholders(DVO, GTZ, local leaders, drug suppliers, local andcommunity based institutions).

Supervision and backstopping. For supervisory andcontinuous backstopping purposes, the CAHWs wereto be supervised and supported by the governmentstaff at divisional levels who were linked to the DVO.

Annual stakeholder reviews of the system were heldat district and divisional levels. At community level,livestock owners assessed their respective CAHW’sperformance.

b. Veterinary drug supply

The first veterinary drug kit that was issued containeddrugs valued at Ksh. 11,280 (Annex 3) and eachCAHW would treat animals at a fee jointly set by theDVO and CAHWs. The system allowed CAHWs tomake a profit of 10% above the cost of the drug as amotivating factor and the remaining 90% wasremitted to the DVO staff at divisional level On behalfof CAHWs, the divisional officer would then obtaindrugs equivalent to the remitted money to refill thekit. The remission of money and the refilling of the kitwere intended to enable the establishment of aveterinary drug revolving fund scheme under themanagement of the DVO at district headquarters. TheDVO was required to write a monthly progress reportto the IFSP-E/GTZ.

This multi-layered revolving fund, with manyintermediaries, did not succeed for several reasons: a) Some CAHWs were not paid by farmersb) Some CAHWs had accrued debts to the revolving

funds because they did not submit all duepayments to the DVO

c) Some CAHWs were remitting money to thedivisional veterinary staff without being re-suppliedwith additional drugs

d) Some divisional veterinary staff were notforwarding the amount of money they were owingto the revolving funds

e) Sometimes the DVO (district headquarters) was notpassing information about the status of the funds tothe IFSP-E/GTZ.

c. Project review

In 1998, workshops was held to review the projectand the following problems were identifiedconcerning the CAHWs:a) Inadequate motivating factors - small profit

marginsb) Inadequate supervision and communication

between the CAHWs and the DVO staff.

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The complexity related to the money collectionand submission complicated the relationshipsbetween the involved parties

c) Incompatibility of function e.g. supervision ofCAHWs and the collection of returned money. Thisresulted into inadequate training and backstoppingsupport to CAHWs

d) The poor availability of drugs.

The review workshops were quite important, becausethey allowed the fine-tuning of the intervention andadjustment to the emerging scenarios. Some of theresolutions were: • The introduction of cost sharing in the initial drug

supply to CAHWs as a sign of commitment andownership of the veterinary drug kit

• The promotion of CAHW self-reliance foracquiring the subsequent drugs, instead of theDVO drug controlled supply system

• Promotion of CAHWs as community-based privateanimal health service providers in the respectivecommunities and linking them to input suppliers(equal emphasis on business management andorganizational development)

• More emphasis on refresher training sessions basedof the identified training needs and frequentexperience sharing sessions at divisional/districtlevels and also other horizontal linkages

• Invitation of more experienced CAHWs toparticipate in the training of new ones toorient/shape and give induction based on theirexperiences

Thus the second phase of the project was borne.

3.2.2 Phase II: 1998 to 2000

This phase of the project was characterised by: -• Building on previous experiences • Identification of new non-served areas to be

included following the previous process anddistrict wide expansion

• Training of 64 new CAHWs following the previousprocedures except that the veterinary drug kit tothe newly graduated CAHWs was reduced to aminimum value of Ksh. 7,000 and the bicycle wasnow to be purchased 50% on cost sharing basis

• Promotion of the CAHW as a business undertakingin a self-reliant manner and the removal ofrevolving funds were effected. CAHWs wereencouraged to source veterinary drug from privateand reliable drug suppliers

• Institutionalisation of participatory evaluation atcommunity, divisional and district state servicelevels

• Induction of DVO staff on participatory, demanddriven, community based extension approachesand skills as a contribution by the IFSP-E toefficiently backstop the CAHWs

• Encouragement of CAHWs to start self-help groups • DVO staff took the driving seat and were enabled

to efficiently backstop the CAHWs.

Achievements during this phase of the project were asfollows:

• 64 CAHWs were identified, trained, equipped,presented to their communities and linked torelevant input suppliers and other relevantinstitutional stakeholders (vertical and horizontallinkages)

• CAHWs changed their attitude from dependencyto more self-reliance, and saw themselves ascommunity-based veterinary service providersinstead of being part of the DVO staff (as was thecase in the previous phase of the project)

• Improved linkages between communities andCAHWs, CAHWs and DVO staff, CAHWs and drugsuppliers

• Initiation of CAHWs divisional self-help groups(four groups were already in place).

3.2.3 Phase III: 2001-2002

Annual reviews of the project up to 2000 enhancedcommunity awareness and resulted in demands forCAH services in hitherto excluded areas. However,not all requests could be met and from 36 communityrequests, 14 new CAHWs were identified, trained,equipped and presented to their communities usingthe approach previously described. This formed thethird phase of the project and was characterised by: • Small expansion in extremely needy areas, the

training of 14 new CAHWs• Consolidation of the previous achievements• The CAHWs’ self-help groups, which were

initiated in second phase, were consolidated andtrained on organisational development amongstother topics.

An umbrella body grouping the self-help groups at thedistrict level was formed and facilitated and is now inplace and operational.

14

4. Methods

4.1 Data collection from CAHWs and AHAs

4.1.1 Questionnaire

A questionnaire was used to collect information fromCAHWs and AHAs. From the 99 CAHWs working inMwingi District, 40 were randomly selected from alist provided by the DVO (Annex 4). The selection ofAHAs was based on their role as divisional heads,and therefore the questionnaire was administered toseven AHAs3. Thirty-four (85%) of the CAHWssampled were men and six (15%) were women. In theactual population sample, women comprised 10(10%) of the total trained 99 CAHWs. All the sevensampled AHAs were men.

The questionnaire was pre-tested on two CAHWs andtwo AHAs, and the content was adjusted accordingly.All questionnaires were administered by the researchteam members, and no other enumerators ortranslators were used.

The questionnaire focused on issues related to thefinancial sustainability of CAHW services and drugsupply, quality of services and working relationshipswith other animal health service providers. A fullcopy of the questionnaire is available4.

Financial sustainability and drug supply

The sustainability of CAHW services was assessedusing indicators such as the longevity of theirbusiness, clinical and non-clinical workload, businessturn-over and trends, service market volume anddemand. Information was also collected on drugsupply systems, service payment terms andmodalities, other non-animal health service relatedincome sources, investment options and disastercoping mechanisms.

Quality

CAHW service quality (which included knowledge,competence and ethical behaviour assessment) wasassessed according to their knowledge of clinicalsigns of disease, identification and reporting onnotifiable diseases, aspects of veterinary public health(namely zoonotic diseases), drug dosage and storage,residues in animal food products and disposal of drugcontainers. A list of diseases that CAHWs were trainedto treat or prevent is provided in Annex 2.

Assessment of CAHW knowledge and skills wasconducted using a marking scheme, as summarised inTable 4.1. The marking scheme took intoconsideration the CAHW training curriculum, theirfield experience and language capacity. Each CAHWwas interviewed by a team of two people comprisingan AHA and former trainer of CAHWs, and anotherstudy team member who did not take part in settingup the CAH scheme in the district nor training of theCAHWs. Assessment of clinical signs of disease wasalso used with seven AHAs.

The assessment involved questioning the CAHWs, butalso visual inspection of their drugs and equipment.For some questions, CAHWs were asked todemonstrate how they conducted a particular task orused a piece of equipment. The component of theassessment called ‘veterinary drug and equipmentusage’ comprised the following sub-components:

• Drug usage in relation to public health issuescomprised of drug residue, withdrawal period andcontainer disposal. This aspect was tested byasking about the appropriate advices which shouldbe given to farmers in relation to edible animalproducts (food items) after dispensing certain drugssuch as antibiotics. This was marked out of 12marks.

3 There were nine AHA divisional heads in the district but only seven participated in the discussions. Of the other two, one was absent and theother was part of the investigation team.4 Contact the CAPE Unit at AU/IBAR, Nairobi.

15

• Drug usage in relation to dosage issues comprisedof drug label reading and interpretation, estimationof cattle weight, dosage of antibiotics and otherdrugs. This was marked out of 11 marks.

• Drug usage in relation to their storage involved thephysical checking of the presence or absence ofexpired drugs, discoloured tetracycline and drugsexposed to sunlight. This was marked out of 12marks.

• Presence of essential drugs, appropriateequipments and their common disinfectants incomparison to the initial kit. This was marked outof 12 marks.

Relationships with other service providers

Assessment of the relationships between differenttypes of AHSP entailed identification of existingAHSPs within the CAHWs’ areas of operation, theirworking relationships (competition/complementarity),the referral system (if any), the impact of theserelationship on each other’s business and suggestionsfor further improvement in collaboration.

In addition to these three sustainability issues, thequestionnaire administered to CAHWs and AHAs alsocollected other information on the age, educationallevel, gender, time laps since last training and numberof refresher courses attended up to the time of thisstudy. The purpose of these auxiliary data was todetermine whether any of these factors had any effecton the three major concerns stated above.

4.1.2 Workshop for AHAs

A participatory workshop for the seven AHAs wasalso held to discuss their views on the three above-mentioned sustainability issues affecting the CAHWs.A Strengths, Weaknesses, Opportunities and Threats(SWOT) analysis was used to facilitate discussions.

4.2 Data collection from livestock keepers

Data was collected from livestock keepers usingparticipatory methods and a questionnaire.

4.2.1 Participatory methods

Participatory methods were used with 250 livestockowners from five community groups, randomlyselected through Chiefs’ barazas in Ciambui (MumoniDivision), Mwangeni (Nuu Division), Kaivirya(Tseikuru Division), Ngomeni (Ngomeni Division) andKyando (Kyuso Division). Of the 250 participants, 108were female and 142 were male. Focussed groupdiscussion was the main method used, but this wascomplemented by other participatory methods asdescribed below.

Estimates of livestock disease prevalence

Two participatory techniques were used to collectinformation on animal disease prevalence viz. pair-wise ranking and proportional piling.

For pair-wise ranking, the livestock owners listedcommon diseases affecting their livestock and thencompared these diseases in pairs. The level ofagreement between the five groups was determinedusing the Kendal coefficient of concordance W (SPSSversion 11.0).

Table 4.1Summary of marking scheme used to assess CAHW and AHA knowledge

Topic Total marks (pass mark)

Clinical diagnostic power on common cattle and goat diseases (CAHWs and AHAs) 40 (20)

Notifiable/reportable diseases (CAHWs only) 3 (1.5)

Zoonotic diseases (CAHWs only) 12 (6)

Veterinary drug and equipment usage (CAHWs only) 47 (23.5)

Ticks, tick-borne disease and their control (CAHWs only) 7 (3.5%)

Drug use record keeping (CAHWs only) 6 (3)

Total 115 (57.5)

16

For proportional piling, each of the five livestockowner groups were given 10 stones per listed diseaseor animal health problem. For example, if a groupselected 12 diseases, they were given 120 stones topile. Each group then chose a representative to pilethe stones according to how they collectivelyconsidered the common animal diseases or healthproblem in their communities. The level of agreementbetween the five groups was determined using theKendal coefficient of concordance W (SPSS version11.0).

Ranks generated by the pair-wise ranking andproportional piling methods were compared using theMann Witney test.

Assessment of animal health service providers

AccessibilityVenn diagrams were used to assess the relativeaccessibility of different AHSPs. The livestock ownersin the focus groups listed all the AHSPs theyencountered when seeking animal health services andthen used a Venn diagram to map out the physical

presence of various service providers in relation totheir households. The nearest AHSPs were placedcloser to livestock owners’ households while the lessaccessible was placed further away.

Affordability, response times and client satisfactionIn order to assess the affordability, time response andclient satisfaction of various AHSPs, a serviceprovider’s matrix was used to rank various AHSPs inrelation to these criteria. Each of the five groups wasasked to award marks ranging from 0 to 3 (don’t know= 0; poor = 1; good = 2 and very good = 3).

4.2.2 Questionnaire

Of the 250 livestock keepers who participated in theparticipatory discussions described above, 85 wereselected by their respective communities (based onvillage representation in the location) to berespondents for a questionnaire. Nineteen (23%) ofthe livestock keepers were female and 66 (77%) weremale. In common with the CAHW/AHAquestionnaire, this questionnaire was pretested ontwo livestock keepers and administered only by theresearch team.

The questionaire covered similar sustainability, qualityand relationships issues as covered by theCAHW/AHA questionnaire, and a full copy isavailable5. The livestock keeper questionnaire alsoincluded questions related to sustainability byassessing livestock density and morbidity, andwillingness to pay for clinical and non-clinicalservices. Livestock keepers’ assessment of qualityentailed post-treatment outcomes and follow-up inrelation to cadres attending cases, plus ranking oftheir social acceptability, problem solving ability,response time, and physical and economicaccessibility.

4.3 Secondary data

In addition to the participatory group sessions andquestionnaire, secondary information related to theabove areas of assessment was collected throughCAHWs financial business analysis (based on monthlybusiness activity). Their monthly reports were used toassess the business success/failure rates, existingclinical workload and potential services demands. Theinvestigators also used some other secondary datafrom the CAHWs daily case and drug use records,and the DVO reports.

5 Contact the CAPE Unit, AU/IBAR, Nairobi.

17

5. Study findings

5.1 Age, education and animal healthtraining of CAHWs and AHAs

The mean age of the CAHWs (n=40) was 35.9 years(95 % CI 33.05, 38.85). The mean age of AHAs (n=7)was 41.1 years (CI 38.45, 43.84). As governmentemployees, AHAs were supposed to retire when theyreached 55 years of age. Among the CAHWs, 12 hadreceived education to Form IV level, 16 had reachedbetween class 8 and Form III, and 4 were educated tobelow class 8 level.

The CAHWs in the sample were trained in six groupsin years before 1992 (n=1), 1996 (n=5), 1998 (n=6),1999 (n=14), 2000 (n=3) and 2001(n=11). Theduration for the initial training of each group ofCAHWs was 14 days and thereafter, three to eighttraining sessions of three days duration wereconducted for each group. Only three out of the 40CAHWs had not attended any refresher courses andall three were members of the last group to be trainedin 2001.

All 7 AHAs were trained at an AHITI for two years,and their work experience varied from 15 to 20 years.No refresher training had been provided to the AHAsapart from participatory extension approaches andproject cycle management by the IFSP-E.

5.2 Financial sustainability and drug supplyin the CAH system

As noted in section 3 the CAH system was based onCAHWs receiving medicines from AHAs, with bothtypes of worker acting as private operators. Otherthan the provision of an initial kit of veterinarymedicines immediately after their training, theCAHWs received no external material support i.e. no NGO, government or donor support. Technicalsupport was provided.

5.2.1 Duration of CAHW and AHA workexperience

Figure 5.1 shows the number of years that CAHWsand AHAs had been working prior to the study.Thirty (75%) of the CAHWs have been in the businessfor four years or more without any external materialsupport (e.g. veterinary drugs and equipment). Thetwo CAHWs with more than 8 years work experiencehad been operating as quacks6 before they wereselected by their communities for training as CAHWs.These CAHWs had been regarded as elite livestockowners or had worked worked as labourers on formerEuropean-owned farms.

5.2.2 Factors influencing service demand

The demand for animal health service is partlydependent on factors such as animal population,types of animals reared, the incidence of differentanimal health problems and the willingness oflivestock keepers to use the service.

Figure 5.1 Work experience of the CAHWs and AHAs

0

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6 The term ‘quack’ is used in Kenya to describe petty traders of veterinary and human medicines who are unlicensed, untrained and un-supervisedbut may claim to have technical knowledge of the products they sell.

18

Table 5.1 Animal ownership in Mwingi District (n=85 households)

Cattle Goats Sheep Donkeys Dogs Cats Poultry

Number of households 72 82 32 71 43 51 79owning livestock (%) (85%) (96%) (38%) (84%) (51%) (60%) (93%)

Mean number of animals 7.6 19.5 6.2 2.0 1.7 1.6 21.5in households with (5.9, 9.3) (13.8, 25.2) (2.4, 10.0) (1.8, 2.4) (1.4, 1.9) (1.4, 1.9) (17.9, 25.1)animals (95% CI)

Table 5.2Relative estimates of cattle disease incidence using proportional piling and pair-wise ranking

Method

Proportional piling: Pair-wise comparisonDiseases Total score Overall rank

Worms 95 1st 1stAnaplasmosis 62 2nd 2ndTrypanosomiasis 38 =3rd 4thEast Coast fever 38 =3rd 3rdFoot and mouth disease 30 5th 5thCBPP 13 6th 6thLumpy skin disease 5 7th =7thBlackquarter 7 8th =7thPneumonia 2 9th 9th

Agreement between W=0.58 W=0.65informant groups1 (n=5) p=0.003 p=0.001

Notes: 1 Assessed by the Kendal coefficient of concordance WThere was no significant difference between the results of the proportional piling and pair-wise ranking method using the Mann-Witney test.

Table 5.3Relative estimates of goat disease incidence using proportional piling and pair-wise ranking

Method

Diseases Proportional piling: Pair-wise comparisonTotal score Overall rank

Worms 88 1st 1stAnaplasmosis 51 2nd 2ndCCPP 49 3rd 3rdOrf 11 =4th 4thFootrot 11 =4th 5thGoat pox 6 6th =6thMange 5 7th =6th


Notes : 1 Assessed by the Kendal coefficient of concordance WThere was no significant difference between the results of the proportional piling and pair-wise ranking method using the Mann-Witney test.

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Table 5.4Relative estimates of sheep disease incidence using proportional piling and pair-wise ranking

Method


Worms 71 1st 1stAnaplasmosis 54 2nd 2ndPneumonia 14 3rd 3rdDiarrhoea 12 4th 4th

Agreement between W=0.81 W=0.80informant groups1 (n=5) p=0.007 p<0.001


Table 5.5Relative estimates of donkey disease incidence using proportional piling and pair-wise ranking

Method


Worms 58 1st 1stWounds 18 2nd 2ndTrypanosomiasis 18 2nd 2ndSkin diseases 11 4th 4thPneumonia 10 5th 5thRectal prolapse1 0 =7th =6thOvergrown hooves 0 =7th =6thRabies 5 6th =6th


Notes: 1 Associated with emaciation in donkeys 2 Assessed by the Kendal coefficient of concordance WThere was no significant difference between the results of the proportional piling and pair-wise ranking method using the Mann-Witney test.

Table 5.6Relative estimates of dog disease incidence using proportional piling and pair-wise ranking

Method


Rabies 62 1st 1stWorms 35 2nd 2ndSkin diseases 8 =5th =3rdFlea infestation 8 =5th =5thDistemper 11 3rd =5thWounds 6 7th 8thSnake bites 0 8th 7thVenereal disease 10 4th =3rd



20

Table 5.7Relative estimates of poultry disease incidence using proportional piling and pair-wise ranking

Method


Newcastle disease 75 1st 1stTick infestation 45 =2nd 2ndFowl typhoid 45 =2nd 3rdChronic respiratory disease 27 4th 4thFowl pox 9 5th 5thFleas 4 7th =6thEye infection 5 6th =6th



Table 5.8Livestock keepers’ (n=85) willingness to pay for different types of service

Type of service Willing to Reasons for willingness to pay Reasons why unwilling to paypay/not pay (Number of respondents) (Number of respondents)(%)

Advice or 7.3/92.7 Service provider has special skills (3) No cost incurred by service provider extension (34); they are expensive (1)

Castration 54.9/45.1 Recognition that the service provider No cost incurred by service provider incurs costs (i.e. equipment) (3); (5); easy, anybody can do it - so whylabour is involved (18); service pay? (2)provider has specialist skills (4); motivation purposes (1)

Hoof trimming 45.8/54.2 Recognition that the service provider No cost incurred by service providerincurs costs (i.e. equipment) (1); (1); Easy, anybody can do it (10);labour is involved (6); time factor (1) not a serious ‘sickness’ (1)

Dehorning 28.6/71.4 Physical labour used (4) Easy, anybody can do it (10)

Vaccination 64.3/35.7 Recognition that the service provider Government should pay (5);incurs costs (i.e. vaccines) (23); these services are funded bylabour involved (1); use of donors (2)specialist skills (2); time factor (1)

Clinical 92.6/7.4 Recognition that the service provider Government should pay (2); farmerstreatment incurs costs (i.e. drugs) (45); time can buy their own drugs (2)

factor (1); use of specialist skills (1)

Branding 0/100 - No cost incurred by service provider(1); they are expensive (2);government should pay (1)

Transport 0/100 - An added cost that make services expensive (1)

Drenching 83.3/16.7 Due to the cost incurred by the Easy and anybody can do it (1)service provider (i.e. drugs) (5)

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a. Animal ownership and observed diseases

Table 5.1 summarises data on animal ownershipamong the livestock keepers (n=85) who participatedin the questionnaire survey and Tables 5.2 to 5.7 showthe relative incidence of animal diseases as perceivedby livestock keepers (n=5 groups).

b. Willingness to pay for services

The livestock keepers who participated in thequestionnaire survey listed the types of animal healthservice they were willing to pay for and explained thereasons behind their decisions (Table 5.8).

The majority of farmers were willing to pay for anyintervention that involved the use of veterinarymedicines, whereas they tended not to want to pay forskilled interventions (e.g. dehorning) or transport. A list of drug prices is provided in Annex 5. Further

questionning was used to crosscheck these responses.For example, between November and December2002 (i.e. the period immediately before the study),71/85 (83.5%) of the livestock keepers requested anintervention from local AHSPs.

This information was further verified by data collectedon CAHWs’ workload and types of service provided,as detailed in Table 5.9. and Annex 6. The clinicalwork entailed the diagnosis and treatment of animaldiseases and confirms the findings of Table 5.8.

In addition to discussion with livestock owners ontheir willingness or unwillingness to pay for theservices, CAHWs and AHAs were requested toestimate their client base. Figure 5.2 illustrates boththe CAHWs and AHAs’ regular and irregular monthlyclient base.

Table 5.9CAHW and AHA caseloads in Mwingi District

Species Mean number of cases handled Mean number of cases handledper CAHW (n=40) per month per AHA (n=7) per month

Cattle 35.8 47.6Goats 83.7 89.6Sheep 9.4 9.0Donkeys 16.6 16.6Dogs 4.4 -Cats 0.8 -Poultry 30.7 -

0

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Num

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Table 5.2Numbers of clients per month as estimated by CAHWs (n=42) and AHAs (n=7)

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Figure 5.5Gross monthly income for CAHW 1, 2000 to 2002

010203040506070

1 - 25 % 26 - 50% 51 - 75% Above 75%

Proportion of income (%)

Pro

port

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Figure 5.4CAHW income derived from veterinary activites

02468

10121416

0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%

Proportion of time spent on veterinary activities

Num

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Figure 5.3How much time do CAHWs (n=39) spend on veterinary activites?

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Figure 5.8Trends in gross monthly income for three CAHWs in Mwingi District, 2000 to 2002

24

5.2.3 CAHW business viability and trends

a. Time spent on veterinary activities

It was assumed that CAHWs would not spend timedoing veterinary work unless they received financialincentives. Figure 5.3 illustrates the time spent byCAHWs (n=39) on animal health care activitiesrelative to other household activities. Twenty-fiveCAHWs (64.5% of respondents) spent over 40% oftheir time on veterinary work.

b. Income from veterinary activities

Income derived from veterinary activities by CAHWsas a proportion of total household income is

illustrated in Figure 5.4. Veterinary work constituted amajor source of income, with 80% of CAHWsderiving 26% or more of their total income from thissource. For 20% of CAHWs, more than 50% of theirincome came from veterinary work.The mean gross monthly income was KSh 1996.10(95% CI 1557.60, 2374.60). Income for three CAHWswas examined over a three-year period and isillustrated in Figures 5.5 to 5.7.

It was observed that business income had beenincreasing since 2001 for the three sampled CAHWs(Figure 5.8). This was attributed to increasing clienteleand awareness. Despite the severe drought of 2001business still showed an upward trend.

Figure 5.9Recurrent expenditure incurred by CAHWs

Figure 5.10How do CAHWs invest their income?

25

c. Uses of income

On ave rage, CAHWs used 55% of their monthlyincome on recurrent expenditures such as food items,clothing, family medical care, school fees, books,uniforms and constructions (Figure 5.9). The remaining45% was used for investments such as the purchase ofl ive s t o ck, veterinary drug kit replenishment, va r i o u sbusiness expansion activities such as food kiosk andretail shops, farm related activities (crop farming andbee-keeping), purchase of land and cash sav i n g s( Figure 5.10).

Being a drought prone area, the investment options(mainly livestock and crop farming) for CAHWs inMwingi District were heavily influenced by the abilityto cope with the frequent droughts. In case of disaster(mainly drought), 72% of the respondents sold theirinvestment, which were mainly livestock, foodreserves (grains) and land, 16% got loans fromfriends, and via social networking (merry-go-rounds);8% used their savings and the remaining 4% hadtemporary employment and reduced their recurrenthousehold expenditures in order to sustain the animalhealth service delivery.

d. Specific expenditure incurred by CAHWs relatedto veterinary activities

While delivering the animal health services, theCAHWs incurred recurrent expenses on items liketransport costs, purchase of syringes and needles,veterinary drugs costs and miscellaneous expenses.Table 5.10 summarises these expenses. The drugsconstituted the largest expenditure while deliveringanimal health services. Since the CAHWs werecovering long distances on foot or bicycle, thetransport expenditure was limited to repairing thebicycle or bus fares when they procured drugs ordelivered services to clients.

Table 5.10Mean monthly CAHW expenditure patterns in relation to veterinary activities

Item Mean monthly expenditure (Ksh) and range

Bicycle/Transport 750 (0-1500)Syringes 50 (0-140)Drugs 1200 (0-3190)Miscellaneous 350 (0-700)

e. CAHW preferences for drug suppliers

In relation to the drug supply system, the studyshowed that CAHWs sourced essential drugs on their

own within an average distance of 15km. The drugswere sourced from two major suppliers namelyagroveterinary (‘Agrovet’) shops at the divisional anddistrict headquarters. The majority of these divisionalAgrovet shops belonged to AHAs who were DVO staffat the divisional level, but also ran these privatebusinesses. Qualified pharmacists, veterinary surgeonsor AHAs owned the Agrovet shops at district level. Itwas observed that the prices offered by each playerdetermined supplier’s competitiveness. In general.price variations between small Agrovet shops at thedivisional level and the district town pharmacies wereminor.

Most CAHWs purchased their drugs at divisional leveland had been sourcing drugs independently fromthese suppliers for more than four years. However, thechoice of a particular supplier at either level wasdetermined by several factors as illustrated in Table5.11 below.

Table 5.11Reasons why CAHWs (n=40) choose their veterinarydrug suppliers

Reason Frequency (%)

Accessible 18 (43.9)Low cost 12 (29.3)Is my supervisor 4 (9.8)Knows about and stocks the best drugs 3 (7.3)Is a friend 2 (4.9)Offers credit 1 (2.4)Reliable 1 (2.4)

Eighty-eight percent of the CAHWs purchased theirdrugs in cash. It appeared that a limited group ofdrugs were popularly used by CAHWs and thisindicated the nature of problems commonly attendedby them. Fo l l owing discussions with the CAHWs andp hysical inspection of their veterinary drug kit anddrug usage records kept over a three year period, the‘ f a s t - m oving’ drugs in a descending order were asf o l l ows: Ve t wo r m / Wormicid (levamisole), Oxykel( o x y t e t ra cycline), Pe n s t r e p t o mycin, Veriben (berenil),N ovidium (homidium) and A l a mycin (oxytetra cy c l i n e ) .More detailed information on drugs procured byCAHWs in provided in Annex 7.

5.2.4 Business expansion and growth

Analysis of business records and discussions withCAHWs revealed that their services had experienceda series of positive and negative changes.

26

Table 5.12Major factors contributing to success or failure

Type of Success factors Failure factorsworker (Percentage of workers citing factor) (Percentage of workers citing factor)

CAHW Clients’ service satisfaction, farmer’s Debts (25%)confidence, and CAHWs’ knowledge/ Poor means of transport (Bicycle), giving right drugand doses (19%) preferred motorcycle (9.8%)Good relationship with clients (12%) Drought leading to low demandAccessibility of the CAHW (8.4%) and poor payment (6.1%)Refresher training attained (6.9%) Increase in cost of drugs (6.1%)Fair means of transport (Bicycle) (6.1%) Unfair competition from “quacks/bush Farmers’ willingness to pay due to doctors” (4.9%)awareness (6.1%) Inadequate diagnostic knowledge leadingIncrease in clients/demand (6.1%) to poor treatment (4.9%)Personal commitment (5.3%) Lack of capital (Drugs) (4.9%)Loyalty/honesty/Trustworthiness (3.8%) Sparse population (3.7%)Marketing of services using public Farmers are not able to afford services (3.7%)barazas (3.8%) Involvement in other activities (2.4%)

AHA Prompt response to cases (14.2%) Lack of adequate diagnostic toolsReasonable charges (14.2%) leading to poor treatment (14.2%)Reliable transport from the Farmers were not willing to pay because government (14.2%) they thought services were free from the Salary that enables them to procure governmentdrugs (14.2%) Long distance to get drugs (for those Confidence/knowledge/skills (14.2%) without adequate transport means) (14.2%)

Farmers are not able to afford services (14.2%)

a. Positive changes

Thirty eight of the CAHWs (95%) noticed a positivebusiness trend. Indicators of this trend included risingincomes, more drugs in their kits and more CAHWsviewing their work as a form of self-employment.Thirty four of the CAHWs (85%) suggested that thistrend was due to an increasing demand associatedwith increased livestock owners’ awareness andsatisfaction. The remaining 6 CAHWs (15%) attributedthe change to a stable demand but good crop harveststhat had boosted livestock owners’ liquidity.

b. Negative changes

Two CAHWs (5%) noticed a negative business trend.The major reason contributing to the failure wasdrought that reduced the number of clients and theirability to pay for services. Other reasons for failureswere loss of veterinary drug kit, late issuance of thekit and increase in the cost of drugs.

When asked to detail the factors that might havecontributed to the business success or failure, both

Table 5.13Reasons for debts and non-payment of services as perceived by CAHWs (n=40)

Reason Frequency of responses

No ready cash until farmers sell the produce/market day 15Farmer have money but don’t want to pay 7Low economic income of farmers/cash flow 4Farmers who think CAHWs are employed/volunteer to offer free services 4Farmers want to pay after seeing the outcome 2Gender discrimination against female CAHWs 1Migrated/not around 1

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CAHWs and AHAs enumerated major factors asshown in Table 5.12.

c. Suggestions for improvement

Both CAHWs and AHAs were asked to suggest waysto improve veterinary services in a sustainablemanner in the district. Their responses weresummarised as follows:

CAHWs• Advanced/further training (AHA level)• Loan for purchase of veterinary drugs, basic

equipment i.e. spray pumps and means oftransport (bicycle, motorcycles)

• Training in vaccination

AHAs• Advanced/further training (Diploma level)• Better salary• Storage of vaccine at divisional level

Regarding the CAHW proposal for training invaccination and the AHA wish for vaccine storage atdivisional level, 64.3% of livestock ownersinterviewed were willing to pay for vaccinationservices (Table 5.8).

d. Non payment for services and debts

Table 5.12 above shows that debts were considered tobe a major factor in business failure. When asked togive reasons why they incurred debts, 90% of CAHWsand AHAs associated non-payment with socio-economic conditions of their communities viz.poverty and subsistence production systems. Table5.13 provides more details on causes of debt.

Considering the importance of debt as a cause ofbusiness failure, CAHWs were requested to indicatehow they recovered debts from their clients andwhether or not they accepted payment in kind. About70% of CAHWs waited until their clients paid thedebt or the CAHWs continued reminding their clientsuntil they paid. About 25% of the CAHs soughtalternative ways of debt recovery such as seekingassistance from provincial administration (Chiefs).About 4% of CAHWs accepted payment in kind,including provision of manual labour (Figure 5.11).The respondents explained that the number (value) ofitems paid in-kind was based on the market value ofany one item at the time.

5.3 Quality of CAHW services

5.3.1 Assessment of the technical competenceof CAHWs and AHAs

A marking scheme for testing CAHW knowledge wasbased on a total score of 115 marks and a pass markof 57.5 marks (Table 4.1). The test results aresummarised in Table 5.14 and show that 36 (90%) ofCAHWs passed the test despite a very short period oftraining (14 days initially followed by three-dayrefresher courses).

a. Knowledge on clinical signs of disease

This part of the test carried 40 marks and the resultsare presented in Table 5.15. This test was also given tothe seven AHAs and all seven passed the test (meanscore 28.4 marks).

It was notable that some CAHWs were able todescribe diseases that were not covered in theirtraining e.g. canine distemper (kwekethya) in dogs,and colic-like disease syndrome and rectal prolapsein donkeys.

b. Knowledge about reportable diseases

CAHWs knowledge and practices related to notifiablediseases were evaluated by asking them to name atleast two notifiable/reportable cattle diseases. It wasmarked out of 3 marks. The pass mark was 1.5 marks.Thirty-six (90%) of the CAHWs passed the test andwere able to convey relevant information to theveterinary authorities in their areas of operation.

c. Knowledge and practices about zoonotic diseases

During this part of the test CAHWs were asked toname three zoonotic diseases, state how they werecontracted and to give methods of prevention.

Figure 5.11 In-kind payments for CAHW services

Table 5.14Overall CAHWs score distribution on quality of services

Topic Mean Proportion of CAHWs(Total marks/pass mark) score passing the test (%)

Clinical signs of disease (40/20) 22.0 67.5Notifiable/reportable diseases (3/1.5) 2.4 90.0Zoonotic diseases (12/6) 4.0 52.5Veterinary drug and equipment usage (47/23.5) 30.5 93.0Ticks and tick-borne disease control (7/3.5) 4.9 88.0Drug use record keeping (6/3) 3.2 72.5

Total (115/57.5) 70.8 90.0

Table 5.15Assessment of CAHW knowledge on clinical signs of disease

Score Proportion of workers achieving score (%)

CAHWs (n=40) AHAs (n=7)

10-14 7.5 015-19 25.0 020-24 27.5 14.325-29 27.5 42.930-34 12.5 42.935-40 0 0

Total 100.00 100.0

NotesThe pass mark for this component of the assessment was 20 marks. 67.5% of CAHWs and 100% of AHAs passed the test.

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It was shown 21 CAHWs (52.5%) passed this sectionof the test. Thus a large proportion of the CAHWswere weak in this area.

d. Knowledge and practice on veterinary drug usage,residues, withdrawal periods and veterinaryequipment

This part of the test covered knowledge and actualuse of veterinary drugs, including estimation ofdosages and safe use of veterinary drugs andequipment. Results are summarised in Table 5.16 andshow that 37 CAHWs (93.5%) passed the test.

Table 5.16Test score distribution for CAHWs’ knowledge anduse of veterinary drugs and equipment usage

Score Number of CAHWs achieving score (%)

18-23 3 (7.5)24-29 13 (32.5)30-35 19 (47.5)36-41 4 (10)42-47 1 (2.5)

Total 40 (100)

NotesThe pass mark for this component of the assessment was 23.5marks. 93.5% of CAHWs passed the test.

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The study revealed that CAHWs were knowledge-able, skilled and ethical in administering and storingessential drugs and equipment. However, 30% of therespondents mentioned the need for refresher trainingin topics such as drug residues and withdrawalperiods. According to both the DVO and CAHWs,these aspects of public health were not well coveredduring the initial and subsequent training.

e. Knowledge on ticks and tick control

The section of the test dealing with ticks and tickcontrol included correct dilution of acaricide. Thirty-five CAHWs (87.5%) passed the test and overall, theirknowledge and practice was considered to beadequate.

f. Record keeping

This section comprised checking the availability ofrecords on drugs usage and the reliability of therecords. Twenty-nine CAHWs (72.5%) passed the test.Although the majority of CAHWs passed, a fewCAHWs need to be reminded on this vital aspect ofservice provision.

g. Future training to improving service quality

In relation to the length of the initial training of theCAHWs (14 days), the relevance of the topics coveredand the provision of any refresher courses (if any), theCAHWs were asked to provide information on theseaspects and how they were relevant to their fieldexperiences. They were also requested to suggestways in which each of these factors could beimproved in future trainings.

All CAHWs said that both the initial and refreshertrainings were relevant to their field experiences.However, certain aspects needed be added orthoroughly re-visited, as knowledge gained in theseareas appeared to have been inadequately covered bythe trainers based on CAHWs field experiences. Asection of the trainers (AHAs) also expressed someknowledge gaps in some areas.

Animal diseasesThe majority of CAHWs and AHAs suggested that thetraining in donkey and poultry diseases needed to beexpanded to cover details about locally endemicdiseases and newly reported diseases. Dog, sheep andgoat diseases followed this closely. It was also felt thatmore information and knowledge on notifiablediseases was needed.

Clinical courseOn clinical subjects the majority of CAHWs suggestedthat their training should touch on basic obstetricsand minor surgery. Although some information wasprovided on drug use (basic pharmacology) duringtheir initial training, the respondents felt that thecoverage was inadequate and CAHWs would likemore exposure in the topic. There was also need formore training on vaccines, vaccine storage andvaccination techniques in all animals. A few CAHWssuggested also that the training should cover postmortem, plant poisoning, and disease diagnosistechniques. It would be prudent to train CAHWs onsome basic sampling techniques, handling andsubmission to the supervisory/referral level where abasic confirmatory diagnostic facility (laboratory) wasavailable.

Animal husbandryThe majority of CAHWs suggested that training shouldcover topics on castration of dogs and donkeys. SomeCAHWs also suggested inclusion of some topics onanimal husbandry such as animal breeding, includingartificial insemination (AI). Basic information aboutadvantages and disadvantages of AI could be taught tothe CAHWs in order to strengthen their positions asfield extension agents.

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Institutional and business developmentMost workers expressed knowledge gaps oninstitutional development, business management andreport writing. These topics were not touched in eitherinitial or refresher courses. Our fieldwork confirmedthe need for the inclusion of these topics in theCAHW/ AHA training.

5.3.2 Perceptions of livestock keepers

In addition to the above assessment of CAHWs’competence, skills and ethical attitude in deliveringveterinary services, other AHSPs operating in thedistrict were also assessed by livestock owners incomparison to CAHWs. The customers’ satisfactionwas assessed using the following criteria:

• Accessibility of service (physical distance andservice cost)

• Response time• Service outcome• Other social responsibilities, if any

The results produced by Venn diagramming of serviceproviders are shown in Figure 5.12 and indicate closeproximity of CAHWs to livestock owners relative toother service providers.

Figure 5.12Accessibility of animal health service providers to livestock owners in Mwingi District

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Table 5.17Livestock owners’ assessment of different animal health service providers

Indicator Median score (range)

AHA CAHW Farmer Traditional Agrovet QuackHealer

Affordability 2.2 2.6 0.6 0.8 0.4 0.2(1-3) (2-3) (0-1) (0-2) (0-1) (0-1)

Response time 2.0 2.6 0.6 0.8 0.6 0.2(1-3) (2-3) (0-1) (0-3) (0-1) (0-1)

Clients service satisfaction 2.4 2.4 0.8 1.0 0.6 0.2(2-3) (2-3) (0-2) (0-1) (0-1) (0-1)

Notes : N=5 informant groups; there was significant agreement between the informant groups (Kendal coefficient of concordance W=0.69. Each informant group scored each animal health service provider using scores of 0 to 3 (0=do not know, 1= very poor, 2=goodand 3=very good).

Table 5.18Livestock owners’ satisfaction of different animal health service providers

Indicator Percentage of informants (n=85) satisfied with:

AHA CAHW Farmer Traditional Agrovet QuackHealer

Affordability 69.1 82.3 63.6 55.6 50.0 0

Response time 61.8 85.5 50.0 66.7 25.0 100

Service outcome 87.3 90.3 54.6 0 50.0 0

Table 5.19Required qualities of CAHWs as perceived by livestock keepers (n=85)

Characteristic Frequency of responses (%)

Socially accessible/responsible (honest/faithful/transparent) 37.7Available/reliable/resident (reliable/family man) 11.9Active/likes and interested in his work (hard work) 11.3Education (preferably above Standard 8/ literate/can read and write) 10.1God fearing, humble, patient, mindful and merciful 7.9Quick response 6.6Volunteer 6.2Can be male or female 3.0Preferably a man 1.7Good health 1.7Livestock farmer 1.4

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The use of ranking methods with the same informantgroups who constructed the Venn diagrams show e dthe relative response time, service outcome andove rall client satisfaction, as summarised in Table 5.17.

The results derived from ranking methods (Table 5.17)were cross-ch e cked against data from thequestionnaire survey with live s t o ck keepers (Ta b l e5 . 1 8 ) .

On general, the results derived from the participatorymethods and the qestionnaire were similar. The mainpoints were as follows:

• CAHWs were highly ranked for offering affordableservices with timely response and a satisfactoryservice outcome. They were closely followed bythe AHAs

• Traditional healers and quarks had particularlypoor post-treatment outcomes

• The Agrovet stores were relatively inaccessible tofarmers and therefore tended to be ranked low.

Although no quantitative associations between serviceoutcomes and factors such as accessibility and timelyresponse were calculated, informants suggested thatCAHWs achieved good recovery rates because oftheir nearness and timely response. A CAHW ‘on thespot’ would get a better recovery rate because of earlytreatment compared with a veterinarian arriving a daylater.

Regarding the social activities of CAHWs, 84% ofCAHW respondents participated in leadership roles intheir communities. These responsibilities includedleadership roles in self-help groups, schoolcommittees and church and volunteer organizations.This might be an indication that their leadership skillswere considered during their selection. CAHWsinvolvement in social responsibility was also a vehiclein marketing their services. Those who were involvedin other social responsibility tended to perform betterin providing AHS.

Since the success of CAHWs heavily depended ontheir selection criteria, livestock owners were asked tostate what characteristics would be used in selectingcandidates to be trained as CAHWs. Table 5.19 showsthe suggestions provided by livestock owners. The fivetop characteristics (80%) were criteria which couldonly be set and evaluated by the community itself(livestock owners).

5.4 Working relations between differentanimal health service providers

5.4.1 Collaboration

Formal, semi-informal and informal animal healthservice providers operated in the district. The formalsector comprised agrovets and state ve t e r i n a r yservice providers viz. six Junior Animal HealthAssistants (JAHAs), nine AHAs and three VO s(including the DVO )7. An organogram of the systemis shown in Annex 8. The informal sector comprisedherbalists, traditional healers and quacks while thesemi-informal sector comprised of CAHWs. Th es t u dy revealed good and complementary wo r k i n grelationships between CAHWs and AHAs, wh oshared veterinary equipment and drugs. They alsoshared knowledge, skills and a bi-directional caser e f e r ral system depending on the case complexity.This model of operation, linking CAHWs to A H A sextended the cove rage of quality services, allow e dviable business volume and kept the service costl ow, thus reducing the poor quality service prov i d e dby the less qualified but competitive informal sector.The system is illustrated in Figure 5.13.

Figure 5.13Drug supply system/technical linkages in the MwingiDistrict CAH system

7 JAHAs have a certificate in animal health (course duration of 1 year), AHAs are diploma holders in animal health (course duration of 2 years),VOs are graduate veterinarians.

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When asked to suggest how they would furtherenhance the existing positive collaboration, CAHWsand AHAs gave different suggestions, as summarisedin Table 5.20.

CAHWs’ suggestions on how to improve theircollaboration included reference to a specificorganisation for CAHWs. It was observed that adistrict level umbrella association called the MwingiDistrict Wasaidizi Association (MDWA) had beenestablished and this association comprised threesmaller divisional Wasaidizi self help groups. Some ofthe functions of these groups include:

• Enhancing the CAH system

• Regulation of their code of conduct (the code ofconduct was agreed upon between the DVO andthe CAHWs, and was functional)

• Promotion of their socio-economic welfare.

The newly formed association was still facing somechallenges especially in the areas pertaining toorganisation development and managerial capacities.In our view, the formation of this association augurswell for the sustainability and quality of CAH deliverysystems and good inter-service provider relationships.

CAHW often referred difficult cases to AHAs andFigure 5.14 gives an overview of the type of casesreferred and the frequency of referral.The distance to the referral points i.e. where thenearest AHA could be reached, ranged from 4 to 40kilometres with the majority (70%) of CAHWsreferring to a distance of between 4 to 20 kilometres,as illustrated in Figure 5.15.

Table 5.20CAHW and AHA suggestions on ways to improve collaboration

CAHWs AHAs

Capacity building Capacity building• Hold regular joint meetings/workshops with • Hold regular meetings/workshops

other AHSPs • Hold field days to help educate farmers • Go for exposure tours about benefits of veterinary care• Increase the number of monitoring visits by • Go for exposure visits/ tours

state veterinary staff• Conduct participatory monitoring• Collaboration should be stressed during

trainings• Strengthen and empower interest groups e.g.

CAHW organisations

Service marketing Service marketing• Sensitise farmers through barazas to seek veterinary • Harmonise the extension approach

services when their animals are sick to farmers• Discourage farmers from buying their own drugs• Encourage the establishment of quality local drug

supply systems• Deploy more AHAs to be closer to CAHWs at

field level

Figure 5.14Type of referral cases and number of CAHWs makingreferrals (n=40)

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Table 5.21Attendance of clinical cases by different animal health service providers in Mwingi District

Species CAHWs AHAs Farmer (self) Quacks Traditional Not attendedhealers

Cattle 38.6 29.8 17.5 5.3 1.8 7.0Goats 54.8 17.7 19.4 4.8 0 3.2Sheep 50.0 0 33.3 16.7 0 0Donkeys 37.5 31.3 0 12.5 0 18.8Dogs 13.3 40.0 13.3 0 0 33.3Poultry 12.8 12.8 38.5 10.3 0 25.6

Note: Data derived from the questionnaire survey of livestock keepers (n=85).

Table 5.22Relationships between CAHWs and other animal health service providers, as perceived by CAHWs

Positive Negative

Other 13 CAHWs reported that they shared 5 CAHWs regarded other CAHWs asCAHWs ideas, knowledge, they sometimes competitors, therefore reducing their profit

loaned/shared vet drugs. margins and service demands.

AHAs 20 CAHWs viewed AHAs as advisers and 5 CAHWs viewed AHAs having a negative impacttrainers to whom they referred difficult on their business due to competition, whichcases and who supervised their work. reduced their profit margin and service They also viewed them as their drug demand.suppliers, assisted them when they were not around and popularised their work.

Traditional 13 CAHWs viewed traditional healers 1 CAHW reported traditional healers operatinghealers operating in the area as complementary in his area as competitors because they reduced

because they shared ideas, knowledge his profit margin and service demandand assisted in their absence. They also dealt with different diseases and used different medicines.

05

1015

2025

3035

4045

4-10 11-17 23 - 29 18 - 22 30 - 36 37 - 42

Distance to referral point (Km)

Pro

port

ion

of C

AH

Ws

(%)

Figure 5.15Cases referred by CAHWs as distance to the nearest AHA

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Farmers 7 CAHWs viewed farmers who offered 31 CAHWs reported farmers as competitorsthe same services as positive and who lowered their service demand, misleadingcomplementing their work. They said that other farmers to reject their services sincethey shared ideas, exchanged knowledge, CAHWs were not GoK staff, making wrong reduced their workload, assisted in their diagnoses, using fake drugs, under-dosingabsence and also helped in offering their patients and hence might cause drug first aid to cases resistance

Quacks 1 CAHW saw quacks’ activities as 11 CAHWs saw quacks as unskilled competitorsbeing positive and complementing who reduced their profit margin, misled farmers,their services and sharing knowledge. made wrong diagnoses, gave wrong treatments,

used fake drugs and therefore believed that they caused deaths in animals

AgroVet 4 CAHWs saw agro-vets as their drugs Nonesuppliers and sometimes offered them drugs on credit.

Table 5.23Relationships between AHAs and other animal health service providers, as perceived by AHAs

Positive Negative

CAHWs All 7 AHAs reported that CAHWs offered 5 AHAs viewed CAHWs as form of first aid to cases and assisted where they competitors who overcharged farmers, undercould not reach, complementing their work, dosed animals therefore caused drug reduced animal death rates and hence resistance and lowered farmers’ confidence increased animal productivity in AHSPs work

Other AHAs 2 AHAs viewed private AHAs1 as comple- One AHA said that private AHAs1 werementarity because they assisted in areas negative to the profession because they did where they could not reach, helped in not give reports nor monitored disease first aid cases, reduced animal death rates situation in their areas of operationand hence increased animal productivity

Traditional None Nonehealers

Farmers 4 AHAs viewed farmers as positive because 6 AHAs viewed farmers as competitors whothey referred cases to them, helped in first reduced their profit margins, gave wrong aid cases, thereby reducing their workload. diagnoses and under dosed animals under

their care, causing drug resistance

Quacks 3 AHAs reported that quacks referred difficult 5 AHAs viewed quacks as competitors whocases to them, shared ideas and knowledge reduced their profit margins, gave wrong with them, and helped in first aid cases, diagnoses, under dosed animals under their

care, causing drug resistance and thereforelowered farmers confidence in AHSPs work

AgroVet None None

1 There were two private AHAs; one was a student who operated during holidays and the other was retired GoK staff who operatedsporadically. We were not able to meet them during the fieldwork

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5.4.2 Competition

Minor competition existed against CAHWs and theformal sector from the informal sector. As shown inTables 5.17 and 5.18, livestock owners preferred touse the semi-informal sector (CAHWs) and the formalsector (AHAs), mainly due to the poor serviceoutcome when informal service providers were used.The relative attendance of cases by different serviceproviders is summarised in Table 5.21 and supportsdata on livestock keepers’ perceptions of theaccessibility, affordability and service outcomes.

Table 5.21 also shows that a considerable untappedmarket for CAHWs and AHAs existed, being the casescurrently handled by farmers, traditional healers,quacks or cases not attended. This volume of businessappeared to be a significant opportunity for CAHWsand AHAs. It was possible that livestock ownersusing the informal sector are far from current CAHWsor any other qualified service.

Looking specifically at different species, sheep wereeither attended to by livestock owners or referred toless expensive AHSPs such as CAHWs; sheep did notconstitute a significant proportion of householdanimal ownership (Table 5.1). Poultry formed a verysignificant proportion of household animal ownershipbut were mainly attended to by livestock ownersthemselves because of two major reasons:• livestock owners were not aware of modern

veterinary medicines for the treatment of poultrydiseases;

• a major problem was Newcastle disease and theirbirds died despite being attended to by CAHWsand AHAs.

When livestock owners felt less knowledgeable abouta particular problem, they preferred to use better-trained service providers such as CAHWs and AHAs.Tables 5.22 and 5.23 show the perceptions of CAHWsand AHAs regarding their relationships with otherservice providers.

6. Discussion

Many studies have been conducted on CAH systemsin Kenya. These include assessments focussing onimpact on livestock disease and benefits to livestockkeepers (Holden, 1997; Odhiambo et al., 1998; TheIDL Group and McCorkle, 2003), assessment of theperformance and sustainability of CAHWs (Mugunieriet al., 2003) and a review of the economic viability ofdifferent delivery models involving CAHWs (Okwiri etal., 2002). Furthermore, the economic rationale for

the privatised delivery of veterinary services includingthe use of para-veterinary professionals is well known(McDermott et al., 1999; Leonard et al., 2003) andspecific experience of private veterinarians workingwith CAHWs is starting to emerge (e.g. Ririmpoi,2002). Our study in Mwingi District agrees with thegeneral findings of these previous studies in otherareas of Kenya, namely that CAHWs are anappropriate way to improve basic veterinary servicesin areas which are under-served by veterinarians. Ourstudy examined the sustainability of CAH in MwingiDistrict and concluded that the existing system basedon CAHWs linked to AHAs performed well withregards financial indicators and quality of service.

6.1 The AHA-CAHW system in MwingiDistrict

The study provided useful information on the financialsustainability, quality and system linkages of CAHWservices in Mwingi District. These three aspects ofsustainability were considered to be closely inter-related. It was concluded that CAHW services were ofadequate quality and complemented the activities ofAHSPs in the district, most notably the AHAs. Fromthe 40 CAHWs sampled, only two (5%) were inactiveand offering only intermittent services.

The CAHW services in Mwingi District wereconsidered to be sustainable. The CAHWs were veryself-reliant with regards procuring relevant inputs andthey were motivated by income derived from theirveterinary work and the social recognition theyreceived. Table 5.8 shows that livestock keepers weremost willing to pay for clinical services (includingdrenching), vaccination, castration and hooftrimming. This finding was supported by informationon CAHW caseloads, showing that they handledsubstantial numbers of cases per month (particularlycattle and goats) (Table 5.9). Furthermore, informationon CAHW incomes indicated that income derivedfrom veterinary work was sufficient to keep theminvolved in the system (Figures 5.4 to 5.7). Althoughsome livestock keepers still felt that the governmentwas responsible for providing assistance such asclinical and vaccination services (Table 5.8), theoverall trend was a rising demand for CAHW services.More livestock owners were requesting the services ofthe existing CAHWs and there were requests toextend the system into areas not covered by CAHWs.When compared to others AHSPs in the district,CAHWs were highly rated in terms of theiraccessibility (Figure 5.12) and affordability, timelyresponse and overall client satisfaction (Table 5.17and 5.18).

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The CAHWs were able to establish a mutuallybeneficial relationship with other AHSPs, especiallythe AHAs. The introduction of the CAH system in thedistrict facilitated a new arrangement for the deliveryof veterinary services. Each cadre exploited a nicheservice market built on a bi-directional referral systemand comparative advantages. Most of the time, AHAsfocused on difficult cases, supplying veterinary drugsand providing backstopping services to CAHWs. Thiscomplementarity between CAHWs and AHAs for theprivate supply of supervised, clinical services agreeswith the findings of previous studies in Kenya (e.g.Holden, 1997). Also, an economic assessment ofdifferent models of veterinary service delivery inWajir, Marsabit, Turkana, Kajiado and Meru districtsconcluded that privatised networks of AHAs linked toCAHWs were the most economically feasibleapproach to provision of sustainable primary-levelservices (Okwiri et al., 2001). In common with ourstudy, this economic review noted the relatively lowsalary expectations of CAHWs and AHAs, theiracceptance by communities and their willingness tolive and work in rural areas (compared withveterinarians). In addition, our study showed thatCAHWs were able to handle non-cash payments fortheir services, including payments in livestock, grainand labour (Figure 5.11). It seems unlikely that higherlevels of veterinary worker, such as veterinarians,would be satisfied with these types of payment.

The drug supply system to the CAHWs was found tobe effective. It was adhered to by the CAHWsprobably because of the necessity to obtain anannually renewable practice licence from the DVO.These DVO-CAHWs linkages also assisted in thesourcing of appropriate veterinary drugs. It wasnoticeable that during the study, only a single case offake trypanocidal drug was encountered amongst the40 CAHWs’ kits. This is likely to maintain quality ofthe CAHWs’ services and is also compatible with thecurrent memorandum of understanding between theDVS and DVOs for purposes of CAHW utilisation andsupervision.

In common with many other rural areas of Kenya,conventional clinical veterinary service delivery basedon private vets providing case-side diagnosis andtreatment is not currently feasible in much of MwingiDistrict. The poor infrastructure in the district,subsistence livestock production systems and hightransport costs for a private veterinarian means thatprofits would probably be too low to support aconventional veterinary practice. In contrast to theneeds of a veterinarian, our study showed thatCAHWs and AHAs were able to operate privateservices and had been doing this for a number of

years. The system would be strengthened by theinvolvement of veterinarians running pharmacies inthe main urban centres to supply and supervise thework of AHAs and the overall service. This approachdeserves further assessment and should take accountof the fact that a private AHA system already existsand has proven to be robust and well-suited to theeconomic conditions in the district. Veterinarianswishing to establish new businesses would need to beconfident that their work would add value to theexisting system and would be paid for by livestockkeepers.

At present, AHAs in Mwingi District are both publicsector employees and private sector owners ofAgrovet shops at divisional level. This dual role of theAHAs seemed to be appropriate in 2003 for theparticular conditions of the district, though it isimportant that AHAs do not have responsibility forinspecting their own businesses. The DVO has overallresponsibility for ensuring that the Agrovet shops arestocking good quality drugs, but to inspect theseshops and monitor the AHAs and CAHWs, the DVOrequires adequate resources.

If, in the future, private vet services are demanded byowners it will be important to ensure semi-privatisedAHAs (partly working in government) do not hindertheir development. The DVS and KVB would be wiseto monitor this situation carefully.

In Mwingi District it was noticeable that the stronglinks between CAHWs and AHAs was partly based ona referral system. As shown in Figure 5.14, all theCAHWs interviewed referred obstetrical and surgicalcases to AHAs, plus cases where a diagnosis was notmade or could not be handled by the CAHW.

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In contrast to the AHA-CAHW relationship, there wassome competition between CAHWs and informalservice providers (farmers, quacks and traditionalhealers) (Table 5.22). This did not seem to affect theCAHWs very much, possibly because many cases inthe district were not attended (Table 5.21). Therefore,further market penetration was still possible forCAHWs. In addition, farmers often noted that CAHWshad taken over the clientele of quacks because peoplerecognised the better quality of the CAHWs.

6.2 Technical competence of CAHWs

An important aspect of sustainability is service quality.The quality of service is not only a professional andethical issue, but also relates to a service-marketingstrategy and association between service sustainabilityand customer satisfaction.

The study looked at service quality from theperspective of livestock keepers (e.g. the clientsatisfaction responses in Table 5.17) and conducted aformal assessment of CAHW skills and knowledge.Based on this formal assessment, the majority (90%)of the CAHWs in the study sample were judged to becompetent in providing services with requireddiagnostic skills, ethical behaviour (including posttreatment follow-ups) and correct use of drugs andequipment (Table 5.14). Although professionalveterinary associations and other bodies often expressconcerns that CAHWs use drugs wrongly andencourage drug resistance (The IDL Group andMcCorkle, 2002), the findings of our assessmentdispute these views. Even with a short initial trainingof only 14 days duration followed by refreshertrainings, CAHWs were technically competent. Thisfinding indicates that duration of CAHW training isnot a useful measure of training quality and thatpolicy makers should not automatically reject coursesthat appear to be of short duration relative to moreformal training approaches. Participatory approachesto CAHW training based on the principles of adultlearning are recommended (Iles, 2002).

According to Taylor (2003), referral systems andrefresher training in CAH systems are useful ways tomaintain and improve diagnostic capacity and use ofdrugs, and thereby limit the emergence of drugresistance. Both a referral system and refreshertraining were features of the CAH system in MwingiDistrict.

The main technical weaknesses of the CAHWs werepoor record keeping and knowledge on zoonoticdiseases. It was interesting to note that both theseareas could be viewed as non-profit making activities

but nevertheless, further training and follow-up wasrequired.

6.3 Some reasons for success

We concluded that the sustainability of the CAHsystem in Mwingi District was related to carefuldesign and management of the system. Importantfactors during project design and implementationwere as follows:

• The need to respond to a major need of thelivestock owners themselves, being improvedaccessibility of veterinary services.

• Adequate community participation in setting upand managing the CAHW services.

• The role of the DVO in initiating, steering andproviding continuous support to the CAHWs.

• Reliable and continuous technical support fromthe IFSP-E to the DVO until the end of the IFSP-Eprogramme in 2001.

• Involvement of other relevant stakeholders in thedistrict to broaden ownership e.g. local leadershipand veterinary drug suppliers.

• Stakeholder determination of their roles andresponsibilities leading to harmonization ofdifferent players in the system.

• An iterative and process-oriented approach, withregular participatory reflection sessions to adjustactivities and ensure regular two-waycommunication within the system.

• Selection of appropriate candiates for training asCAHWs viz. candidates with social back-ups,personal interests in delivering animal healthservices and adequate literacy levels.

• Development of a relevant CAHW trainingcurricula and training approaches with emphasison practical sessions and use of proper trainingneeds assessments.

In addition to the factors above, an understanding ofthe willingness of farmers to pay for services in a freemarket enabled the programme to be designedaccordingly and with long-term sustainability in mind.

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7. Recommendations

The current state of veterinary legislation in Kenyaand proposed reforms to better support community-based animal health delivery systems (CAHS) andprivatisation in marginalised areas were described byMunyua Muchina and Wabaka (2003). Our studysupports many of the policy and legislative changesproposed by the KVB to strengthen linkages betweenprivate veterinary practitioners and CAHWs. Wesupport moves towards a clear policy to allow moreefficient utilisation of the CAHWs via the legalempowerment of veterinarians and para-professionalsto trade in veterinary drugs. The CAHWs could thensource their drugs from and be supervised byindependent and legalised private veterinary drugsuppliers. In this context the proposed certification ofveterinary pharmacies or Agrovet shops would go along way to solve the problem of drug supply to thismarket in the future.

Recommendations to the Department ofVeterinary Services

• In Mwingi District, basic veterinary services areprovided by AHAs who are both governmentemployees and private sector operators. In thissituation, the DVS should review the public sectorroles of the AHAs and the potential to encouragefull privatisation of the system. In such a system,the AHAs would no longer be employed bygovernment but, as private operators, could receivecontracts from government for specific publicsector tasks (under the supervision of the DVO). Itis likely that such an arrangement would be morecost efficient. In addition, savings derived fromimproved efficiency could be directed towardsenabling the DVO to fulfil monitoring andregulatory functions more effectively.

• In underserved areas the DVS should facilitateDVOs to provide direct or indirect assistance inthe identification, training and temporarysupervision of CAHWs according to district-specific needs. Ideally, the trained and licensedCAHWs should be linked to private AHAs and vetsfor efficient supervision and backstopping. Ifprivate AHAs or veterinarians do not yet exist insome areas, every effort should be made toencourage private sector development as CAHWsare trained.

• The licensing of a CAHW should be contingentupon an AHA or veterinarian being identified, on

the license, as the supervisor of that CAHW. Thestudy team emphasises that CAHWs shouldoperate in the private sector. Government AHAsand veterinarians should only be supplying drugsto CAHWs in areas where private veterinarypractices run by AHAs or vets have yet to beestablished.

• Care and attention is required to ensure thatgovernment employees, including those who arealso engaged in private activities, do not preventthe development of fully privatised systems.Supervision and supply of CAHWs by governmentAHAs and vets should be seen as a temporarymeasure to improve the quality of veterinaryservices to underserved livestock owners, ratherthan a long-term solution.

• The establishment of CAH systems should bebased on a Memorandum of Understanding (MoU)between the DVS, DVOs and other relevantagencies in those areas where CAHWs are needed.The content of the MoU should be made availableto the veterinary regulatory body (KVB) and otherinterested stakeholders.

• The DVS should continue to inform those donorsand NGOs who support CAH initiatives of thenecessity of signing an MoU prior to thecommencement of their activities. This will help toharmonise approaches, ensure quality and enableappropriate project design according to the needfor immediate and full involvement of the privatesector. The DVS should formulate a set ofminimum standards and guiding principles thatimplementing agencies are required to follow andwhich can form the basis for the MoUs.

• The DVS should support the DVOs to sensitise andprepare the communities to ensure sustainability ofCAHW activities.

• Under current arrangements many state veterinarypersonnel are to be retired by the year 2012.Therefore, there is urgent need to maximise theuse of public sector veterinarians and resources forthe encouragement of private service delivery. It islikely that contracting out activities such asvaccination and surveillance will play a key role inenabling the private sector in marginalised areas.These contracts will have to be formulated andmonitored by the DVS and DVO.

• In collaboration with communities and the AHITIs,the DVOs should identify well performing andqualified CAHWs for certificate training. After

40

training, former CAHWs could be licensed to workin their locations as private AHAs.

• Where private veterinarians do exist, private AHAsshould work under their supervision. The processof licensing and monitoring is the responsibility ofthe statutory veterinary body (the KVB) in closecollaboration with the DVS. In areas where noprivate veterinarians are working, the KVB andDVS will need to conduct regular reviews toensure that government services and/or privatepara-veterinary professionals are not hinderinginvolvement of private professionals. The aimshould be for licensing arrangements to supportcomplementarity linkages and quality services.

• Veterinary investigation laboratories should, wherenecessary, be facilitated to carry out confirmatorydisease diagnostic surveys to confirm local diseasedistributions. This would help in developing aneeds-driven training curriculum for CAHWs inspecific areas. Simple diagnostic tests for epizooticor notifiable diseases should be provided atdivisional and district levels.

• The veterinary public health division of the DVSshould be strengthened to carry out regular spot-checking on animal food products at the marketlevel to determine the actual levels of drugresidues and ensure the availability of wholesomefoods according to national and internationalmarket standards. It is understood that this must beaccompanied by efforts to raise the producers’awareness on the effects of the drug usages andwithdrawal period on their incomes and on humanhealth.

Recommendations to the Kenya VeterinaryBoard

• In line with recent reports from the OfficeInternational des Epizooties (OIE), the KVB shouldcontinue to delegate its supervisory powers to theDVS and DVOs in conjunction with its owncapacity to provide field inspection. This wouldstrengthen and widen its regulatory functionscountrywide. There is a need to further identify,define and license the various categories of para-veterinary professionals (including CAHWs)practicing in the districts and this information canbe compiled in the central KVB registry.

• Registered veterinarians should carry out alltraining in veterinary-related topics for CAHWs. InMwingi District there may be scope to increase theinitial 14 day training course to 21 days, in order

to strengthen training in those topics that werefound to be weak among CAHWs viz. recordkeeping and zoonoses.[L39] Other topics thatmight be included in the initial CAHW training areminor surgery and wound treatment, someimproved livestock production techniques, aspectsof business management and organisationaldevelopment plus exposure to other sourceincomes such as honey production or preparationof hides and skins (in order to complement incomederived from veterinary work).

• Trained CAHWs should be issued with a certificateof training and annually renewable work licenses.The latter should be subject to an annual,combined report of their supervisor and the DVO.Similarly, AHAs should also be regulated by theKVB and their appropriateness as independentprivate operators should be reviewed regularly.

• The KVB should identify and register suitabletrainers and examiners of CAHWs, who mightserve as an accreditation boardon their behalf. Thetraining of such trainers and examiners needs to bedeveloped. The mechanisms for providing licensesto para-professionals such as CAHWs, throughDVOs and the DVS also needs to developed.

Recommendations to the Kenya VeterinaryAssociation

• The KVA should inform it’s members about theresults of this study, particularly with regards thetechnical competence of CAHWs, the potential touse CAHWs to improve the sustainability ofprivatised veterinary services in under-served areasand the potential to develop systems based onmutually supportive relationships betweenCAHWs, AHAs and veterinarians.

• The KVA should encourage those membersinterested in establishing private CAH systems toseek appropriate training in subjects related to thedesign and development of such systems, with aparticular focus on sustainability issues. There is awide range of training and information materialsavailable in written and video formats for thoseinterested (see Annex 9 for a list and sources ofrelevant materials).

• The KVA should continue to participate actively inpolicy dialogue concerning CAH systems in Kenya,and encourage the involvement of it’s membersfrom under-served areas in national-level debatesand meetings.

41

• The KVA should continue to participate in futurestudies on veterinary service provision, includingCAH systems.

Recommendations to the AfricanUnion/Interafrican Bureau for AnimalResource

• Based on the study findings, AU/IBAR shouldcontinue to advise its partners at policy level onthe extension of CAHWs to underserved areas.

• Through its intermediaries e.g. government, NGOs,CBOs and livestock owners’ organisations,AU/IBAR should continue to assist nationalveterinary services to gain the experience andcapacity to provide technical and organisationaladvice to relevant institutions involved in theinitiation and management of CAH systems.

• AU/IBAR should continue to work with veterinaryfaculties and veterinary policy makers to generatereliable information on CAH systems fordissemination to its partners. The involvement oflocal agencies facilitates and accelerates thelearning, attitudinal and institutional changeprocesses.

• As access to appropriate animal health services isa livestock owner’s basic right and a key factorcontributing to livestock production, AU/IBARshould seek to influence national policy makers toensure they improve the representation and activeinvolvement of livestock owners at policy levels.

District CAHW organisations

The capacity of CAHW umbrella organisations, wherethey exist, is still very weak. Enhancing their capacitywould go along with empowering the CAHWs toengage with other stakeholders such as the AHAumbrella organisation, livestock owner associationsand even the KVB. It could further encourage thedevelopment of codes of conduct and other self-regulatory mechanisms, improve linkages amongstCAHWs and with other stakeholders, includingprivate veterinarians.

References

Catley A., Leyland, T. and Kaberia, B. (2002). Taking along-term perspective: sustainability issues. In: Catley,A., Blakeway, S. and Leyland, T. (eds). Community-Based Animal Healthcare: A Practical Guide toImproving Primary Veterinary Services. ITDGPublishing, London.

Mwingi District Veterinary Office (2000). 2000Annual Report.

Holden, S. (1997). Community-based animal healthworkers in Kenya: an example of private delivery ofanimal health services to small-scale farmers inmarginal areas. DFID Policy Research ProgrammeR6120CA. Department for International Development,London.

Integrated Food Security Programme-Eastern (1998)1997 Annual Report. GTZ, Nairobi.

Iles, K. (2002). How to design and implement trainingcourses. In: Catley A., Blakeway, S. and Leyland, T.(eds). Community-Based Animal Healthcare: APractical Guide to Improving Primary VeterinaryServices. ITDG Publishing, London.

Leonard D.K., Ly, C. and Woods P.S.A. (2003).Community-based animal health workers and theveterinary profession in the context of Africanprivatisation. In: Sones, K. and Catley, A. (eds.).Primary Animal Health Care in the 21st Century:Shaping the Rules, Policies and Institutions.Proceedings of an international conference held inMombasa, Kenya 15th to 18th October 2002. AfricanUnion/Interafrican Bureau for Animal Resources,Nairobi.

McDermott, J. J., Randolph, T.F. and Staal, S.J. (1999).The economics of optimal heath and productivity insmallholder livestick systems in developing countries.

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Revue Scientifique et Technique Office Internationaldes Epizooties, 18(2), 399-419.

Muchina Munyua, S.J. and Wabacha, K.J. (2003).Community-based animal health in Kenya: Kenya’sexperiences in re-engineering its structural, policy andlegal frameworks. In: Community Based AnimalHealth Workers - Threat or Opportunity? The IDLGroup, Crewekerne, UK. pp 135-149

Mugunieri, L., Omiti, J. and Irungu, P. (2003). Animalhealth service delivery susyems in Kenya’s MarginalAreas Under Market Liberalization: A case forCommunity-based animal health workers. 2020 VisionNetwork for East Africa Report 3. Institute of PolicyAnalysis and Research, Nairobi and InternationalFood Policy Research Institute, Washington DC.

Odhiambo, O., Holden, S. and Ackello-Ogutu, C.(1998). OXFAM Wajir Pastoral Development Project:An Economic Impact Assessment. Oxfam UK/Ireland,Nairobi.

Okwiri F. O., Kajume J. K., and Odondi, R. K. (2001).An Assessment of the Economic Viability of PrivateAnimal Health Service Delivery in Pastoral Areas inKenya. African Union/Interafrican Bureau for AnimalResources, Nairobi.

Office of the Vice-President and Ministry of Planningand National Development (1997). Mwingi DistrictDevelopment Plan 1999-2001. Government Press.Nairobi

Ririmpoi, B. (2002). Integration of community animalhealth into private practice: the case of West PokotDistrict. In: Proceedings of the 10th DecentralisedAnimal Health Workshop, Lake Bogoria Hotel, Kenya,8th to 11th September 2002. Community-basedLivestock Initiatives Programme (CLIP), Nairobi.

Sones, K. and Catley, A. (eds.) (2003). Primary AnimalHealthcare in the 21st Century: Shaping the Rules,Policies and Institutions. Proceedings of aninternational conference held in Mombasa, Kenya15th to 18th October 2002. AfricanUnion/Interafrican Bureau for Animal Resources,Nairobi.

Taylor, D. (2003). Antimicrobial resistance andcommunity-based animal health: In: Community-based Animal Health Workers - Threat orOpportunity? The IDL Group, Crewekerne. pp. 56-64.

The IDL Group and McCorkle, C. (2002).Community-based animal healthcare, participationand policy: where are we now? PLA Notes, 45, 8-12.

The IDL Group and McCorkle, C.M. (2003). DoCBAHWs provide services that work? Evidence ofimpact from Kenya, Tanzania and The Philippines. In:Community Based Animal Health Workers - Threat orOpportunity? The IDL Group, Crewekerne. pp 76-90.

Tiffen, M., Mortimore, M. and F. Gichuki (1994).More People, Less Erosion: Environmental Recoveryin Kenya. John Wiley & Sons, London.

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Annex 1

Agroecological zones in Mwingi Disttrict

45

Annex 3

Sample of veterinary drug kit composition

46

Annex 4

List of CAHWs in Mwingi District

Sampled CAHWs are in bold type

No. Name Location Division Sub-Location Year Training Level of Education

1 Sammy K. Ngui* Tseikuru Tseikuru Ngalange 1996 Form III2 Musembi Musyoka* Musavani Tseikuru Useuni 1999 Form II3 Mwendwa Mututa* Musavani Tseikuru Kyenini 1999 Std. 84 Pauline Kikuu* Masyungwa Tseikuru Kitovoto 1999 Form IV5 Muthengi Kisaili* Musavani Tseikuru Ngereni 1999 Std. 76 Kivilu Musyoka* Masyungwa Tseikuru Kathiani 1999 Std. 77 Kilonzo Vere Tseikuru Tseikuru Kasyathuni 1999 Form IV8 Sammy Musyimi Musavani Tseikuru Kaningo 2001 Form IV9 Kirema Kivui* Tseikuru Tseikuru Ngongoni 2001 Form IV10 Munwoki Musyoka Masyungwa Tseikuru Kandani 2001 Form V11 Julius S. Maithya* Tseikuru Tseikuru Kaivirya 2001 Form IV12 John Mwendwa* Tharaka Mumoni Gacigongo 1996 Std. 813 John Magondu Tharaka Tseikuru Gacigongo 1999 Form IV14 Musyimi Ngili* Waita Central Waita 2000 Std. 415 David Kyele* Waita Central Waita 1998 Std. 616 Njoki Kimwele* Endui Central Enziu 1998 Std. 717 Domnic Kitheka Kyethani Central Wikithiki 2000 Std. 818 Andrew Ndingu Kiomo Central Kairungu 2000 Form IV19 Nicholas Munyoki Mwingi Central Enziu 2000 Form IV20 Kilonzo Nduku Waita Central Ndithi 2000 Form IV21 Martha Simon Endui Central Mutuangombe Std. 722 Mutua Kiteme Nzeluni Central Nzatani 2001 Form IV23 Muthengi Nzau Endui Central Nyanya 1989 Std. 624 Gideon Mwendwa Mumbuni Central Katalwa 2001 Form IV25 John K. Kimotho* Kyuso Kyuso Gai 1992/1996 AHITI-Kabete26 David Musyoki Muli* Kamuwongo Kyuso Kamuwongo 2001 Std. 827 Jennifer K. Muvinzu Mivukoni Kyuso Manzuva 1999 Std. 828 Peter Mwendwa Mukiti Mivukoni Kyuso Katuka 2001 Std. 729 Robert M. Kiteme* Kamuwongo Kyuso Itiva Nzou 2001 Std. 830 Francis Mwema Masoso Kimangau Kyuso Maseki 1999 Std. 831 Jackson M. Mwangangi Kamuwongo Kyuso Tulanduli 1996 Std. 732 John Kimanzi Kaliu Kyuso Kyuso Gai 1996 Std 433 Johnson M. Muthengi Kyuso Kyuso Gai/Matooni 1996 Std. 634 John Musyoka Kalei Mivukoni Kyuso Kamula 1996 Std. 835 Aberdneco M. Kitheka Kyuso Kyuso Ngaaiye 2001 Std. 836 Muthengi Nguna Kimangau Kyuso Kivangwa 1996 Std. 737 Sylvia Kitondo Kitheka Mivukoni Kyuso Mataka 2001 Form IV38 Peter Kimwele* Mitamisyi Ngomeni Kamusiliu 2001 Form IV39 P. M. Kisilu Mitamisyi Ngomeni Ndatani 1996 Form II40 Mukiti Ndoo* Mitamisyi Ngomeni Kimela 2001 Form IV41 Metemi Kitheka* Ngomeni Ngomeni Kavani 1998 Form IV42 Joseph Kisinga* Ngomeni Ngomeni Maringani 1999 Form II43 David Mbithi Mwiu* Ngomeni Ngomeni Kalwa 1999 Std. 844 Ben Mutemi Mitamisyi Ngomeni Mitamisyi 1996 Form IV45 Jackson Mwanzia Mitamisyi Ngomeni Kamusiliu 1999 Form IV46 Paul Mulei Ngomeni Ngomeni Manguu 1999 Form II

47

47 Rose Kivonya* Ngutani Migwani Kitulani 2001 Form IV48 Fredrick Nzitu Tungu Ngutani Migwani Nzalae 2000 Form IV49 Jonathan Kasuki Ngutani Migwani Nzalae 2001 Form IV50 Francis Boyano Thana Nzau Migwani Inzuva 2000 Form II51 Bornface Kamotho* Thana Nzau Migwani Winzyeei 2000 Form II52 Simon Siilu Thana Nzau Migwani Thaana 2000 Form IV53 Shadrack K.Kanyalu* Ngutani Migwani Nzawa 2000 Form IV54 Mwalimu Musya* Wingemi Nuu Malawa 1999 Form II55 William M. Muthui Wingemi Nuu Kyangati 1999 Std. 856 Safari Muthuka* Mutyangome Nuu Ngieni 2001 AHITI57 Kananda Mutinda Nyaani Nuu Nyani 1999 Std. 758 Jane Nundu Kiseu* Mutyangome Nuu Mwangeni 1999 Std. 859 Munyoki Mbuvi Nuu Kamengo 200160 Clement Mathuva Karitini Mui Yumbu 199961 Ngati Mathuva* Mui Mui Ngoo 2001 Form IV62 Francis S. Solomon Mui Mui Kathonzeni 199963 K. Mutia Ukasi Nguni Mwalali 2001 Form IV64 Jackson S. Kasyoka* Ukasi Nguni Mbuvu 1999 Std. 765 Joel M. Nyalu* Ukasi Nguni Mwalali 2001 Form IV66 Charles Kimanzi* Nguni Nguni Mathyakani 2001 Std. 767 Malusi Mwasya Ukasi Nguni Mwalali 2001 Form IV68 Joel K. Musya Ukasi Nguni Mwalali 1999 Std. 769 Beth Kanana* Nguni Nguni Mwasuma 1992 Std. 470 Mwangangi Mwanzia* Nguni Nguni Kyavyuka 2001 Form IV71 David Mwasi Nguni Nguni Kyavyuka 1999 Form IV72 John Kimanya* Tharaka Mumoni Kariini 1996 Form IV73 John Muciini* Tharaka Mumoni Ngoru 1999 Form IV74 John Kibara* Tharaka Mumoni Gachigongo 1999 Form IV75 John Mwenga Tharaka Mumoni Kamayagi 1996 Std. 876 John Ndagara Tharaka Mumoni Kanyengya 1999 Form IV77 Julius Njeru Tharaka Mumoni Ciatungu 1996 Form II78 Daniel Kondiki* Tharaka Mumoni ** 1999 Std. II79 David Mbagi* Kanthungu Mumoni Uvete 1999 Std. IV80 Jonnes Munoi* Kanthungu Mumoni Eturamula 1999 Form IV81 John Nthumbi Kanthungu Mumoni Kiuga 1999 Form IV82 John Muteria Kivya Kanthungu Mumoni 1996 Form IV83 David Karurnguru Kanthungu Mumoni Kamaidi 1999 Form IV84 Scholar K. Mutemi* Katse Mumoni Mbarani 1998 Form II85 Muthengi Mwasya* Katse Mumoni Kamathitu 1998 Std. 886 Job M. Mwinzi Katse Mumoni Mbarani 1998 Form IV87 James Maithya Katse Mumoni Konyu 1998 Std. 788 John Kivole* Katse Mumoni Mbarani 1996 Form IV89 Lucas K. Mwenga Mutanda Mumoni Kaisinga 1996 Form IV90 Kathini Mukiti Mutanda Mumoni Kininge 1998 Std. 891 Peter Musyimi Mutanda Mumoni Wangutu 1998 Std. 892 Sammy Kilonzo Nguku Mumoni Kata 1998 Form IV93 Jonna M. Muimi Kakuyu Mumoni Kalatine 1998 Form IV94 Peter Mukiti* Kakuyu Mumoni Ngungani 1998 Form IV95 David Ndeto Kakuyu Mumoni Mukonga 1998 Form IV96 Peter Ndei Kakuyu Mumoni Mukonga 1996 97 Karungu Maluki* Kakuyu Mumoni Tyaa Kamuthale 1996 Std.898 Peter munywa Kakuyu Mumoni Ikongo 199699 Joseph Muthungu Kakuyu Mumoni Mukonga Std. 7

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Annex 5

Prices of veterinary drugs and equipment in Mwingi Town

Price List (KShs)

Wholesale Retail AHA/CAHW Special price

Antibiotics

Alamycine (100mls 10%) 180

Adamycin (100mls 10%) 250 290 280

Penstrep (100mls 10%) 320 380 350Oxyteracycline (Oxykel) (100mls 10%) 160 180 170

Supportive Drugs

Oxytet spray (200g) 200 250 215

Multivitamin (100mls) 250 270

Sulphur based drugs

Fuzol (120mls) 55 70 60S-dine (100mls) 75 90 80

Acaricide

Acaricide (Triatix) (100mls) 160 180 170

Sevin (sachet) 68 80 75

Anti-protozoal

Novidium (tablet) 50 70 60

Berenil (1g sachet) 50 70 60

Norotryp (1g sachet) 50 60 60

Veriben (1g sachet) 50 70 60

Anthelmintics

Ascarex (Sachet 30g) 45 65 50

Levamisole (1 Litre) 190 240 220

Ascaten tablet 10 15 12

Vetworm/Wormicid (1 Litre) 190 240 220

49

Annex 6

Caseloads of CAHWs and AHAs

Table A6.1: Cases of cattle diseases/problems attended by CAHWs (n=40) per month

Worms Tryps. Anaplas. CBPP/ Abscess/ Babesiosis Footrot Diarrhoea FMD Mastitis Bloat Obstetrical HeartwaterPneumonia wounds

Number of CAHWsattending the cases/ 37 31 25 23 16 12 7 5 4 4 3 3 3month (%) (92.5%) (77.5%) (62.5%) (57.5%) (40%) (30%) (17.5%) (12.5%) (10%) (10%) (7.5%) (7.5%) (7.5%)

Mean number of cases attended byCAHWs/month 18.1 6.1 6.8 6.5 3.2 4 8.9 7 3.8 1.5 2.3 2.3 5.3(95% CI) (12.8-23.4) (2.2-10) (4.3-9.3) (4.2- 8.8) (1.9-4.5) (2.3-5.7) (1.3-16.4) (-1.6-15.6) (-1.7-9.2) (0.6-2.4) (-1.5- 6.1) (-1.5-6.1) (-2.7-13.3)

Table A6.2: Cases of goat disease/problems attended by CAHWs (n=40) per month

Worms Anaplas. CCPP/ Tryps. Abscess/ Footrot Diarrhoea Mange Mastitis Obstetrical Heart water Skin diseasePneumonia wounds

Number of CAHWsattending the cases/ 35 40 39 10 12 7 6 66 5 4 3 3month (%) (87.5%) (100%) (97.5%) (25%) (30%) (17.5%) (15%) (15%) (12.5%) (10%) (7.5%) (7.5%)

Mean number of cases attended byCAHWs/month 30.5 19.4 24 6.1 9.8 15.1 9.7 26.5 4.6 3.5 13 3.3(95% CI) (18.8-42.3) (14.0-24.9) (15.2-32.7) (1.7-10.5) (4.3-15.3) (3.6-26.7) (-1.1-20.4) (-0.5-13.5) (-2.7-11.9) (-3.4-10.4) (-21.1-47) (-2.4-9)

Table A6.3: Cases of sheep disease/problems attended by CAHWs (n=40) per month

Worms Anaplasmosis Footrot Trypanosomiasis

Number of CAHWs attending the cases/ 20 11 4 3month (%) (50%) (27.5%) (10%) (7.5%)

Mean number of cases attended byCAHWs/month 8.7 11.5 13 7(95% CI) (4.1-13.2) (6.7-16.2) (-6.0-32.0) (-10.9-24.9)

Table A6.4: Cases of donkey disease/problems attended by CAHWs (n=40) per month

Worms Tryps Abscess/ Rectal Pneumonia Anaplasmosis Bloat Diarrhoea Babesiosis Tetanuswounds prolapse

Number of CAHWs attending the cases/ 33 13 13 10 7 4 3 3 3 3month (%) (82.5%) (32.5%) (32.5%) (25%) (17.5%) (10%) (7.5%) (7.5%) (7.5%) (7.5%)

Mean number of cases attended byCAHWs/month 11.7 6.9 3.9 1.2 4.7 8 7.3 6.7 3.3 2.3(95% CI) (7.8-15.6) (-1.3-15.2) (1.1-6.8) (0.9-1.5) (0.7-8.8) (-10.1-26.1) (-2.1-16.7) (-13.4-26.8) (-2.9-9.6) (-1.5-6.1)

Table A6.5: Cases of dogs disease/problems attended by CAHWs (n=40) per month

Worms Canine TVT Woundsdistemper

Number of CAHWs attending the cases 21 7 5 3in a month (%) (52.5%) (17.5) (12.5%) (7.5%)

Mean number of cases attended byCAHWs/ month 7.5 3.0 3.2 1.3(95% CI) (3.1-11.9) (-1.8-37.0) (-1.6-8.0) (-0.1-2.8)

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Table A6.6: Cases of cats disease/problems attended by CAHWs (n=40) per month

Worms Mange

Number of CAHWs attending the cases 7 1/month (%) (17.5%) (2.5%)

Mean number of cases attended byCAHWs/month 3.6 10(95% CI) (-0.5-7.6) (nc)

Table A6.7: Cases of poultry disease/problems attended by CAHWs (n=40) per month

Worms Fowl Typhoid NCD

Number of CAHWs attending the cases 16 12 9/month (%) (40%) (30%) (22.5%)

Mean number of cases attended bycases /month 43.5 23.3 27.8(95% CI) (16.7-70.5) (6.2-40.4) (5.7-59.9)

Notes for Tables A6.1 to A6.7Only cases reported by more than 2 CAHWs were considered except mange in cats; nc = not calculated In each Table, the mean number of cases attended by CAHWs/month refers only to those CAHWs who attended cases for the disease/probem in question.

Table A6.8: Cases of cattle disease/problems attended by AHAs (n=7) per month

Worms Anaplas. Tryps. CBPP/ Obstetrical Mastitis Babesiosis ECF WoundsPneumonia

Number of AHAs attending the cases/ 7 7 3 2 2 2 1 1 1month (%) (100%) (100%) (42.9%) (28%6) (28%6) (28%6) (14.3%) (14.3%) (14.3%)

Mean number of caseattended byAHAs/month 23.7 8.7 12.3 17.5 11 2.5 1 3 4(95% CI) (-7.4-55.3) (2.7-14.8) (-17.3-42.0) (-14.3-42.0) (-103.7-125) (-3.9-8.9) (nc) (nc) (nc)

Table A6.9: Cases of goats disease/problems attended by AHAs (n=7) per month

Worms CCPP/ Anaplas. Obstetrical Foot rot MastitisPneumonia

Number of AHAs attending the cases/ 7 7 5 2 1 1month (%) (100%) (100%) (71.4%) (28%6) (14.3%) (14.3%)

Mean number of cases attended byAHAs/month 40.7 18.9 32.2 20.5 8 1(95% CI) (-5.0-86.4) (10.6-27.1) (-25.3-85.7) (-227.1-268.7) (nc) (nc)

Table A6.10: Cases of sheep disease/problems attended by AHAs (n=7) per month

Worms Pneumonia Anaplasmosis

Number of AHAs attending the cases/ 3 2 1month (%) (42.9%) (28.6%) (14.3%)

Mean of cases attended by AHAs/ 11 10 10month (95% CI) (2-20) (nc) (nc)

51

Table A6.11: Cases of donkey disease/problems attended by AHAs (n=7) per month

Worms RAB/ PneumoniaRectal prolapse

Number of AHAs attending the cases/ 5 2 2month (%) (71.4%) (28.6%) (28.6%)

Mean of cases attended 12.6 15 12by AHAs/month (95% CI) (-13.5-38.7) (-48.5-78.5) (-89.7-113.7)

nc = not calculated

Annex 7

List of fast-moving drugs via CAHWs

Number of times cited by CAHWs (n=40)Vetworm/Wormicid 40Oxytetracycline 32Penstrep 29Veriben 17Novidium 15Furaxol 9Oxytet spray 6S-dine 6Ascaten tablets 5Alamycine 5Sevin 4Diseptoprim 3Triatix 3Healing oil 3Epson salt 3Multivitamin 3Adamycine 3Eye ointment 2Stop bloat 2Ascarex 2Steladon 2Berenil 2Fuzal 1Dust powder 1Intramammary tubes 1Amitrax 1Levacide 1Accaricide 1Wound powder 1Wormicid Bolus 1Vetmycine 1Wormita 1

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Annex 8

Organogram of the CAH system in Mwingi District

53

Books, reports, training manuals and policy issues

African Union/Interafrican Bureau for AnimalResources (2003). Policy on Community-basedAnimal Health Workers. http://www.cape-ibar.org

Anon (2000). Community-based Animal Healthcare inEast Africa: Experiences and case-studies withparticular reference to Kenya, IntermediateTechnology Development Group (East Africa),Nairobi.

Appropriate Technology, 19 (4), (1993). IntermediateTechnology Publications, London - special issuededicated to primary veterinary services.

Catley, A., Blakeway, S. and Leyland, T. (eds.) (2002).Community-based Animal Healthcare: A PracticalGuide to Improving Primary Veterinary Services. ITDGPublishing, London. 360 pages.Order from: [email protected]

Catley, A. and Leyland, T.J. (2001). CommunityParticipation and the Delivery of Veterinary Servicesin Africa. Preventive Veterinary Medicine, 49, 95-113.

Grandin, B., Thampy, R. and Young, J. (1991). VillageAnimal Healthcare: A community-based approach tolivestock development in Kenya, IntermediateTechnology Publications, London.

Hadrill, D. (1989). Vets in Nepal and India: Theprovision of barefoot animal health services. In: TheBarefoot Book: Economically appropriate services forthe rural poor, Carr, M. (ed.), Intermediate TechnologyPublications, London.

Halpin, B. (1981). Vets: Barefoot and otherwise,Pastoral Development Network Paper 11c, OverseasDevelopment Institute, London. http://www.odi.org.uk

Hanks, J., Oakeley, R., Opuku, H., Dasebu, S. andAsaga, J. (1999). Assessing the Impact of CommunityAnimal Healthcare Programmes: Some experiencesfrom Ghana, Veterinary Epidemiology and EconomicsResearch Unit, University of Reading and Ministry ofFood and Agriculture, Republic of Ghana.http://www.cape-ibar.org

IDL Group (2003). Community-based Animal HealthWorkers: Threat or Opportunity? IDL Group,Crewekerne. Order from: [email protected]

Kenya Veterinary Board & Department of VeterinaryServices. Minimum Standards and Guidelines forTraining Community-Based Animal Health Workers inKenya. Kenya Veterinary Board, Uthiru.

Leyland, T. and Catley, A. (2002). Community-basedanimal health delivery systems: improving the qualityof veterinary service delivery. In: Proceedings of theOIE Seminar Organisation of Veterinary Services andFood Safety, World Veterinary Congress, 27-28September 2002, Tunis. Office International desEpizooties, Paris. pp. 129-144. http://www.cape-ibar.org

Okwiri F. O., Kajume J. K., and Odondi, R. K. (2001).An Assessment of the Economic Viability of PrivateAnimal Health Service Delivery in Pastoral Areas inKenya. African Union/Interafrican Bureau for AnimalResources, Nairobi. http://www.cape-ibar.org

PLA Notes (2002). Special Issue on Community-basedAnimal Healthcare. PLA Notes 45, InternationalInstitute for Environment and Development, London.http://www.planotes.org

Sandford, D. (1981). Pastoralists as Animal HealthWorkers: The Range Development Project in Ethiopia,Pastoral Development Network Paper 12c, OverseasDevelopment Institute, London. http://www.odi.org.uk

Silkin, T. and Kasirye, F. (2002). Veterinary Services inthe Horn of Africa: Where Are We Now? A review ofanimal health policies and legislation in pastoralareas. African Union/Interafrican Bureau for AnimalResources, Nairobi. http://www.cape-ibar.org

Sones, K. and Catley, A. (eds.) (2003). Primary AnimalHealthcare in the 21st Century: Shaping the Rules,Policies and Institutions. Proceedings on aninternational conference, 15th-18th October 2002,Mombasa, Kenya. African Union/Interafrican Bureaufor Animal Resources, Nairobi. http://www.cape-ibar.org

Mugunieri, L., Omiti, J. and Irungu, P. (2003). Animalhealth service delivery systems in Kenya’s Marginal

Annex 9

Reports, books and videos on CAH

54

Areas Under Market Liberalization: A case forCommunity-based animal health workers. 2020 VisionNetwork for East Africa Report 3. Institute of PolicyAnalysis and Research, Nairobi and InternationalFood Policy Research Institute, Washington DC.http://www.ipar.or.ke

United Mission to Nepal (1998). Textbook for VillageAnimal Health Workers, Rural Development Centre,United Mission to Nepal, PO Box 126, Kathmandu,Nepal.

Videos

Available from the CAPE Unit at AU/IBAR:

Community-based Animal Healthcare: The How-To-Do-It Videos 1 and 2

These ‘How-To-Do-It’ videos describe the key issuesto consider when setting up a community-basedanimal health system. The videos will be useful forveterinarians who work for government, NGOs or theprivate sector who want to establish a community-based project, or improve an existing project.

Video 1 covers the following topics:• Community Participation• Sustainability• The Role of Vets

Video 2 covers the following topics:• Participatory Approaches to Adult Learning• Project Monitoring and Evaluation• How to Influence Policy

Community-based Animal Healthcare: Issues for Policy Makers

This video presents the key issues for policy makers toconsider when assessing community-based animalhealth systems. The video also describes ways toinvolve policy makers in learning more aboutcommunity-based approaches and formulatingappropriate policies.

community-based animal health workers in kenya

Documents