On June 21, 11 days after the Ministry of Health launched home-based care guidelines for Covid-19 patients, Muthee Wa Mwangi went on his daily morning run.
Later that day, he learnt that 550 Covid-19 patients had been discharged from hospital to continue with recovery at home. The Cabinet Secretary for Health Mutahi Kagwe announced that they had been discharged after 14 days in hospital because “it is difficult to spread the virus after that.”
For Muthee, it was just another day and just another announcement from the Ministry of Health. He had seen a PDF of the home-based care guidelines forwarded in a WhatsApp group, but he didn’t pay much attention to it.
The next day Muthee developed symptoms – morning chills, fever and a slight cough – that he attributed to the cold from his morning run. After three days of symptoms, he sought medical attention. While his chest was clear, a test showed that he had a chest infection. He was put on antibiotics, cough syrup and paracetamol and sent home to recover. Four days into treatment, his symptoms persisted. He returned to hospital and this time round, the doctor recommended a Covid-19 test. It was positive.
“I was ready to be admitted to hospital for treatment, but the doctor who called to share the Covid-19 test results told me the hospital was full and advised me to consult my employer,” he says.
His employer referred him to their company doctor, who did an assessment on whether Muthee’s home was conducive for home-based care.
Being referred for home-based care is dependent on meeting certain conditions spelt out in the Home-based Care Guidelines for Covid-19 Patients: a positive Covid-19 test, no underlying health conditions and no household members with underlying health conditions. Moreover, a suitable home should have no pregnant women, elderly persons or children under the age of two in the household. It should also have access to an isolation space, preferably with a separate bathroom for the patient.
The government launched home-based care with a 22-page home-based care guidelines for patients with Covid-19, saying that 78 percent of patients in hospitals had either mild symptoms that could be managed from home or no symptoms at all. In later days, the government announced that 90 percent of patients are either asymptomatic or have mild symptoms that can be managed from home. Home-based care for these patients would ease pressure on hospitals, leaving hospitals for patients with more serious symptoms or vulnerabilities.
On June 3, a week before the guidelines were launched, the Kenyatta University Teaching and Referral Hospital which had set aside 456 beds for Covid-19 patients, had 346 of them occupied. Moreover, the Kenya Medical Practitioners and Dentists Council CEO Daniel Yumbya wrote in The Star that there were 113 isolation facilities with a capacity of 3,800 patients for the entire country, yet there were 4,952 Covid-19 patients at the time.
Besides easing pressure on hospitals, home-based care is also meant to ease the cost of providing care for patients admitted to hospital for Covid-19 treatment. Health Director General Patrick Amoth has previously said that it costs Sh21,400 per day to care for a patient with mild symptoms, and Sh21,300 for asymptomatic patients making home-based care nine times cheaper than hospital-based care.
By Sunday 26th July when Kenya announced 17,603 cases of Covid-19, a document sent to newsrooms by the Ministry of Health showed that 3,810 people had been discharged from home-based care. As at 11th August when 372 patients were discharged from home-based care, there were 13,180 active cases of Covid-19, of which 90 percent – 11,862 – are deemed to be asymptomatic or have mild symptoms that can be managed from home. So far, tallies from the daily health briefings suggest that more than 6,000 patients have been discharged from home-based care.
After assessment for home-based care by his doctor, and after informing his close contacts and family that he had tested positive for Covid-19, Muthee retreated to his bedroom where he would remain for the next 17 days as a home-based care patient. The doctor gave him advice on protecting his family – wife and two daughters – and easing symptoms, and assured him that there was nothing he would get from hospital care that he couldn’t get at home.
In the days that followed, his fever worsened and he was often drenched from night sweats. His cough also worsened, his mouth and throat were dry, everything tasted like soil and he had headaches.
“Walking three metres to the bathroom would have me out of breath and coughing till my muscles hurt like hell. Taking a shower was an uphill task and I had to get the aid of my spouse several times.
“My whole life was doing a dance in my head. At some point I was delirious and I felt like someone was kneading my brain. I might have been mad for a while … it’s hard to explain,” he says.
All this time, he had not heard from anyone on the Ministry of Health’s home-based care team, and instead relied on his wife, the company doctor who was on call day and night and a psychologist who was paid for by his employer.
While Muthee was grappling with his symptoms, Bonnie Musambi, a journalist at the Kenya Broadcasting Corporation, started feeling unwell. Suspecting malaria, he bought anti-malaria drugs. However, they did not ease his symptoms: headache, fatigue and unbearable chills, which gave way to sore throat and loss of smell.
“I didn’t suspect Corona (Covid-19) because I had neither fever nor cough,” he says, adding that he saw the Covid-19 test that was offered at work as routine.
“When they called to tell me I had Covid-19 three days later, I laughed. It was the last thing on my mind. I was advised to stay home and told that the Ministry of Health would be in touch,” he says.
By the next day, nobody had called him, so he called the Covid-19 helpline 719.
“They gave me some numbers to call and when I called one of the numbers, I was advised to eat a balanced diet and a lot of fruits,” says Bonnie.
The day after that, a doctor from the Kenyatta University Teaching and Referral Hospital called and advised him to take medication based on his symptoms, to take vitamin C and to call 719 for an ambulance if he developed breathing difficulties.
Given that they were left to handle their cases mostly on their own, with help from caregivers, personal doctors if available and the internet, Muthee and Bonnie didn’t know about the Ministry of Health system for home-based care patients.
The Head of Primary Healthcare at the Ministry of Health Salim Hussein, under whose docket home-based care falls, says that as as soon as a patient gets a report that their Covid-19 test result is positive and is advised to isolate at home, the patient should register on the Jitenge MOH Kenya app available on Google Playstore and log his or her symptoms and temperature for 14 days. Those without smartphones can do the same by dialing *299#. A copy of the daily symptom monitoring form can also be found on page 12 of the home-based care guidelines.
Neither Muthee nor Bonnie had knowledge of this. However, Muthee got a thermometer from his employer to monitor his temperature and Bonnie bought a thermometer to monitor his temperature at home.
Dr Hussein acknowledged that the majority of home-based care patients do not register on the Jitenge home-based care system, and said that there is need for more publicity and continuous education on how to register on the home-based care platform, and what to do during home-based care.
“There are about 3,000 home-based care patients registered on the Jitenge system, mostly in Mombasa, where home-based care was piloted and where a lot of effort has been put on awareness. One of the reasons why not every home-based care patient is in the system is lack of publicity. There is also fear that if one registers, he or she will be carted away to a quarantine facility,” he said in a phone interview.
Aside from the Jitenge system, the home-based care guidelines show that patients are to be monitored by community health volunteers.
Ruth Ngechu, the deputy country director of Living Goods, a non-governmental organisation that supports community health volunteers in several counties, explains that community health volunteers are the link between patients at home and the health system.
“The caregivers at home monitor the patient’s vitals and offer care at home, while the community health worker’s role is to monitor and report in case a patient’s situation changes,” says Ms Ngechu.
“Some patients may also be in denial and continue with life as normal instead of isolating at home despite a positive Covid-19 test. In this case, the community health volunteers report the lack of compliance,” she adds.
The community health volunteers are also expected to give advice on diet and household sanitation measures to prevent transmission of Covid-19 from the patient to other household members. They are also expected to offer psychosocial support and to help identify probable isolation centres in places like informal settlements where a patient’s home may not work for home-based care.
Where patients cannot isolate at home, Dr Hussein, says that community isolation centres, identified by the community health workers would be used. These could be social halls, religious institutions (churches, mosques and temples) or a stadium converted into an isolation space. No such isolation centres are in place at the moment.
“Patients should expect continuous support through community health volunteers, who are supervised by a healthcare worker. We also have psychologists and psychiatrists on board so patients can also call 719 which is manned 24 hours and they will be directed to the appropriate support, including emotional support,” says Dr Hussein, adding that patients should also call 719 if they experience serious symptoms like breathing difficulties.
Muthee did not hear from anyone from the Ministry of health until after he had recovered, and when they did call two-and-a-half weeks after his first Covid-19 test, they told him that his symptoms were serious enough to have him in hospital, rather than on home-based care.
“On July 18 just after my third Covid-19 test that showed I had recovered, someone from the Ministry of Health called. She said she had been informed that I had been exposed to Covid-19. I asked her which of the three tests I had done she was talking about. She said the one on July 1 – the very first test.”
“On hearing about my symptoms, she said that I should have been receiving treatment at a hospital, rather than home-based care,” says Muthee, adding that he would still opt for home-based care if he had to do it again, because the care and support and proximity to family at home are more conducive to recovery.
Later that evening, someone from Embakasi sub-county, where he lives, called asking for the same information.
“Are you not consulting from the same database?” he had asked her, somewhat irritated. He wondered why he was being called after he had recovered, rather than soon after the first test.
Bonnie, on the other hand, did get a follow-up call from a public health official, two days into home-based isolation and care. However, he feels that government health officials could have done much more.
“None of the people I talked to told me what to do. I didn’t get any guidance on home-based care. I just knew that I could only get food at the door and that I couldn’t get close to anyone else,” he says, adding that he had to rely on his wife, the information he had gleaned on Covid-19 while executing his duties as a journalist, and internet research. Bonnie also turned to a friend who is a nurse for reassurance.
While community health volunteers are expected to offer the support that ensures the success of home-based care and the recovery of the bulk of Covid-19 patients, they feel ill-prepared to execute this role.
“For starters, we need enough masks to execute our duties safely. We don’t feel safe. Do you see this mask I am wearing? it is supposed to be used once, but I wear it all day for two days, because we only get three masks to take us through two to three weeks,” says Asha Hassan, a community health volunteer in Soweto East, an informal settlement in Langata Sub-county in Nairobi.
According to Ms Ngechu of Living Goods, this sentiment of feeling exposed and inadequately protected has come up often when community health volunteers – more than 60,000 countrywide – are being trained on their role in healthcare during the pandemic.
“Most community health volunteers are using cloth masks and given that they are not health workers, there is a concern about who will cater for their healthcare bills if they get Covid-19 on the job,” says Ms Ngechu.
This lack of sufficient personal protective equipment for frontline health workers, including community health workers has also been flagged in the latest UN OCHA Situation Report for Kenya (August 10).
The other challenge, according to Mary Nanjoli, another community health volunteer in Kibra in Nairobi County, is lack of compensation for the work they do.
“We play a big role in ensuring healthy communities. We make sure pregnant women attend antenatal clinics and that they give birth in hospital. We make sure that children under the age of five get immunised … We have played a big role in the fight against Covid-19. We would like the government to recognise us, not just by lip service on TV, but with a stipend,” says Ms Nanjoli, who has been working as a community health volunteer since 2009.
According to Ms Ngechu of Living Goods, compensation for community health volunteers is an aspect the government has shied away from, and this could hamper their ability to offer home-based care, given the risks involved.
“Most counties have not been paying the community health volunteers. They are not provided with mobile phone airtime, which they need to follow up patients and to give daily reports. They have to call some patients and spend four or so minutes with them. Nobody is talking about how that will be catered for. How are they expected to work?” she poses, adding that it is important to define what they are entitled to for their work.
On the day of the interview Ms Hassan in Soweto East, she says that after the interview, she will accompany a colleague to a place where food was being donated to get a meal for the day.
“Doing this work without pay is challenging because we have children that need to eat. We survive on donated food rations just like the rest of the community because the laundry jobs we used to do for money are no longer available,” she says, adding that most of her colleagues survive on a meal a day and have difficulties paying rent.
So far, there have been no cases of Covid-19 in the communities they serve, but Ms Hassan and Ms Najoli say that it would be difficult to put themselves and their families at risk offering home-based care without a stipend, if they get home-based care patients in their communities.
Without support from the Ministry of Health, patients like Muthee and Bonnie are nursing themselves back to health with support from their caregivers. Muthee’s symptoms eventually subsided and on July 17 when he did his third Covid-19 test, it was negative. His family also tested negative. Bonnie also tested negative after three weeks in isolation.
The test results had taken a while longer than the ones from their previous tests, another challenge that Dr Salim of the Ministry of Health acknowledges that is afflicting home-based care.
Now that he has recovered, Muthee says that households and the caregivers offering home-based care at home should be empowered with information and sensitised on what to do if a loved one gets exposed to Covid-19. Bonnie adds that the government should put as much emphasis on home-based care, as they did on prevention, since many patients on home-based care are shooting in the dark.
“Everyone now knows how to prevent – wash, sanitise, social distance – now we need more support on what to do when you test positive,” says Bonnie.
(This report was supported by the Africa Women Journalism Project (AWJP) in partnership with the International Center for Journalists (ICFJ)