‘I tried to quit many times’: A community health promoter decries unpaid labour

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The pain began slowly: a strange, interminable fatigue, then aching and swelling of the legs. The pain grew, forcing her to go to Kajiado County Referral Hospital. At the facility, Mary Njogu received a diagnosis that sounded like a death sentence: she had tuberculosis.

The news hit her like a sledgehammer. A mother and a casual labourer with an unsteady income, tuberculosis was as debilitating financially as it was physically. She was bedridden, unable to fend for herself and her school-going children. Even getting money for transport to the hospital for a check-up and medication became a tall order.

“I had to sell my bed just to raise money to go to the hospital,” Mary said.

Food grew scarce, and rent went unpaid for months. For Mary, survival meant more than medicine. Frail, she continued collecting her medicine as she waited, in her words, “for death to take me.”

Then one afternoon, while waiting at the hospital, she was spotted by Eunice Akoth, one of the indefatigable community health promoters who works with patients in the county. Eunice vividly remembers that day: “Mary was extremely ill; she had reached a critical stage when she came to the hospital. She arrived in a wheelchair.”

Eunice moved to support Mary fight for life. Every day, for a month and a half, she would draw water into a syringe, crush four tablets, mix them, and coax Mary to take them alongside the food. Eunice would visit Mary’s home, clean, change her diaper, and sometimes simply sit beside her in bed. 

Slowly, the care and medicine began to work. Within a month, Mary could stand, wash dishes, and care for her children.

“There was a time I thought this was the end,” Mary said. “But, if I could recover, then no one else should give up.”

“I followed her through the entire process, taking sputum samples from her to the hospital until the tests came back negative for TB,” Eunice told Defrontera.

Eunice is a cadre of about 108, 000 workers recognised as a critical part of Kenya’s healthcare system. They are not trained like doctors, clinicians, or nurses, but they do a job the medics cannot do. Counties recruit them from the communities and train them for the role. For people like Mary, community health promoters deliver the main — and sometimes the only — healthcare they receive, helping them battle deadly diseases such as tuberculosis.

The government’s demand on Eunice’s time as a community health promoter is extensive: health education, maintaining basic records of who is vaccinated, who has hygiene facilities, and some clinical work to check for symptoms of infectious diseases such as malaria, TB, HIV, and others. A hairdresser by profession, Eunice sets aside her paid work every day to ensure patients like Mary are not left behind by the healthcare system. Daily, Eunice packs medicines, refills her cooler box with supplies, folds patient notes into a notebook, and visits at least three homes.

“I usually start around nine in the morning and work until three in the afternoon,” she said.

In the 46 households in her catchment, Eunice looks for signs of TB – drastic weight loss, persistent cough, fever, and chills — and persuades anyone who exhibits these to seek care. Most of them, she said, already live on the edge of poverty, and when tuberculosis strikes, it pushes them over. In 2023, Kenya had an estimated 124,000 people who have TB, but only 97,126 were diagnosed and recorded in the health system. About 26% of cases were missed: roughly 32,000 people with TB still live in the community, unknowingly infecting others.

Yet, for all her work, Eunice receives a stipend of KES 1,200 (US$9), through a programme funded by the United States government, disbursed through the Kajiado County government. The money covered her transport costs. So, when the Donald Trump administration gave the Stop Work Order in February 2025, Kenya’s TB programme was left KES 12.2 (US$ 94 million) poorer. Her stipend was discontinued. The volunteer says she has seen patients die — including her own sister, who fell ill and did not seek treatment. Her concern for patients has pushed her to continue helping them, this time using her modest income from her hairdressing job to finance the visits.

“When things became difficult, I just continued working in the community whenever I could… This is my burden too,” she said empathetically. “I’ve tried to quit many times, then someone calls about a sick neighbour and suddenly I’m making a referral… helping start treatment. Only later do I remember I was quitting.”

Even before donor cuts, the Kenyan government had acknowledged the life-saving work of community health promoters but did little about their facilitation. A proposed legislation, the Community Health Promoters Bill 2024, is before parliament, meant to formalise and regulate their work, and with provisions for payment. The 2025 County Governments Additional Allocations Bill for the 2024/2025 financial year was meant to further anchor this shift, introducing a Community Health Promoters Fund. And a yet-to-be-established council will be tasked with maintaining standards of practice. But the proposal does not clearly state how the community health promoters themselves will be paid.

Statements on the Ministry of Health’s website describe nearly everything about community health promoters — training, their kits, and the government “initiating” their payment — but remain vague on the actual remuneration. In 2024, Amref Africa reported that the national and county governments had agreed that counties would contribute KES 2,500, with the national government covering the remaining half of a proposed KES 5,000 monthly stipend for each promoter. International non-profits and aid organisations — including the Bill & Melinda Gates Foundation, Global Fund to Fight AIDS, Tuberculosis and Malaria, and USAID — have invested billions of dollars in Kenya’s health system. Yet the success of the programmes funded by these donors depends heavily on community health promoters like Eunice, while only a fraction of that funding reaches them.

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Public health experts say supporting these workers is essential, especially for TB care — from diagnosis to treatment adherence. Evaline Kibuchi, national coordinator for the Stop TB Partnership, said community health workers create awareness, support patients on treatment, help find new cases, and address stigma.

“If they are not supported, we risk going back to where we were ten years ago,” she said.

Even after diagnosis, adhering to treatment remains a challenge, especially in expansive counties like Kajiado. Joseph Sankok, Kajiado County TB coordinator, acknowledges the role of community health promoters in reducing the number of patients who stop treatment.

“Kajiado is a vast county,” he said. “People think of places like Kitengela or Ngong, but more than 50 per cent of this county is rural.”

For patients already weakened by illness, the distance to health facilities is too long. “They stop treatment, and treatment interruption in this county is about eight per cent every year,” Sankok said.

Stigma towards TB among the Maasai community, combined with the physical and psychological toll of treatment, further complicates adherence. For decades, TB treatment involved painful injections and long drug regimens lasting up to two years. Side effects ranged from loss of mobility to hearing loss. Although Kenya has since introduced shorter, pill-based treatments, adherence remains a struggle. One in 20 TB patients – about 5,000 people – drop out of treatment each year.

In Kajiado, Eunice and other community health promoters now deliver medicines directly to patients, reducing long journeys and helping more people complete treatment. Now, default rates have fallen from 14% in 2021 to about 7% in 2025 in the county.

“Doctors wait at hospitals for patients to come, but I go door-to-door looking for them. No doctor will go house-to-house searching for patients, but I do,” she said.

This story is part of Gasping for Breath, a special focus on Tuberculosis.