Ameso, Edwin Ambani; P ince, Ru h Jane
A icle — Published Ve sion
Visions o Communi y Heal h and he Social Good
in Kenya: Tu ning Communi y Heal h Wo ke s in o
En ep eneu s
De elopmen and Change
P o ided in Coope a ion wi h:
John Wiley & Sons
Sugges ed Ci a ion: Ameso, Edwin Ambani; P ince, Ru h Jane (2025) : Visions o Communi y
Heal h and he Social Good in Kenya: Tu ning Communi y Heal h Wo ke s in o En ep eneu s,
De elopmen and Change, ISSN 1467-7660, Wiley, Hoboken, NJ, Vol. 56, Iss. 2, pp. 278-305,
h ps://doi.o g/10.1111/dech.12877
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Visions o Communi y Heal h and he Social Good in
Kenya: Tu ning Communi y Heal h Wo ke s in o
En ep eneu s
Edwin Ambani Ameso and Ru h Jane P ince
ABSTRACT
In Eas A ica, social en e p ises ha use de elopmen wo k wi h
en ep eneu ial ac i i ies and a language o ‘inno a ion’ a e becoming p om-
inen . C i ical o he NGO/dono model, which hey hold as unsus ainable,
such o ganiza ions a e unded by co po a e in es men and philan h opic
capi al bu aim o sel - eliance h ough enlis ing local ac o s o ma ke
social se ices, while p o iding loans, digi al in as uc u es and aining
in en ep eneu ship. Based on e hnog aphic ieldwo k in Kenya, his a -
icle examines he e hos, ambi ions and p ac ices o one such en e p ise
ope a ing ac oss A ica — Heal hy En ep eneu s. This no - o -p o i o gan-
iza ion seeks o enable communi y heal h wo ke s o become ‘heal h en e-
p eneu s’ by aining hem in business managemen and o e ing hem a loan
and mobile phone om which hey o de heal h commodi ies online and sell
hem o u al communi ies. Focusing on he pe spec i es, mo i a ions and
expe iences o local manage s and he en ep eneu s hemsel es, he a -
icle explo es ela ions be ween en ep eneu ism, communi y heal h wo k,
sus ainabili y and he ‘social good’, and he ic ions su ounding hem.
The model o u ning communi y heal h wo ke s in o en ep eneu s, which
os e s compe i ion while placing he bu den o success on o he indi idual,
shi s he e hos o communi y heal h wo k owa ds a ocus on business.
Howe e , he mo al economies in which communi y heal h en ep eneu s
a e embedded complica es his pic u e.
INTRODUCTION: A SOCIAL ENTERPRISE MODEL FOR COMMUNITY
HEALTH WORK
A a ‘clus e mee ing’ held unde a ee a a u al heal h acili y in wes e n
Kenya, Mike,1a young man in his mid-30s, examined a pile o pape o ms
placed on a wooden able. Facing him we e 10 communi y heal h wo ke s,
eb anded as ‘communi y heal h en ep eneu s’, d essed in hei signa u e
1. All pe sonal names and loca ions used ha e been al e ed as pa o anonymi y and con i-
den iali y conside a ions.
De elopmen and Change 56(2): 278–305. DOI: 10.1111/dech.12877
© 2025 The Au ho (s). De elopmen and Change published by John Wiley & Sons L d on behal
o Ins i u e o Social S udies.
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License,
which pe mi s use, dis ibu ion and ep oduc ion in any medium, p o ided he o iginal wo k is
p ope ly ci ed.
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 279
g een shi s and caps. They we e wai ing o ecei e he o -p esc ip ion
medicines and commodi ies hey had o de ed, which Mike had anspo -
ed in he boo o a Toyo a. Mike — a g adua e om a Kenyan uni e si y
and he a he o wo small child en — was he local manage o Heal hy
En ep eneu s, hence o h HE, a no - o -p o i social en e p ise ounded by
a Du ch expa ia e in Uganda in 2011. The o ganiza ion seeks o suppo
p ima y heal hca e by c ea ing al e na i e in as uc u es o deli e ing
heal h commodi ies and in o ma ion o u al popula ions, and aims o make
communi y heal h wo k mo e ‘sus ainable’ by o e ing communi y heal h
wo ke s (hence o h CHWs) an al e na i e o m o income gene a ion
(Bo s e al, 2019; HE, 2022). In pa icula , HE seeks o c ea e wha i calls
‘en ep eneu s’ ou o some o he olun ee CHWs, by p o iding he in a-
s uc u es o enable hem o un small businesses selling o -p esc ip ion
medicines and o he commodi ies.
As Mike checked h ough he o de s, wo o he communi y heal h en e-
p eneu s (CHEs) dis ibu ed pa ace amol able s, sani a y pads, condoms,
mul i i amins, pain- elie ing gels and balms and o he p oduc s, wi h each
indi idual ecei ing he i ems hey had o de ed. These CHEs we e a g oup
o eigh women and wo men, aged be ween 30 and 60, who had ecei ed
a wo-day aining om HE on business managemen , heal h in o ma ion,
and on using he o ganiza ion’s digi al pla o m. Mike had ec ui ed hem
om a pool o CHWs who we e a ached o he coun y go e nmen ’s ‘com-
muni y uni s’;2 hey con inued o se e as CHWs, linking u al house-
holds o heal hca e acili ies, o e ing heal h in o ma ion and epo ing i al
e en s, among o he du ies. To become a CHE, hey we e equi ed o aise
4,000 Kenyan shillings (Ksh) — ci ca US$ 40 — and a end he aining.
Along wi h he dis inc i e g een T-shi s and caps, ecei ed o ee as pa
o HE’s a emp s o, in Mike’s wo ds, mo i a e and incen i ize hem, he
o ganiza ion issued he CHEs wi h sma phones and a s a e pack wi h
heal hca e p oduc s and o -p esc ip ion medicine wo h US$ 70, on c edi .
I also o e ed he CHEs a s a -up loan o Ksh 8,400 (c. US$ 84) o be epaid
in ins almen s o Ksh 700 (c. US$ 7). Fo he c edi ex ended o CHEs, he
o ganiza ion expec ed epaymen wi hin he i s yea .
A mon hly clus e mee ings like he one Mike o ganized unde he ee,
he CHEs ecei e he p oduc s hey ha e o de ed online om digi al pla -
o ms, usually on c edi .3The o ganiza ion buys hese medicines and com-
modi ies wholesale and deli e s hem o CHEs who sell hem o ‘communi y
2. The coun y go e nmen s a e he 47 semi-au onomous poli ical and legal en i ies which ac
as adminis a i e uni s unde Kenya’s 2010 Cons i u ion ha ushe ed in a de ol ed sys em
o go e nance. A communi y uni e e s o he lowes le el o heal h se ice deli e y which
is p o ided by ained olun ee CHWs and includes basic heal h p omo ion and disease-
p e en ion se ices (A idi e al., 2014).
3. Paymen is ia Mpesa, Kenya’s mobile money paymen pla o m, un by he elecommuni-
ca ions gian Sa a icom.
280 Edwin Ambani Ameso and Ru h Jane P ince
membe s’, choosing a p ice ha hey ind sui able and using he small p o i
o pay o he loan and o de mo e goods. Thei ea nings a e supposed
o supplemen he Ksh 2,000 (c. US$ 20) hey ecei e (o should ecei e)
mon hly om he coun y go e nmen as communi y heal h wo ke s, p o id-
ing, in Mike’s opinion, a mo e sus ainable income.
A he ime o ou esea ch (2018–20), Heal hy En ep eneu s was ope -
a ing in eigh coun ies ac oss he A ican con inen , wi h s a -up unding
om he Du ch go e nmen , he Ga es Founda ion and co po a e in es o s.
In Kenya, i was p esen in six coun ies o he wes e n egion (Kisumu,
Homa Bay, Siaya, Vihiga, Kisii and Kakamega), ocusing on u al and
emo e, ‘ha d- o- each’ communi ies whe e, acco ding o HE, people ex-
pe ience limi ed access o heal h acili ies and a pe ennial sho age o heal h
commodi ies, including o -p esc ip ion d ugs (HE, 2019).4As explained o
us by i s Kenya-based s a , and as ou lined on i s websi e, HE p omises
o s imula e social de elopmen by in oducing CHE p og ammes cen ed
a ound social ma ke ing, social anchising and mic o-en ep eneu ship o
achie e social goals, among hem imp o ed communi y heal h (Bo s e al.,
2019). I a ge s u al popula ions by aining selec ed CHWs as mic o-
en ep eneu s who sell a o dable heal h p oduc s and o -p esc ip ion medi-
cines, while p o iding in o ma ion and o he se ices (HE, 2019). These
ac i i ies a e in addi ion o he ou ine communi y heal h wo k hey do,
which is suppo ed by coun y go e nmen s.
HE is managed by s a deeply mo i a ed by conce ns abou how o
do de elopmen in wha hey pe cei e as a mo e sus ainable way. They
a e c i ical o dominan models o inancing and o ganizing communi y
heal h wo k. In Kenya, as in many A ican coun ies, CHWs a e olun-
ee s and a e supposed o ecei e a US$ 20–30 minimum mon hly s ipend
om coun y go e nmen s, NGOs, o dono - unded p ojec s. HE a gues his
model is unsus ainable, gi en ha CHWs ecei e hei mon hly s ipends
ei he i egula ly o no a all. Ins ead, HE aims o c ea e a ne wo k o hese
communi y heal h ‘en ep eneu s’, expanding u al communi ies’ access o
heal h p oduc s and se ices while de eloping al e na i e o ms o income
o communi y heal h wo ke s. The o ganiza ion he e o e ec ui s selec -
i ely om an exis ing pool o CHWs, aining hem in en ep eneu ship,
including accoun s managemen and how o un a small business.
Du ing he pas decade, social en e p ises in ol ing new models o
communi y heal h wo k ha e become p ominen in many coun ies in he
Global Sou h, alongside a gumen s ha hey o e mo e sus ainable ways o
o ganizing p ima y heal hca e (e.g. Bä n eu he , 2023; Gandhi and Raina,
2018). Following ends in de elopmen mo e b oadly, such o ganiza ions
4. In 2023, HE s a ed i s aim o expand in o o he Kenyan coun ies and o c ea e 3,500 com-
muni y heal h en ep eneu s (Challenge Fund, 2024). Liaising wi h ocal pe sons wi hin he
coun y Minis ies o Heal h, HE has en u ed in o Ma sabi , Kili i and Naku u coun ies
(HE, 2021, 2022).
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 281
in oduce wha hey call ‘ma ke -d i en solu ions’ in o de elopmen and
global heal h (Dolan, 2012; Huang, 2020; Ka , 2017; Schwi ay, 2011), p o-
mo ing hemsel es as sus ainable en u es combining business p inciples
wi h ‘a passion o social impac ’ (Macassa, 2021: 1). Making use o eme -
ging inancial, echnical and digi al in as uc u e and p omo ing a language
o ‘dis up ion’, hey a gue ha models o en ep eneu ship, sel -help and
social en e p ise a e key o d i ing he inno a i e social change ha has
been lacking in s a e-cen ed o NGO-d i en de elopmen (I ani, 2019). In
he social en ep eneu ship li e a u e, ‘social business’ desc ibes an o gan-
iza ion ha uns comme cial ope a ions o add ess socie al p oblems (San-
os e al., 2015). As he language o sus ainable de elopmen has become
cen al o he social business model, he idea o he lexible en ep eneu —
a bo om-o - he-py amid igu e who can ‘adap luidly o mul iple economic
ac i i ies, embody isk- aking subjec i i ies, and mo e easily ac oss social
and spa ial bounda ies’ (Huang, 2020: 33) — has become highly alued (see
His ich e al., 2017; Lomba d and S ydom, 2011; P aszkie and Nowak,
2012). An ‘e hos o inno a ion and en ep eneu ship … has colonised phil-
an h opy, de elopmen p ojec s, [and] go e nmen policies’ (I ani, 2019: 1),
including, inc easingly, global heal h and p ima y heal hca e (Bä n eu he ,
2023). Like o he social en e p ises, HE aims o ins il ma ke pa icipa ion
a he bo om o he py amid, o ha ness he powe o ‘social connec i i y’
and o o e he p omise o social mobili y (Elyacha , 2012).5This model
is supposed o empowe CHWs, eleasing hem om dependence on NGOs
and he e a ic go e nmen al mon hly s ipend.
C i iques o his model o en ep eneu ial de elopmen a e mani old (e.g.
Dolan, 2012; Dolan e al., 2012; Huang, 2017, 2020; I ani, 2019; Ka , 2017;
Laza , 2004; Schwi ay, 2011) and make a numbe o poin s. De elopmen is
ou sou ced o he en ep eneu (o en emale, ma ginalized and poo ) who
is made esponsible, h ough he en ep eneu ship and empowe men , o
de elopmen ou comes. The ocus on en ep eneu ship assumes ha inde-
pendence, empowe men and success can be achie ed h ough de eloping
business acumen, asse ing new mo al epe oi es o he social good and he
mo al indi idual while igno ing p e-exis ing hie a chies and he social ela-
ions in which people a e embedded. Such social en e p ises o en in ol e
compe ing goals, such as p omo ing women’s empowe men while igh ly
con olling hei ac i i ies and moni o ing hem. Mo eo e , as Huang’s e h-
nog aphy demons a es o iAgen s in Bangladesh, he en ep eneu ship
model is no s able bu in ansi ion, may be only pa ially ansla ed, and
is o en con es ed, bo h because he a ge ed communi ies app oach social
en e p ises wi hin olde models o de elopmen pa onage and because ma -
ke models exploi exis ing mo al o de s o sociali y (see also Bä n eu he ,
2023). The en ep eneu s hemsel es mus he e o e na iga e compe ing
5. This ideology has been c i iqued o c ea ing wha has been called ‘po e y capi alism’.
282 Edwin Ambani Ameso and Ru h Jane P ince
logics and con lic ing oles, leading o un esol ed ensions and con a-
dic ions. While he model may indeed empowe some indi iduals, i also
c ea es new issu es be ween hose who succeed and hose who don’ —
be ween he dese ing and undese ing poo (Dolan, 2012). Finally, en e-
p eneu s a e ulne able o he p eca i y o hei ma ke s, hence, ‘an icipa ed
u u es may be sho -li ed’ (ibid.: 7).
D awing on e hnog aphic esea ch conduc ed in Kenya be ween 2018 and
2020, his a icle explo es he model o u ning communi y heal h wo k-
e s in o en ep eneu s, which os e s compe i ion while placing he bu den
o success on o he indi idual, and which p oduces in as uc u es o heal h
se ice deli e y ha un pa allel o (while piggybacking on) he go e nmen
heal h sys em. Cognizan o he c i iques o he en ep eneu ship model, as
ou lined abo e, we add ess he ques ion o why manage s and he heal h
en ep eneu s hemsel es emb aced i . Thus, we examine he alues and
belie s ha unde gi d he social en e p ise model and people’s commi men
o i , he a gumen s hey make, and he solu ions hey seek, while explo ing
he ensions and con adic ions ha eme ged and how hese we e nego ia ed.
In so doing, we highligh he o en-ambi alen pe spec i es, mo i a ions and
expe iences o membe s o HE’s s a , as well as he heal h en ep eneu s
hemsel es, conce ning he ela ions and ic ions be ween en ep eneu -
ism, communi y heal h wo k, sus ainabili y and he nebulous concep o he
social good. While HE shi s he e hos o communi y heal h wo k om a
ocus on se ice o a ocus on business, he mo al economies in which com-
muni y heal h en ep eneu s a e embedded complica es his pic u e.
Below, we discuss ou esea ch and me hods and in oduce he Kenyan
con ex . We hen examine he e hos, ideology and p ac ices o HE’s social
en e p ise app oach o communi y heal h wo k; i s concep ions o he
social good and en ep eneu ship; i s app oaches o sus ainabili y; and i s
social business model, including ensions be ween o -p o i and no - o -
p o i goals, app oaches o audi and measu es o success. We explo e he
iews o communi y heal h en ep eneu s hemsel es, and he ic ions
ha eme ge. Finally, we discuss he limi a ions o he en ep eneu ial
app oach o communi y heal h wo k. While ecognizing ha CHW p o-
g ammes ha e been bese wi h mul iple challenges, we explain why we
a e c i ical o he u n owa ds a social en e p ise model o deli e ing
p ima y heal hca e, in Kenya and beyond, and how i sub e s much o
he e hos o communi y heal h wo k as i has been unde s ood since he
1970s.
METHODS
Ou in oduc ion o HE was h ough Onyango, a communi y heal h wo ke
whom he i s au ho , Edwin Ameso, shadowed as he made ou ine house-
hold isi s o e se e al mon hs. Edwin was cu ious abou he g een shi s
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 283
ha se e al CHWs, Onyango included, o en wo e, which bo e bo h Min-
is y o Heal h insc ip ions and he HE logo and slogan. Onyango explained
ha he had been ec ui ed by Heal hy En ep eneu s in 2018 o become a
CHE, and o e ed o ake Edwin along o he nex mee ing.
The ma e ial we p esen he e p oceeds om his en y poin and is
based on e hnog aphic ieldwo k in Kisumu, Homa Bay, Kakamega and
Siaya coun ies om 2018 o 2020 as pa o ou la ge p ojec explo ing
he Kenyan go e nmen ’s a emp s o expand ci izens’ access o heal hca e
unde i s uni e sal heal h co e age (UHC) agenda. Du ing he ime o ou
ieldwo k, HE ope a ed in u al wes e n Kenya, wi h i s modes headqua -
e s and adminis a ion in Homa Bay and Kisumu coun ies espec i ely, and
wi h plans o expand in o neighbou ing coun ies.
We conduc ed obse a ions, in e iews and in o mal con e sa ions wi h
membe s o HE’s on- he-g ound s a , whom we also accompanied on ield
ips and o HE clus e mee ings. We also conduc ed g oup discussions,
in o mal obse a ions and in e iews wi h CHEs. Edwin spen ou mon hs
ollowing CHWs who doubled up as CHEs in hei e e yday wo k, and con-
duc ed household isi s o he CHEs a e ini ial in i a ions. He ca ied ou
six in e iews wi h HE ield o ice s deli e ing, documen ing and aking
paymen s o p oduc o de s made by CHEs, and u he in e iews wi h
he HE p ojec coo dina o in he egion. Accompanying HEs allowed o
obse a ion o he HE supply chain and he digi al echnology used, as well
as in e ac ions be ween local manage s and CHEs. Meanwhile, he second
au ho , Ru h P ince, ocused mainly on a smalle non-communicable dis-
ease p ojec ha he o ganiza ion was pilo ing in a neighbou ing coun y,
in e iewing he manage s, pha macis and ele-doc o , a ending clus e
g oup mee ings a he local ma ke be ween CHEs and a g oup o 15 elde ly
pe sons wi h hype ension and diabe es, as well as ollowing he CHEs in
hei daily wo k. Toge he , we conduc ed g oup discussions wi h communi y
heal h wo ke s and wi h CHEs. Con e sa ions and g oup discussions wi h
heal h en ep eneu s as well as wi h communi y heal h wo ke s who we e
no CHEs ga e us insigh s in o di e se pe spec i es, expe iences and dis-
ag eemen s. In e iews wi h manage s and a ious cad es o heal h wo ke s,
pha macis s and ield o ice s we e oppo uni ies o ank discussions abou
he o ganiza ion, i s objec i es, limi a ions and challenges, and i s ision o
communi y heal h wo k.
This esea ch o med pa o a la ge esea ch p ojec on he Kenyan go -
e nmen ’s expe imen s wi h uni e sal heal h co e age, de ined by he Wo ld
Heal h O ganiza ion (WHO) as ensu ing ha ‘e e yone has access o he
heal h se ices hey need wi hou inancial ha dship’ (WHO, 2010; see also
P ince, 2017; P ince and Neuma k, 2022). We conduc ed esea ch in go e n-
men bu eauc acies, NGOs, heal h insu ance o ices; wi h heal h wo ke s, in
hospi als and clinics; and wi h pa ien s and hei amilies as hey nego ia ed
284 Edwin Ambani Ameso and Ru h Jane P ince
access o heal hca e (Ameso, 2022; Ameso and P ince, 2022; Muinde and
P ince, 2023; P ince, 2022, 2023, 2024).6
INNOVATIVE SOLUTIONS TO PRIMARY HEALTHCARE IN KENYA?
Since he 1970s, communi y heal h wo ke s ha e been ecognized as c ucial
building blocks s eng hening p ima y heal hca e sys ems, o e ing a b idge
be ween heal h cen e and communi y, pa icula ly in u al and emo e a eas,
and ac ing as agen s o heal h educa ion, disease p e en ion and de elop-
men (Chen e al., 2021; F ankel and Dogge , 1992; Masis e al., 2021;
Wa en e al., 2021).7Howe e , s uc u al and adminis a i e cons ain s
hampe he de elopmen o obus na ional CHW p og ammes (F ankel
and Dogge , 1992; Win up, 2023). Communi y heal h wo k aces mul iple
challenges de i ing om, among o he issues, poo inancing and emune -
a ion o communi y heal h wo ke s (concei ed o as ‘ olun ee s’) and an
o en- oman icized pe cep ion o a holis ic communi y. Tensions conce n-
ing emune a ion, suppo s uc u es and in eg a ion a e e lec ed in com-
muni y heal h wo k and p og ammes in se e al coun ies (see, e.g., Aseyo
e al., 2018; B unie e al., 2014; Dil e al., 2012; Lusambili e al., 2021;
Maes, 2017). Mo eo e , CHW p og ammes a e o en embedded in pa i-
a chal, gende ed and au ho i a i e, op-down go e nance s uc u es. C i ics
ha e a gued ha CHWs, as olun ee s, a e exploi ed o hei ee labou by
p omo ing an ideology o sel -sac i ice and he i ues o ha ing a ‘com-
muni y spi i ’. The ecen u n owa ds expanding heal hca e access and se -
ices unde he UHC umb ella has e i ed in e es in communi y heal h
wo k, wi h CHWs p omo ed as ha ing he capaci y o each u al communi-
ies (Aseyo e al., 2018; Sain -Fi min e al., 2021; Win up, 2022). Howe e ,
hese p og ammes a e o en pu sued wi hou inco po a ing lessons lea ned
om pas ailu es and successes (Win up, 2023).
F om 2017 o 2022, he Kenyan go e nmen ac i ely pu sued a UHC
agenda. Policies included imp o ing access o p ima y heal hca e and ex-
pe imen ing wi h a ious heal h- inancing models. F om Decembe 2018,
public heal hca e was o e ed o ee in ou Kenyan coun ies, o one yea ,
as pa o a UHC pilo unded in pa by he Wo ld Bank. Re o ms o he
pa as a al Na ional Hospi al Insu ance Fund, o expand membe ship and se -
ices co e ed, we e also pu sued (Muinde and P ince, 2023; P ince, 2017,
6. Edwin conduc ed 12 mon hs o PhD ieldwo k om Feb ua y 2019 o Feb ua y 2020, while
Ru h conduc ed six mon hs o ieldwo k. Resea ch was unded by a Eu opean Resea ch
Council g an no. 759820, PI Ru h P ince (EU Ho izon 2020), and An h opology o Human
Secu i y in A ica (ANTHUSIA), EU g an no. 764546.
7. Communi y heal h wo k p og ammes a e a c ucial componen o he p inciples o p ima y
heal hca e a icula ed in WHO’s 1978 Alma-A a Decla a ion. Th ough CHWs, hese p o-
g ammes seek o p o ide heal h p omo ion, disease p e en ion and heal hca e se ices a
p ac icable cos s (see F ankel and Dogge , 1992).
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 285
2022, 2023) and con inue oday. These mo es ha e aken place amids a
educ ion in dono unding o global heal h a e he 2008–09 inancial
c ises. In e na ional o ganiza ions as well as go e nmen s a e encou aging
‘al e na i e inancing’ o heal h sys ems, looking pa icula ly o co po a e
in es o s and p i a e–public pa ne ships. En ep eneu ship is p omo ed as
one such inancing mechanism. This e ain o e s e ile g ound o o gan-
iza ions like Heal hy En ep eneu s, which aise unds om philan h opic
and co po a e in es o s, wi h he aim o becoming sel -su icien .
I is impo an o unde s and ini ia i es such as Heal hy En ep eneu s
in he con ex o Kenya’s heal h sys em. The 2010 Kenyan Cons i u ion
de ol ed some aspec s o managemen and deli e y o heal hca e se ices o
he 47 coun y go e nmen s, e aining policy and egula o y unc ions a he
na ional le el (Masaba e al., 2020; Moses e al., 2021). Wi hin he de ol ed
sys em, CHWs cons i u e he basic ie o ca e — epo ing on mo bid-
i ies and mo ali ies, connec ing p egnan women and in an s o clinics, and
o e ing heal h in o ma ion h ough household isi s. Reb anded ‘ olun-
ee s’ in 2018 and ‘communi y heal h p omo e s’ in 2023,8 hese CHWs
ecei e a mon hly s ipend and a na ional heal h insu ance co e adminis e ed
by coun y go e nmen s bu p ima ily inanced by NGOs and o he de elop-
men pa ne s (Ameso, 2022; Ameso and P ince, 2022).9These mon hly
emune a ions o CHWs ha e been e a ic, despi e ecen e o s o coun y
go e nmen s o ea ma k unds o communi y heal h se ices (Abuya e al.,
2021; Koon e al., 2013).
Du ing ou ieldwo k, CHWs we e becoming mo e ocal in poin ing
ou he challenges acing hem in deli e ing communi y heal h. In se -
e al coun ies, CHWs had s a ed o ganizing hemsel es, o ming Wha sApp
g oups o mee and p o es in he egional capi al, Kisumu. They a gued ha
he mon hly s ipend o US$ 20 is no commensu a e wi h hei wo kloads,
claiming i ea s hem as ‘ olun ee s’ and o ces hem o seek al e na i e
o ms o income o make ends mee , while hey a e expec ed o spend many
hou s p o iding ca e in hei communi ies. They oiced hese conce ns in
se e al g oup discussions we o ganized wi h CHWs. In he wo ds o one o
hei leade s, Rose:
They [go e nmen ] pay us no hing and hey a e calling us communi y heal h wo ke s! And
you know a communi y heal h wo ke has a amily, has child en and would like he child en
o a end school, jus like any o he child in he communi y. You know, you money is you
money, howe e li le i is …. Bu when you a e planning ha i I wo k by he end o he
mon h I’ll ge 2,500 [shillings], and no hing comes, some imes he wo k becomes e y
8. The e o s by he na ion s a e o eb and communi y heal h wo ke s as ‘heal h p omo e s’
e ames he p e-Yaoundé Con e ence concep o communi y heal h wo k. Howe e , he
1980s CHWs con e ence in Yaoundé was aimed a highligh ing he indispensable ole ha
hese lay wo ke s ha e in achie ing p ima y heal hca e goals (F ankel and Dogge , 1992).
9. His o ically, NGOs and o he de elopmen pa ne s ha e de eloped CHW p og ammes
p o iding se ices in ‘ e ical’, disease-speci ic p og ammes while engaging wi h go e n-
men s in ‘ho izon al’ CHW p og ammes (Hodgins e al., 2021).
292 Edwin Ambani Ameso and Ru h Jane P ince
Measu es o Success and Impac
Ma y explained ha HE was conce ned o assess he sus ainabili y o i s
p og ammes in e ms o hei impac :
We look a ou comes di e en ly om he dono wo ld, which looks a numbe s o CHWs
ained. Fo example, i 2,000 CHWs a e ained, he dono s ake his as a measu e o success.
The in es men wo ld sees his [success] in e ms o e enue. We measu e success in e ms
o he pe o mance o CHEs, whe he hey a e epaying hei deb s and how much p o i hey
make o hemsel es. Re enue is a measu emen o he pe o mance o he CHW, hus o he
quali y o he wo k. We wan well-pe o ming CHWs. So, we measu e in e ms o economic
impac .24
This demons a es ha echnologies o audi a e an impo an pa o HE’s
wo k and o m an e hico-mo al amewo k in which he ma ke is alued as a
d i e o de elopmen and social good, conside ed necessa y o p oducing
social impac (see Mu ay e al., 2022; Sche z, 2014). The emphasis on such
echnologies pa allels a ocus on esul s-based inancing (RBF) in global
heal h and de elopmen in e en ions.25 Such echnologies allow HE o
emain p o i able and inancially aluable o in es o s (Po eda e al., 2019).
Add essing communi y heal h conce ns is hus deeply in e wined wi h he
inancial as well as he social alues ha o m he o ganiza ion’s co e e hos.
Social impac was measu ed by he pe o mance o CHEs, which, in e m,
was measu ed no by hei impac s on communi y heal h o he quali y o
ca e hey o e ed (which a e di icul o assess h ough numbe s), bu by
he e enue hey made. Added o his a e ha d- o-measu e conside a ions o
he ‘ ime sa ed’ by membe s o he communi y who use CHEs a he han
spending ime and money ge ing o heal hca e acili ies. Asked o explain
how he o ganiza ion concep ualized social impac , Ma y eplied: ‘This is
he basic impac we ocus on: he cos and ime sa ed. We calcula e ha
abou 50 pe cen o heal h cos s a e spen on anspo , so we see ha his
is ou in e en ion. Ou business has an impac in e ms o cos s sa ed and
ime sa ed. This is he social impac measu emen ’.26 Al hough Ma y was
op imis ic abou HE’s po en ial o c ea e a mo e sus ainable model o com-
muni y heal h wo k, a e wo yea s o wo king wi h CHEs, she was no
naï e abou he challenges such a p og amme aced. Al hough she had been
ained in he language o business, Ma y desc ibed he sel as ‘mo e o a
social alue pe son’ han a ‘business pe son’.
24. KII, Heal hy En ep eneu s p ojec lead, Homa Bay coun y, 7 Ma ch 2020.
25. RBF e e s o inancial mechanisms ha a e being p omo ed by in e na ional de elopmen
agencies and s akeholde s o link incen i es o imp o ed heal h ou comes, especially in low-
and middle-income coun ies (see James e al., 2020: Oxman and F e heim, 2008).
26. KII, Heal hy En ep eneu s p ojec lead, Homa Bay coun y, 7 Ma ch 2020.
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 293
Seeing as ‘Communi y Heal h En ep eneu s’
Wha pe spec i es do communi y heal h en ep eneu s hemsel es o e on
he ela ions and ensions be ween communi y heal h wo k and he business
model ad oca ed by Heal hy En ep eneu s? And how do hei expe iences
compa e o hose CHWs who we e no chosen by he o ganiza ion? As no ed
abo e, communi y heal h wo ke s we in e iewed exp essed deep us a ion
wi h he emune a ion hey ecei ed, o en un eliably, om he coun y go -
e nmen . As on line heal h wo ke s, hey knew hey we e indispensable in
p ima y heal hca e, ye hey ecei ed li le ecogni ion om he go e nmen .
The ollowing exce p s om g oup discussions unde line hei us a ions:
Wi hou us [communi y heal h wo ke s], hey canno e en know how many an ena al mo h-
e s [ he e a e] in he communi y. They canno know how many people ha e de aul ed om
aking hei d ugs, how many people ha e de aul ed om going o he mo he ’s clinic. They
canno know. I is us [communi y heal h wo ke s], because we a e s aying wi h hese people.
So we know how many dea hs ha e aken place, which a eas chole a has jus d opped oday,
which hings a e happening …. I is he communi y heal h olun ee s ha know hem,
because hey [ he go e nmen o icials] jus come, hey si he e a he hospi al, bu wi h
us, we a e in he communi y.
Wi hou ou wo k, he hospi al canno mo e. E en igh now i you go back o he illage and
say ha we a e no going o do any hing conce ning la ines, conce ning heal h, conce ning
any hing, hings will ge wo se.27
A communi y heal h en ep eneu and CHW explained ha he mon hly
s ipend om he go e nmen ‘ a ely comes’. In his si ua ion, people app e-
cia ed he oppo uni ies ha HE o e ed o making a li ing: ‘Ha ing HE
a ound has eally mo i a ed us o con inue se ing ou communi ies. We a e
encou aged o go see he sick and we know ha in hese emo e a eas, wi h
hese medicines and small hings we sell, a leas we can ha e ood on he
able’.28 Ano he s a ed, ‘This en ep eneu ship was helping us, a he same
ime hey we e helping he communi y …. Because he d ug ha a clien
could buy a 150 [shillings], he o she will ge om us a 100 shillings, his
pe son has sa ed 50 shillings’. She explained ha a e being ec ui ed by
Heal hy En ep eneu s: ‘We ne e e en ca e o he s ipend om he go -
e nmen , we we e li ing a good li e … because a he end o he day, when
we come … om he ma ke , we’ll come back home wi h sal , suga , milk
and e en mea , we can pu mea on ou able, no [like be o e] e e y day
[only] omena, e e yday [only] ege ables’.29
The CHEs epo ed ha he households hey isi ed also app ecia ed
being able o buy i ems such as ibup o en, cough sy ups and bedbug ea -
men s. Some CHEs we e able o make up o Ksh 3,000 (US$ 30) a mon h;
27. FGD, Communi y Heal h Wo ke s, Kombewa (Kisumu coun y), 31 Janua y 2020.
28. FGD, Communi y Heal h En ep eneu s, Kisumu coun y, 1 Feb ua y 2020.
29. Ibid. Omena a e small ish, a local s aple, highly nu i ious and cheap, bu associa ed wi h
po e y.
294 Edwin Ambani Ameso and Ru h Jane P ince
one epo ed a lucky mon h when his ea nings eached Ksh 8,000 (pa ly
because he owned a mo o bike). Being able o se p ices acco ding o wha
people would pay was also an asse . Howe e , he good sales hey expe i-
enced ini ially we e pa ly he esul o he coun y go e nmen allowing
CHEs o sell mala ia es s and d ugs. A e wo mon hs, his policy was
e e sed, and CHEs we e back o selling ‘pampe s [nappies], cough sy up
and medicine o bedbugs’.30
O he CHEs aced se backs, epo ing ha i was di icul o ensu e a
p o i , as hey ga e ou goods on c edi o a low p ices, especially o
neighbou s, amily membe s and ulne able households hey isi ed. These
dilemmas illus a e how hey na iga e hese exchanges wi hin pa icula
social ela ions and mo al economies.31 As one CHE old Ru h:
I know e y well ha his pe son, I don’ wan o lea e he o die and she canno ge his
100 [shillings] o he an imala ial d ug. I’ll jus gi e he , i she will b ing [some hing o
me la e ] I’ll app ecia e, i she doesn’ , I’ll no go o i . … Bu when I go o you house, like
you Ru h. I jus look a you and know Ru h is wo king somewhe e [i.e. is ea ning money].
And i I know he d ug is 250 a he chemis s, I’ll s a wi h, ‘jus gi e me 250’. Yah, ha ’s
he same p ice a he chemis s, hen emo e 20 shillings and gi e me 230. … Tha is why,
when I go o somebody who is capable, ins ead o selling ha bedbug d ug a 130, I’ll sell i
a 200 when somebody has go he money.32
Gi ing away he i ems hey hoped o sell, o p o iding hem a lowe p ices
han expec ed, was economically challenging o CHEs, leading o anxie ies
abou being able o pay back deb s. Howe e , CHEs also epo ed ha ecipi-
en s o en ied o compensa e hem by b inging ood as paymen in kind,
such as maize om hei ga dens — ‘One go ogo o [one in o maize], e en
wo go ogo o’.
CHE1: Someone doesn’ ha e money, so ins ead [she says] ‘ ake my maize and gi e me d ugs’,
o ‘ ake my bananas and gi e me d ugs, o ake my beans…’.
CHE2: E en beans, you can ake hose beans o he ma ke and you eco e he money.
CHE1: O you can use i a home.
CHE3: So somebody canno die and you ha e medicine, you exchange he hings in he
communi y.33
CHEs epo ed acing hos ili y om some local businesses, such as he
small p i a e chemis s and shops selling pha maceu icals ha a e common
in e e y ma ke place and illage: ‘They see ha we can be aking some
cus ome s away om he pha macies o om chemis s’.34
While he CHEs we alked o we e ai ly sa is ied wi h HE’s suppo and
he oppo uni ies i ga e hem, we should unde line ha hey belonged o
a g oup o mo e success ul CHEs. The o ganiza ion epo ed ha some
30. FGD, Communi y Heal h Wo ke s, Kombewa, 20 Janua y 2020.
31. Ibid. See Roi man (1995) and Ship on (2007) o a discussion o he social cons i u ion o
o ms o c edi and deb in Came oon and Kenya, espec i ely.
32. FGD, Communi y Heal h En ep eneu s, Kombewa, 20 Janua y 2020.
33. FGD, Communi y Heal h En ep eneu s, Kombewa, 13 Janua y 2020.
34. Ibid.
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 295
CHEs we e unable o pay back hei loan, o we e acing ongoing di i-
cul ies. Mo eo e , many communi y heal h wo ke s could no join HE’s
aining because hey could no aise he ini ial unds. Heal hy En ep en-
eu s’ ec ui men s a egy he e o e appea s o a ge hose who we e al eady
be e -o economically han o he s. This led o some ensions be ween
CHWs and CHEs, al hough hese we e only e e ed o obliquely in ou
con e sa ions.
Du ing some o he g oup discussions, we became awa e ha no all pa -
icipan s we e CHWs o CHEs, and ha he CHEs who o ganized he mee -
ings wi h us had, in ac , in i ed o he people o join, o allow hem o ecei e
he compensa ion we o e ed o ‘ anspo ’. This expe ience unde lines
how CHWs and CHEs posi ion hemsel es as b oke s, making oppo un-
i ies a ailable o o he s. Indi idual CHEs exp essed some ambi alence abou
hei CHE wo k: hey we e glad ha i b ough oppo uni ies o income
gene a ion, bu el ha i added o he bu den o hei daily CHW wo k.
Mo eo e , hey we e unsu e how o deal wi h he ensions i c ea ed wi h
o he CHWs who could no become ‘heal h en ep eneu s’, as well as wi h
neighbou s, amily and iends. Pe haps his b oke age was an a emp o
de use hese ensions.
‘DISRUPTING’ COMMUNITY HEALTH WORK
While doing esea ch, we became a he scep ical o he app oach o
HE, and hus ini ia ed se e al discussions wi h bo h manage s and CHEs
du ing which we elayed, in a espec ul way, ou conce ns and c i ique.
We also discussed he heal h en ep eneu model wi h membe s o coun y
go e nmen heal h eams, who we e in cha ge o managing coun y-le el
heal h se ices; some we e c i ical o he enc oachmen o en ep eneu ship
in o communi y heal h wo k. Ou c i iques we e no new o HE’s local
manage s, who engaged in li ely discussions wi h us, acknowledging ou
conce ns bu also main aining hei iew ha en ep eneu ship and social
en e p ise we e indeed mo e sus ainable app oaches; hey had li le ai h
in he go e nmen ’s capaci y o will o implemen a mo e sus ainable com-
muni y heal h s a egy. Below, we ou line i e main c i icisms conce ning
he en ep eneu ship model, which we aised du ing hese discussions.
Fi s , he HE business model is selec i e and compe i i e. Only some
CHWs manage o ge h ough he aining, o indeed aise he necessa y
unds o Ksh 4,000 (c. US$ 40) o begin aining; and o hose who ained,
no all become success ul CHEs, able o pay back deb s and make a li ing.
HE i sel documen s ha many CHWs do no succeed in becoming CHEs
and ha hose who succeed in ge ing en olled as CHEs ind i di icul
o pay back hei loans o o c ea e a sus ainable income om selling
commodi ies. This is because HE’s model o success is based on de el-
oping a pa icula o m o ‘en ep eneu ship’ among people who li e in
296 Edwin Ambani Ameso and Ru h Jane P ince
communi ies whe e li elihoods a e insecu e. CHEs li e amongs and mus
sell hei commodi ies o people who ha e low and uns able incomes, and
who o en ely on c edi om neighbou s, digi al lende s o CHWs o ge
essen ial se ices. They ha e o c a ‘clien s’ ou o amily, neighbou s and
membe s o he communi ies in which hey li e. Whe he such a business
model is sus ainable emains ques ionable; HE’s assessmen as well as ou
in e iews sugges ha many CHEs do no manage o sus ain hei business.
Second, he HE p og amme c ea es ensions in he communi ies he CHEs
li e and wo k in. Tensions exis be ween CHEs and hose CHWs who do no
ge selec ed, o wi h hose who canno pay back hei deb s and d op ou
o he o ganiza ion. The p ocess o selec ion, and he ensuing di e ence in
oppo uni ies o income gene a ion be ween CHEs and o he CHWs, isks
c ea ing en y and di isions among he CHWs hemsel es. Such ic ions
a e no new, howe e ; hey a e pa o he e e yday landscape ha many
CHWs a e used o dealing wi h, whe e NGOs con inue o o e new p ojec s
and he e is compe i ion o access hem. HE hus simply adds ano he laye
o a dense o es o heal hca e ac o s compe ing o space in he Kenyan
public heal hca e sys em. Howe e , whe e HE di e s om o he p ojec s
is i s clea ocus on compe i ion and indi idual success, measu ed by how
well he CHEs can un hei business. The p og amme also c ea es con lic s
wi h o he heal h wo ke s, no ably pha macis s and nu ses who o en un
chemis s o small shops in u al o semi-u ban ma ke s, whe e hey sell simi-
la commodi ies o hose ha HE sells. Du ing ieldwo k, Edwin became
awa e o he h ea s ha CHEs expe ience and he ea s o pa icipa ion ha
accompany he h ea s, especially om senio cad es o heal h wo ke s (who
un small businesses on he side, as hey oo y o gene a e income beyond
hei go e nmen sala ies). Fa om being emo e, ou -o - he-way places,
he illages and small ma ke owns whe e CHEs ope a ed we e al eady
h i ing heal hca e ma ke s, well-connec ed o ci cui s o pha maceu icals
(see Why e e al., 2003). CHEs mus na iga e, hen, be ween di e en ac o s
and o ganiza ions ha a e al eady p esen and ha sell heal hca e se ices
and commodi ies, as well as juggling hei oles as en ep eneu s, and he
expec a ions o neighbou s, amily membe s and he communi ies in which
hey li e.
Thi d, as became clea in ou g oup discussions and in e iews wi h
CHEs, he en ep eneu ship model o communi y heal h wo k bu dens
CHEs wi h e en mo e asks and wi h o en con lic ing du ies, as hei en e-
p eneu wo k simply adds o (and maybe akes ime away om) hei wo k
o he go e nmen as CHWs. In Kenya, some coun y go e nmen s we e
ini ially hesi an o welcome he HE model, as hey ea ed i would di e
CHWs away om communi y ca e. Coun y heal h o icials we in e iewed
in Kisumu oiced such conce ns, a guing ha he en ep eneu ship model
had a nega i e e ec on he deli e y o p ima y heal hca e and he olun-
a y na u e o communi y heal h wo k. Ins ead o building up communi y
heal h wo k and in eg a ing i in o exis ing heal h sys em s uc u es, hey
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 297
wo ied ha HE piggybacks on exis ing s uc u es, while expec ing CHEs
o do addi ional wo k o gain an income.35
Ou c i ique o he business model o communi y heal h wo k does no
imply ha we idealize he 1970s’ model o communi y heal h wo k. The e
is much di e si y in hese p og ammes, ac oss coun ies, cul u es, unding
models and heal h sys ems, and an ex ensi e li e a u e analyses hei a ious
successes and ailu es. While he e a e examples o p og ammes ha ha e
been sus ainably inanced by na ional go e nmen s, o example in E hiopia
(Maes, 2017) and in Mali (Sain -Fi min e al., 2021), adequa e emune a ion
emains a majo challenge, owing o he eluc ance o go e nmen s o i-
nance hem. In many cases, CHWs a e expec ed o wo k la gely olun a ily
wi h li le compensa ion. Communi y heal h wo ke p og ammes can also
be accused o being pa ia chal and exploi a i e, as hey use low-income,
o en emale olun ee s (Bä n eu he , 2023) — al hough such p og ammes
may o e oppo uni ies o women o widen hei social ne wo ks ou side
o he household (Nading, 2014). Communi y heal h wo k has also been
unde mined by he o en-simpli ied imagina ion o wha a communi y is,
o e looking di isions, powe s uc u es and hie a chies. Communi y heal h
wo k is hus a complex and o en con adic o y endea ou , he eali ies o
which may be a om he ideal desc ibed in he 1978 Alma A a Decla -
a ion. Ou a gumen , howe e , is ha hese ‘ ailu es’, complexi ies and
challenges do no jus i y gi ing up on he model o s a e-o ganized CHW
p og ammes, whe e communi y heal h wo ke s a e p ope ly emune a ed
and in eg a ed in o PHC sys ems, as he s a e has geog aphical, poli ical
and empo al con inui y which NGOs and social en e p ises canno o e .
The isibili y and success o o ganiza ions such as HE indica es he
deg ee o which Kenya’s public heal h sys em is being ans o med in he
di ec ion o social en e p ise and en ep eneu ship. A he same ime, i
is clea ha HE depends on i s pa ne ships wi h coun y go e nmen s o
c edibili y, as well as o access o pools o al eady- ained CHWs and
hus o new bo om-o - he-py amid ma ke s. The exis ing in as uc u e o
he public heal h sys em enables HE o scale up i s ope a ions. Does his
mean ha he p eca i y o communi y heal h wo ke s is being no malized,
allowing he Kenyan s a e o u he di es i sel om esponsibili y o
hei li elihoods while ou sou cing he p o ision o se ices? The ambigu-
i y exp essed by some coun y heal h o icials conce ning he ope a ions o
Heal hy En ep eneu s sugges s his ques ion emains open.
A ou h c i icism o he HE model is ha i claims o o e se ices ha
i does no ac ually p o ide. Ea lie in his a icle, we quo ed Mike, who
claimed ha HE ensu es ha ‘essen ial and quali y medicines’ a e made
a ailable o people in u al a eas who o he wise would no ha e access
o hese d ugs, o who would ha e o make leng hy jou neys o heal h
35. KII, Heal h Managemen Team membe , Kisumu coun y, 29 Janua y 2020.
298 Edwin Ambani Ameso and Ru h Jane P ince
acili ies o ecei e hem. Howe e , he coun y go e nmen s in Kenya
ha e no allowed HE o dis ibu e p esc ip ion d ugs.36 Apa om he
pilo NCD p ojec desc ibed abo e, a ailable in jus one coun y, CHEs
dis ibu ed non-p esc ip ion medicines only — p oduc s ha a e al eady
widely a ailable in local shops, pha macies and ma ke s o es — as well as
non-medical commodi ies.
Finally, he inse ion o en ep eneu ship in o communi y heal h wo k
undamen ally changes he la e ’s e hos: i ep esen s an app oach o com-
muni y heal h wo k ha is no longe g ounded in willingness o se e bu
in he capaci y o ea n, e oding alues based on olun ee ism, in e es and
empa hy. This is unde lined in he blu ing o bounda ies be ween com-
muni y wo k o -p o i and no - o -p o i (Bä n eu he , 2023; Maes, 2017;
Neuma k and P ince, 2021; Sche z, 2014). This ep oduces inequali ies, en-
sions and hie a chies among communi y heal h wo ke s, as hose who do no
quali y o su i e he igou s o en ep eneu ship eel excluded, while hose
who pa icipa e ace he dilemma o app oaching communi y membe s as
po en ial consume s. Since he pool o cus ome s is ied o neighbou liness
and kinship ela ions, na iga ing and nego ia ing he supply o heal h com-
modi ies as a business is complica ed and augh wi h unce ain ies and
isk.
While i is ue, as we explained abo e, ha heal hca e in Kenya is al eady
comme cialized, and mone a y exchanges, bo h o mal and in o mal, pe -
ade much o he public heal hca e sys em (and ‘ adi ional’ medicine
oo), communi y heal h wo k i sel has been enced o om comme cial
exchanges, a leas o mally. By con as , HE o e s a model o communi y
heal h wo k ha has as i s co e ma ke exchange, i emizing and selling
pa icula commodi ies. While his wo k is concei ed as aking place
alongside and in addi ion o ongoing p ima y heal hca e, i p esen s a s a k
con as o an ideology o communi y heal h wo k and p ima y heal hca e
as non-commodi ized se ices. The success o CHEs is assessed on he bal-
ance o hei accoun ing books, hei abili y o pay back loans and o make
a p o i . In he p ocess, he e hos o communi y heal h wo k as a public
good is aded o o heal h as a commodi y and heal h wo k as a business
en u e, whe e u al communi ies become a ma ke pool o be p o i ed om.
Al hough HE s a and manage s did no ag ee wi h all ou c i iques, hey
lis ened o hem. They also poin ed ou ha he o ganiza ion and i s s a
a e no unc i ical o i s p og ammes and a e keen o imp o e hem. In he
cou se o ou con e sa ions wi h Ma y, she admi ed ha ‘ he e a e many
ques ions, and we a e s ill no su e wha a e he answe s, and whe he we
36. The wo excep ions o his ha e been: a ial p ojec in Siaya coun y, which had CHEs
dis ibu ing mala ia es s and an imala ial medicines ( he coun y go e nmen p ohibi ed his
p ac ice in 2019); and HE’s pilo NCD p ojec , desc ibed abo e, which was allowed because
he ele-doc o p esc ibed he medicines ha we e dis ibu ed ( his p ojec was ongoing in
2020, bu acing p oblems o inancial iabili y).
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 299
ha e ound he igh solu ion’. HE local manage s such as Ma y, Mike, he
ele-doc o and he pha macis o en discussed wi h CHEs he challenges
hey ace selling p oduc s o people in hei neighbou hoods who canno
a o d o pay. Re using o sell on c edi is, CHEs old us, ‘no neighbou ly’,
and a isk mos CHEs canno a o d o ake. This model makes i ha d o
he CHEs o make a p o i and pay back hei loan, especially when ‘clien s’
a e ela i es, neighbou s and iends. Mike, oo, was awa e o such delica e
issues:
We ha e had cases whe e people de aul , bu we always ell he CHEs ha his is hei busi-
ness and hey ha e lea n abou business skills. They also know he people well, so hey mus
do hei due diligence. We ad ise hem o conside he economic aspec s in hei communi-
ies o en bu also a oid any hing ha will uin hei ela ionships wi h hei neighbou s, who
a e essen ially hei cus ome s and clien s.37
Howe e , as Mike’s wo ds unde line, he challenges aced by CHEs in mak-
ing a iable business did no , o mos HE s a , unde mine hei ai h in he
social business model o de elopmen .
Why, despi e all he ensions we ha e ou lined, does ai h in he social
business model o de elopmen emain s ong among HE s a , and why is
i emb aced by he heal h en ep eneu s? One eason is ha , o some people
— bo h o he manage s and s a employed by HE, and o he success ul
CHEs — i has deli e ed (some) ma e ial gains. A posi i e expe ience o
income gene a ion may con as wi h hei expe iences o NGO-led de el-
opmen , whe e oppo uni ies come and go, and o he Kenyan s a e, which
is expe ienced as un eliable and ex ac i e. CHEs and o he s a e hus open
o ying ou new s a egies o make li elihoods. Mo e b oadly, he ocus on
os e ing independence and sel -de elopmen speaks o an impo an o ien-
a ion ha has long been encou aged in pos -independence Kenya, e en i
such goals emain ha d o each (Lockwood, 2023; Neuma k, 2017; P ince,
2015; Smi h, 2008).
CONCLUSION
In his a icle we ha e o e ed insigh s in o how and why no ions and
p ac ices o social en e p ise based on a concep ion o he ‘social good’
a e making in oads in o A ican public heal hca e sys ems. We ha e also
unde lined he ways hey a e being modi ied and ansla ed by ac o s on
he g ound. Following he ic ions su ounding Heal hy En ep eneu s,
we ha e explo ed how alues placed on ma ke mechanisms and business
models in d i ing sus ainable de elopmen a e con ex ualized and ansla ed
in he con ex o agmen ed heal h sys ems, u al communi ies and local
mo al economies, by manage s and by CHEs hemsel es.
37. KII, Heal hy En ep eneu s local manage , Kisumu coun y, 13 Ma ch 2020.
300 Edwin Ambani Ameso and Ru h Jane P ince
Following Ong and Collie (2007), we can app oach he social en e p ise
model as a ‘global assemblage’ o ideas and alues conce ning en ep e-
neu ship, de elopmen and he social good, ha mo e a ound he globe as
hey a e emb aced by a ious ac o s and o ganiza ions. Ye hese ideas and
alues do no mo e seamlessly. Anna Tsing a gues ha global o uni e sal
concep s and ideas a e always engaged in ‘s icky loca ions’, which gi e hem
ac ion bu also shape hei ajec o ies and how hese un old.
Engaged uni e sals a el ac oss di e ence and a e cha ged and changed by hei a els.
Th ough ic ion, uni e sals become p ac ically e ec i e. Ye hey can ne e ul il hei
p omises o uni e sali y. E en in anscending locali ies, hey don’ ake o e he wo ld.
They a e limi ed by he p ac ical necessi y o mobilizing adhe en s …. All uni e sals a e
engaged when conside ed as p ac ical p ojec s accomplished in a he e ogenous wo ld.
(Tsing, 2004: 8)
As ‘engaged uni e sals’, models o social en e p ise and en ep eneu ship
a e slowed down by he ic ions hey encoun e in pa icula locales (ibid.).
Heal hy En ep eneu s engages communi y heal h wo ke s in mul iple
ways, including by o e ing aining in new digi al and business skills, c e-
a ing new connec ions and oppo uni ies, and p o iding heal h in o ma ion
se ices. Heal hy En ep eneu s a icula es an ideology and se o p ac-
ices aimed a incen i izing and o ganizing u al ci izens o pa icipa e in
he ealm o heal hca e as cus ome s and clien s, and o app oach com-
muni y heal hca e se ices as pa o a heal hca e ma ke . HE p omises
in es o s po en ial e u ns h ough hei capi al lows as CHEs a e en i-
sioned as agen s o change, imp o ing heal h, bu also ins illing en ep e-
neu ial cul u es in u al communi ies (Huang, 2020). This model is sup-
posed o empowe CHEs. I ani (2019) desc ibes how en ep eneu ial expe -
imen s in sus ainable de elopmen a e aimed a being eplicable and low-
cos , p omising o c ea e s able and eliable economic in as uc u es o
ex ac alue a he bo om o he py amid. In his model, communi y heal h
en ep eneu s mus p o ide se ices a hei own inancial isk, aking ou
loans in o de o inance hei businesses. Thus, he model o loads isks
and esponsibili ies on o CHEs, who mus ‘ ansla e be ween ma ke -based
mo al epe oi es, and local no ions o sociali y and e hical pe sonhood’
(Huang, 2017: 614), making hem in o ambiguous igu es o heal h wo k
and de elopmen in hei own communi ies.
The alues ha Heal hy En ep eneu s nu u es di e om olde isions
o communi y heal h wo k, which p omo ed no ions o communi y, al u-
ism, solida i y and ‘ha ing hea ’, as many o he CHWs we spoke o emin-
isce. These olde alues a e being subs i u ed wi h ma ke -o ien ed ideals
o heal hca e as a commodi y o be bough and sold. Ou esea ch shows,
howe e , ha hese subs i u ions a e pa ial and ha hey a e, in he day- o-
day in e ac ions ha communi y heal h wo ke s engage in, con inually con-
es ed. While Heal hy En ep eneu s’ ocus on en ep eneu ship eshapes
he e hos o communi y heal h wo k owa ds a business-o ien ed model, he
Tu ning Communi y Heal h Wo ke s in o En ep eneu s in Kenya 301
mo al economies in which CHEs a e embedded complica e his. Thus, some
heal h en ep eneu s ended up selling medicines and o he p oduc s o eld-
e ly people ei he on c edi o a low p ices, because he elde ly o en could
no a o d o buy hem; hey also el unde p essu e om amily and iends
o ‘lend hem’ goods. Mo eo e , he en ep eneu ’s business did no neces-
sa ily en ail commodi ica ion o communi y heal h wo k bu was pa o
a gi e-and- ake o making li elihoods in u al communi ies. Thus, i hey
a e unable o pay money o he goods hey buy om heal h en ep eneu s,
people will endea ou o o e some hing ‘in kind’, such as a sack o beans
o maize om hei own ga dens. The ac ha he wo k o heal h en ep e-
neu s, like ha o CHWs, akes place wi hin ongoing ela ionships (o
ex ending c edi and incu ing deb ) wi h neighbou s, amily and o he s,
sugges s ha , al hough o ms o en ep eneu ial sel -making may become a
no malized pa o communi y heal h wo k and p ima y heal hca e, such
global ‘models-in-mo ion’ (Huang, 2017: 604) un old in local con ex s
whe e o he mo al economies a e a wo k.
ACKNOWLEDGEMENTS
We a e g a e ul o ou in e locu o s Ma y, Mike, Jaduong Onyango and
o he s who sha ed hei insigh s and expe iences in a ied capaci ies. This
esea ch p ojec ecei ed unding om he Eu opean Union’s Ho izon 2020
esea ch and inno a ion p og amme, he ‘An h opology o Human Secu -
i y in A ica’ (ANTHUSIA), unde Ma ie Skłodowska-Cu ie g an ag ee-
men No. 764546, and he ‘Uni e sal Heal h Co e age and he Public Good
in A ica’ p ojec unded by he Eu opean Resea ch Council, g an ag ee-
men No. 759820. We a e g a e ul o P o esso s Onyango-Ouma, Cha les
Olungah, Lo e Meine and Wenzel Geissle o hei suppo du ing he
esea ch. We hank Tom Neuma k, Sand a Bä n eu he and Ma ian Bu ch-
a d , along wi h he jou nal’s e iewe s and edi o s, o hei aluable com-
men s and inpu s.
Open access unding enabled and o ganized by P ojek DEAL.
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