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      Exploring perceptions of community health policy in Kenya and identifying implications for policy change

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          Abstract

          Background: Global interest and investment in close-to-community health services is increasing. Kenya is currently revising its community health strategy (CHS) alongside political devolution, which will result in revisioning of responsibility for local services. This article aims to explore drivers of policy change from key informant perspectives and to study perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change.

          Methods: We conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives, including those who will influence or be influenced by CHS policy change in Kenya (policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members) in two purposively selected counties: Nairobi and Kitui. Qualitative data were digitally recorded, transcribed, translated and coded before framework analysis.

          Results: There is widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas for change identified include: lack of clear supervisory structure including provision of adequate travel resources, current uneven coverage and equity of community health services, limited community knowledge about the strategy revision and demand for home-based HIV testing and counselling.

          Conclusion: This in-depth analysis which captures multiple perspectives results in robust recommendations for strategy revision informed by the Five Wonders of Change Framework. These recommendations point towards a more people-centred health system for improved equity and effectiveness and indicate priority areas for action if success of policy change through the roll-out of the revised strategy is to be realized.

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          Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research.

          C Pope, N Mays (1995)
          Qualitative research methods have a long history in the social sciences and deserve to be an essential component in health and health services research. Qualitative and quantitative approaches to research tend to be portrayed as antithetical; the aim of this series of papers is to show the value of a range of qualitative techniques and how they can complement quantitative research.
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            The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya.

            Kim Lindblade, Maurice Ombok, Allan Audi … (2008)
            To explore the impact of distance on utilisation of peripheral health facilities for sick child visits in Asembo, rural western Kenya. As part of a demographic surveillance system (DSS), censuses of all households in the Asembo population of 55,000 are conducted three times a year, data are collected at all outpatient pediatric visits in seven DSS clinics in Asembo, and all households are GIS-mapped and linkable to a child's unique DSS identification number. Between May 1, 2003 and April 30, 2004, 3501 clinic visits were linked to 2432 children among 10,973 DSS-resident children < 5 years of age. Younger children and children with more severe illnesses travelled further for clinic visits. The median distance travelled varied by clinic. The rate of clinic visits decreased linearly at 0.5 km intervals up to 4 km, after which the rate stabilised. Using Poisson regression, controlling for the nearest DSS clinic for each child, socio-economic status and maternal education, and accounting for household clustering of children, for every 1 km increase in distance of residence from a DSS clinic, the rate of clinic visits decreased by 34% (95% CI, 31-37%) from the previous kilometer. Achieving equity in access to health care for children in rural Kenya will require creative strategies to address a significant distance-decay effect in health care utilisation.
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              Can Volunteer Community Health Workers Decrease Child Morbidity and Mortality in Southwestern Uganda? An Impact Evaluation

              Jennifer L. Brenner, Jerome Kabakyenga, Teddy Kyomuhangi … (2011)
              Background The potential for community health workers to improve child health in sub-Saharan Africa is not well understood. Healthy Child Uganda implemented a volunteer community health worker child health promotion model in rural Uganda. An impact evaluation was conducted to assess volunteer community health workers' effect on child morbidity, mortality and to calculate volunteer retention. Methodology/Principal Findings Two volunteer community health workers were selected, trained and promoted child health in each of 116 villages (population ∼61,000) during 2006–2009. Evaluation included a household survey of mothers at baseline and post-intervention in intervention/control areas, retrospective reviews of community health worker birth/child death reports and post-intervention focus group discussions. Retention was calculated from administrative records. Main outcomes were prevalence of recent child illness/underweight status, community health worker reports of child deaths, focus group perception of effect, and community health worker retention. After 18–36 months, 86% of trained volunteers remained active. Post-intervention surveys in intervention households revealed absolute reductions of 10.2% [95%CI (−17.7%, −2.6%)] in diarrhea prevalence and 5.8% [95%CI (−11.5%, −0.003%)] in fever/malaria; comparative decreases in control households were not statistically significant. Underweight prevalence was reduced by 5.1% [95%CI (−10.7%, 0.4%)] in intervention households. Community health worker monthly reports revealed a relative decline of 53% in child deaths (<5 years old), during the first 18 months of intervention. Focus groups credited community health workers with decreasing child deaths, improved care-seeking practices, and new income-generating opportunities. Conclusions/Significance A low-cost child health promotion model using volunteer community health workers demonstrated decreased child morbidity, dramatic mortality trend declines and high volunteer retention. This sustainable model could be scaled-up to sub-Saharan African communities with limited resources and high child health needs.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Health Policy Plan
                Journal ID (iso-abbrev): Health Policy Plan
                Journal ID (publisher-id): heapol
                Journal ID (hwp): heapol
                Title: Health Policy and Planning
                Publisher: Oxford University Press
                ISSN (Print): 0268-1080
                ISSN (Electronic): 1460-2237
                Publication date (Print): February 2016
                Publication date (Electronic): 26 March 2015
                Publication date PMC-release: 26 March 2015
                Volume: 31
                Issue: 1
                Pages: 10-20
                Affiliations
                1Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK,
                2Research and Strategic Information Department LVCT Health, Nairobi, Kenya,
                3KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands, and
                4Community Health and Development Unit, Ministry of Health, Kenya
                Author notes
                *Corresponding author. Rosalind McCollum, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK. E-mail: r.mccollum@ 123456liverpool.ac.uk
                Article
                Publisher ID: czv007
                DOI: 10.1093/heapol/czv007
                PMC ID: 4724165
                PubMed ID: 25820367
                SO-VID: 200f5917-9fda-4e1a-8b60-611ea3e836ec
                Copyright © © The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date accepted : 31 January 2015
                Page count
                Pages: 11
                Categories
                Subject: Original Articles

                ScienceOpen disciplines: Social policy & Welfare
                Keywords: community health extension worker,community health worker,close to community provider,kenya,policy
                Data availability:
                ScienceOpen disciplines: Social policy & Welfare
                Keywords: community health extension worker, community health worker, close to community provider, kenya, policy

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