Institutionalizing Community Health Services in Kenya: A Policy and Practice Journey

1. The Importance of Context (Devolution/Decentralization)

In 2013, Kenya devolved health and other services from the central government to 47 new subnational governments known as counties, which are semiautonomous units responsible for implementation of health services. The national government is responsible for training and development of policies and guidelines. Devolution presented a number of challenges,^10,11 including the differences in how counties implemented the second 2014–2019 community strategy. Some county leaders did not recognize the CHVs' role in the health system. Other counties developed their own models of the strategy and overhauled the entire program with varying levels of success.¹² Some counties served as model counties by establishing mechanisms for remunerating CHVs (Siaya County), and others adapted the strategy to prioritize their health needs.¹³ The varying implementation of the community strategy highlighted to the national MOH the urgent need for development of a national community health policy in response to the changes to the legal policy and institutional framework governing the health sector. This policy would be informed by county priorities and would enable buy-in and implementation by counties.

2. Evidence-based Policy Making

Community health policy and guidelines development in Kenya has been informed by research and evaluations conducted by the MOH in partnership with various stakeholders. The first strategy (2006) was informed by implementation research that demonstrated improved health indicators due to work performed by CHVs. After the first 5 years of scale-up, a countrywide evaluation revealed that the strategy was successful in improving indicators such as hygiene, sanitation, uptake of antenatal care services, and child health (immunization and diarrhea). The evaluation also identified high CHV attrition due to lack of a reward or remuneration system, inadequate empowerment of community members, and weak accountability and governance structures.¹⁴

After this evaluation, the 2014–2019 community strategy was defined, recognizing the challenge of nonremunerated CHVs and proposing a monthly stipend equivalent to US$20. It proposed a new structure for the community unit with fewer CHVs and 5 CHEWs who could provide health promotion and basic curative services at the household level. The revised strategy also recognized the need for adaptation of the strategy based on the diverse socioeconomic and ecological contexts seen in the country (i.e., urban, agrarian, nomadic, and pastoralist communities).⁷ In 2015, various stakeholders in all counties conducted a national evaluation that provided the evidence demonstrating the need for a community health policy, due to the lack of a legislative framework, that counties could use to advocate for and budget for CHV remuneration and other CHS costs.¹⁵

A 2018 national assessment of the community health strategy in the 47 counties (unpublished) found that most counties did not have specific community health policies or guidelines, and they relied on the national guidelines and the constitution to guide their community health planning. About 10 counties had a community health bill (legislation to recognize CHVs in law). About two-thirds of the counties reported allocating funds for community health, albeit inadequate. A third of the counties reported providing financial incentives to CHVs although this was inconsistent. The assessment identified challenges related to the varied implementation of community strategy across counties: varying number of CHVs per community unit, training, and supervision structures; lack of budgetary allocation and proper utilization of funds for community health in most counties with reliance on donors or nongovernmental organizations (NGOs) in others; low quality of community health services due to lack of training, commodities, supervision, and quality improvement of CHWs; and poor coordination of partners/stakeholders including funders at the county level. Finally, lack of a legal framework to sustain the funding for community health services at the national or county level was a common and urgent problem similar to that identified in the 2015 evaluation and informed the need to expedite finalization of the community health policy that had been in development since 2016.

3. Stakeholders' Engagement

The policy's development and launch was a result of concerted efforts since 2016 by many stakeholders, including the county governments and partners led by the MOH. The community health program has benefited from support from various stakeholders at the national and subnational levels including development partners such as United Nations Children's Fund (UNICEF), U.S. Agency for International Development (USAID), NGOs, religious bodies, community-based organizations, and community leaders. This has been in line with recommendations from various global guidelines.^16,17

In 2017, Kenya's MOH officials and stakeholders, including UNICEF, USAID, and NGO representatives that are members of the Community Health Technical Working Group, attended the first Institutionalizing Community Health Conference in Johannesburg, South Africa. This delegation developed an action plan toward institutionalizing community health in Kenya, reflecting on progress made, key challenges, and priorities for achieving goals based on their knowledge of the Kenyan community health landscape.

The stakeholders set 3 priority objectives that have contributed to the institutionalization of community health described in this article.

1. Finalize the Community Health Services Policy: The progress had begun in 2016 but had stalled and needed engagement with counties for input and finalization.

2. Conduct an assessment/evaluation of Kenya's community health services: Although the revised community strategy had been launched in 2014, it had been developed prior to devolution and was due for a review that would meet the varying needs of counties. This process informed an evaluation in 2018 that is being used to revise the strategy that is ongoing at the time of submission of this article.

3. Increase the visibility of community health services: Stakeholders felt that community health services in Kenya were not prioritized beyond the Division of Community Health Services or adequately financed by the MOH and other donors¹⁴ despite being in existence and mentioned in several government policy documents since 2006. At the time of the conference, the MOH Community Health and Development Unit only received salaries from the government and completely relied on donors and NGOs to conduct operational activities in their work plans. In addition, although the community strategy had been in place since 2006, it was not recognized, integrated, or budgeted for across all program areas and priority government initiatives, including Linda Mama (free maternal health care) and UHC programs that had been rolled out by the government. The stakeholders agreed to utilize all opportunities to advocate for CHWs in all programs.

The action plan helped to synergize and catalyze efforts toward strengthening and institutionalizing community health services in Kenya by all stakeholders. The MOH Division of Community Health Services regularly convened stakeholders through technical working groups to conduct a national evaluation of the community strategy and support the development of the policy and other relevant policy documents and guidelines. Throughout all these processes, county governments were engaged to provide input into the development as they are responsible for the implementation of the community health strategy in the county. The result has been national documents that have input from a wide range of stakeholders and are likely to be sustained.

4. Political Leadership and Alignment with Political Priorities

The role of politics in informing health policies and financing cannot be understated.¹⁸ The stakeholders involved in developing the community health policy recognized that for community health to be integrated and institutionalized in the health system in Kenya, there had to be buy-in from the top government leadership. They identified opportunities or policy windows¹⁹ that had presented themselves to support recognition of the community strategy. The most important was the UHC agenda.

As part of the Kenya President's Big Four Agenda for development 2017–2022, the UHC agenda aims to ensure affordable and quality health care for all and specifically mentions scaling up CHVs as a priority initiative. The Cabinet Secretary for Health attended the Global Conference on Primary Health Care in Astana, Kazakhstan, in October 2018, and Kenya endorsed the declaration on PHC that prioritized working with CHWs.²⁰ The Primary Health Care Strategy 2019–2024, which incorporates CHVs as members of the multidisciplinary team at the PHC level, is set to drive the UHC agenda in Kenya.⁹ The Cabinet Secretary for Health has committed to prioritize institutionalization and integration of community health in all health policies.

The 47 county governments have all endorsed the UHC agenda, the Primary Health Care Strategy, and the Community Health Policy as a result of the political buy-in from the President and the Cabinet Secretary for Health. This has resulted in increased commitments from counties to prioritize and budget for CHVs and other community health cadres in their counties.