Factors Influencing the Functionality and Sustainability of Community Units in Rural Kenya; The Case of Makueni County.

Factors Influencing the Functionality and Sustainability of Community Units in Rural Kenya; The Case of

Makueni County

Karijo Evalin, Kampen Denise, Gitimu Anne, Oruko Happiness , Karijo Evalin, Kampen Denise, Gitimu Anne, Oruko Happiness , Ndunge Fidelina, Ogendo Ken, Ofware PeterNdunge Fidelina, Ogendo Ken, Ofware Peter

AMREF Kenya, Free University of Amsterdam, Kenya Ministry of HealthAMREF Kenya, Free University of Amsterdam, Kenya Ministry of Health

Outline of Presentation• Background

• Problem Statement

• Research Questions

• Methodology

• Results

• Conclusion

• Recommendations

Background• Community Health Worker programs – in line with the Alma Atta

declaration for Primary Health Care & vital for MDGs’ achievement

(WHO, 2010).

• Kenya – primary health care

institutionalized in 2006 through

the Community Strategy

(GoK, 2006)

• Benefits in improving community

knowledge on maternal health & child health (USAID, 2013)

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Background

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Structure of Community Strategy - Community Units

Problem Statement• Constraints of Community Units implementation (GoK, 2010):

i) Community Strategy budgetary commitment : 9% of health care funding

ii) Harmonizing different approaches of CU implementation

iii) Sustaining CUs after exit of development agencies

• Community Units (CUs) in Makueni, Kenya (GoK, 2013): 11 non-operational, 46 semi-functional, 16 functional

• Little comprehensive research on functionality & sustainability of CUs – most focus on CHW attrition only & not the actors of CU implementation in entirety

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Research Questions1. What community level factors influence the functionality and sustainability of Community Units?

2. What factors of the Community Unit workforce cadre, influence the functionality & sustainability of Community Units?

3. What factors in the CU link health facility influence the functionality and sustainability of Community Units?

4. What factors from supporting development agencies, and the government influence the functionality and sustainability of Community Units?

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Conceptual Framework(Adapted from CU functionality score-card (AMREF, 2013) & Implementation Science

(Schel, et al, 2013)

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MA

KUEN

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COMMUNITY UNITS

Community Level

CU Workforce

Cadre

Link Health Facility

Government and

development agencies

Methodology• Study design:

-Qualitative exploratory study

• Purposive sampling

-Study population – 73 CUs

-Sample population – 4 CUs

• Data collection

-Semi-structured interview guides

-16 Focus Group Discussions - CHWs, CHC, community men & women

-15 Key Informant Interviews - CHEWs, SCHMT & development agencies

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Sampling Technique

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MethodologyData management

• Transcription & Translationo Tape recording & transcription – Listen & Write softwareo Direct translation into English

• Validityo Spot checks for translation errors o Triangulation on stakeholder levels

• Semi-open coding o Coded with MaxQda10 softwareo Matrix grouping of codes per level o Most frequent factors and relationships were analyzedo Texts analyzed for inter-play of factors

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Results1. Factors at community level

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Functionality themes

Sustainability themes

ResultsFactors at community level

Underlying issues:

a) Community members’ awareness on CHWs & CHC role: CHWs well accepted for their direct contact with community members.

“They (CHWs) have been good advisers for women in the reproductive age, and more so who like giving birth at their homes. They are also advised on the importance of attending ANC clinics” [Community Women FGD]

b) Community participation in CU activities: Minimal involvement by community in CU financial initiatives & plans

c) Fulfillment of community members needs: desired provision of more medical supplies e.g drugs and aqua tabs, & desired meetings with CHWs

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Results2. Factors of CU work-cadre

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Functionality themes

Sustainability themes

ResultsFactors of CU work-cadre

Underlying issues:

a)CHWs expectation versus reality:

"I expected that if I remain active as a

community health worker I will be able

to get employed and work for my

children". [CHW FGD]

b) Required support versus actual support:

inadequate incentives & working aids hence diminished motivation

c) Workforce struggles:

Conflict between CHWs & CHC: CHWs deemed superior

•Other studies: WHO (2007) – complex factors are required for motivation & attrition including financial & intrinsic rewards

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Results3. Factors of CU-Link Health Facility

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Functionality themes

Sustainability themes

ResultsFactors of CU-Link Health Facility

Underlying issues:

a)CHEWs’ increased work-load

CU technical advisor cum health facility

staff responsibilities

b) Link health facility services

•Services at CU link facility beneficial to community. However low quality

of services due to including inadequate essential commodities & limited

hours of service delivery & staff shortage

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Results4. Government and Development Agencies support

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Functionality themes

Sustainability themes

ResultsGovernment and Development Agencies support

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a) Incentives hampering sustainability:

Temporary solution for functionality if they cease abruptly

b) Implementing partner withdrawal/exit:

Inadequate exit strategies for sustainability are fatal for community units

c) Government limitations:

Government supervisory/management role lacking for CU workforce

•Other studies (USAID, 2013) – coordination of development agencies’ support vital for sustainability

Results

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Themes with strongest Inter-relationThemes with strongest Inter-relation

ThemesThemes

Conclusion

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• Most important themes: based on predominance, strongest relations & underlying issues:

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COMMUNITY UNITS

Community Level

CU Work-Cadre

CU Link Health Facility

Government –

coordination & resource allocation

RecommendationsFunctionality and Sustainability

In Kenya’s devolved system of governance – for CUs to have

sustainable impact on maternal and child health:

County Governments : resource allocation & technical oversight

to ensure:

-Organizational capacity: effective governance of CU, skilled &

motivated workforce, and adequate working aid

-Development agencies’ coordination & phase out strategy for

sustainability

-Community partnership & ownership in implementation

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Acknowledgment• Research Investigators: Evalin Karijo, Denise Kampen, Anne

Gitimu, Happiness Oruko, Fidelina Ndunge, Ken Ogendo, Peter Ofware

• Comic Relief - UK: Project donor

• Makueni Health Management Teams: Kibwezi, Makueni, and Mbooni Sub-Counties

• AMREF Kenya Ag. Country Director: Dr. Meshack Ndirangu

• AMREF RABD Unit: Anne Murugi, Dr. Ojakaa

• AMREF ESRC for approval of Research

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