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 ,
Ndunge Fidelina, Ogendo Ken, Ofware Peter
AMREF Kenya, Free University of Amsterdam, Kenya Ministry of Health
Outline of Presentation
•
•
•
•
•
•
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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
Structure of Community Strategy - Community Units
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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 nonoperational, 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 Questions
1. 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)
MAKUENI COUNTY, KENYA
COMMUNITY UNITS
Community
Level
CU
Workforce
Cadre
Link Health
Facility
Government
and
development
agencies
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Methodology
• Study design:
-Qualitative exploratory study
Sampling Technique
s - a eni
• 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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en a
ea s
t s ect
s esta ishe
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a encies in the same ea
s esta ishe in
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Methodology
Data management
• Transcription & Translation
o Tape recording & transcription – Listen & Write software
o Direct translation into English
• Validity
o Spot checks for translation errors
o Triangulation on stakeholder levels
• Semi-open coding
o Coded with MaxQda10 software
o Matrix grouping of codes per level
o Most frequent factors and relationships were analyzed
o Texts analyzed for inter-play of factors
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Results
1. Factors at community level
Functionality themes
Sustainability themes
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Results
Factors 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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Results
2. Factors of CU work-cadre
Functionality themes
Sustainability themes
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Results
Factors 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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Results
3. Factors of CU-Link Health Facility
Functionality themes
Sustainability themes
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Results
Factors 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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Results
4. Government and Development Agencies support
Functionality themes
Sustainability themes
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Results
Government and Development Agencies support
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) – c
support vital for sustainability
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inati n
eve
ment a encies’
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Results
Themes with strongest Inter-relation
Predominance
70
60
50
40
30
20
10
0
Workforce &
Organzational
capacity
Workforce &
Partnership
Workforce & Implementation Implementation
Implementation & Organizational & Partnership
capacity
Themes
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Conclusion
• Most important themes: based on predominance, strongest relations
& underlying issues:
MAKUENI COUNTY, KENYA
COMMUNITY UNITS
Community
Level
Government
–
coordination
& resource
allocation
CU WorkCadre
CU Link
Health
Facility
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Recommendations
Functionality and Sustainability
In
en a’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 a encies’ 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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