community health strategy implementation guide 2007

iImplementation Guidelines

Republic of Kenya

Community StrategyImplementation Guidelines

for

Managers of theKenya Essential Package for Health

at the Community Level

Ministry of HealthMarch 2007

Reversing the trendsThe Second

NATIONAL HEALTH SECTORStrategic Plan of Kenya

ii Taking KEPH to the Community

THIS PUBLICATION is one of a series that the Ministry of Health will produce to support theachievement of the goals of the second National Health Sector Strategic Plan, 2005–2010 (NHSSP II).Aiming to reverse the declining trends in key health sector indicators, NHSSP II has five broad policyobjectives. These are:• Increase equitable access to health services.• Improve the quality and responsiveness of services in the sector.• Improve the efficiency and effectiveness of service delivery.• Enhance the regulatory capacity of MOH.• Foster partnerships in improving health and delivering services.• Improve the financing of the health sector.

Any part of this document may be freely reviewed, quoted, reproduced or translated in full or inpart, provided the source is acknowledged. It may not be sold or used in conjunction with commercialpurposes or for profit.

Community Strategy Implementation Guidelines for Managers of the Kenya Essential Package forHealth at the Community Level

Published by: Ministry of HealthSector Planning and Monitoring DepartmentAfya HousePO Box 3469 - City SquareNairobi 00200, KenyaEmail: [email protected]

iiiImplementation Guidelines

Contents

Lists of Tables and Figures vList of Abbreviations viForeword viiAcknowledgements viii

1. Introduction to the Community Strategy 11.1 Objectives of the Community Strategy

Guidelines 31.2 The Purpose and Overview of the Guidelines 3

1.2.1 Why the Guidelines 31.2.2 What Methods Are to Be Used 3

2. The Essential Elements of the CommunityStrategy 5

2.1 The Linkage Mechanisms and Structures 52.1.1 Community Units 52.1.2 Community Health Committee (CHC) 62.1.3 Level 2 Management Committee 72.1.4 Level 3 Health Facility ManagementCommittee 72.1.5 Divisional Health Stakeholder Forum 82.1.6 The District Health Stakeholder Forum 92.1.7 District Health Management Board 11

2.2 The Management Structures 112.2.1 District Health Management Team 112.2.2 Provincial Health Management Team 112.2.3 Technical Stakeholder Committees 112.2.4 Health Sector CoordinatingCommittee 13

3. Launching the Community Strategy –Community Entry 14

3.1 STEP 1: Creating Awareness 143.2 STEP 2: Situation Analysis and Household

Registration 153.3 STEP 3: Planning Actions for Improving

Health Status 163.4 STEP 4: Establishing Information

Systems to Monitor Change 16

4. The Workforce 174.1 The Categories 17

4.1.1 Community Health Workers 174.1.2 The CHEW 194.1.3 The CHC 19

4.2 Training Service Providers for Level 1 204.2.1 Community Health ExtensionWorkers’ Training 204.2.2 Community Health Workers’ Training 21

5. Key Health Messages by Cohort for Level 1 235.1 Communicating the Messages 235.2 COHORT 1: Pregnancy, Delivery and

Newborn 245.3 COHORT 2: Early Childhood (2 Weeks to

5 Years) 255.4 COHORT 3: Late Childhood (6–12 Years) 255.5 COHORT 4: Adolescence and Youth (13-24

Years) 255.6 COHORT 5: Adults 25–59 Years 265.7 COHORT 6: Elderly Persons (over 60 Years) 26

6. Service Delivery at Level 1 276.1 Levels of Service Delivery 276.2 Key Components of KEPH at Level 1 28

6.2.1 Reproductive Health 296.2.2 HIV/AIDS Prevention and Care 306.2.3 Malaria 306.2.4 Community IMCI 316.2.5 Tuberculosis 31

6.3 Service Provision at Level 1 326.3.1 Service Provision by Householdsand Communities as Partners in ServiceDelivery 326.3.2 Service Provision by CHEWs and CHWs 33

6.4 Supportive Supervision 346.5 Referral Mechanisms 34

6.5.1 Essential Elements of a ReferralSystem 346.5.2 Steps in the Referral Process 35

iv Taking KEPH to the Community

7. Community-Based Health InformationSystem 36

7.1 Why a Community-Based HealthInformation System 36

7.2 Definition of Community-Based HealthInformation System 37

7.3 Setting up a Community-Based HealthInformation System 37

7.3.1 The Type of Information Collectedand Who Collects It 377.3.2 How the Information Is Collated andAnalysed 387.3.3 Use of Community-Based HealthInformation System 387.3.4 Characteristics of a Good Community-Based Health Information System 38

vImplementation Guidelines

Tables

2.1: Linkages of the DHSF with DHMT and DHMB 92.2: Summary of timing and types of meetings 102.3: Role and functions of the DHMT 132.4: Roles and functions of the PHMT 134.1: Summary of functions of the Community

Strategy workforce 186.1: Description of services at community

levels (1–3) 276.2: Expertise by level of services 286.3: KEPH service delivery matrix by cohort

and level 28

Figures

1.1: Health sector coordinating structure 22.1: Community Strategy linkage structure 62.2: MOH implementation structure 125.1: Effective communication is a two-way

process 246.1: Levels of service delivery under KEPH 277.1: The process of establishing a community-

based health information system 37

List of Tables and Figures

vi Taking KEPH to the Community

List of Abbreviations

AFB Acid fast bacilliAIDS Acquired immune deficiency

syndromeANC Antenatal careAOP Annual operational planART Anti-retroviral therapyARV Anti-retroviral drugBCC Behaviour change communicationCBD Community-based distributor/

distributionCBHIS Community-based health information

systemCBO Community-based organizationCHC Community health committeeCHW Community health workerCHEW Community health extension workerDDC District development committeeDHMB District health management boardDHMT District health management teamDMOH District Medical Officer of HealthDHS District health systemDHSF District health stakeholder forumDMS Director of Medical ServicesDC District CommissionerECN Enrolled community nurseFBO Faith-based organizationFP Family planningGOK Government of KenyaIEC Information, education and

communicationHCMC Health centre management

committeeHF Health facilityHFMC Health facility management

committeeHIV Human immunodeficiency virusHMB Hospital management boardHMIS Health management information

system

HQ HeadquartersHR Human resourceHSCC Health Sector Coordinating

CommitteeHSR Health sector reformIBP Individual birth plansIMCI Integrated management of childhood

illnessIHI Institute for Health ImprovementITN Insecticide treated (bed) netsIVC Integrated vector controlJICC Joint Interagency Coordinating

CommitteeKDHS Kenya Demographic and Health

SurveyKEPH Kenya Essential Package for HealthMCH Maternal and child healthMDGs Millennium Development GoalsMOH Medical Officer of HealthNDP National Drug PolicyNGO Non-government organizationOPD Outpatient departmentOVCs Orphans and vulnerable childrenNHSSP II Second National Health Sector

Strategic Plan 2005–2010PDW People with disabilityPHT Public Health TechnicianPHO Public Health OfficerPLHA People living with HIV and AIDSPMO Provincial Medical OfficerPMTCT Prevention of mother-to-child

transmission (of HIV)RH Reproductive healthSTI Sexually transmitted infectionSTD Sexually transmitted diseaseTB TuberculosisTBA Traditional birth attendantVCT Voluntary counselling and testing

viiImplementation Guidelines

The Kenya Essential Package forHealth (KEPH) is the new approachthrough which the goals of theNational Health Sector Strategic Plan

2005-2010 (NHSSP II) will be accomplished.Realizing the importance of empoweringhouseholds and communities in the delivery ofthe KEPH at level 1, the Ministry of Health andsector partners developed and launched aCommunity Strategy in 2006. The strategyoutlined the type of services to be provided atlevel 1, the type of human resources requiredto deliver and support level 1 services, theminimum commodity kits required, and themanagement arrangements to be used.

The development of the CommunityStrategy guidelines contained in this book is animportant milestone in the implementation ofthe Community Strategy as they outline the“how” of the strategy. The guidelines discussthe establishment of community healthservice linkage structures, as well as thelaunch and management of the CommunityStrategy at the local level. They providedirection for building the capacity of thecommunity health extension workers (CHEWs)and community health workers (CHWs),establishing a communication strategy thateffectively improves health seeking behaviour,and providing level 1 services. Importantly forfuture monitoring and evaluation, they detailthe mechanisms for evidence-based dialogue

informed by community- and facility-basedinformation systems.

These guidelines are for use by frontlinehealth sector managers who have primaryresponsibility for managing theimplementation of KEPH at level 1 of thehealth system. The guidelines are neitherprescriptive nor restrictive. They are, rather,facilitative and enabling, as they set a firmfoundation for Taking the Kenya EssentialPackage for Health to the Community. Theyseek to help the managers to get the necessaryskills to work with clients, households andcommunities within the proposed partnershipapproach.

It is my own hope – and that of the Ministry– that the use of these guidelines will improvethe delivery of KEPH at level 1 and willcontribute to the realization of the healthsector vision of “reversing the trends” inKenya’s impact and outcome indicators.

Dr. T. GakuruhHead, Sector Planning and MonitoringDepartmentMinistry of Health

Foreword

viii Taking KEPH to the Community

Many individuals andinstitutions at the differentlevels of the health caresystem have participated in

the process of developing this manual. TheMinistry of Health is grateful to all of themfor their concerted effort to improve thehealth of the communities of Kenya.

Appreciation also goes the Departmentsof Preventive and Promotive Health Servicesand of Curative and Rehabilitative Health

Services for providing valuable inputs to thecommunity implementation framework.

The Ministry would like also toacknowledge our development partners,especially the World Health Organization(WHO), the Department for InternationalDevelopment (DFID) and the SwedishInternational Development CooperationAgency (Sida) for the technical and financialassistance provided during the manualdevelopment process.

Acknowledgements

1Implementation Guidelines

1. Introduction to the CommunityStrategy

Communities are at the foundation ofaffordable, equitable and effectivehealth care. The community, in fact,represents level 1 in the Kenya

Essential Package for Health (KEPH) proposed inthe second National Health Sector Strategic Plan2005–2010 (NHSSP II). It is so important to thesuccess of NHSSP II that a specific strategy wasdeveloped for rolling out the strategic plan atcommunity level: Taking the Kenya EssentialPackage for Health to the Community: A Strategyfor the Delivery of LEVEL ONE SERVICES1

(hereafter referred to as the CommunityStrategy).

The overall goal of the Community Strategy isto enhance community access to health care inorder to improve individual productivity and thusreduce poverty, hunger, and child and maternaldeaths, as well as improve educationperformance. This goal is to be accomplished byestablishing sustainable level 1 services aimed atpromoting dignified livelihoods across all thestages of the life cycle, and throughout thecountry through the decentralization of services,as well as enhanced accountability andresponsibility among all concerned partners.

The community-based approach, as set out inthe Community Strategy, is the mechanismthrough which households and communitiesstrengthen their role in health and health-related development by increasing theirknowledge, skills and participation. The intentionis to strengthen the capacity of communities toassess, analyse, plan, implement and managehealth and health-related development initiativesso that they can contribute effectively to thecountry’s socio-economic development. Theapproach recognizes that all communities are

already actively engaged in health activities forthe survival of their households. Their actions forhealth could be strengthened through anincreased knowledge and skills base as well as bybetter planning of their activities.

In addition, the approach recognizes thepivotal role of the health system in supportingcommunity efforts. It is through partnershipbetween the system and the communities thatimprovement can be realizedand sustained. It is thereforecritical to integrate level 1health activities by allstakeholders into the healthcare system. The integrationrequires mechanisms andstructures that provide thenecessary linkage. Suchstructures would enhance andenable effective participationof communities in health-related decision makingprocesses at the communitylevel, as well as at theinterface between level 1 andlevels 2 and 3. This is theintention of the decentralization policy that iskey to Kenya’s ongoing health sector reform,NHSSP II and KEPH. Figure 1.1 illustrates NHSSPII’s vision of the decentralized coordination ofthe health sector overall. As can be seen in thediagram, the community is the foundation of thecoordination structure.

The Community Strategy spells out thelinkage structures at district, divisional, healthfacility and community levels that are expectedto provide citizens with sufficient representationand voice in all issues affecting service provisionat level 1. The health facility in-charges (support-ed by the district health management team –1 Published by the Ministry of Health in June 2006.

The community-based approach isthe mechanismthrough whichhouseholds andcommunitiesstrengthen theirrole in health andhealth-relateddevelopment byincreasing theirknowledge, skillsand participation.

2 Taking KEPH to the Community

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DHMT), community health extension workers(CHEWs), community health workers (CHWs),village elders and chiefs, and other extensionworkers are the sinews that bind these structuresand enable sustained community leadership inaddressing health problems, through the forma-tion of linkage committees at all these levels.

Since this is a new approach, health caremanagers and providers accustomed to the oldertop-down way of operating may require insightsinto how to make the strategy work. This volumetherefore spells out the guidelines for ensuringthe equitable and effective operation of theCommunity Strategy. This introductory chapterpresents the objectives and purpose of theguidelines and how the book is organized.

1.1 Objectives of the CommunityStrategy Guidelines

The Community Strategy intends to improvethe health status of Kenyan communitiesthrough the initiation and implementation

of life-cycle focused health actions at level 1.This document provides guidelines for:w Establishing community health service

linkage structures through effectivedecentralization and partnership for theimplementation.

w Launching and managing the CommunityStrategy.

w Building the capacity of the communityhealth extension workers (CHEWs) andcommunity health workers (CHWs) to provideservices at level 1.

w Establishing a communication strategy thateffectively improves health seeking behaviour.

w Providing level 1 services.w Establishing mechanisms for evidence-based

dialogue informed by community and facility-based information systems.

1.2 The Purpose and Overviewof the Guidelines

These guidelines target frontline managers,including district managers, responsible forenhancing the linkage between the health

system and the communities. The target groupincludes the frontline managers from the districthealth managers to the sub-district down to local

levels who have the task ofoversight of the linkagestructures and their functionsas well as support for servicedelivery at levels 1, 2, 3 and4. It also includes the CHEWs,and members of the linkagestructures, including localleaders at community andadministrative structures.

1.2.1 Why theGuidelines

Because most serviceproviders act top-downaccording to training and experience, they maynot have given an alternative approach adequateconsideration. For this reason, not allprofessionals will have the necessary skills towork with clients, households and communitiesas partners rather than simply recipients ofservices. These guidelines intend to helpfacilitators and managers work within theproposed partnership approach to enable clients,households and communities to increase theircontrol over their situation through moreinformed and effective actions.

In this way the guidelines hope to empowerboth communities and providers to improvehealth at the frontlines, working as partners inaction. The communities will also be able toexercise effective demand for quality care, withmutual accountability and responsibility forbetter health for all across all cohorts. This willbe achieved through community—health systemlinkage, enhanced ownership of facilities,enhanced community control and greaterpersonal responsibility for health. The guidelinesdescribe the processes and structures forincluding communities in the governance ofhealth facilities and related resources. This willincrease people’s self-esteem, capacity forinformed dialogue and control. The guidelinesintroduce and strengthen the culture ofassessment, dialogue, planning and actionthroughout the country to ensure sustainedimprovement at level 1.

1.2.2 What Methods Are to Be Used

It is best to use participatory methods thatencourage the active involvement of individualsin group processes, no matter their background,

These guidelinesdescribe theprocesses andstructures forempowering bothcommunities andhealth careproviders toimprove health atthe front lines,working aspartners inaction.


leading to informed decision making andplanning. The methods enhance trust and respectamong participants and between levels ofcontrol. The principles are those of participatorylearning for change. The methods are designed tobuild the confidence of people in themselves andtheir ability to improve their situation. As theymake changes, there are improvements, whichbuild confidence even further. Using participatorymethods is rewarding to communities and tofacilitators alike.

1.2.3 How the Guidelines AreOrganized

Following this introduction, the guidelines areorganized into six chapters:w Chapter 2 presents the linkage structures,

their formation and functions.

w Chapter 3 discusses the launch andmanagement of the strategy.

w Chapter 4 presents the criteria for theidentification and training of the workforce.

w Chapter 5 outlines the communicationstrategy – the basic health messages to beshared with families and communities.

w Chapter 6 summarizes service delivery atlevel 1.

w Chapter 7 details the information system formonitoring and evaluation.


2. The Essential Elements of theCommunity Strategy

This chapter defines and outlines thestructures and mechanisms that linkthe community with the health systemat all levels needed to support level 1

services. The specific committees and forums aredescribed in terms of their composition,formation, roles and responsibilities.

2.1 The Linkage Mechanisms andStructures

Community linkages are important points ofemphasis in NHSSP II. The strategic planrecognizes that the health facilities at

levels 2 and 3 will improve the effectiveness oftheir service delivery if they work closely withtheir catchment communities through variouscommittees in the community strategyframework that link to service delivery at thehousehold level. The structures provideopportunity to generate informed dialoguebetween the health system and the community,to create demand for quality services on the partof the community, and to enhance their

responsibility for actionfor health at level 1.For this to happen, thecommittee structuresmust be inclusive interms of administrativeareas as well as interestgroups. The structuresdefined in the sectionsbelow and illustratedschematically in Figure2.1 are key to theCommunity Strategyframework.

2.1.1 Community Units

The “community unit” as defined in this contextcomprises approximately 1,000 households or5,000 people who live in the same geographicalarea, sharing resources and challenges. In mostrural areas such a unit would be a sub-location,the lowest administrative unit. The number ofhouseholds in a community unit will determinethe number of community health workers to beselected, so that 1 CHW serves approximately 20households.

The household level consists of individualsassociated with and usually headed by thehousehold head or caregiver. It is the members ofhouseholds and families who are both theprimary targets and the primary implementers oflevel 1 services. They are responsible for the day-to-day upkeep of the household affairs as well asfor participating in community-organized healthactivities. They have contacts with the CHWs andthe formal health system where they seek andutilize health services. The household forms thefirst level of care that is universally available.

The community units are organized in villagesand other interest groups that are responsible foridentifying and supporting the CHW. The CHWsreport to the community health committee (CHC)through the community health extension worker(CHEW), who is the secretary to the committee.All the villages within the community unit shouldbe represented on the CHC. Since health statusdepends on factors beyond the health sector,coordinated action across sectors at thecommunity level will increase efficiency inimproving health outcomes. This includesnurturing economic empowerment andtransformation, enhancing access to the meansof production and marketing, and paying

It is themembers ofhouseholds andfamilies whoare both theprimary targetsand the primaryimplementersof level 1services.


attention to the social determinants of health.All these sectors and actors should berepresented on the CHC to the extent possible.

2.1.2 Community Health Committee(CHC)

The health governance structure closest to thecommunity is the CHC, elected in such a waythat all the villages in the community unit arerepresented. The CHC should be elected at theAssistant Chief’s baraza under the chair of theAssistant Chief. The committee is chaired by arespectable member of the community. It isrecommended that a CHW should be electedtreasurer and that the CHEW should be thesecretary. There should be nine additionalmembers, to include representatives of: youth,faith groups, women’s groups, NGOs, peopleliving with HIV and AIDS (PLWHAs), people withdisability (PWDs), and relevant others. At leastone-third of the committee members should bewomen.

Role and FunctionsThe role and functions of the CHC will include:w Identifying community health priorities

through regular dialogue.w Planning community health actions.w Participating in community health actions.

w Monitoring and reporting on planned healthactions.

w Mobilizing resources for health action.w Coordinating CHW activities.w Organizing and implementing community

health days.w Reporting to level 2 on priority diseases and

other health conditions.w Leading community outreach and campaign

initiatives.w Advocating for good health in the community.

Meetings and AgendaThe committee should meet at least monthly toreceive reports from the villages to enable theCHEW to compile monthly reports for level 2 or 3management committees. The standing agendashould include:w Review of actions agreed on in the previous

meeting and progress made in theirimplementation.

w Review of the chalkboard records of keyindicators by village (immunizations,deliveries, cases of fever and diarrhoea inchildren, the chronically ill, use ofinsecticide treated nets [ITNs], maternal andchild mortality).

w Identification of and dialogue on areasneeding improvement and planning action toimprove.

Figure 2.1: Community Strategy linkage structure

Level 6

Level 4

Level 5

Representation at the HFC

Levels 3, 2

Level 1

DISTRICT/DHSF

HSCC

JICC

HFCHFC HFC HFC HFC

CHC CHC CHC

JICC = Joint Interagency Coordinating Committee HSCC = Health Sector Coordinating CommitteeDHSF = District Health Stakeholder Forum

HFC = Heath facility committee CHC = Community health committee

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w Advocacy issues to be taken up to the nextlevel.

w Recognition of the CHW of the month, basedon data.

2.1.3 Level 2 Management Committee

This committee should have 12 members withequal representation of the community unitsserved. The chair and treasurer should be electedfrom among members, while the secretary shouldbe the facility in-charge. The CHEW should beincluded and eight other members appointed byCHCs. The election of the level 2 committeechair and treasurer should be supervised by theDHMT, and they should come from the differentcommunity units. Each CHC will nominateamongst themselves up to five people to serve onthe level 2 committee.

Role and Functionsw Establishing the linkage between the health

system and the community, helping to marketthe health facility to enhance its credibilitybased on quality of care so as to promotepeople’s confidence in services beyond level 1.

w Planning, implementing, monitoring andevaluating health actions at the facility andin the community units served.

w Providing feedback on LEVEL ONE SERVICES.1

w Facilitating regular dialogue between thecommunity and the health service providersbased on available information.

w Mobilizing resources for development of thehealth facility as well as supporting outreachand referral activities.

w Participating in community health days,outreaches and campaigns.

w Strengthening community involvement indecision making.

w Promoting inter-sector collaboration.w Overseeing the community unit’s processing

of community-based and facility-based healthinformation systems (CBHIS and FBHIS,respectively), displaying and discussing thedata for action, addressing facility-based andcommunity-based issues that cause gapsindicated in the data so as to ensurespecificity of responsibility.

w Facilitating budgeting, budget controls andaccountability to ensure availability ofresources needed for LEVEL ONE SERVICES.

w Listening to and addressing complaints ofclients expressed through a suggestion box orclient satisfaction questionnaire.

w Coordinating the recruitment of CHEWs.w Liaising with CHCs in convening monthly

community health days for joint healthaction.

Meetings and AgendaThe committee should meet at least monthly toreceive reports from the community units toenable the in-charge to compile the monthlyreport to the level 3 management committee.The standing agenda should include:w Review of actions agreed on in the previous

meeting and progress made inimplementation.

w Review of service and community-based datapresented by community units on keyindicators such as completed immunization of<1’s, health facilitydeliveries, the chronicallyill, use of ITNs, maternaland child mortality.

w Review of clientsatisfaction records.

w Identification of anddialogue on areas needingimprovement and planningaction to do so.

w Advocacy issues to betaken up to level 3.

w Recognition of the 3 topCHWs, CHEWs and serviceproviders of the monthbased on data.

2.1.4 Level 3 Health FacilityManagement Committee

The committee should have 14 membersrepresenting level 2 units served within thecatchment area. The level 3 facility in-chargeand the Public Health Officer (PHO) in thedivision will be ex officio members (that is,members by reason of their position). The chairand treasurer will be popularly elected, while thelevel 3 facility in-charge will serve as thesecretary.

Election of the 14 level 3 committeemembers should be held at the District Officer’s(DO) baraza supported by representation fromthe District Health Management Team (DHMT).There should be 2–3 members from each level 2committee in the catchment area, paying

1 Throughout this document, where LEVEL ONE SERVICES appearsin all capital letters, it refers to the entire community-basedcomponent of the Kenya Essential Package for Health activities.

The communityhealth committeeis the healthgovernancestructure closestto the commu-nity. Its membersshould be electedin such a waythat all thevillages in thecommunity unitare represented.


attention to the principle of representation of allcommunity units served.

Role and FunctionsThe Level 3 health facility managementcommittees should meet at least monthly toreview progress from the indicators generatedthrough the CBHIS and FBHIS and to makedecisions for continued actions for health atfacility, community, household, political andadministrative levels. The facility in-chargeshould collate the data obtained from the CHEWsand the health facility in order to share theinformation with the other sectors by displayingit on boards, disseminating summaries andpresenting the summaries at stakeholder forums.Specifically, the committee has responsibility for:w Supervising activities at level 2 and

immediate catchment area CHC.w Organizing quarterly performance review

meetings for all facilities in the catchmentarea and facilitating corrective measures.

w Preparing quarterly reports and submittingprogress reports to the DHMT, DO, level 2 andCHCs.

w Overseeing the functioning of the healthcentre in support of level 1 service provision.

w Ensuring implementation of policy guidelines.w Training trainers and CHEWs on LEVEL ONE

SERVICES and overseeing training of CHWs.w Providing technical and professional guidance

through supportive supervision.w Coordinating CBHIS and FBHIS and divisional

experience sharing and dialogue forums.w Disseminating information to relevant levels.w Managing relationship with divisional level

stakeholders.w Mobilizing resources for development of the

health facility as well as supporting outreachand referral activities.

Meetings and AgendaThe committee should meet at least monthly toreceive reports from the community units toenable the in-charge to compile the monthlyreport for the level 3 management committee.The standing agenda should include:w Review of actions agreed on in the previous


w Review of service and community-based datapresented by community units and level 2facilities on key indicators such as completedimmunization of <1’s, health facility

deliveries, the chronically ill on treatment,patients completing TB treatment, use ofITNs, maternal and child mortality.

w Review of client satisfaction records.w Identification of and dialogue on areas

needing improvement and planning action toimprove.

w Advocacy issues to be taken up to level 4.w Recognition of the top CHW, CHEW and

service provider of the month based on data.

2.1.5 Divisional Health StakeholderForum

The membership should include: the DistrictOfficer as chair and the PHO as secretary, withrepresentatives of CBOs, FBOs, NGOs, and othersectors such as agriculture, education, water,social services, roads, environmental services.

Role and Functionsw Sharing information and areas of coverage

amongst partners.w Identifying gaps in divisional health

interventions.w Mobilizing any additional resources to address

the gaps.w Proposing areas of harmonization of CHC,

level 2, level 3 and stakeholder plans.w Participating in selection of district health

management board (DHMB) members.w Submitting reports to district health

stakeholder forum.

Meetings and Standing AgendaThe forum should meet at least once in fourmonths to receive reports from level 3 as well asother stakeholders in the health sector. Thestanding agenda should include:w Review of actions agreed on in the previous


w Reports from various stakeholders as well ashealth facility management committees.

w Review of service and community-based datapresented by management committees in thecatchment area on key indicators such ascompleted immunization of <1’s, healthfacility deliveries, the chronically ill, use ofITNs, maternal and child mortality.

w Review of client satisfaction records.w Identification of and dialogue on areas

needing improvement and planning action toimprove.


w Advocacy issues to be taken to the districthealth stakeholder forum.

w Recognition of 10 top CHWs, 5 top CHEWsand 3 top service providers of the quarterbased on data.

2.1.6 The District Health StakeholderForum

Within the district, the organization andmanagement of LEVEL ONE SERVICES should beintegrated into the health sector and localgovernment reform frameworks. The DHSF drawsits membership from all the organizationsinvolved in the provision of curative, promotive,preventive and rehabilitative health care serviceswithin the district, including NGOs, FBOs, CBOs,private sector institutions (such as hospitals,nursing homes, clinics and pharmacies),government line ministries, developmentpartners in the district, civil society, the media,constituency development committees, women’swelfare associations (such as Maendeleo ya

Wanawake), health partners and provincialadministration (DCs, DOs and chiefs).

Linkages between the DHSF and the districthealth management team and board are summar-ized in Table 2.1. Types of management meetingsand their timetable are shown in Table 2.2.

Formation and CompositionAll organizations that are implementingprogrammes within the district are members ofthe general assembly of the stakeholder forum.Sector district officers whose functions havedirect or indirect impact on the management andeffectiveness of health service delivery in thedistrict – e.g., treasury, education, agriculture,etc. All members have the right to be eligible forelection to the steering committee of the DHSFas a representative of their respective constitu-ency – e.g., CBO, NGO, FBO representative.

The DHSF steering committee will becomposed of the following:w Chair – District Commissionerw Vice Chair – DHMB Chair

Functional linkages No.

Function DHMT DHSF DHMB

1. Leadership § Provides technical leadership in health service delivery in the district

§ Assists the DHMT and DHMB to focus on joint programming and implementation, including resource mobilization

Oversees all the health service delivery in the district

2.

Needs identification and priority setting

§ Identifies health priorities by scanning both the internal and external environments

§ Discusses the priorities and provides recommendations to be included in the district’s annual operational plans

Approves the priorities for implementation

3. Implementation § Coordinates the implementation of programmes

§ Identifies bottlenecks, recommends and takes appropriate actions

§ Ensures that programme activities are executed according to the plan

§ Ensures that all actors are implementing their plans as contained in the district health plan (DHP) and reporting to the DHMT on a agreed timelines

Ensures programme implementation is in line with stipulated rules, procedures and regulations

4. Monitoring and evaluation

§ Collects and produces summarized quarterly implementation reports

§ Organizes review meetings with the steering committee

§ Undertakes follow-up actions based on the outcomes of review meetings

§ Submits monthly and quarterly implementation reports to the DHMT for consolidation and analysis

§ Discusses the quarterly implementation report and provides recommendations on appropriate actions

§ Takes stock of actions carried out to improve performance by individual members of the forum

§ Compares district performance in health with the set targets based on district’s annual operational plans

Approves the quarterly reports

Table 2.1: Linkages of the DHSF with DHMT and DHMB


w Secretary – DMOHw Members

- CBO representatives- NGO representatives- FBO representatives- Other sectors

Role and Functionsw Reviewing divisional health stakeholder forum

reports and providing appropriate feedbackand guidance on the operations of divisions.

w Discussing the health priorities in the districtwith the DHMT and agreeing on programmaticinterventions.

w Providing input into the district healthplanning process.

w Facilitating collection, collation anddeliberation on implementation progressreports by all stakeholders.

w Participating in resource mobilization andallocation by presenting and discussingpartners’ programmes and resourceenvelopes (including the MOH’s) and aligningthe same with agreed prioritizedinterventions.

w Participating in joint planning and budgetingto develop integrated district health plans.

w Reviewing the comprehensive district healthplans and other reports and advising theDHMB to approve as appropriate.

w Agreeing on the modalities for jointperformance monitoring mechanisms,reporting, review meetings, joint supervisionand follow-up action.

w Sharing information on best practices, newdevelopments or emerging issues, and policyand strategy development.

w Submitting reports to DHMB.

Meetings and Standing AgendaThe forum should meet at least once in fourmonths to receive reports from divisional forumsas well as other stakeholders in the health sector.The standing agenda should include:w Confirmation of previous minutes.w Review of actions agreed on in the previous


w Reports from various stakeholders as well ashealth facility management committees.

Table 2.2: Summary of timing and types of health care management meetingsType of meeting Time line Possible issues to be discussed

First quarter General stakeholders First week of October

§ Confirmation of previous minutes. § First quarter monitoring and evaluation report. § Resource mobilization for the first joint health activities. § Information sharing and reporting. § Emerging health issues.

Second quarter General stakeholders Second week of January

§ Confirmation of previous minutes. § Taking stock of actions carried out since quarter one. § Six-month progress report. § Resource mobilization for joint health activities in the

second quarter. § Adjusting DHP targets based on achievement, if necessary. § Agreement on timetable for planning and submission of

programme and resource envelope. § Information sharing and reporting. § Emerging issues

Third quarter Second week of April

§ Confirmation of previous minutes. § Planning for the annual elections. § Resource mobilization for the third joint health activity. § Nine-month progress report. § Appraisal of the integrated DHP and recommendation for

change and approval. § Information sharing and reporting. § Emerging issues.

Annual Annual General Meeting Second week of July

§ Confirmation of previous minutes. § Election of new office bearers (after two years). § Taking stock of the achievements and lessons learnt for

better planning, implementation and coordination. § Monitoring and evaluation reports of the joint health

activities. § Presentation of annual reports by the DHSF. § Emerging issues.


w Review of service and community-based datapresented by Divisions on key indicators suchas completed immunization of <1’s, healthfacility deliveries, the chronically ill, use ofITNs, maternal and child mortality.

w Review of client satisfaction records.w Identification of and dialogue on areas needing

improvement and planning action to improve.w Advocacy issues to be taken to the district

health stakeholder forum and the DHMB.w Recognition of the 10 top CHWs, 5 top CHEWs

and 3 top service providers of the quarterbased on data.

2.1.7 District Health ManagementBoard

The DHMB provides leadership and accountabilityin support to level 1 activities. The boardreceives reports from the DHSF and providesfeedback to facilitate monitoring of overalldistrict activities according to the annualoperational plan (AOP). The DHMB is in turnlinked to the district development committee(DDC) but focuses on health issues.

Formation and CompositionThe membership is drawn from representativesof community units, with up to 16 members toinclude: the chair and the secretary (DMOH) as exofficio members and 14 others. The members arenominated during the selection process for level2 and level 3 committee members. Each division-al health stakeholder forum elects 1–2 peoplefrom the CHC submitted list and submits to theDHMT. The DHMT submits names to the DHSF forthe purpose of selecting the 14 DHMB members.

Role and Functionsw Coordinating district health services in

collaboration with stakeholders.w Approving plans and budget.w Receiving implementation progress report.w Supervising level 1 – level 4 committees.w Mobilizing resources and allocates to various

levels and units.w Submitting reports to facilities, community,

provincial and national level structures.

Meetings and Standing AgendaThe Board should meet at least once in fourmonths to receive reports from the DHSF as wellas other members of the Board. The standingagenda should include:

w Review of actions agreed on in the previousmeeting and progress made in implementation.

w Implementation reports from the DHMT.w Review of service and community-based data

presented by Divisions on key indicators suchas completed immunization of <1’s, healthfacility deliveries, the chronically ill, use ofITNs, maternal and child mortality.

w Review of client satisfaction records.w Identification of areas needing improvement

and planning action to improve.w Advocacy issues to be taken up to the

Provincial Health Board.

2.2 The Management Structures

Some of the structures described above havemanagement as well as implementationresponsibilities. These include the district

health management team and the provincialhealth management team. Other managementstructures are the technical stakeholdercommittees and the Health Sector CoordinatingCommittee (HSCC). The relationships amongthese organs are illustrated in Figure 2.2 andsummarized below.

2.2.1 District Health ManagementTeam

The DHMT provides technical support to level 1activities that includes planning, implementation,monitoring and supervision. The DHMT has eightfunctional clusters, taking into consideration theimplementing role of the district. These clustersare shown in Table 2.3.

2.2.2 Provincial Health ManagementTeam

The PHMT roles are clustered into three, takinginto consideration the coordinating andsupervisory role of the district. The roles aresummarized in Table 2.4.

2.2.3 Technical StakeholderCommittees

These committees are chaired by the respectiveheads of departments, while heads of divisionsserve as secretary. The members should includerepresentatives of NGOs, FBOs, private and othergovernment sectors as the committee decides.


Figure 2.2: MOH implementation structure

The committees have the following roles andfunctions:w Sharing information and areas of coverage

amongst partners.w Identifying gaps in specific area

interventions.w Proposing areas for policy improvement.

w Reviewing, adopting strategies and guidelinesfor the specific area of concern (e.g.,malaria).

w Reviewing DHSF reports and providingfeedback.

w Submitting reports to the Health SectorCoordinating Committee (HSCC).

HQ Functional Clusters

1 2 3 4 5 6 7 8 9 10 11 12 13

PHMT Functional Clusters

General Levels 4–5 service Monitoring andmanagement support review support

DHMT Functional Clusters

Community Level 2–3 Monitoring Accounting Infrastructure Emergency HR GeneralSupport service and review and records logistics and response mgt mgt

support support commoditymgt support

Level 3 facility in-charge PHO in charge of division

Level 2 facility in-charge CHEW supervisor

CHEW

CHW

Household

Key for HQ functional clusters1. Training and development2. Service standards and regulation3. Performance and M&E planning4. General management

5. Technical HR support service6. Human resource management7. Finance and resource mobilization8. Commodity management

9. Community health support10. Primary health care service support11. Specialized health care service support12. Specialized programme13. Communication


2.2.4 Health Sector CoordinatingCommittee

This is a committee of 20 members, chaired bythe Permanent Secretary with the MinistryMonitoring Unit (MMU) as Secretary. The memberswill include representatives of various GOKministries (HOD finance, education, agriculture,water, social services), two NGO representatives,three FBO representatives and one private sectorrepresentative, plus two DHMB chairs at any onetime, rotated on provincial basis.

The committee has the following functions:w Approving and adopting AOPs.w Reviewing and developing health sector

policy documents.w Approving global initiative proposals.w Mobilizing and allocating resources.w Receiving AOP implementation status reports

and conducting regular reviews.w Facilitating harmonization/alignment of plans

to the Joint Programme of Work and Funding(JPWF) and reporting to joint implementationcoordinating committees (JICCs).

DHMT role Commu Levels Monitor Account Infrastruc Emer HR Gennity 2–3 ing & ing & ture logis- gency mgt eral

support service review records tics & response mgtsupport support commodity

mgt support

Training PHO div üTraining level 2-3 serviceproviders üSupport and regulatory supervision üReport writing üDistrict planning üMonitoring/evaluation üReporting & feedback üSecretariat to DHMB, DHSF üPersonnel management üAccounting and record keeping üInformation management üCommodity management üInfrastructure and logistics mgt üEmergency response üCluster coordination üOperational research ü

Table 2.3: Role and functions of the DHMT

Table 2.4: Roles and functions of the PHMT

PHMT role General Levels 4–5 service Monitoring andmanagement support review support

Training DHMT üTraining levels 4 – 5 üSupportive supervision üReport writing üProvincial plan üMonitoring and evaluation üReporting and feedback üSelection of HMB üPersonnel management üFinancial management üCommodity management üInfrastructure and logistics management üEmergency response üCluster coordination üGuidelines and tools dissemination üOperational research ü


3. Launching the CommunityStrategy – Community Entry

Recognizing the central role of thepeople in making decisions and takingactions that influence their health, theCommunity Strategy acknowledges

that the community is indeed in charge of theirown health and development whetherappreciated by the formal sector or not.Community members are in fact already activelyinvolved in taking care of their own health needsaccording to their capacity. The CommunityStrategy thus aims to develop linkages into thatexisting household/ community-based caresystem in order to learn from as well as influenceit to ensure the adequacy and effectiveness ofhealth actions. This can best be done throughpartnership, which requires recognition ofcommunity systems and a careful process ofengagement to build a relationship with thecommunity-based service providers.

This chapter outlines the steps in the launchof the Community Strategy at the district level,where most of the activities will take place ininitiating and managing the strategy.

In order to build partnership with thecommunity, it is necessary to gain entry througha structured, step-by-step approach that involvescreating awareness, conducting situationanalyses, forming linkage structures, training

teams, and establishing monitoring andevaluation mechanisms. Effective communityentry must be based on a process of engagementthat recognizes the need for the health system tonegotiate its way into the community agenda andcare system as a way of addressing their healthand development issues. The entry processinvolves a number of distinct steps as describedbelow.

3.1 STEP 1: Creating Awareness

Awareness creation among district leaders isundertaken through the existing structuresand officials including the District

Commissioner (DC), the District DevelopmentCommittee (DDC) and relevant line ministries.The facilitating team should ensure adequateknowledge of the district situation as part of thisfirst step. This can be undertaken in a 1—3-dayworkshop that ends in the formation orconfirmation of the district health stakeholderforum (DHSF). During this workshop theCommunity Strategy is introduced, focusing onthe linkage structures, their formation,composition and functions, as described inChapter 2.

In addition, the workshop would outline adistrict-level Community Strategyimplementation plan and identify officials tospearhead it. This workshop should be followedby workshops and meetings at divisional andhealth facility levels, and cascading down tocommunity unit levels, repeating the sameexercise of awareness creation, formation ofstructures and planning the implementationprocess, and thus launching the strategy at alllevels.

Steps in community entry1: Create awareness2: Conduct situation analysis and

household registration3: Plan actions for improving health

status4: Establish information systems to

monitor change


3.2 STEP 2: Situation Analysisand Household Registration

Implementing divisions will conduct situationanalyses using participatory approaches. Theparticipatory assessment and household

registration are intended to provide informationfor planning. The situation analysis will include:

1. Exploration: This sub-step entails a relativelylow-key fact finding mission to enable the serviceproviders, particularly the CHEWs, coming intothe community to gain an understanding of lifeas it is lived in the community. The findingsshould be written up and shared with thecommunity, highlighting the facts thatcommunity people speak about with emotionssuch as fear, frustration, anger, joy, hope andanticipation.

2. Protocol: This sub-step entails identifyingthe gatekeepers (formal and informal leaders) inorder to formalize the process and gain authorityto work with the community. The facilitatorsintroduce the Community Strategy idea to theleaders in order to involve them in the rest ofthe community process. Together the groupclarifies the objectives and identifies all thetarget groups to ensure that they are included.This process should lead to identification of taskgroups to spearhead the actual situation analysisand detailed implementation planning.

3. Participatory assessment: This process startswith discussions with the key individuals at everylevel and control point down to the household.This ensures that the introduction of theCommunity Strategy takes full cognisance ofwhat is going on in the community. The idea hasto be negotiated through the gatekeepers atevery level, down to the level of individualsconcerned. In this process the community isasked to define the issues to be included in theassessment, and thus set objectives for it.

Under each objective the assessment andplanning task group defines indicators/keyquestions, identifies the sources of reliableinformation, and determines the mostappropriate methods of gathering the informa-tion. They then develop information gatheringtools (checklists, interview guides, etc.). Thescope of the assessment should include:w The population size and structurew Community structures

w Any existing communityinformation systems

w Resource availability,access and management(money, manpower,material)

w Service delivery and thepackage of care andsupport

w Communication strategy,networking, collaborationand linkages

w Coping mechanisms,innovations and best practices

w The status of health and wellbeing, based onagreed indicators

w The status of food security and nutrition,based on agreed indicators

w Care seeking behaviourw The environment (water, sanitation, shelter,

soils, vegetation, infrastructure)w Identified dialogue centres and groups

(religious institutions, schools, civic leaders,youth groups and other sectors), their rolesand responsibilities

The assessment methods may includetransect walks, direct observation, mapping ofthe availability and access to resources, and aseasonal calendar of events, activities, diseases,food availability, etc., and daily activities bygender. Other tools might be Venn diagrams tounderstand stakeholders, key informantinterviews of individuals from the community andfocus group discussions. During this process thetask group may also carry out householdregistration and mapping to create villageregisters to be kept by frontline health providers,the CHWs. Specific activities may include:ü Activity 1: Review the history of the

community over ten years – events,achievements and challenges.

ü Activity 2: Carry out household registrationand mapping, creating the village register.

ü Activity 3: Review community resources,assets, manpower, networks, etc.

ü Activity 4: Map the community healthsituation and the causes, thus summarizingthe community profile, based on thehousehold register (population structure,environment, immunization, place ofdelivery, ITNs, use of family planning,diseases, births and deaths by age and sex,education, food, income)

In theparticipatoryprocess thecommunity isasked to definethe issues to beincluded in theassessment, andthus setobjectives for it.


3.3 STEP 3: Planning Actions forImproving Health Status

Once obtained and processed, the findingsare used for dialogue in the establishedstructures to prioritize issues and decide

on action. The community participants reflect onthe future they want (their vision/dream of theway things ought to be) and agree on the mainaction points. The same task group as well asadditional working groups, identified according topriority issues, are assigned to prepare plans thatare collated and presented to the whole groupfor consideration and adoption. The processallows for all partners to explore what relevantactions are already in place in order to adddoable options that are lacking. Planned actionsmust be based on available resources for action.

The activities may include:ü Activity 5: Facilitate dialogue on the

community health situation (why, what hasbeen done, what more can be done).

ü Activity 6: Identify action options, selectdoable options.

ü Activity 7: Outline actions by time frame forvarious groups and individuals.

The plans from the different interest groupsshould be harmonized into one community unitplan. The CHEW, local NGOs and CBOs, and other

extension staff within the community unitprovide technical assistance throughout thisprocess of assessment and planning, with theCHEW as the responsible technical person. Theintegrated community unit plans are submittedto the health facility committees where they arediscussed and approved by the committees,based on resource implications. Finally, thecommunity unit plans are consolidated into oneintegrated divisional health plan for level 1activities and submitted to the DHMT.

3.4 STEP 4: EstablishingInformation Systems toMonitor Change

As described further in Chapter 7, theinformation system for monitoring changewill be set up in the following way:

ü Activity 8: Analyse the information gatheredby the CHWs and supporting task groups.

ü Activity 9: Facilitate regular evidence-baseddialogue and community days.

ü Activity 10: Disseminate analysedinformation for dialogue, advocacy and socialmobilization.


4. The Workforce

People make any strategy work. Thischapter aims to provide informationabout the workforce charged with theresponsibility of providing health care

services in the community. The chapter looks attheir roles and responsibilities, how they link upwith the rest of the formal health system, andhow the volunteer segment of the workforce is tobe motivated and sustained. The chapter alsodescribes their training in terms of objectives,content and organization.

4.1 The Categories

Essentially, NHSSP II calls for two categoriesof personnel promoting health at thecommunity level. These are community

health workers (CHWs), who work on a volunteerbasis, and community health extension workers(CHEWs), who are MOH employees. Thecommunity health committees (CHCs) manage thetwo. The functions of these categories aredescribed below and summarized in Table 4.1.

4.1.1 Community Health Workers

Community health workers are expected to bemature, responsible and respected members ofthe community, men or women chosen by thecommunity to provide basic health care. Theyshould be good communicators and leaders whohave shown signs of healthy practices as a parentor caregiver in their own household. In manycommunities there are community-based resourcepersons such as community-based distributors(CBDs), TB ambassadors and others. All theseresource persons at the community level shouldbe incorporated into the strategy as CHWs, if

they have the characteristics described in thissection.

The Roles and Functions of CHWsCHWs have several functions in the communitythat are influenced by community priorities andthe availability of health services to thecommunity. Their main role is to promote goodhealth by:w Teaching the community how to improve

health and prevent illness by adoptinghealthy practices.

w Treating common ailments and minorinjuries, as first aid, with the support andguidance of the CHEW.

w Tending the CHW kit with supplies providedthrough a revolving fund generated fromusers.

w Referring cases to the nearest healthfacilities.

w Promoting care seeking and compliance withtreatment and advice.

w Visiting homes todetermine the healthsituation and dialoguewith household membersto undertake thenecessary action forimprovement.

w Promoting appropriatehome care for the sickwith the support of theCHEWs and level 2 and 3facilities.

w Participating in monthlycommunity unit healthdialogue and action daysorganized by CHEWs andCHCs.

Community healthworkers (CHWs),who work on avolunteer basis,and communityhealth extensionworkers (CHEWs),who are MOHemployees, arethe front line ofthe CommunityStrategy. Thecommunity healthcommitteesmanage the two.


w Being available to the community to respondto questions and provide advice.

w Being an example and model of good healthbehaviour.

w Motivating members of the community toadopt health promoting practices.

w Organizing, mobilizing and leading villagehealth activities.

w Maintaining village registers and keepingrecords of community health related events.

w Reporting to the CHEW on the activities theyhave been involved in and any specific healthproblems they have encountered that need tobe brought to the attention of higher levels.

How a CHW Is SelectedTo the extent possible CHWs should be acceptedby the whole community as they are the link-pinbetween the household system and the healthsystem. It is therefore critical that thecommunity be briefed on the functions of theCHW to enable them to select persons who canwork effectively with them in promotion of goodhealth among households. Village leaders willorganize meetings to inform the people aboutthe CHWs’ functions in the community, linked tothe launching workshops described in Chapter 3.

At a village meeting convened by the elders,consenting nominees are presented forconsideration by the villagers. In this forum thevillagers select the individual of their choice onthe basis of on the following criteria:w A permanent resident in the area.w Able to read and write, and enthusiastic to

learn more.w Concerned about the welfare of the people.w Willing to volunteer.w Physically fit.

w Willing to visit all village members.w Respected by villagers as an example of

healthy behaviour.w Having demonstrated attitudes valued by the

community.w Backed by immediate family members

(particularly the spouse).

How a CHW Is MotivatedBecause they are volunteers, CHWs may requirespecific incentives to remain motivated to servetheir communities. Years of experience workingwith CHWs has revealed the following motivatingmechanisms:w Continuous lifelong training based on the

needs expressed by CHWs.w Religious commitment, giving meaning to

service to others.w Having responsibility over households to

which they belong and cultural, religious oreconomic ties permitting permanent loyaltyand reciprocal giving and receiving frommembers.

w Organizing their work into fixed number ofdays in a quarter/year, beyond which theymust be financially compensated (e.g., onehousehold visit for two hours for 20households per quarter and one dialoguemeeting/baraza or health day per month).

w Supportive supervision and coaching asindividuals or groups based on need, givingthem regular feedback on performance andimprovement being made.

w Giving them priority when there are paid jobsfor health campaigns and mass treatments,for example, or distribution of communities(if they have served the community for twoyears after initial training).

Table 4.1: Summary of functions of the Community Strategy workforce

Function Level 1 Level 1 Level 2 Level 3 Divisional DistrictCHW CHEW In-charge PHO PHO DHMT

Registers and record keeping üReport writing ü ü ü ü ü üFacilitating HH and comm. dialogue ü ü ü ü üFacilitating evidence-based planning ü ü ü ü üAction monitoring and follow up ü ü ü ü ü üCoordinate CHWs activities üDistribute CHW kits ü üTraining of CHWs ü ü üTraining of CHCs ü ü üTraining of level 2 and 3 committees ü ü üSupervision and follow up ü ü ü ü üTraining of CHEWs and PHOs ü ü


w Encouraging them to take up paid jobs whensuch opportunities are available and accept-ing them back when such assignments end (itmay be necessary to train an alternate coun-terpart CHW per village when the first onehas been serving for more than two years).

w Logistical support, regularly providingworking materials (transport, basic kit)

w Evidence-based output linked to rewards atregular celebrations.

w Organizing them into savings and creditassociations to enhance their own incomeearning capacity as well as linking them toother CHWs through exchange visits andmeetings.

w Training them in productive skills accordingto their own interests and capacities, beyondhealth issues.

w Attending relevant conferences.

4.1.2 The CHEW

Community health extension workers (CHEWs)are trained health personnel with certification innursing or public health. They will superviseCHWs and will be Ministry of Health employees.

The Roles and Functions of CHEWsAs provided for in the Community Strategyimplementation framework, CHEWs constitute anew cadre of health worker. Their function is tofacilitate the provision of quality services byCHWs and to ensure a smooth referral mechanismlinking the community to level 2 and 3 facilities.The CHEWs’ main functions therefore include:w Overseeing the selection of CHWs.w Organizing and facilitating CHW training.w Monitoring the management of the CHWs’ kit.w Supporting the CHWs in assigned tasks and

coaching them to ensure achievement ofdesired outputs and outcomes.

w Collating information gathered by the CHWs todisplay summaries at strategic sites to providerelevant feedback as well as material fordialogue at household and community levels.

w Compiling reports from CHWs and forwardingto level 2 and 3 management committees.

w Receiving feedback from level 2 and 3facilities and passing it on the CHCs andCHWs through dialogue and planning thatleads to actions to improve identified issues.

w Following up and monitoring actionsemerging from dialogue and planning sessionsto ensure implementation.

How a CHEW Is SelectedThe DHMT will take the lead in the recruitmentof the CHEWs with the support of level 3management committees. Community healthcommittee (CHC) members will be informedabout the roles and functions of CHEWs by theDHMT to enable them to make informed decisionson the type of persons they elect as CHEWs fortheir community, as described in Chapter 3. TheCHEW should be received by the community at acommunity unit meeting that is open to allmembers. Selection criteria should include:w Having suitable qualification in nursing or

public health.w Being a mature and responsible person.w Being acceptable to and respected by the

whole community.w Being a good communicator.w Being able to work with people of diverse

backgrounds.w Being willing to teach and mentor others.w Being able to be available to the service

consumers according to demand.

4.1.3 The CHC

A community health committee (CHC) is a groupof people who are charged with the responsibilityof leading community health action at thecommunity unit level. The committee iscomposed of 8–12 people selected from thecommunity. Membership must be sensitive togender balance and equal representation ofvillages and all interest groups in the community.The CHC elects officials from among themembers: Chair (a respected communitymember), secretary (the CHEW) and treasurer (aCHW). The CHC has regular meetings that relateto the 100-day improvement cycle as well ascommunity dialogue and action days. When theymeet they discuss health-related communityissues and review progress of households, CHWsand CHEWs on the basis of planned action forhealth guided by available data. Village andactivity specific data are presented for dialogueand planning to ensure adequate targeting ofareas and specific interventions.

The Roles and Functions of CHCsw Leading monthly dialogue sessions at

community unit level on the basis of datapresented by villages and activities, leadingto planning action.


w Providing structures for community action forhealth, emphasizing key household healthpractices.

w Providing a channel for external assistance tobe continued where necessary.

w Providing a channel of communication withthe levels 2 and 3 management committees,divisional health forum and the districthealth stakeholder forum.

w Facilitating community change by activelyadvocating the CHWs’ work, backing them upin their tasks.

w Monitoring trends of key community healthdata and reporting to level 2 and 3management committees for quarterlydialogue, planning and action.

w Overseeing CHW activities and appraisingCHWs in preparation for recognition duringcommunity health days or forums at variouslevels.

w Seeking and mobilizing local human andfinancial resources for health action, on thebasis of priorities identified by availabledata.

How a CHC Is SelectedThe selection of members to the CHC is led outby the administrative head of the communityunit, an Assistant Chief. The respective level 3management committee facilitates the processby sending representatives to attend meetingsorganized by the administrator for the purpose ofselecting CHC members. The characteristics ofpeople to be identified are explained and thenconsenting nominees are identified forconsideration by the baraza, with attention toinclusive representation as described in Chapter3. The following characteristics are considered inthe selection:w Residency in the area.w Ability to read and write.w Demonstrated leadership qualities.w Demonstrated role model in positive health

practices.w Representative of a constituency in the

community (village, faith communities,youth, disabled, women, etc.).

4.2 Training Service Providersfor Level 1

The implementation of the CommunityStrategy requires training or orientation forall the people involved so they can acquire

the necessary skills to initiate and manage thelinkage structures described in Chapter 2. Theseskills are critical for the success of the strategyin delivering services at level 1. The orientationof personnel in a cascade of training workshopsfrom the provincial teams to the districts downto the community levels should be followedimmediately by the launch of activities at therespective levels. The programme should begin inat least four districts and two divisions in eachdistrict, based on the enthusiasm and availabilityof champions, scaling up to the rest of the countryby 2008. Training for each batch at every levelshould be a continuous exercise applying formal,informal and non-formal approaches to learning.

4.2.1 Community Health ExtensionWorkers’ Training

The training of the CHEWs intends to enhancetheir capacity to serve as extension healthworkers in the community working with andthrough the CHWs. The CHEWs have the overalltechnical and managerial responsibility of theCHWs with the support of the community healthcommittees, which they serve as secretaries.Besides their certification in health (nursing,public health, etc.), CHEWs require skills on howto organize, manage and support theimplementation of community-based activitiesinitiated by the community and the CHW.

ObjectivesThe aim of the training is to enhance the CHEWs’capacity to supervise, monitor, manage andsupport the implementation of the CommunityStrategy. They are also expected to collateinformation from the villages in order to presentfor dialogue and planning at the CHC as well asgive feedback to the community health workerswho gather the information. The CHEW should betrained to carry out the following tasks:w Organizing and facilitating the training of

CHWs.w Monitoring the use of simple drugs and

preventive materials used by CHWs.w Organizing and facilitating community

animation and mobilization.

CHEWs are a new cadre of health workerwhose function is to facilitate theprovision of quality services by CHWsand ensure a smooth referral mechanismlinking the community to level 2 and 3facilities.


w Practising evidence-based management ofservice delivery at level 1, based on thecontinuous improvement strategy.

w Supporting the CHWs in the communitymotivation process by encouraging them tocarry on with their planned activities anddialogue with the community.

w Providing supportive supervision to CHWs inthe course of their activities.

w Playing a leadership role among the CHWs intheir jurisdiction.

w Initiating community mobilization andawareness sessions for identified priorities inthe community.

w Collating health data records from CHWs andforwarding this to the health facilitiesthrough the level 2 and 3 managementcommittees.

w Providing a link between the community andthe health committees.

w Assisting in the selection of CHWs.w Facilitating evidence-based dialogue sessions

at community unit level.w Communication through advocacy, social

community mobilization and interactivecommunication.

w Supporting CHWs in recognition of healthproblems, classification and action.

w Promoting inter-sector action for health,working with various extension workers.

w Functioning as link person betweencommunities and the health system.

w Carrying out immunization, family planning,antenatal care, home delivery, diseasesurveillance, treatment of commonconditions, prevention and control of HIV/AIDS, STIs, TB and school health.

w Facilitating assessment, planning,implementation, monitoring and evaluationof LEVEL ONE SERVICES.

w Establishing and managing the community-based health information system, whichincludes data collation, storage, analysis,interpretation and utilization, in dialogue forcontinuous improvement.

w Leading CHW teams in household registrationand mapping.

w Carrying out baseline survey and analysingthe data.

w Keeping records of daily activities of servicesdelivered and producing and submittingreports.

w Organizing documentation and filing system.

Training ContentThe CHEW training will cover the following topics:w An overview of the training coursew The function of the CHEW as a facilitatorw Concepts in health and developmentw Population structure, distribution and

functionsw Components of NHSSP II, focusing on the

KEPH strategyw Community entry processw Group dynamicsw Community-based education and

competency-based trainingw Communication strategy with emphasis on

interactive dialoguew Personal and environmental hygienew Clinical and technical updates (reproductive

health, HIV/AIDS, safe motherhood,integrated management of childhood illness -IMCI, malaria, TB, nutrition, disability).

w How to assess, classify and identifyappropriate action for a sick person

w Referralw Community- and facility-based information

systems to enable evidence-basedmanagement of LEVEL ONE SERVICES,monitoring and evaluation.

4.2.2 Community Health Workers’Training

The training of CHWs aims at building thecapacity of the CHW to work, on part time basis,directly with communities to promote theirhealth, through involvement and participation.The CHWs will support the households in theirefforts to identify and solve their problemswithin their context. They will provide informa-tion and strengthen the knowledge of thecommunity, essentially through dialogue.

The training willtherefore provide therelevant knowledge andskills that CHWs shouldhave in order for toinfluence key householdpractices for health inthe village ofresponsibility. Thetraining is intended to beproblem based and lifelong, applying formal,informal and non-formalapproaches to learning.

CHEWs willsupport theCHWs in themotivationprocess byencouragingthem to carryon with theirplannedactivities anddialogue withthe community.


ObjectivesBy the end of the training the CHWs will be ableto do the following:w Mobilizing and organizing the community for

health action.w Promoting good health practices and

educating the community on the same.w Recognizing common ailments and taking

appropriate action (advise, treat or refer).w Referring cases to the health facilities.w Advising on compliance with treatment and

advice.w Facilitating community dialogue for health

status improvement with the support of theCHEWs.

w Responding to any questions from communitymembers.

w Carrying out home visits to assess the healthissues of families based on evidence anddialogue with the households towards actionfor change.

w Being an example and model ofrecommended health practices.

w Keeping the village household register andother records of community health events.

Training Contentw Concept of developmentw Concept of healthw Community organization, mobilization and

participationw Group dynamicsw Leadershipw Communication (dialogue)w Adult learningw Evidence-based dialogue for action for

change at household and community levelsw The KEPH by cohort at the community levelw Personal and environmental hygiene and

related health problemsw Pregnancy and childbearing (reading and

applying the ANC card to household dialogue)w Common conditions and their role in dealing

with them (malaria, worms, conjunctivitis,skin infections, wounds, scabies, STIs/STDs,HIV/AIDS)

w Immunization (reading and applying the childhealth card to household dialogue)

w Nutritionw Monitoring and evaluation: the village

register/map, record keeping, use of data


5. Key Health Messages byCohorts for Level 1

Aselection of key messages isintended for use by the CHWs inpromoting important household andcommunity practices for health

improvement, through dialogue. Published in aseparate reference manual and summarizedbelow, the messages become a reference for theCHWs to refer to for needed information forevery household and cohort under their care.They are a tool for effective home visiting anddialogue grounded in the situation of thehousehold visited and the set of informationavailable. The mechanisms of communicationshould be multiple, taking advantage ofopportunities that may trigger behaviour changeat household or community levels. This chapterbriefly reviews approaches to effectivecommunication, then outlines the key messagesby cohort.

The objective of these messages is toenhance key household practices for healthimprovement relating to each cohort. Themessages go beyond providing people withinformation; they aim at triggering respectfuldialogue that ensures interest and relevancethrough an interactive, two-way process ofsharing ideas, knowledge and opinions.

5.1 Communicating the Messages

Effective communication requires a message,the sender of the message, the receiver ofthe message, and feedback from the

receiver to the sender and back again. There aremany different ways of communicating, butwhether you are working person-to-person withina community, advocating with political leaders ordeveloping messages to be publicized in the massmedia, the basic principles are the same:

1. Know who needs the information and find outabout their living conditions, language,customs and level of knowledge. This helps toidentify the messages that are most relevant,most easily understood, and most likely to beaccepted and acted upon.

2. When adapting or translating the messages,use language that people understand. Do notoverload the messages with too many actionsor technical details. Keep to the verifiedinformation in the reference manual. If themessages are adapted, their accuracy shouldbe verified.

3. Make sure the audience understands theinformation and knows how to put it intopractice. This can be done by sharing thedraft messages and visual materials withparents and other caregivers in thecommunity, asking them open-endedquestions and encouraging discussion todetermine whether the intended message isboth clearly understood and feasible. Utilizetheir feedback to adjust the messages andvisual aids.

4. Make the message relevant to people’s lives,addressing them, through dialogue, in thecontext in which they live. Find ways tomake the messages interesting and

The Kenya Essential Package for Healthdefines six life-cycle cohorts:♦ Pregnancy, delivery and the newborn

(first 2 weeks of life)♦ Early childhood (2 weeks to 5 years)♦ Late childhood (6 to 12 years)♦ Adolescence (13-24 years)♦ Adult (25-59 years)♦ Elderly (over 60 years)


meaningful to each household andcommunity, such as by illustrating them withlocal examples and stories.

5. Select the communication channels andmedia that are most effective at reachingthe target audience. Pay particular attentionto existing media and use these media asmuch as possible. Do not rely on a singlemeans of communication but instead use amix of channels and media so that theaudience receives the message repeatedlyand in many variations.

6. Repeat the information to reinforce it.

5.2 COHORT 1: Pregnancy,Delivery and Newborn

w Know the warning signs during pregnancy andchildbirth and have plans and resources forgetting immediate skilled help.

w Remind community members that physicalabuse of women for any reason is dangerousand unacceptable.

w Encourage pregnant women to attend atleast four ANC visits before delivery.

w Encourage all pregnant mothers to sleepunder insecticide treated nets (ITNs) toprevent malaria.

w Help a pregnant woman prepare a birth plan,that is, what to do when the time comes.

w Encourage all pregnant women to deliverwith the assistance of skilled medicalpersonnel.

w Recognize the following risk factors inpregnancy:� An interval of less than two years since

an earlier birth.

� A girl who is under 18 or a woman who isover 35 years of age with first pregnancy.

� The woman has already had four or moredeliveries.

� The woman has had a previous prematurebirth or baby weighing less than 2kilograms at birth.

� The woman has had a previous difficultor Caesarean birth.

� The woman has had a previousmiscarriage or stillbirth.

w Recognize the following warning/danger signsduring pregnancy and take action:� Anaemia, paleness inside the eyelids, or

being tired or easily out-of-breath.� Swelling of legs, arms or face.� The foetus moves very little or not at all.� Spotting or bleeding from the vagina

during pregnancy (or profuse orpersistent bleeding after delivery).

� Severe headaches or abdominal pains.� Severe or persistent vomiting.� High fever.� The water breaks before due time for

delivery.� Convulsions.� Prolonged labour.

w Encourage mothers to get immunized againsttetanus.

w Immunize all newborn children against thepreventable diseases.

w Ensure all births are notified and registered.w Remember that the child health card is an

important document that must be kept safelyto monitor growth and immunization andother services to the child.

w Wash hands before feeding or breastfeeding,after cleaning the baby’s faeces, and afterusing the toilet.

w Breastfeed your baby within an hour of birth.w Follow instructions given at the health

facility FOR EACH SERVICE.w Involve fathers in the reproductive health of

the family.

Figure 5.1: Effective communication is a two-way process

Sender ReceiverMessage

Feedback

Girls who are under 18 and women whoare over 35 with first pregnancy are atrisk.


5.3 COHORT 2: Early Childhood(2 Weeks to 5 Years)

w Immunize all children during the first year oflife to protect against diseases.

w Give all children Vitamin A supplementation.w Monitor the child’s growth every month from

birth to age two, and thereafter when a childhas a health problem.

w Recognize warning signs showing that thechild’s growth and development are faltering.

w Give the child proper mix of foods in threemeals a day.

w Provide stimulation and affection to ensuresocial, physical and intellectualdevelopment.

w Provide exclusive breastfeeding to the infantfor the first six months.

w Introduce weaning foods to infants from theage of six months, but continuebreastfeeding through the child’s second yearand beyond.

w Keep the child health card safe. It is animportant document that has all theinformation about child immunization andgrowth.

w Remember that diarrhoea kills children bydraining water from the body, thusdehydrating the child. As soon as diarrhoeastarts, give the child extra fluids as well asregular foods.

w Give the child an extra meal a day for atleast two weeks while recovering fromdiarrhoea.

w To prevent diarrhoea, wash hands thoroughlywith soap or ash and water after contactwith faeces and before touching food orfeeding children.

w Keep a child with cough or cold warm andcontinue normal feeding and drinking.

w Ensure children sleep under ITNs to preventmalaria.

w Have a child with a fever examinedimmediately by a trained health worker andreceive an appropriate anti-malariatreatment as soon as possible.

w Watch young children when playing and keeptheir environment safe to avoid accidents.

w Do not use drinking bottles to store poisons,medicines, bleach, acid or liquid fuels such asparaffin. All such liquids and materials shouldbe kept in clearly marked containers out ofchildren’s sight and reach.

w Involve fathers in the care of their children.

5.4 COHORT 3: Late Childhood(6—12 Years)

w Ensure all children attend primary school.w Ensure children receive an adequate

balanced diet, three meals a day.w Respond to child’s need for care by playing,

talking with and providing a stimulatingenvironment to promote mental andpsychological development.

w Seek health care as soon as an illness appearsor is suspected.

w Insist that children sleep under ITNs toprevent malaria.

w Treat all drinking water at the point of use.w Wash hands after visiting toilets and before

eating in school and at home.w Introduce sexuality education at focal points

(home, church and school).w Follow the instructions given at the health

facility for each service.

5.5 COHORT 4: Adolescence andYouth (13—24 Years)

w Seek health care as soon as an illness appearsor is suspected.

w Sleep under ITNs to prevent malaria.w Treat water at point of use.w Remember that abstinence is the safest way

to prevent STDs and HIV infection.w Delay sexual activity as long as possible.w Use protection during sex if one must have

sex.w Follow all the instructions given at the health

facility for each service.w Avoid the use of alcohol, cigarettes and

drugs.w Involve both parents in the care of their

adolescents and in reproductive health of thefamily.

w Encourage parents to discuss sexuality issueswith their adolescent children.

w Prevent unwanted pregnancy through familyplanning.

Abstinence is the safest way to preventSTDs and HIV infection and has no sideeffects.


5.6 COHORT 5: Adults 25—59Years

w Remember that all people are at risk of HIV/AIDS; use condoms to reduce this risk.

w If you suspect that you might be infectedwith HIV, contact a health worker or a VCTcentre to receive confidential counsellingand testing.

w Reduce the risk of getting HIV through sex bynot having sex at all or by being faithful toone partner, whose only partner is you.

w Parents and teachers, help young peopleprotect themselves from HIV/AIDS by talkingwith them about how to avoid getting andspreading the disease.

w Discuss sexuality and HIV/AIDS with childrenearly enough.

w Get information on lifestyle related illnesses.w Check regularly for non-communicable

illnesses like diabetes, hypertension,cholesterolaemia, etc.

w Seek health care as soon as illness appears oris suspected.

w Sleep under ITNs to prevent malaria.w Treat drinking water at the point of use.

5.7 COHORT 6: Elderly Persons(over 60 Years)

w Seek health care as soon as illness appears oris suspected.

w Use ITNs when sleeping to prevent malaria.w Treat drinking water at point of use.w Follow instructions given at the health

facility for any service.w Take regular exercise to the extent of ability.w Go for regular medical check ups.


6. Service Delivery at Level 1

NHSSP II organizes health services intosix levels of delivery recognizing theKenya Essential Package for Health(KEPH) over the six stages in the life

cycle of human development. The five key policyobjectives of the strategy highlight equity,access, effectiveness, efficiency, partnershipsand resource mobilization as the pillars ofimproved health care. Through the strategy, theGovernment of Kenya focuses on human capitaldevelopment as well as human rights principles inrecognition of health care as a basic human right.Priority interventions include those that must beprovided at the household and community levelsby individuals and CHWs. It is envisaged by MOHthat the implementation of KEPH requireseffective decentralization of governance,management and service delivery, bringingdecision making and health action as close aspossible to households, which are both consumersand providers of care.

This chapter details the services needed atlevel 1 according to the service providers(household caregivers, CHWs and CHEWs). Thechapter describes how level 1 services are linkedto the rest of the service delivery system andexplains the referral mechanisms.

6.1 Levels of Service Delivery

The Community Strategy frameworkdescribes the critical interface betweenthe community and the health care system,

which is further elaborated in these guidelines tofacilitate implementation (see Figure 6.1). Tables6.1—6.3 provide an additional glimpse,respectively, at service delivery structures,required expertise by level, and the servicedelivery matrix by cohort and level.

INTERFACE1

Community: Villages/households/families/individuals

6Tertiary

hospitals

2Dispensaries/clinics

3Health centres, maternities, nursing

homes

4Primary hospitals

5Secondary hospitals

Figure 6.1: Levels of service delivery underKEPH

Table 6.1: Description of services atcommunity levels (1–3)

Service Administrative Service deliverylevel unit unit

Level 1 Community/ � Personal,Village family,

household &communitypractices

� Pharmacies

Community–System InterfaceLevel 2 Sub-location � Dispensary

� ClinicLevel 3 Location � Health centre

� Nursing/maternityhome


6.2 Key Components of KEPH atLevel 1

At the community level, level 1, the mainfocus is to promote positive healthbehaviours and to create demand for

health services that are provided at other levelsof health care. The corollary is to equipcommunities with comprehensive information onpractices leading to improved health throughresource persons at the community level, theCHWs. In this way KEPH brings basic healthservices close to the people and provides a

Table 6.2: Expertise by level of services

Promotive Curative& preventive & rehabi-

litative

Level 1: Communityhealth services +++ —-

Level 2+3: Primaryhealth services +++ +—

Level 4+5: Referralhospitals (public) +— +++

Level 6: Teaching hospitals —- +++

Cohort KEPH level 1 KEPH levels 2 and 3

1. Pregnancy and newborn

§ IEC on early recognition of danger signs; referral

§ Birth preparedness § Health promotion § Community midwifery

§ Focused ANC, IPT for malaria § VCT, PMTCT or referral § Basic emergency obstetric care,

post-abortion care, referral services § Oversight of CHW services § Maternal death review

2. Early childhood § Behaviour change communication (BCC) to promote key household care practices in prevention, care of the sick child at home, service seeking and compliance, promoting growth and development

§ Community dialogue and action days § Referral services

§ Immunization, growth monitoring, treatment of common conditions (pneumonia, malaria, diarrhoea)

§ Community dialogue § Oversight of CHW services § Essential drugs list § Referral services

3. Late childhood § School enrolment, attendance and support

§ Support for behaviour formation and good hygiene

§ Screening for early detection of health problems

4. Adolescence and youth

§ BCC and IEC § Community-based distribution (CBD)

services § Peer education and information § Supply of preventive commodities § Referral services

§ All basic youth-friendly services, BCC and IEC

§ Syndromic management of STIs § Lab diagnosis of common infections § Essential drugs list § Referral services § Oversight of CHW services

5. Adulthood § BCC and IEC, community dialogue § CBD services; home care, treatment

compliance (TB, ART) § Supply of preventive commodities § Water and sanitation § Referral services § Promotion of gender and health

rights

§ BCC and IEC, VCT, ART and support groups

§ Syndromic management of STIs § Diagnosis and treatment of common

conditions; TB treatment § Essential drugs list § Manage clients’ satisfaction § Referral services

6. The elderly § IEC and BCC to reduce harmful practices

§ Referral services

§ Advocacy; management and rehabilitation of clinical problems

§ BCC and IEC § Screening, early detection of disease

and referral

Table 6.3: KEPH service delivery matrix by cohort and level


The three delaysboost maternalmortality1. Delay in

seeking carefor pregnancyrelatedcomplications.

2. Delay inreaching thecare facility.

3. Delay in beingexamined andtreated at thehealth facility.

mechanism for easy referral for those who needmore specialized care. This will ensure coverageof physically, socially and economicallyvulnerable and disadvantaged groups by makingservices affordable, with adequate safety netsfor the economically disadvantaged. The outputsof KEPH at the community level must includebasic services that are available, accessible,appropriate, acceptable, affordable, effectiveand efficient.

The Kenya Essential Package for Health(KEPH) is designed as an integrated collection ofcost-effective interventions that addresscommon diseases, injuries and risk factors,including diagnostic and health care services, tosatisfy the demand for prevention and treatmentof these conditions. Using an evidence-basedplan, health committees organize actions forhealth based on their own capacities. Theconditions identified and included in their planare those in which LEVEL ONE SERVICES can makethe most significant contribution to theimprovement of the health and the well being ofKenyans.

At the community level the activities focuson effective communication aimed at behaviourchange, access to safe water/sanitation andbasic care. Among the key issues arereproductive health, malaria, tuberculosis, HIV/AIDS and integrated management of childhoodillness (IMCI).

6.2.1 Reproductive Health

Maternal mortality remains unacceptably high inKenya (414 maternal deaths per 100,000 livebirths), with almost all of the deaths being theresult of well-known and preventable causes suchas haemorrhage, eclampsia, obstructed labourand puerperal sepsis. These common causes ofmaternal and neonatal deaths have beenobserved to be due to unsafe traditionalpractices during delivery. Such practices need tobe checked to ensure that clean hands, cleandelivery and clean instruments for cutting thecord are maintained in order to minimizecomplications. The other contributing factors arethe three delays:2

1. Delay by the pregnant mother in deciding toseek care for pregnancy related

complications. This occursfor several reasons,including late recognitionthat there is a problem,fear of the health facilityor the cost that will beincurred in seeking care,or lack of an availabledecision maker (e.g., thehusband, mother-in-law,etc.).

2. Delay in actually reachingthe care facility, which isusually caused by lack oftransport or unfavourableinfrastructure. Manycommunities have verylimited transportationoptions and poor roads.

3. Delay in being examined and receivingappropriate definitive treatment once at thehealth facility. This is one of the most tragicissues in maternal mortality. Often womenwill wait for many hours at the referralfacility because of poor staffing, prepaymentpolicies, or difficulties in obtaining bloodsupplies, equipment or the operating theatre.

Evidence from a number of studies globallyhas shown a reduction in maternal and perinatalmortality when women have skilled attendantspresent at every birth. This must be assured atlevel 1 service delivery through effective birthplans and availability of service delivery points.

The present policy requires that all pregnantwomen should have access to skilled carethroughout the pregnancy-delivery-postnatalcontinuum, yet many community units grapplewith gaps in service availability and must identifyworkable alternatives to meet the needs ofpregnant women. With regard to safemotherhood, traditional birth attendants can beempowered to educate, encourage and assistwomen, their partners and families to anticipateand recognize signs of life-threateningcomplications, to know when and where to refercases, to encourage development of birthpreparedness plans including emergencytransport, and where possible to accompanywomen coming for delivery at health facilities(Reproductive Health Policy Draft 3, 2005).2 United Nations Population Fund, State of the African

Population Report: Population and the PovertyChallenge, Addis Ababa, Ethiopia, 2004.


6.2.2 HIV/AIDS Prevention and Care

At the community level the major obstacle toeffective HIV/AIDS care and control is lack ofaccess to different services, e.g., voluntarycounselling and testing (VCT), laboratory servicesand anti-retroviral therapy (ART). Services arerestricted to major hospitals and big urban healthinstitutions. The standard care in ART requireslaboratory monitoring of response, yet thesetests are expensive and available only at alimited number of health facilities. Recentlegislative amendments by GOK aimed atenhancing access to ART, together with dramaticprice reductions, have seen thenumber of deserving patients on ARTincrease significantly. This hasresulted in improved health outlookand reduced mortality. The net resultis to convert HIV/AIDS to a chronicdisease that if properly managed canallow sufferers to continue living andfulfilling their life goals and remainproductive for the family, communityand nation. The role of care at level 1is critical in realizing this goal.

Services to prevent mother-to-childtransmission (PMTCT) of HIV are beingsystematically integrated into maternal and childhealth (MCH) and family planning services, andthus guided by standards of care that have beendeveloped, including codes and ethics ofpractice, clinical guidelines, and guidelines foroperational procedures. The goal of the PMTCTprogramme is to increase access to PMTCT bydeveloping capacity of health workers, expandingfacilities, encouraging utilization of services, andstrengthening information and reporting systems.These objectives will not be achieved withoutadequate information, education and communi-cation (IEC) at household and community levels.

MCH/FP programmes are in a unique positionto assist in HIV/AIDS control as well as care.There is long experience within MCH/FPprogrammes dealing with such matters assexuality, counselling, contraception methods,care during pregnancy and childbirth, andbreastfeeding, all of which are closely related torisk and prevention of HIV transmission. Greaterimpact of MCH/FP programmes on HIV/AIDSentails expansion of services to include IEC andcounselling on a variety of sexuality, fertility andrelationship issues. Routine infection controlprocedures need to be strengthened, while IEC

aimed at changing knowledge, attitudes andpractices related to sexual behaviour could bemost effective at level 1.

Providers at level 1 are involved in clinicalcare, nursing care, nutrition, counselling andpsycho-spiritual support, social support to clientswith HIV/AIDS or TB, and support to orphans andchildren made vulnerable by AIDS.

6.2.3 Malaria

The greatest burden of malarial disease anddeath lies with the poor, who also have the leastaccess to interventions against malaria. Effective

interventions against malaria areavailable, yet the burden persists,because most people at risk ofmalaria have little or no access tothem for reasons including those ofdistance and affordability. Pooraccess to public health facilities is arecognized constraint to theprovision of early treatment. A largeproportion of people who are illwith malaria are treated at home,

with medicines from shops – often inappropriatemedicines.

Since the majority of children who die frommalaria do so within 48 hours of the onset ofillness, and often at home, the early use ofeffective malaria medicines at or near the homewill reduce the burden of malaria in endemicareas. This acknowledged time element is criticalto saving child lives in stable malaria areas, andto reducing mortality in non-immune olderchildren and adults in areas that are prone toepidemics. Recognizing these constraints, oneaim of the Community Strategy must be to maketreatment available as near the home aspossible, be that in the community or in thehome itself. The strategy must ensure earlyrecognition of, and prompt and appropriatetreatment for, malaria illness in the home orcommunity. Specifically the strategy must:1. Enable communities and caregivers to

recognize malaria illness promptly and takeearly appropriate action at home and withinthe community.

2. Ensure that service providers, includingshopkeepers and CHWs, have adequateknowledge and capacity to respond tomalaria illness.

3. Promote integrated vector control (IVC)according to endemicity type.

ART is a helpbut not a cure.The person canbe re-infectedwith the virusand can infectothers.


6.2.4 Community IMCI

The community component is well developed inthe concept of integrated management ofchildhood illness (IMCI). The households areengaged in the 20 key care practices that havebeen identified and agreed upon and henceintroduced to the households through dialoguewith CHWs. The households are thus strengthenedto improve the health status of their children,mostly those in the second cohort. The criticalcomponents include: disease prevention, care ofthe sick child, care seeking and compliance, andpromotion of early childhood growth anddevelopment.

6.2.5 Tuberculosis

It is estimated that 35% of the Kenyanpopulation is infected with the TBbacillus (Mycobacteriumtuberculosis), the causative agent ofTB. The majority of these people willnever develop disease because theirimmune (defence) systems are able toprevent the bacillus from multiplying and causingdisease. If the immune system is weakened, forexample by HIV infection, the TB bacilli begin toreplicate and eventually lead to disease. Since anestimated 7% of Kenyans are currently infectedwith HIV, it follows that a significant proportionof Kenyans are concurrently infected with bothHIV and the TB bacillus. These individuals have aconsiderably higher risk of developing TB disease.

Tuberculosis is a disease that usually attacksthe lungs (80%), but can affect almost any part ofthe body except the hair and the nails. The TBbacteria usually enter the body through the lungsand may reside there without causing any disease.TB is spread through the air by a sick personthrough coughing, sneezing, singing or evenspeaking to a healthy person who inhales the TBbacilli. TB patients with bacteria in their sputum(smear positive TB) are the sources of infection.

Recognition of TBCough that lasts for two or more weeks, loss ofappetite, weight loss, chest pains, shortness ofbreath, and night sweats may indicate that aperson has TB. Some people may present withbloodstained sputum. All patients presenting withpulmonary TB and a cough should have threesputum samples collected for microscopicexamination for acid fast bacilli (AFB). A chest x-ray is also useful but not diagnostic for TB.

TB TreatmentTB is curable even in people living with HIV, aslong as the diagnosis is made early and treatmentis prescribed and taken adequately. Thetreatment is free at all government facilities andin some designated health facilities, e.g., missionhospitals, where TB services are offered. Theduration of TB treatment ranges from 6 to 8months. The preferred approach is referred to asdirectly observed treatment, short course(DOTS), meaning that the service providerobserves the patient taking the drugs.

For better adherence to TB treatment, it isrecommended that every TB patient should have

a treatment supporter. TB patientscan get their drugs daily from thenearby health facility or from thecommunity (community-basedDOTS).

Links between HIV and TBHIV/AIDS and TB are so closelyconnected that the term “co-epidemic” or “dual epidemic” isoften used to describe their

relationship. HIV affects the immune system andincreases the likelihood of people acquiring newTB infection. It also promotes both theprogression of latent TB infection to activedisease and the relapse of the disease inpreviously treated patients. Tuberculosis kills upto half of all AIDS patients and is the mostimportant cause of death among people livingwith HIV. An estimate one-third of the 40 millionpeople living with HIV/AIDS worldwide are co-infected with TB. In Kenya the national averagestands at 50–60%, but in some regions it is muchhigher; in Nyanza, 80–90% of TB patients are alsoinfected with HIV.

Each disease speeds up the progress of theother and TB considerably shortens the survivalof people with HIV/AIDS. People who are HIV-positive and infected with TB are up to 50 timesmore likely to develop active TB in a given yearthan people who are HIV-negative. Furthermore,without proper treatment, approximately 90% ofthose living with HIV die within months ofcontracting TB.

Key TB Information for the CommunityCrucial information to be shared with communitymembers includes the following:w A cough lasting two weeks or more could be

TB, so one should go for a check up as earlyas possible.

TB is not HIVand HIV is notTB. They aretwo differentdiseases and ofthem TB iscurable.


w Treatment to cure TB isavailable free of charge atall government healthfacilities and otherdesignated health facili-ties like mission hospitals.

w Early treatment preventsthe spread of TB tohealthy people/community.

w TB patients who aretaking their medicationproperly are not likely tospread the disease.

w Patients who adhere totheir treatment com-pletely get cured even ifthey have HIV infection.

w Patients can lead perfectly normal lives.w Community participation in TB control

activities will help to win the fight against TB,and fewer people will die from the disease.

w TB is not HIV and HIV is not TB. They are twodifferent diseases and of them TB is curable.

Role of CHEW in TB ControlThe key role of the CHEW is to ensure that theCHWs carry out the tasks assigned to them. They:w Create awareness in the community on TB

control and prevention.w Identify suspected TB cases.w Refer the TB suspects to the health facility

for screening.w Ensure that the TB treatment supporter

observes the patient take/swallow themedicine (DOTS)

w Ensure that the appointment card is tickedby the treatment supporter after observingthe swallowing of medicine.

w Follow up the TB cases to ensure that theyare taking the drugs correctly.

w Act as the link between the community andthe health facility.

w Ensure proper recording and reporting ofboth the TB suspects and patients.

w Carry out defaulter tracing.

6.3 Service Provision at Level 1

This section lists the services to be providedby households and communities, as well asCHEWs and CHWs, and the process of

supportive supervision. The section then

summarizes the basics of referral mechanisms,including essential elements of a referral systemand the steps to take in making a referral.

6.3.1 Service Provision by Householdsand Communities as Partners inService Delivery

The households have important responsibilitiesfor addressing health needs at all stages in thelife cycle. Among these are health promotion,disease prevention, care seeking and participa-tion in governance of health care services.

Health Promotionw Eating a healthy diet for people at all stages

in life in order to meet nutritional needs.w Building social capital to ensure mutual

support in meeting daily needs as well ascoping with shocks in life.

w Demanding health and social entitlements ascitizens.

w Monitoring health status for early detectionof problems for timely action.

w Exercising regularly.w Ensuring gender equity.

Disease Preventionw Practising good personal hygiene in terms of

washing hands, using latrines, etc.w Treating drinking water.w Practising integrated vector control measures

(e.g., cutting brush and draining stagnantwater to control mosquitoes).

w Preventing accidents and abuse, and takingappropriate action when they occur.

w Promoting dialogue on responsible sexualbehaviour to prevent transmission of sexuallytransmitted diseases.

Care Seeking and Compliance withTreatment and Advicew Providing home care for the sick members.w Completing scheduled immunizations of

infants before first birthday.w Recognizing and acting on the need for

referral or seeking care outside the home.w Complying with recommendations given by

health workers in relation to treatment,follow-up and referral.

w Ensuring that every pregnant woman receivesantenatal and maternity care services.

Households haveimportantresponsibilities foraddressing healthneeds at all stagesin the life cycle.Among these arehealth promotion,disease preven-tion, care seekingand participationin governance ofhealth careservices.


Governance and Management of HealthServicesw Attending and taking an active part in

meetings to discuss trends in coverage,morbidity, resources and client satisfaction.

w Giving feedback to the service system eitherdirectly or through representation.

6.3.2 Service Provision by CHEWs andCHWs

The service functions of CHEWs and CHWs includea wide range of activities, from health promotionto disease prevention and control, to hygiene andcompliance with treatment, among others.

Health Promotionw Demonstrating a healthy diet for people at

all stages in life in order to meet nutritionalneeds.

w Providing guidance on social capital to ensuremutual support in meeting daily needs as wellas coping with shocks in life.

w Encouraging demand for health and socialentitlements as citizens.

w Observing health status to ensure earlydetection of problems for timely action.

w Providing guidance on gender equity.w Encouraging emergency preparedness.

Disease Prevention and Control to ReduceMorbidity, Disability and Mortalityw Promoting the control of communicable

disease through behaviour formation,modification and change towards healthypractices (HIV/AIDS, STIs, TB, malaria).

w Providing/demonstrating first aid andemergency preparedness, treatment ofinjuries and common ailments.

w Demonstrating good personal hygiene interms of washing hands, using latrines, etc.

w Ensuring access to water treatment for safedrinking water.

w Demonstrating and encouraging integratedvector control measures.

w Enhancing prevention of accidents and abuse,and taking appropriate action when theyoccur.

Expanding Family Planning, Maternal,Child and Youth Servicesw Promoting/facilitating MCH/FP, maternal

care, seeking trained obstetric care,immunization, nutrition, C-IMCI.

w Promoting enhanced adolescent reproductivehealth through household and community-based dialogue, targeting behaviourformation, modification and change.

w If appropriate, organizing community-basedday-care centres.

w Organizing community-based referral system,particularly for emergencies.

w Encouraging payment for first-contact healthservices provided by CHWs.

Hygiene and Environmental Sanitationw Providing IEC for water, hygiene, sanitation

and school health.w Ensuring proper excreta/solid waste disposal.w Improving water sources to ensure access to

safe drinking water.w Practising/promoting proper food hygiene.w Practising/promoting good personal hygiene.w Developing kitchen gardens.w Organizing community dialogue and health

days.

Care Seeking and Compliance withTreatment and Advicew Training and supporting home caregivers.w Facilitating availability of and access to

vaccines.w Training caregivers to recognize health

problems and on the need for referral orseeking care outside the home.

w Encouraging compliance with recommenda-tions given by health workers in relation totreatment, follow-up and referral.

w Ensuring every pregnant woman receivesantenatal and maternity care services.

Governance and Management of HealthServicesw Attending and taking an active part in

meetings to discuss trends in coverage,morbidity, resources and client satisfaction.

w Giving feedback to the service system eitherdirectly or through representation.

Claiming Rightsw Promoting the rights communities have in

health.w Building capacity to claim these rights

progressively.w Ensuring that health providers in the

community are accountable for effectivehealth service delivery and resource use, andabove all are functioning in line with theCitizen’s Health Charter.


6.4 Supportive Supervision

The health system should be able to providesupportive supervision to the LEVEL ONESERVICES frontline personnel. Supervisory

teams should have an appropriate,multidisciplinary skills mix so as to ensurestandards in terms of quantity and quality ofwork. Other components of effective supervisionare regular performance appraisals based onchecklists to measure performance; goodcommunication and discussions; and appropriaterewards to CHWs.

During supervisory visits, the team should:w Discuss with CHEWs and CHWs the aim of

supervision and the content and use ofchecklists.

w Discuss with committees and consumersissues for attention.

w Observe performance based on jobdescriptions; guide, direct and encourage.

w Check recording and data systems.w Check stocks of supplies, note gaps.w At end of mission, provide feedback and wind

up with an agreed plan of action.

The team should then prepare a field reportand send it to the CHC, HFC and the DHMT forfollow up and needed action. Such action mayinclude: in-service training, continuing educationand improvements in the supply of materialsprovided by the health centre (HC) or districthealth office.

6.5 Referral Mechanisms

Areferral system is an interlinked network ofservice providers and facilities that providea continuum of care for acute and chronic

health conditions. The network may include bothindividuals and organizations working to providecare and support to people who are unwell.There are typically four levels to a healthreferral network: the community, primary,secondary and tertiary levels. This sectionfocuses on the community level. The communitylevel consists of household caregivers, CHWs andCHEWs, linked to levels 2 and 3. These providersshould be trained to recognize illness and gaugeits severity in order to provide prompt treatment(if they have the necessary capacity) or refer,when they are unable to treat, to the nextappropriate level of care.

It is the responsibilityof the one initiatingreferral to document thereferral activity andfollow up with clients toensure they received thenecessary attention atthe level of care to whichthey were referred.

The objectives of areferral system are toimprove the access ofclients to services,reduce the time it takesfor them to receiverequired care and avoidunnecessary delays.Achieving these aimsrequires a collectiveeffort of manyindividuals at variouslevels to strengthen access to existing services aswell as linkages among the providers, includingformal referral arrangements, propercommunication, transport and the use ofstandard tools.

This obviously demands coordination,communication and arrangements to ensure thataccess to required services is as quick aspossible, that confidentiality is maintained, andthat referrals can be easily traced and followedup. It also means that referral outcomes can bedocumented, feedback from clients on theservices they received can be noted, gaps in thesystem can be identified and steps can be takento improve service provision.

6.5.1 Essential Elements of a ReferralSystem

The following elements need to be put in placeto build and maintain an effective referralsystem and ensure positive outcomes for clients,their families and the entire community:

w Service availability: The foundation of thesystem is the availability at the next level ofcare of services that are accessible andaffordable to the general community, on thebasis of prevailing local health problems.

w Coordination of referral activities: Specificindividuals should be designated at thecommunity level to coordinate the referralactivities and provide feedback as necessary.

Effectivesupervisionrequires multi-sectorcoordinationand collabora-tion at variouslevels increating asupervisorysystem made upof staff withtechnical andmanagementskills working asa team.


Effective M&Econtributes toaccountability oncurrent activities(reporting andassessing impact)and helpsimprove planningand implementa-tion of futureactivities.

w Relationships: Ideally level 3 facilitiesshould take the lead in establishing andmaintaining referrals by supportingcommunity level providers. Both providersand clients should work as partners in thesystem.

w Communication and transport: Effectivecommunication and transport arrangementsare crucial for the completion of effectivereferrals. Identification of the cheapestmeans of transport should be done and ifpossible discussed by the key partners in thereferral system. One possible solution wouldbe to choose members of the community whohave access to transport to assist othercommunity members with transport duringreferrals.

w Feedback mechanism: A feedback systemshould be established to help with thetracking of referrals from the point ofinitiation to the point of delivery. This willprovide evidence that the client completedthe referral process and whether the client issatisfied with the services received.

w Monitoring and evaluation: The referralsystem should be included in the monitoringand evaluation mechanisms at this level toensure continuous assessment andimprovement of the referral system, processand outcomes.All health care providers should be

knowledgeable about all the service providerswithin their areas. This can be done bydeveloping a list of all providers in the area and

where they are located.The list should includedifferent types ofservices provided byeach service provider.Health providers shouldto the extent possibledevelop goodrelationships with otherservice providers andestablish a means ofcommunication witheach of them. Eachfacility or service group

should have a contact person with means ofcommunication. This will enable the providers toenhance each other’s work, leading to improvedcare of patients within the system.

6.5.2 Steps in the Referral Process

The referral process should be carried outthrough a dialogue between the provider and theclient, with the goal of addressing the perceivedneeds of the client and the client’s caregivers.The following steps are undertaken:1. Assess needs: Discuss with the client to

identify their immediate needs.2. Determine alternatives: Discuss what the

client would have to do to reach the nextlevel of care and assess the adequacy of orgaps in proposed action.

3. Identify options: Brainstorm with both theclient and the caregiver to come up withoptions.

4. Appraise options: Select the most doableoption based on available resources.

5. Commit to action: Discuss the consequencesof taking or not taking the agreed action.

6. Develop a plan of action: Map out what is tobe done, fill out the referral documents toenable follow-up and tracking.

7. Take action: Move on the option as plannedand follow up.

8. Assess the action and provide feedback:Assess the action and through regularmeetings inform the caregivers and therelevant members of the referral networkabout the results of the action.


Evaluation asks whether we succeededor failed, whether we used resourcesappropriately, and whether our actionswill have long-term results. We can’tknow unless our information systemprovides the means to monitor ourprogress.

When it is working properly, afunctioning community-basedhealth information system (CBHIS)makes an important contribution to

improving the provision of basic health careservices to communities. This chapter describesthe CBHIS and its role in providing informationfor regular dialogue, monitoring and evaluationfor informed health-related decisions at thecommunity level. The chapter:w Defines a community-based health

information system.w Outlines how a community-based health

information system is established.w Describes the scope of a community-based

health information system.w Summarizes the qualities of a good

community-based health information system.

Measurement of the effectiveness of servicedelivery at level 1 is based on the essential carepackage, organized by life-cycle cohort, asdescribed in Chapter 6. Among the criticalelements of care are focused antenatal care,newborn care, nutrition, breastfeeding,prevention of mother-to-child transmission ofHIV, delivery by trained midwives and familyplanning. Other aspects of the essential packageare family and community support, water andsanitation, community IMCI, education, foodavailability, and screening. All these elements are– or should be – reflected in the CBHIS.

7. Community-Based HealthInformation System

7.1 Why a Community-BasedHealth Information System

Back in 1993, the World Bank’s WorldDevelopment Report proposed that healthstatus could be substantially improved

without the investment of a large amount offinancial resources if priority setting, planning,and action were based on the evidence of diseaseburden. It predicted that by reaching 80% of thepopulation with cost-effective packages ofessential interventions, the burden of diseasecould be reduced by 32%. Experience in variousareas has confirmed this proposition.

At individual and community levels,information is needed for assessing the extent towhich services are meeting the needs anddemands of the communities. Better availabilityand use of information can cut costs, reducesystem inefficiencies and improve healthoutcomes.

The Community Strategy recognizes that allstakeholders must be involved in designing andimplementing a CBHIS if it is to be successful.The system must include indicators forassessment that relate to outcomes people careabout. These are indicators that are likely to

All stakeholders must be involved indesigning and implementing acommunity-based health informationsystem if it is to be successful.


trigger a strong response from the communityand the health system while paying attention tothe assessment of progress towards NHSSP IIobjectives and the Millennium DevelopmentGoals (MDGs).

7.2 Definition of Community-Based Health InformationSystem

Simply put, the system is described by itsname: It is a system that generates health-related information through sources at the

community level. It has potential to becomprehensive because it has the possibility ofcovering everyone in a health unit under theresponsibility of a CHC, according to their needfor care. This type of system is able to collectinformation even about illnesses that arestigmatized like disability and various chronicconditions because the people who do thecollecting are from within the community. Moreimportantly, the system captures informationfrom both those who visit and those who do notvisit health facilities.

7.3 Setting up a Community-Based Health InformationSystem

The system collects information to help theCHC plan and manage health activities atthe community level. Within parameters

set by MOH, each CHC should decide on the scopeof their CBHIS, guided by the CHEW. On the basisof their experience and available informationfrom the community, the CHC prioritizes theproblems that determine the indicators to beincluded. Figure 7.1 outlines how an informationsystem is established.

After prioritization and agreement onpossible courses of action, the CHC with thesupport of the CHEW plans specific actions toimprove the community health situation. Tomonitor and evaluate the actions and the level ofimprovement achieved, the CHC identifies thetype of information to be collected, who collectsit and what tools are necessary. In addition, thecommittee has to describe how the informationwill be collected, analysed, disseminated,utilized and stored for future use.

7.3.1 The Type of InformationCollected and Who Collects It

In order to have an effective CBHIS, thecommunity must be involved in its design,implementation and evaluation. This increasesthe acceptance and use of the system’s output.Ideally the system will collect data based on theactivities of CHWs, CHEWs and CHCs, as well asgeneral information on community developmentissues, socio-economic and demographic indexesof households, community resources, diseases,etc. The information is collected mostly by theCHWs, supported by the CHEWs and CHCmembers. Typically, the following as indicatorsnormally apply:w Births and deathsw Children with child health cardw Children who have completed immunization

Figure 7.1: The process of establishing acommunity-based healthinformation system

Situationanalysis

Dialogue &participatory

planning

Householdregistration &

mapping

Householdvisits

data formonitoring

Priority setting& identification

of indicators

Data analysis

ACTION

ACTION

Dissemination,usage in

dialogue andreplanning

A good information system captures allthe events being monitored and in allhouseholds and individuals within thearea of responsibility.


w Number of pregnant women attendingantenatal clinics

w Mothers using oral rehydration salts fordiarrhoea in their children

w Children under five sleeping under insecticidetreated mosquito nets

w Households having latrinesw Households treating drinking waterw Households with food items in stock

7.3.2 How the Information Is Collatedand Analysed

The information is collected through simpleformats that the CHC, CHWs and CHEWs agreeon, such as tally sheets or simple questionnaires.The CHC agrees on the frequency of datacollection, linked to their health plan, andmonitors data collection, compilation andanalysis. It also decides on the format in whichthe information is presented for disseminationand utilization within the community – reports,posters or chalk boards placed in strategic placeswithin the community like schools, dispensariesor chiefs’ offices.

7.3.3 Use of Community-Based HealthInformation System

The information collated through the CBHIS canbe used for many purposes, among which are:w Contributing to dialogue, planning, action

and assessment processes to fuel continuoushealth improvement.

w Informing the participating community abouttheir health situation and progress beingmade towards improvement.

w Comparing efforts by different communitiesin terms of health improvement.

7.3.4 Characteristics of a GoodCommunity-Based HealthInformation System

The following are some of the marks of a goodhealth information system:w The information collected is accurate,

reliable and timely.w The information gathered is complete in

terms of capturing all the events beingmonitored and in all households andindividuals within the area of responsibility.

w The data are easy to collect, analyse andinterpret.

w The information collected is useful to theperson who is collecting it and to theparticipating community because it reflectsissues that the community is concernedabout.

w The system provides feedback to all thehouseholds in the participating community.

w The system uses simple data collection tools.w The system is inexpensive, requiring limited

resources for it to function effectively.w The information available can be and is

referred to frequently.w All data are updated twice a year.


Notes

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Ministry of HealthMarch 2007

Reversing the trendsThe Second

NATIONAL HEALTH SECTORStrategic Plan of Kenya

Republic of Kenya

Community StrategyImplementation

Guidelinesfor

Managers of theKenya Essential

Package for Healthat the Community Level

Ministry of HealthSector Planning and Monitoring DepartmentAfya HousePO Box 3460 - City SquareNairobi 00200, KenyaEmail: [email protected]

Community Strategy Implementation Guidelines for Managers of theKenya Essential Package for Health at the Community Level

Communities are the central focus of affordable, equitable and effectivehealth care. Representing the first level of health care, they are the core ofthe Kenya Essential Package for Health defined in Kenya’s second NationalHealth Sector Strategic Plan. The goal of Community Strategy is to enhancecommunity access to health care in order to improve productivity and thusreduce poverty, hunger, and child and maternal deaths, as well as improveeducation performance across all the stages of the life cycle. Serviceprovision at level 1 is organized in three tiers starting with household-basedcaregivers, adult members of the household who provide the essentialelements of care for health in all dimensions and across life-cycle cohorts.These household-based caregivers are supported by community-ownedresource persons - CORPs - who are in turn supported and managed by arange of community structures to be established or strengthened through theimplementation of the strategy. This book provides a guide for bringingcommunities on board, to ensure the full involvement and ownership bycommunity members.

community health strategy implementation guide 2007

Health & Medicine