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

2. Outline of Presentation Background Problem Statement Research Questions Methodology Results Conclusion Recommendations

3. Background Community Health Worker programs – in line with the Alma Atta declaration for Primary Health Care & vital for MDGs’ achievement (WHO, 2010). Kenya – primary health care institutionalized in 2006 through the Community Strategy (GoK, 2006) Benefits in improving community knowledge on maternal health & child health (USAID, 2013) 10 June 2015 3

4. Background 10 June 2015 4 Structure of Community Strategy - Community Units

5. Problem Statement Constraints of Community Units implementation (GoK, 2010): i) Community Strategy budgetary commitment : 9% of health care funding ii) Harmonizing different approaches of CU implementation iii) Sustaining CUs after exit of development agencies Community Units (CUs) in Makueni, Kenya (GoK, 2013): 11 non- operational, 46 semi-functional, 16 functional Little comprehensive research on functionality & sustainability of CUs – most focus on CHW attrition only & not the actors of CU implementation in entirety 10 June 2015 5

6. Research Questions 1. What community level factors influence the functionality and sustainability of Community Units? 2. What factors of the Community Unit workforce cadre, influence the functionality & sustainability of Community Units? 3. What factors in the CU link health facility influence the functionality and sustainability of Community Units? 4. What factors from supporting development agencies, and the government influence the functionality and sustainability of Community Units? 10 June 2015 6

7. Conceptual Framework (Adapted from CU functionality score-card (AMREF, 2013) & Implementation Science (Schel, et al, 2013) 10 June 2015 7

8. Methodology Study design: -Qualitative exploratory study Purposive sampling -Study population – 73 CUs -Sample population – 4 CUs Data collection -Semi-structured interview guides -16 Focus Group Discussions - CHWs, CHC, community men & women -15 Key Informant Interviews - CHEWs, SCHMT & development agencies 10 June 2015 8 Sampling Technique

9. Methodology Data management Transcription & Translation o Tape recording & transcription – Listen & Write software o Direct translation into English Validity o Spot checks for translation errors o Triangulation on stakeholder levels Semi-open coding o Coded with MaxQda10 software o Matrix grouping of codes per level o Most frequent factors and relationships were analyzed o Texts analyzed for inter-play of factors 10 June 2015 9

10. Results 1. Factors at community level 10 June 2015 10

11. Results Factors at community level Underlying issues: a) Community members’ awareness on CHWs & CHC role: CHWs well accepted for their direct contact with community members. “They (CHWs) have been good advisers for women in the reproductive age, and more so who like giving birth at their homes. They are also advised on the importance of attending ANC clinics” [Community Women FGD] b) Community participation in CU activities: Minimal involvement by community in CU financial initiatives & plans c) Fulfillment of community members needs: desired provision of more medical supplies e.g drugs and aqua tabs, & desired meetings with CHWs 10 June 2015 11

12. Results 2. Factors of CU work-cadre 10 June 2015 12

13. Results Factors of CU work-cadre Underlying issues: a)CHWs expectation versus reality: "I expected that if I remain active as a community health worker I will be able to get employed and work for my children". [CHW FGD] b) Required support versus actual support: inadequate incentives & working aids hence diminished motivation c) Workforce struggles: Conflict between CHWs & CHC: CHWs deemed superior Other studies: WHO (2007) – complex factors are required for motivation & attrition including financial & intrinsic rewards 10 June 2015 13

14. Results 3. Factors of CU-Link Health Facility 10 June 2015 14

15. Results Factors of CU-Link Health Facility Underlying issues: a)CHEWs’ increased work-load CU technical advisor cum health facility staff responsibilities b) Link health facility services Services at CU link facility beneficial to community. However low quality of services due to including inadequate essential commodities & limited hours of service delivery & staff shortage 10 June 2015 15

16. Results 4. Government and Development Agencies support 10 June 2015 16

17. Results Government and Development Agencies support 10 June 2015 17 a) Incentives hampering sustainability: Temporary solution for functionality if they cease abruptly b) Implementing partner withdrawal/exit: Inadequate exit strategies for sustainability are fatal for community units c) Government limitations: Government supervisory/management role lacking for CU workforce Other studies (USAID, 2013) – coordination of development agencies’ support vital for sustainability

18. Results 10 June 2015 18

19. Conclusion 10 June 2015 19 Most important themes: based on predominance, strongest relations & underlying issues:

20. Recommendations Functionality and Sustainability In Kenya’s devolved system of governance – for CUs to have sustainable impact on maternal and child health: County Governments : resource allocation & technical oversight to ensure: -Organizational capacity: effective governance of CU, skilled & motivated workforce, and adequate working aid -Development agencies’ coordination & phase out strategy for sustainability -Community partnership & ownership in implementation 10 June 2015 20

21. Acknowledgment Research Investigators: Evalin Karijo, Denise Kampen, Anne Gitimu, Happiness Oruko, Fidelina Ndunge, Ken Ogendo, Peter Ofware Comic Relief - UK: Project donor Makueni Health Management Teams: Kibwezi, Makueni, and Mbooni Sub-Counties AMREF Kenya Ag. Country Director: Dr. Meshack Ndirangu AMREF RABD Unit: Anne Murugi, Dr. Ojakaa AMREF ESRC for approval of Research 10 June 2015 21