"It's like these CHCs don't exist, are they featured anywhere?": Social network analysis of community health committees in a rural and urban setting in Kenya

Health managers' perspectives of community health committees' participation in the annual health sector planning and budgeting process in a devolved unit in Kenya: a cross-sectional study

Introduction

health sector planning and budgeting are concerned with identifying priorities that guide budgetary allocation to improve health outcomes. Engaging the community in this process empowers them to manage their own health. Despite the benefits and the availability of legislation and structures to mainstream community participation, their involvement is minimal and marred with challenges. This study, therefore, aimed to examine the level and perspectives of health managers on community health committees´ (CHC) participation in health sector planning and budgeting.

Methods

the study utilized a cross-sectional research design, incorporating both quantitative and qualitative research methods. Study participants were involved in planning and budgeting. Quantitative data were collected from 100% (n=170) of health managers, while qualitative data were gathered from 100% (n=3) of county department of health executives and 94% (n=83) of community health committee members. Descriptive statistics were utilized to analyze quantitative data, while qualitative data were analyzed thematically.

Results

although 87% of the health managers agreed that community health committee participation is beneficial, only 11% of them were satisfied with their participation, and 54% rated CHC participation as low; furthermore, over 50% of health managers disagreed that Community Health Unit (CHUs) have the necessary skills to effectively participate in the process, that adequate budget and time are allocated for CHC participation, and that feedback about the process is provided to them.

Conclusion

the county health department of health should allocate more funds and design sustained capacity-building programs to enhance CHC participation in health sector planning and budgeting.

Teamwork in community health committees: a case study in two urban informal settlements

BACKGROUND

Community health committees (CHCs) are mechanisms for community participation in decision-making and overseeing health services in several low-and middle-income countries (LMICs). There is little research that examines teamwork and internal team relationships between members of these committees in LMICs. We aimed to assess teamwork and factors that affected teamwork of CHCs in an urban slum setting in Nairobi, Kenya.

METHODS

Using a qualitative case-study design, we explored teamwork of two CHCs based in two urban informal settlements in Nairobi. We used semi-structured interviews (n = 16) to explore the factors that influenced teamwork and triangulated responses using three group discussions (n = 14). We assessed the interpersonal and contextual factors that influenced teamwork using a framework for assessing teamwork of teams involved in delivering community health services.

RESULTS

Committee members perceived the relationships with each other as trusting and respectful. They had regular interaction with each other as friends, neighbors and lay health workers. CHC members looked to the Community Health Assistants (CHAs) as their supervisor and "boss", despite CHAs being CHC members themselves. The lay-community members in both CHCs expressed different goals for the committee. Some viewed the committee as informal savings group and community-based organization, while others viewed the committee as a structure for supervising Community Health Promoters (CHPs). Some members doubled up as both CHPs and CHC members. Complaints of favoritism arose from CHC members who were not CHPs whenever CHC members who were CHPs received stipends after being assigned health promotion tasks in the community. Underlying factors such as influence by elites, power imbalances and capacity strengthening had an influence on teamwork in CHCs.

CONCLUSION

In the absence of direction and support from the health system, CHCs morph into groups that prioritize the interests of the members. This redirects the teamwork that would have benefited community health services to other common interests of the team. Teamwork can be harnessed by strengthening the capacity of CHC members, CHAs, and health managers in team building and incorporating content on teamwork in the curriculum for training CHCs.

Who makes health governance decisions at the local level? A cross sectional study from primary health facilities in Tanzania

Background and Aims

Lower- and middle-income countries have decentralized decision-making at the community level, as well as community governance structures, to encourage community participation in governance processes, particularly in primary healthcare (PHC). In Tanzania, decentralization resulted in the establishment of Health Facility Governing Committees (HFGCs) to encourage community participation in the governance of primary health facilities to improve the quality and responsiveness of health service delivery. Nonetheless, despite the presence of HFGCs, PHC delivery remains ineffective and of poor quality. It is unclear who makes governance decisions at PHC facilities to ensure that services delivered are of expected quality and respond the community's needs, tastes, and preferences. This paper aims to assess the perspectives of members of the HFGC on who make governance decision in the context of fiscal decentralization.

Design and Methods

A cross-section design was used to collect both quantitative and qualitative data. A four-multistage sampling technique was adopted to selects regions, council, health facilities, and HFGC members. Respondents who participated in structured questionnaire responses were chosen using proportional sampling, whereas those who participated in in-depth interviews and Focus Group Discussions were chosen using purposive selection. The data was analyzed descriptively and thematically.

Results

The study revealed that HFGCs members perceive that governance decisions in primary health facilities are primarily made by the health facility management, and later are presented in HFGCs. As such, HFGCs are used a passively used to justify participation in decision that was already made by the management, which contradict with the principal of decentralization that emphasizes community participation on fiscal decisions.

Conclusion

Decentralization of PHC facilities does not guarantee the participation of community members in fiscal decision of their respective primary health facilities through HFGCs. HFGC is passively used governance structure to substitute community participation in primary health facilities' fiscal decisions. Enforcement mechanisms are required to facilitate effective community participation.

Health facility delivery and early initiation of breastfeeding: Cross-sectional survey of 11 sub-Saharan African countries

Background and Aims

Early initiation of breastfeeding (EIB) remains one of the promising interventions for preventing neonatal and child deaths. EIB is positively associated with healthcare delivery or childbirth. Meanwhile, no study in sub-Saharan Africa (SSA) appears to have investigated the relationship between health facility delivery and EIB; thus, we assessed the correlation between health facility delivery and EIB.

Methods

We used data from the Demographic and Health Survey (DHS) of 64,506 women from 11 SSA countries. The outcome variable was whether the respondent had early breastfeeding or not. Two logistic regression models were used in the inferential analysis. With a 95% confidence interval (CI), the adjusted odds ratios (aORs) for each variable were calculated. The data set was stored, managed, and analyzed using Stata version 13.

Results

The overall percentage of women who initiated early breastfeeding was 59.22%. Rwanda recorded the highest percentage of early initiation of breastfeeding (86.34%), while Gambia recorded the lowest (39.44%). The adjusted model revealed a significant association between health facility delivery and EIB (aOR = 1.80, CI = 1.73-1.87). Compared with urban women, rural women had higher likelihood of initiating early breastfeeding (aOR = 1.22, CI = 1.16-1.27). Women with a primary education (aOR = 1.26, CI = 1.20-1.32), secondary education (aOR = 1.12, CI = 1.06-1.17), and higher (aOR = 1.13, CI = 1.02-1.25), all had higher odds of initiating early breastfeeding. Women with the richest wealth status had the highest odds of initiating early breastfeeding as compared to the poorest women (aOR = 1.33, CI = 1.23-1.43).

Conclusion

Based on our findings, we strongly advocate for the integration of EIB policies and initiatives with healthcare delivery advocacy. Integration of these efforts can result in drastic reduction in infant and child mortality. Essentially, Gambia and other countries with a lower proclivity for EIB must reconsider their current breastfeeding interventions and conduct the necessary reviews and modifications that can lead to an increase in EIB.

Community participation in the health system: analyzing the implementation of community health committee policies in Kenya

BACKGROUND

Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya.

METHODS

Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies.

FINDINGS

Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs.

CONCLUSION

Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.

How context influences the functionality of community-level health governance structures: A case study of community health committees in Kenya

Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community-level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya. Using a case study design, we explored the influence of context on CHCs using 18 focus group discussions with 110 community members (clients, CHC members, and community health volunteers [CHVs]) and interviews with 33 health professionals. Essential CHC functions such as 'leadership' and 'management' were weak, partly because Health professionals did not involve CHCs in developing health plans. Community Health Committees were active in the supervision of CHVs, reviewing their household reports, although they did not utilise these data for making decisions. Resource mobilisation and evaluation of health programs were affected by the lack of administrative and operational support, such as training. Despite having influential membership, CHCs could not provide leadership and management functions. Health system actors perceived the roles of CHCs as service providers rather than structures for governance and oversight. Insufficient awareness of CHC roles among health professionals, lack of training and operational support for community-based activities constrained CHCs' functionality and thus their role in community participation. While there are efforts to institutionalise community-level governance structures for health at sub-national level, there is a need to scale-up these efforts countrywide. We recommend that community-level governance structures be empowered, mandated, and provided with resources to take on the responsibility of overseeing community health services and exacting accountability from health providers.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis

Background

Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA).

Methods

We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases. Articles were eligible if they involved health committees in SSA. Our search yielded 279 articles and 7 duplicates were removed. We further excluded 255 articles following a review of titles and abstracts by two authors. Seventeen abstracts were eligible for full text review. After reviewing the full-text, we further excluded two articles that did not explicitly describe the role of health committees in community participation. We therefore included 15 articles in this review. Two authors extracted data on how health committees contributed to community participation in SSA using a conceptual framework for assessing community participation in health. We derived our themes from five process indicators in this framework, namely, leadership, management and planning, resource mobilization from external sources, monitoring and evaluation and women involvement.

Findings

We found that health committees work well in voicing communities’ concerns about the quality of care provided by health facility staff, day-to-day management of health facilities and mobilizing financial and non-financial resources for health activities and projects. Health committees held health workers accountable by monitoring absenteeism, quality of services and expenditures in health facilities. Health committees lacked legitimacy because selection procedures were often not transparent and participatory. Committee members were left out in planning and budgeting processes by health workers, who perceived them as insufficiently educated and trained to take part in planning. Most health committees were male-dominated, thus limiting participation by women.

Conclusion

Health committees contribute to community participation through holding primary health workers accountable, voicing their communities’ concern and mobilizing resources for health activities and projects. Decision makers, health managers and advocates need to fundamentally rethink how health committees are selected, empowered and supported to implement their roles and responsibilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12730-y.

Community health workers at the dawn of a new era: 9. CHWs' relationships with the health system and communities

BACKGROUND

This is the ninth paper in our series, "Community Health Workers at the Dawn of a New Era". Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities.

METHODS

The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes.

RESULTS

The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders.

CONCLUSION

To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.

Health system responsiveness: a systematic evidence mapping review of the global literature

BACKGROUND

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness.

METHODS

A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts.

RESULTS

Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system.

CONCLUSIONS

This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.