Introducing The 4byFour Model
01 October 2019
REACHOUT at the Global Symposium on Health Systems Research
01 October 2018
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Kenya has a strong health component in its ‘Vision 2030’ policy, which aims to build a prosperous country with a high quality of life. Within this policy the delivery of community based services are a flagship project. Kenya revised its Community Strategy in 2007 as the vehicle to deliver the National Health Sector Strategic Plan. Vertical programmes use close-to-community providers to deliver services including maternal and child health, HIV, TB and malaria with varying degrees of success. These programmes have assisted the government to increase the number of trained community health workers and functional community units. The government through the Division of Community Health Services has recently developed a scheme of service for close to community providers and is reviewing the community strategy model based on lessons learnt and experiences from other countries.
Although the Community Strategy has been in use in Kenya since 2007, it has not been fully integrated into all programmes, especially those for HIV, and it lacks clear quality assurance and reporting structures to make it fully functional. The Division of Community Health Services has developed a scheme for community health extension workers as the primary caregivers at the community level and redefined the roles of community health workers so that they are ‘mobilizers’. The implementation of the scheme needs to be informed by evidence, and include quality assurance, to ensure its success.
HIV is a major public health concern in Kenya. Through the Community Strategy, Kenya wants to expand HIV services at community level to ensure identification and effective referral and linkage of clients to HIV prevention and treatment. But there are areas where capacity needs to be developed, for example in: standardised human resource management, including remuneration and training; a strategy to deal with high attrition rates; clear links with existing health management systems; and a standardised community-based health information system that reflects key public health priorities. Quality assurance within the community strategy needs to be addressed based on lessons learnt from HIV programmes: Clear guidelines, standard operating procedures, supervision mechanisms, quality indicators, and other tools are all needed to address this gap.
At provider level there is a willingness to embrace and implement the Community Strategy and the role of community health workers within the Community Strategy is legitimised by the national strategy document. However the Community Strategy has not been uniformly implemented and there has been limited documentation of work or sharing of best practice, including human resource management, reporting, monitoring and supervision. There are no guidelines on how to monitor and standardise services offered by community health workers nor are there mechanisms for quality assurance of close-to-community services.
At policy level there are mechanisms that encourage interaction between policy makers, practitioners, and researchers in the form of technical working and interagency coordinating committees. Policy makers are increasingly well versed in current trends in various fields including community strategy. Kenya has become a regional leader in HIV policy development and implementation and encourages the sharing of knowledge. Despite this technical capacity to interpret and use research, at times there is lack of coordination between different policy making organs which results in duplication and lack of integration.
In Kenya REACHOUT will build on existing expertise to respond to identified issues affecting community health workers providing HIV-related services. The focus will be on developing and testing comprehensive quality assurance approaches and on monitoring and evaluation and data collection mechanisms. The evidence generated will provide a basis for future efforts to improve monitoring and evaluation and quality assurance of community health programming in other parts of the health system. The approach will also contribute to developing a human resource management system that addresses factors that influence the sustainability of community health worker programmes in Kenya. These factors include training and supervision needs, and motivation and incentives. The impact of this approach has already been demonstrated in facility-based services. The project will also provide evidence and a model for integrating HIV into the community strategy.The project will capitalise on close links with policy makers and coordinating agencies to help inform a coordinated approach to policy and practice relating to Kenya’s Community Strategy.
This project is funded by the European Union.