Community Health Strategy in Kwale County, Kenya and the challenges of implementing Community Units and a digital health information system.
Kenya’s Community Health Strategy is a national strategic plan to improve and invest in Community Health in every county and in so doing, access health care needs at the source, which is the home and village. It is part of a plan for Universal Health Coverage and to balance the resources put into facility and hospital-based care along with community care. The goal is to understand the health needs at community level, to encourage referrals, to collect health data and to facilitate awareness of healthcare challenges within the community and liaise with the health care system. By focusing on education in areas of hygiene, open defecation free communities, preventative measures such as universal use of mosquito nets, mother and child needs etc, a proactive preventative and treatment-based intervention could be established.
In spite of the well documented value of employing a vigorous community health strategy, involving the training of Community Health Workers/Volunteers (the term Worker is more commonly used but in Kenya the word volunteer is used as they are not formally paid), establishing Community Health Committees and engaging in many health-care education and activities, the experience in Kenya is very varied, county to county and in many cases, is not supported at a county level through the allocation of appropriate funds to create Community Units, train workers, pay stipends and support the community at every level. Some counties rely on NGO’s to come and carry out this policy and therefore, a sustainable vision for Community Health Strategy is not being owned at this time. Also, the financial implications of fully adopting the proposed Community Health Strategy has not been embraced at this time and the roles and status of Community Health Workers/volunteers remains ambiguous as they are designated as volunteers and yet at times are given much work to do.
Kwale County has been fairly active in its implementation of developing Community Units. The whole county has been fairly well mapped, with a total coverage being around 145 Community Units. As of January 2019, 4Kenya Trust has established or refurbished 24 Community Units. 4 are in Kinango sub-county, 4 in Matuga sub-county and 16 in Msambweni sub-county. All are being monitored regularly with review meetings, supported with monthly stipends based on activities in data collection and other health action days and activities. 4Kenya Trust is working closely with the Ministry of Health, public health officers and facilities in charge in the Community Units. However, selection of CHW’s is left to the community without insistence that those chosen have a level of education necessary (minimum of form 4 qualification) and an adequate knowledge of English and Kiswahili. Younger, more active CHWs would give greater capacity to their role. Payment of stipends and allocating these costs as part of a concerted Community Health policy would greatly assist the trust and recognition of the role of CHWs. As of now the government is not paying these stipends even though its recommended policy. The CHW’s can often be put under a lot of work pressure, both from NGOs who may be sponsoring the CU and paying their stipends and from the MoH as it implements various health action agendas. This can lead to frustration and disenchantment. Without clear oversight and the lack of PHO’s to monitor the function of CHW’s, it is hard to see how in the long run their role can be clearly monitored and supervised.
One important function of the CHW is the collection of health data, in the form of 513 household registration and 514 log book. The first is collected every 6 months and the latter on a monthly basis. These are given to the PHO who creates the 515 summary report which is given to the health information officer to upload into the national system called DHIS2. DHIS2 is the open source health information used by the MoH in Kenya, one of a number of digital and paper-based health information systems. Its strength is the collection and analysis of data at every level of the system, from local facility to sub county hospital, to county level and national level. However, in reality, data is only looked at from county and national level, and even then in a sporadic way.
As of this point in Kwale County, it is questionable how much of the community data is uploaded in a timely manner and there is little oversight of this process. New CU’s established by 4Kenya have not been integrated into the national DHIS2 system after their establishment, making one question whether the data is being either integrated into the 515 summary form and/or uploaded by the Health Information Officers.
4Kenya Trust has implemented an innovative digital health information system using a phone app based on DHIS2 called Tracker. It allows health data to be collected in real time on a smart phone and for that data to be uploaded to a server as soon as wifi connection is made. It also allows data to be collected for each individual, as apposed to the aggregate scores created by the normal DHIS2 system.
The following issues have been found to be important in establishing a successful digital health system at community level:
1. Appropriate level of training for CHW’s especially in using smart phone technology.
2. CHW’s having knowledge of English (as log books are also in English) and ability to know what needs to be asked and to know their role in data collection.
3. Appropriate monitoring and support from the PHO’s and/or facilities in charge and/or CHEWS, so they know how they are working, especially in data collection but also in their broader function as CHWs.
4. Significant monitoring and support from 4Kenya to ensure that their phones are working effectively, that the data being collected is relevant and that all households are being covered.
5. Effective evaluation of the data by DHIS2 experts so the data can be utilized for health policy at sub-county, county and national level and for a broader advocacy of using the DHIS2 system, especially the tracker.
6. Utilization of a server that is in the cloud and is being regularly updated. We have experienced considerable frustration in our server not being available, and that our technical support team have not been available on a regular basis to deal with technical issues.
7. Technical issues have proved to be a serious issue at times, which we are documenting as we make progress with DHIS2 tracker implementation. The key for the sustainability of Community Health Strategy depends on both the national agenda for encouraging Community Strategy as part of Universal Health Care, and how each county’s Ministry of Health adopts this and allocates funds and policies to support the strategy. As healthcare is devolved in Kenya, it has given the responsibilities for much of healthcare policy to the county. Greater awareness and advocacy for the Community Health Strategy is needed at a county level in order for the strategy to be effective, especially in data collection and analysis.