Republic Of Kenya Strategic Plan Of Kenya
Reversing the trendsThe SecondNATIONAL HEALTH SECTORStrategic Plan of KenyaRepublic of KenyaTaking the Kenya EssentialPackage for Health to theCOMMUNITYA Strategy for the Delivery ofLEVEL ONE SERVICESMinistry of HealthJune 2006Taking KEPH to the Communityi
THIS PUBLICATION is one of a series that the Ministry of Health will produce tosupport the achievement of the goals of the second National Health Sector StrategicPlan, 2005–2010 (NHSSP II). Aiming to reverse the declining trends in key health sectorindicators, NHSSP II has five broad policy objectives. 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 translatedin full or in part, provided the source is acknowledged. It may not be sold or used inconjunction with commercial purposes or for profit.Taking the Kenya Essential Package for Health to the Community: A Strategy forthe Delivery of LEVEL ONE SERVICESPublished by: Ministry of HealthHealth Sector Reform SecretariatAfya HousePO Box 3469 - City SquareNairobi 00200, KenyaEmail: secretary@hsrsmoh.go.kewww.hsrs.health.go.keCover photos: Lady in AIDS T-shirt by Dr. T. Gakuruh; others by Dr. H. Karamagi.iiTaking KEPH to the Community
ContentsList of TablesList of FiguresAbbreviationsForeword1: Introduction and Background1.1 The Context1.2 Strategic Objectives1.3 Justification for the Community-Based Approach1.4 Learning from Past Experiences in Community-Based Health Care (CBHC)1.5 The Key Role of Households and Communities as Partners in LEVEL ONESERVICESivivvvii1133472: Service Provision at Level 12.1 Norms and Services at Level 12.2 Definition of Services Provided at Level 12.3 Supportive Supervision2.4 Communication Strategy at Level 1991013143: Implementation Framework and Process3.1 Organizational Structures and Coordination Framework3.2 The Entry Steps3.3 Feedback and Participatory Planning of Level 1 Service Activities161618204: Linkage between Community and Health Facility and Sustainability4.1 Structures and Their Functions in Supporting Services at Level 14.2 LEVEL ONE SERVICES Sustainability4.3 Strengthening Rights to Health Aspects of LEVEL ONE SERVICES212125255: Recruitment and Training of Service Providers for Level 1 Service Provision5.1 Training Trainers of Service Providers at Level 15.2 Recruitment and Training of CORPs2727296: Monitoring and Evaluation6.1 Issues in Monitoring and Evaluation6.2 Implementing Monitoring and Evaluation323233Taking KEPH to the Communityiii
7: Activities and Inputs for Implementing the Community Strategy7.1 Assembling Key Implementation Partners7.2 Building the Human Resource7.3 Introducing and Sustaining Service Delivery at Level 17.4 Strengthening Linkage between the Health System and the Communities7.5 Monitoring and Evaluating Level 1 Activities3636373839428: Budget8.1 Budget Parameters8.1 Budget by Objectives and Activities, 2006–20098.2 Annual Budget Summary for LEVEL ONE SERVICES44444548References49Tables1: Service activities and requirements at level 1, by cohorts in a populationof 5,0002: Levels of action to support level 1 services3: Summary of training content by category and tasks4: Types of health information to be collected in community by category andsource5: Programme timetable, April 2006 – March 20096: Summary of budget by objectives and activities, 2006–2009 (in US )7: Summary yearly budget for LEVEL ONE SERVICES, 2006–2009 (in US )11173034424548Figures1: Suggested organizational linkages and structuresiv21Taking KEPH to the Community
HFEFPGOKHHsHCHDCHEHFCHIVHMISHSRIDCCSAcquired immune deficiency syndromeAfrican Medical and Research FoundationAcute respiratory tract infectionBehaviour change communicationBamako InitiativeCommunity-based health careCommunity-based information systemCommunity-based organizationCompetency-based trainingCommunity-based workersCommunity health extension workerCommunity level integrated management of childhood illnessesChurch Organizations Research Advisory TrustCommunity-owned resource personDistrict CommissionerDistrict Development CommitteeDistrict Health Management BoardDistrict Health Management TeamDemocratic Republic of CongoEarly childhood developmentEnrolled community nurseEnvironmental healthKenya Expanded Programme of ImmunizationFacility-based information systemFamily health field educatorFamily planningGovernment of KenyaHouseholdsHealth centreHealth development committeeHealth educationHealth facility committeeHuman immunodeficiency virusHealth management information systemHealth sector reformInter Diocesan Christian Community ServicesTaking KEPH to the Communityv
IECInformation, education and communicationIMRInfant mortality rateITNInsecticide treated netKAPKnowledge, attitude and practiceKDHSKenya Demographic and Health SurveyLDCLocational development committeeMCHMother and child healthMOHMinistry of HealthNGONon-government organizationNHSSP II Second National Health Sector Strategic Plan, 2005–2010ORSOral rehydration salts/solutionPHPublic healthPHCPrimary health carePHNPublic health nursePHOPublic health officerPHTPublic health technicianRHReproductive healthSDPService delivery pointSTISexually transmitted infectionTBTuberculosisTBATraditional birth attendantTICHTropical Institute of Community Health and DevelopmentTOTTraining of trainers / Trainer of trainersVCTVoluntary counselling and testingVHCVillage health committeeviTaking KEPH to the Community
ForewordKenya’s second National Health Sector Strategic Plan (NHSSP II – 2005–2010)defined a new approach to the way the sector will deliver health careservices to Kenyans – the Kenya Essential Package for Health (KEPH). KEPHintroduced six life-cycle cohorts and six service delivery levels. One of thekey innovations of KEPH is the recognition and introduction of level 1 services, whichare aimed at empowering Kenyan households and communities to take charge ofimproving their own health.This document, Taking the Kenya Essential Package for Health to the Community:A Strategy for the Delivery of LEVEL ONE SERVICES, intends to make KEPH a reality atlevel 1 – the community level. The document was developed through wideconsultation among stakeholders in the sector to help revitalize community healthservices in Kenya. The document clearly defines the type of services to be providedat level 1, the type of human resources required to deliver and support this level ofcare, the minimum commodity kits required, and the management arrangements tobe used in implementation.The strategy sets an ambitious target of reaching 16 million Kenyans (3.2 millionhouseholds) in the next four years. It envisages building the capacity of householdsnot only to demand services from all providers, but to know and progressively realizetheir rights to equitable, good quality health care. The strategy introduces innovativeapproaches for accomplishing these challenging but realizable targets. Theapproaches include: Establishing a level 1 care unit to serve a local population of 5,000 people. Instituting a cadre of well trained Community-Owned Resource Persons (CORPs)who will each provide level 1 services to 20 households. Supporting every 25 CORPs with a Community Health Extension Worker. Ensuring that the recruitment and management of CORPs is carried out by villageand facility health committees.Iam fully confident that the implementation of this strategy will help us addressthe issue of providing equitable access to basic primary health services and by sodoing will help to “reverse the trends” in our health indexes in an acceleratedmanner. However, I am also aware that we will have to collectively, as stakeholders,face many technical, managerial and other challenges and resolve them along theway. During the implementation process, we will learn many lessons from practiceand these will enrich this strategy further.Taking KEPH to the Communityvii
Implementing community health services is the top priority of the Ministry ofHealth and its partners in the sector. This is articulated well in our Joint Programmeof Work and Funding, 2006/07–2009/10.The opportunity for actualizing the sector stakeholders’ main policy agenda –reaching the poor through basic health care – has now presented itself to us in theform of implementing this community strategy. I call on our districts andimplementing partners to exert their maximum effort to bring this dream to reality –the dream of having a community health service that is sustainable and responsive tothe needs of our many diverse localities. I also call on our development partners toprioritize this service as one of “first call” in supporting the health sector.Dr. James NyikalDIRECTOR OF MEDICAL SERVICESMinistry of HealthJune 2006viiiTaking KEPH to the Community
1: Introduction and BackgroundCommunities are at the foundation of affordable, equitable and effectivehealth care, and are the core of the Kenya Essential Package for Health(KEPH) proposed in the second National Health Sector Strategic Plan 2005–2010 (NHSSP II). This strategy document sets out the approach to be taken toensure that Kenyan communities have the capacity and motivation to take up theiressential role in health care delivery. The overall goal of the community strategy is toenhance community access to health care in order to improve productivity and thusreduce poverty, hunger, and child and maternal deaths, as well as improve educationperformance across all the stages of the life cycle. This will be accomplished byestablishing sustainable community level services aimed at promoting dignifiedlivelihoods throughout the country through the decentralization of services andaccountability. Throughout this document, where LEVEL ONE SERVICESappears in all capital letters, it refers to the entire community-basedcomponent of the Kenya Essential Package for Health.Poverty1.1 The ContextAcompoundspowerlessnessand increases illhealth, as illhealth increasespoverty. Bothhave becomeprogressivelyworse since the1990s.large proportion of Kenyans continue to carry one of the highestpreventable burdens of ill health in the world. Much of this burdencan be lifted and prevented with existing knowledge andresources. Despite having well defined national health policies and areform agenda whose overriding strategies are focused on improvinghealth care delivery services and systems through efficient and effectivehealth management systems and reform, there has not been abreakthrough in improving the situation of households entrapped in thevicious cycle of poverty and ill health. Poverty compounds powerlessnessand increases ill health, as ill-health increases poverty. Both have becomeprogressively worse since the 1990s, with appalling disparity within and betweenprovinces. The situation is further complicated by the emergence of new andresurgence of old communicable diseases. The community systems are faced with thechallenge of coping with the growing demand for care, in the face of deepeningpoverty and dwindling resources.The result has been deteriorating trends in health status throughout the countrywith unacceptable disparities between and within provinces. In addition, the cost ofTaking KEPH to the Community1
health services has escalated well beyond the financing capacity of the Ministry ofHealth. This is in part the premise for the evidence-based, life-cycle approach tohealth care introduced in NHSSP II. The approach is critical in order to insure theNHSSP II goals of equity, effectiveness and efficiency.The worsening indicators include the following: Rising infant mortality rate from 64 per 1,000 live births in 1993 to 72 in 1998, 74in 2000 and 77 in 2003 (KDHS 2003). Rising under-five mortality rate from 90.9 per 1,000 live births in 1989 to 115 per1,000 live births in 2003 (KDHS 2003) High maternal mortality rate of 590 per 100,000 in 1998 and 414 in 2002 per100,000 live births (MOH 2005). The 2003 Kenya Demographic and Health Survey also revealed that:30.7% of children under five years are stunted.Only 2.6% children are still exclusively breastfeeding at six months, while 56.8%are still breastfeeding by the end of 23 months.61.5% of under-fives had child health cards.Only 59.2% of children in the second year of life are fully immunized.Only 4.3% of under-fives and 4.5% of pregnant mothers sleep under ITNs.Only 40.8% of deliveries are assisted by a health professional and only 39.4% occurin health facilities.Both the health sector reforms (HSRs) and the primary health care (PHC) concepthave advocated for better health for Kenyans through people’s active initiative andinvolvement. HSR expanded the community-based health care (CBHC)principles by decentralization to formalize people’s power indetermining their own health priorities and to link them with the formalThe overallhealth system in order to reflect their decisions and actions in healththrust of theplans. In addition, people themselves would also participate in resourcesecond Nationalmobilization, allocation and control. This approach is well articulated inHealth SectorNHSSP II and supported by local government reforms that would ensureStrategic Planthe effectiveness of decentralization, as power is shifted to the(NHSSP II) is tocouncils, and governing structures that enhance transparency andinvolve theaccountability.communities inThe community-based approach, as set out in this strategy, is theaddressing themechanism through which households and communities take an activedownward spiralrole in health and health-related development issues. Initiativesof deterioratingoutlined in the approach target the major priority health and relatedhealth status.problems affecting all cohorts of life at the community and householdlevels – level 1 of the KEPH-defined service delivery. It is envisionedthat the households and communities will be actively and effectively involved andenabled to increase their control over their environment in order to improve theirown health status. The intention, therefore, is to build the capacity of communitiesto assess, analyse, plan, implement and manage health and health relateddevelopment issues, so as to enable them to contribute effectively to the country’ssocio-economic development. The second major intended impact of the approach isthat the communities will thereby be empowered to demand their rights and seekaccountability from the formal system for the efficiency and effectiveness of healthand other services.2Taking KEPH to the Community
1.2 Strategic ObjectivesT he community strategy intends to improve the health status of Kenyancommunities through the initiation and implementation of life-cycle focusedhealth actions at level 1 by:Providing level 1 services for all cohorts and socioeconomic groups,Turning theincluding the “differently-abled”, taking into account their needscompetingand priorities.health careBuilding the capacity of the community health extension workerssystems into(CHEWs) and community-owned resource persons (CORPs) to providecollaboratingservices at level 1.partners willStrengthening health facility–community linkages through effectiveadd value to alldecentralization and partnership for the implementation of LEVELand benefit theONE SERVICES.householdsStrengthening the community to progressively realize their rights formore.accessible and quality care and to seek accountability from facilitybased health services.1.3 Justification for the Community-Based ApproachService providers are increasingly aware that households not only take themajority of preventive and promotive health actions, they also provide clinicalcare of the critically and chronically ill. Studies in Tanzania and Malawi haveshown that 70% of child deaths occur at home, without any contact with the healthsystem, caused by preventable or easily curable diseases such as malaria, measles,acute respiratory infections (ARI), pneumonia, diarrhoea and malnutrition.The culture of dominance among service providers against that of silence amonghouseholds and communities makes it difficult for the ideas of the communities to beheard. Service providers never really get to know what their clients understand. Thusthey often assume that what they have said, advised or given has been accepted andwill be done, only to be surprised later that no change has taken place in terms ofbehaviour or practice and therefore health outcomes. It is to be realized thathouseholds have the deepest interest of their own health at heart and they are alwaystrying their best even when what they do appears unreasonable. Yet the providers donot listen enough to hear what the consumers are expressing in their own terms andcontext, because providers tend to be uprooted from their socio-cultural contexts.This leads to loss of trust as local efforts and initiatives are ignored or displaced bytemporary actions that fizzle away.The providers, like people everywhere, have perspectives and viewpoints on theway things are that under gird their values. They interpret everything they experiencethrough these mental maps. They see the world as they are conditioned to see it. Thecommunity people, for their part, also see things through their own legitimate maps,the lenses of their own experiences. People have alternatives in meeting their healthneeds; they have their own interests that cannot be ignored if we are to do businesswith them through the community-based Kenya Essential Package for Health (LEVELONE SERVICES). Yet traditional approaches to care continue to be ignored at a timewhen the coverage by the formal facility-based health care system has graduallydeclined as people’s confidence in the formal health sector has eroded. Most serviceTaking KEPH to the Community3
users turn first to non-formal and traditional sources of care, since they are readilyavailable to the households, and only come to the health facilities as a last resort.These seemingly competing systems of care must be taken into account and strategiesto formally strengthen their linkages and synergy have to be thought through indesigning LEVEL ONE SERVICES, as part of the sector-wide approach,since they are significantly appreciated by the people regardless of theirContinuedeffectiveness in improving health conditions.respectfulThe people have learnt through experience that they should not relydialoguewithonly on the conventional service providers. There is therefore an overcommunities willwhelming need to negotiate with people and households as partners inhelp us tohealth care, giving them a chance to influence the way care is deliveredenlarge theirand thus restore their confidence in the health system. Meeting thischoices as weneed means focusing attention on enhancing the capacity of householdssupport them into play their role in action for health effectively. Through continuedmaking rational,respectful dialogue, we will be able to enlarge their choices as we seekevidence-basedto support them in making rational, evidence-based decisions concerndecisionsing their health needs across all stages in the human life cycle, and thusabouttheir healthreverse the trends in health indicators. Turning the competing systemsneeds.into collaborating partners will add value to all and benefit thehouseholds more.It is for this reason that the overall thrust of the second NationalHealth Sector Strategic Plan (NHSSP II) is to involve the communities in addressing thedownward spiral of deteriorating health status. The goal of reducing health inequitiescan only be achieved effectively by involving the population in decis
This document, Taking the Kenya Essential Package for Health to the Community: A Strategy for the Delivery of LEVEL ONE SERVICES, intends to make KEPH a reality at level 1 – the community level. The document was developed through wide consultation among stakeholders in the sector to help revitalize community health services in Kenya.
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