title: Exploring perceptions of community health policy in Kenya and identifying implications for policy change.
abstract: BACKGROUND
  Global interest and investment in close-to-community health services is increasing. Kenya is currently revising its community health strategy (CHS) alongside political devolution, which will result in revisioning of responsibility for local services. This article aims to explore drivers of policy change from key informant perspectives and to study perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change.
  
  
  METHODS
  We conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives, including those who will influence or be influenced by CHS policy change in Kenya (policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members) in two purposively selected counties: Nairobi and Kitui. Qualitative data were digitally recorded, transcribed, translated and coded before framework analysis.
  
  
  RESULTS
  There is widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas for change identified include: lack of clear supervisory structure including provision of adequate travel resources, current uneven coverage and equity of community health services, limited community knowledge about the strategy revision and demand for home-based HIV testing and counselling.
  
  
  CONCLUSIONS
  This in-depth analysis which captures multiple perspectives results in robust recommendations for strategy revision informed by the Five Wonders of Change Framework. These recommendations point towards a more people-centred health system for improved equity and effectiveness and indicate priority areas for action if success of policy change through the roll-out of the revised strategy is to be realized.
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK, r.mccollum@liverpool.ac.uk.
authors.forename: Rosalind
authors.initials: R
authors.lastname: McCollum
authors.affiliation: Research and Strategic Information Department LVCT Health, Nairobi, Kenya.
authors.forename: Lilian
authors.initials: L
authors.lastname: Otiso
authors.affiliation: Research and Strategic Information Department LVCT Health, Nairobi, Kenya.
authors.forename: Maryline
authors.initials: M
authors.lastname: Mireku
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.
authors.forename: Sally
authors.initials: S
authors.lastname: Theobald
authors.affiliation: KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands, and.
authors.forename: Korrie
authors.initials: K
authors.lastname: de Koning
authors.affiliation: Community Health and Development Unit, Ministry of Health, Kenya.
authors.forename: Salim
authors.initials: S
authors.lastname: Hussein
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.
authors.forename: Miriam
authors.initials: M
authors.lastname: Taegtmeyer
mesh_terms: D003153:Community Health Services / Q000458:organization & administration; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006291:Health Policy; D006801:Humans; D007407:Interviews as Topic; D007630:Kenya; D008297:Male; D011050:Policy Making; D036301:Qualitative Research
keywords: Community health extension worker; Kenya; close to community provider; community health worker; policy
references.citation: Malar J. 2009;8:39
references.pmid: 19272157
references.citation: PLoS One. 2011;6(12):e27997
references.pmid: 22194801
references.citation: Midwifery. 2011 Feb;27(1):15-22
references.pmid: 19783081
references.citation: Cochrane Database Syst Rev. 2010;(3):CD004015
references.pmid: 20238326
references.citation: BMC Health Serv Res. 2014;14 Suppl 1:S3
references.pmid: 25079378
references.citation: BMC Health Serv Res. 2014;14 Suppl 1:S4
references.pmid: 25079588
references.citation: Health Res Policy Syst. 2009 Nov 25;7:26
references.pmid: 19939279
references.citation: Health Policy Plan. 2015 Nov;30(9):1207-27
references.pmid: 25500559
references.citation: J Health Care Poor Underserved. 2009;20(4 Suppl):99-115
references.pmid: 20168036
references.citation: Lancet. 2004 Oct 23-29;364(9444):1541-8
references.pmid: 15500901
references.citation: Soc Sci Med. 2012 Aug;75(3):511-5
references.pmid: 22595068
references.citation: BMJ. 2008;337:a288
references.pmid: 18687727
references.citation: Cochrane Database Syst Rev. 2013;10:CD010414
references.pmid: 24101553
references.citation: J Adv Nurs. 2006 Aug;55(3):291-300
references.pmid: 16866823
references.citation: BMJ. 1995 Jul 1;311(6996):42-5
references.pmid: 7613329
references.citation: Soc Sci Med. 2010 Jun;70(12):1920-7
references.pmid: 20382464
references.citation: Hum Resour Health. 2010 Mar 30;8:6
references.pmid: 20353561
references.citation: AIDS Patient Care STDS. 2012 Feb;26(2):101-7
references.pmid: 22224411
references.citation: Trop Med Int Health. 2009 Jan;14(1):54-61
references.pmid: 19021892
references.citation: AIDS Care. 2010 Jul;22(7):895-902
references.pmid: 20635254
references.citation: BMC Med Res Methodol. 2013;13:117
references.pmid: 24047204
references.citation: Int Breastfeed J. 2006 Oct 20;1:19
references.pmid: 17054796