Community participation in community health

Community Health Committees (CHCs) have been shown to deepen community engagement and responsibility in health decision-making. This research sought to improve our understanding of how and what contextual factors influence CHCs. It is hoped that the findings will help unlock the potential of CHCs to engage with communities and provide leadership in the improvement of community health services. We presented our research findings at the 2019 Learning Event.

Community Health Committees (CHCs) have been shown to deepen community engagement and responsibility in health decision-making. This research sought to enhance understanding of how and what contextual factors influence CHCs. It is hoped that the findings will help unlock the potential of CHCs to engage with communities and provide leadership in the improvement of community health services.

The research was a qualitative case study using purposive sampling. Data was collected through semi-structured interviews and focus group discussions between October 2017 and February 2018. The participants were County and Sub-County Managers, Primary Health Workers, CHCs, CHV and community members.

Our findings are grouped under the following themes: perception of CHC roles, CHC factors, community, health administration, health facility and societal contexts.

CHC roles

  • Most respondents believed the main role of CHCs was the supervision of CHVs. Supervision was interpreted as accompanying CHVs during household visits and reviewing monthly service delivery reports.
  • CHCs viewed themselves as a link between health workers and community. However, health professionals did not recognize CHCs as their link to the community.
  • CHCs perceived themselves more as service providers than a governance and oversight structure. Health professionals expected them to be involved in referral, health education, immunization of children and involvement in malaria control interventions alongside CHVs.

“I don’t think I have a CHC. They are there by name, not by action. Most of them are there by name; you can say this and this, but these people are not available”

Female CHEW, Nairobi

CHC factors

  • All CHC members reported being motivated by a sense of indebtedness, responsibility and pride they felt to serve. Lack of incentives was a major source of demotivation, which led to high attrition. Some CHC chose to work as CHVs.
  • CHCs in urban slum settings were mainly comprised of “structure owners” and influential community leaders. Several members had been “promoted” from being CHVs. They continued to provide CHV services.
  • Many CHC members had multiple leadership roles and were influential their communities. This influence they had in the community was not beneficial in driving the CHC agenda.

Community context

  • Community members could not differentiate between CHVs and the CHC and did not know the roles of CHCs. This often led to hostility, apathy and lack of trust toward CHC members

“So the community members see the CHC to be useless, as they don’t take any report. They just sit there, look at what the CHV is doing, then we get up and leave…they just see the CHC as someone just useless, as they don’t have the referral book. So they don’t really understand the CHC”.

Female CHV in a focus group discussion, Migori

Health facility context

  • None of the CHCs in our study interacted with their local Health Facility Management Committees (HFMCs)
  • Some health workers and managers did not know about CHCs and had never interacted with them. To some health workers, CHCs did not exist

Health administration context

  • None of the CHCs had been involved in the development of annual community health plans. CHEWs reported developing community unit plans and submitting to the health facility
  • Some health professionals were not familiar with the roles of CHCs. They blamed this lack of awareness on inactivity of CHCs. We found tense relationships between CHCs and other health system actors in two study settings
  • CHCs reported lacking capacity in governance, planning and resource mobilization. Most CHC were untrained

Societal context

  • Respondents reported lack of clarity on how to manage community participation since they did not have guidance from the County Departments of Health

“It has wiped out our work [Devolution]! That is why we are not doing anything right now, because back then the national government were recognizing the CHCs and they saw our importance but since the start of devolution CHCs are not recognized.”

Man in a CHC focus group discussion, Migori

  • Health professionals acknowledged that community health services relied heavily on vertical donor funded NGO projects that focused on CHV and not governance

“…most of the community health agenda is partner [donor] driven. We have no direct resources that go direct from the government to the community units. We find it easier engaging the volunteers more…because of the results, immediate results and overlooking the CHC role because there are no immediate results that you get by engaging them.”

Interview with a male Health System Manager, Kajiado

Feedback from participants

Feedback from participants in relation to community engagement included:

  • Maintaining the current selection criteria as per the CHC guidelines
  • Ensuring that CHC members are people with passion on health matters and role models in the community
  • Increasing the composition of health facility committees from eight to 12 to cater for CHCs
  • Making budgetary allocation to CHCs for quarterly meetings
  • Better defining the roles and responsibilities of the CHCs
  • Providing stipends to CHCs committees
  • Selecting CHC members through the community at chief barazas
  • Ensuring that CHCs are formaly introduced to the community by the health administration in barazas
  • Proving CHC members with proper training and capacity building on their roles and on the health issues they will be dealing with
  • Giving them a form of ID like a badge
  • Involving CHCs in data collection on community health