Reversing the trends

The Second
NATIONAL HEALTH SECTOR
Republic of Kenya Strategic Plan of Kenya

Taking the Kenya Essential

Package for Health to the

COMMUNITY
A Strategy for the Delivery of
LEVEL ONE SERVICES

Ministry of Health
June 2006
Taking KEPH to the Community i
THIS PUBLICATION is one of a series that the Ministry of Health will produce to
support the achievement of the goals of the second National Health Sector Strategic
Plan, 2005–2010 (NHSSP II). Aiming to reverse the declining trends in key health sector
indicators, 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 translated
in full or in part, provided the source is acknowledged. It may not be sold or used in
conjunction with commercial purposes or for profit.

Taking the Kenya Essential Package for Health to the Community: A Strategy for
the Delivery of LEVEL ONE SERVICES

Published by: Ministry of Health

Health Sector Reform Secretariat
Afya House
PO Box 3469 - City Square
Nairobi 00200, Kenya
Email: secretary@[Link]
[Link]

Cover photos: Lady in AIDS T-shirt by Dr. T. Gakuruh; others by Dr. H. Karamagi.

ii Taking KEPH to the Community

 Contents

List of Tables iv
List of Figures iv
Abbreviations v
Foreword vii

1: Introduction and Background 1

1.1 The Context 1
1.2 Strategic Objectives 3
1.3 Justification for the Community-Based Approach 3
1.4 Learning from Past Experiences in Community-Based Health Care (CBHC) 4
1.5 The Key Role of Households and Communities as Partners in LEVEL ONE
SERVICES 7

2: Service Provision at Level 1 9

2.1 Norms and Services at Level 1 9
2.2 Definition of Services Provided at Level 1 10
2.3 Supportive Supervision 13
2.4 Communication Strategy at Level 1 14

3: Implementation Framework and Process 16

3.1 Organizational Structures and Coordination Framework 16
3.2 The Entry Steps 18
3.3 Feedback and Participatory Planning of Level 1 Service Activities 20

4: Linkage between Community and Health Facility and Sustainability 21

4.1 Structures and Their Functions in Supporting Services at Level 1 21
4.2 LEVEL ONE SERVICES Sustainability 25
4.3 Strengthening Rights to Health Aspects of LEVEL ONE SERVICES 25

5: Recruitment and Training of Service Providers for Level 1 Service Provision 27

5.1 Training Trainers of Service Providers at Level 1 27
5.2 Recruitment and Training of CORPs 29

6: Monitoring and Evaluation 32

6.1 Issues in Monitoring and Evaluation 32
6.2 Implementing Monitoring and Evaluation 33

Taking KEPH to the Community iii

7: Activities and Inputs for Implementing the Community Strategy 36
7.1 Assembling Key Implementation Partners 36
7.2 Building the Human Resource 37
7.3 Introducing and Sustaining Service Delivery at Level 1 38
7.4 Strengthening Linkage between the Health System and the Communities 39
7.5 Monitoring and Evaluating Level 1 Activities 42

8: Budget 44
8.1 Budget Parameters 44
8.1 Budget by Objectives and Activities, 2006–2009 45
8.2 Annual Budget Summary for LEVEL ONE SERVICES 48

References 49

Tables
1: Service activities and requirements at level 1, by cohorts in a population
of 5,000 11
2: Levels of action to support level 1 services 17
3: Summary of training content by category and tasks 30
4: Types of health information to be collected in community by category and
source 34
5: Programme timetable, April 2006 – March 2009 42
6: Summary of budget by objectives and activities, 2006–2009 (in US$) 45
7: Summary yearly budget for LEVEL ONE SERVICES, 2006–2009 (in US$) 48

Figures
1: Suggested organizational linkages and structures 21

iv Taking KEPH to the Community

 Abbreviations

AIDS Acquired immune deficiency syndrome

AMREF African Medical and Research Foundation
ARI Acute respiratory tract infection
BCC Behaviour change communication
BI Bamako Initiative
CBHC Community-based health care
CBIS Community-based information system
CBO Community-based organization
CBT Competency-based training
CBWs Community-based workers
CHEW Community health extension worker
C-IMCI Community level integrated management of childhood illnesses
CORAT Church Organizations Research Advisory Trust
CORP Community-owned resource person
DC District Commissioner
DDC District Development Committee
DHMB District Health Management Board
DHMT District Health Management Team
DRC Democratic Republic of Congo
ECD Early childhood development
ECN Enrolled community nurse
EH Environmental health
KEPI Kenya Expanded Programme of Immunization
FBIS Facility-based information system
FHFE Family health field educator
FP Family planning
GOK Government of Kenya
HHs Households
HC Health centre
HDC Health development committee
HE Health education
HFC Health facility committee
HIV Human immunodeficiency virus
HMIS Health management information system
HSR Health sector reform
IDCCS Inter Diocesan Christian Community Services

Taking KEPH to the Community v

IEC Information, education and communication
IMR Infant mortality rate
ITN Insecticide treated net
KAP Knowledge, attitude and practice
KDHS Kenya Demographic and Health Survey
LDC Locational development committee
MCH Mother and child health
MOH Ministry of Health
NGO Non-government organization
NHSSP II Second National Health Sector Strategic Plan, 2005–2010
ORS Oral rehydration salts/solution
PH Public health
PHC Primary health care
PHN Public health nurse
PHO Public health officer
PHT Public health technician
RH Reproductive health
SDP Service delivery point
STI Sexually transmitted infection
TB Tuberculosis
TBA Traditional birth attendant
TICH Tropical Institute of Community Health and Development
TOT Training of trainers / Trainer of trainers
VCT Voluntary counselling and testing
VHC Village health committee

vi Taking KEPH to the Community

 Foreword

K
enya’s second National Health Sector Strategic Plan (NHSSP II – 2005–2010)
defined a new approach to the way the sector will deliver health care
services to Kenyans – the Kenya Essential Package for Health (KEPH). KEPH
introduced six life-cycle cohorts and six service delivery levels. One of the
key innovations of KEPH is the recognition and introduction of level 1 services, which
are aimed at empowering Kenyan households and communities to take charge of
improving 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 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. The document clearly defines the type of services to be provided
at level 1, the type of human resources required to deliver and support this level of
care, the minimum commodity kits required, and the management arrangements to
be used in implementation.
The strategy sets an ambitious target of reaching 16 million Kenyans (3.2 million
households) in the next four years. It envisages building the capacity of households
not only to demand services from all providers, but to know and progressively realize
their rights to equitable, good quality health care. The strategy introduces innovative
approaches for accomplishing these challenging but realizable targets. The
approaches 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 village
and facility health committees.

I
am fully confident that the implementation of this strategy will help us address
the issue of providing equitable access to basic primary health services and by so
doing will help to “reverse the trends” in our health indexes in an accelerated
manner. However, I am also aware that we will have to collectively, as stakeholders,
face many technical, managerial and other challenges and resolve them along the
way. During the implementation process, we will learn many lessons from practice
and these will enrich this strategy further.

Taking KEPH to the Community vii

 Implementing community health services is the top priority of the Ministry of
Health and its partners in the sector. This is articulated well in our Joint Programme
of 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 the
form of implementing this community strategy. I call on our districts and
implementing 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 to
the needs of our many diverse localities. I also call on our development partners to
prioritize this service as one of “first call” in supporting the health sector.

Dr. James Nyikal

DIRECTOR OF MEDICAL SERVICES
Ministry of Health

June 2006

viii Taking KEPH to the Community

 1: Introduction and Background

C
ommunities are at the foundation of affordable, equitable and effective
health 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 to
ensure that Kenyan communities have the capacity and motivation to take up their
essential role in health care delivery. The overall goal of the community strategy is to
enhance community access to health care in order to improve productivity and thus
reduce poverty, hunger, and child and maternal deaths, as well as improve education
performance across all the stages of the life cycle. This will be accomplished by
establishing sustainable community level services aimed at promoting dignified
livelihoods throughout the country through the decentralization of services and
accountability. Throughout this document, where LEVEL ONE SERVICES
appears in all capital letters, it refers to the entire community-based
component of the Kenya Essential Package for Health. Poverty
compounds
1.1 The Context powerlessness
and increases ill

A
large proportion of Kenyans continue to carry one of the highest health, as ill-
preventable burdens of ill health in the world. Much of this burden health increases
can be lifted and prevented with existing knowledge and poverty. Both
resources. Despite having well defined national health policies and a have become
reform agenda whose overriding strategies are focused on improving progressively
health care delivery services and systems through efficient and effective worse since the
health management systems and reform, there has not been a 1990s.
breakthrough in improving the situation of households entrapped in the
vicious cycle of poverty and ill health. Poverty compounds powerlessness
and increases ill health, as ill-health increases poverty. Both have become
progressively worse since the 1990s, with appalling disparity within and between
provinces. The situation is further complicated by the emergence of new and
resurgence of old communicable diseases. The community systems are faced with the
challenge of coping with the growing demand for care, in the face of deepening
poverty and dwindling resources.
The result has been deteriorating trends in health status throughout the country
with unacceptable disparities between and within provinces. In addition, the cost of

Taking KEPH to the Community 1

 health services has escalated well beyond the financing capacity of the Ministry of
Health. This is in part the premise for the evidence-based, life-cycle approach to
health care introduced in NHSSP II. The approach is critical in order to insure the
NHSSP 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, 74
in 2000 and 77 in 2003 (KDHS 2003).
• Rising under-five mortality rate from 90.9 per 1,000 live births in 1989 to 115 per
1,000 live births in 2003 (KDHS 2003)
• High maternal mortality rate of 590 per 100,000 in 1998 and 414 in 2002 per
100,000 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% occur
in health facilities.

Both the health sector reforms (HSRs) and the primary health care (PHC) concept
have advocated for better health for Kenyans through people’s active initiative and
involvement. HSR expanded the community-based health care (CBHC)
principles by decentralization to formalize people’s power in
The overall determining their own health priorities and to link them with the formal
thrust of the health system in order to reflect their decisions and actions in health
second National plans. In addition, people themselves would also participate in resource
Health Sector mobilization, allocation and control. This approach is well articulated in
Strategic Plan NHSSP II and supported by local government reforms that would ensure
(NHSSP II) is to the effectiveness of decentralization, as power is shifted to the
involve the councils, and governing structures that enhance transparency and
communities in accountability.
addressing the The community-based approach, as set out in this strategy, is the
downward spiral mechanism through which households and communities take an active
of deteriorating role in health and health-related development issues. Initiatives
health status. outlined in the approach target the major priority health and related
problems affecting all cohorts of life at the community and household
levels – level 1 of the KEPH-defined service delivery. It is envisioned
that the households and communities will be actively and effectively involved and
enabled to increase their control over their environment in order to improve their
own health status. The intention, therefore, is to build the capacity of communities
to assess, analyse, plan, implement and manage health and health related
development issues, so as to enable them to contribute effectively to the country’s
socio-economic development. The second major intended impact of the approach is
that the communities will thereby be empowered to demand their rights and seek
accountability from the formal system for the efficiency and effectiveness of health
and other services.

2 Taking KEPH to the Community

1.2 Strategic Objectives

T
he community strategy intends to improve the health status of Kenyan
communities through the initiation and implementation of life-cycle focused
health actions at level 1 by:
• Providing level 1 services for all cohorts and socioeconomic groups,
including the “differently-abled”, taking into account their needs Turning the
and priorities. competing
health care
• Building the capacity of the community health extension workers
systems into
(CHEWs) and community-owned resource persons (CORPs) to provide
collaborating
services at level 1.
partners will
• Strengthening health facility–community linkages through effective
add value to all
decentralization and partnership for the implementation of LEVEL
and benefit the
ONE SERVICES.
households
• Strengthening the community to progressively realize their rights for more.
accessible and quality care and to seek accountability from facility-
based health services.

1.3 Justification for the Community-Based Approach

S
ervice providers are increasingly aware that households not only take the
majority of preventive and promotive health actions, they also provide clinical
care of the critically and chronically ill. Studies in Tanzania and Malawi have
shown that 70% of child deaths occur at home, without any contact with the health
system, 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 among
households and communities makes it difficult for the ideas of the communities to be
heard. Service providers never really get to know what their clients understand. Thus
they often assume that what they have said, advised or given has been accepted and
will be done, only to be surprised later that no change has taken place in terms of
behaviour or practice and therefore health outcomes. It is to be realized that
households have the deepest interest of their own health at heart and they are always
trying their best even when what they do appears unreasonable. Yet the providers do
not listen enough to hear what the consumers are expressing in their own terms and
context, 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 by
temporary actions that fizzle away.
The providers, like people everywhere, have perspectives and viewpoints on the
way things are that under gird their values. They interpret everything they experience
through these mental maps. They see the world as they are conditioned to see it. The
community people, for their part, also see things through their own legitimate maps,
the lenses of their own experiences. People have alternatives in meeting their health
needs; they have their own interests that cannot be ignored if we are to do business
with them through the community-based Kenya Essential Package for Health (LEVEL
ONE SERVICES). Yet traditional approaches to care continue to be ignored at a time
when the coverage by the formal facility-based health care system has gradually
declined as people’s confidence in the formal health sector has eroded. Most service

Taking KEPH to the Community 3

 users turn first to non-formal and traditional sources of care, since they are readily
available 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 strategies
to formally strengthen their linkages and synergy have to be thought through in
designing LEVEL ONE SERVICES, as part of the sector-wide approach,
since they are significantly appreciated by the people regardless of their
Continued
effectiveness in improving health conditions.
respectful
The people have learnt through experience that they should not rely
dialoguewith only on the conventional service providers. There is therefore an over-
communities will whelming need to negotiate with people and households as partners in
help us to health care, giving them a chance to influence the way care is delivered
enlarge their and thus restore their confidence in the health system. Meeting this
choices as we need means focusing attention on enhancing the capacity of households
support them in to play their role in action for health effectively. Through continued
making rational, respectful dialogue, we will be able to enlarge their choices as we seek
evidence-based to support them in making rational, evidence-based decisions concern-
decisions ing their health needs across all stages in the human life cycle, and thus
abouttheir health reverse the trends in health indicators. Turning the competing systems
needs. into collaborating partners will add value to all and benefit the
households more.
It is for this reason that the overall thrust of the second National
Health Sector Strategic Plan (NHSSP II) is to involve the communities in addressing the
downward spiral of deteriorating health status. The goal of reducing health inequities
can only be achieved effectively by involving the population in decisions and in the
mobilization and allocation of resources, and thereby promoting community
ownership and control in the context in which they live their lives. This is a paradigm
shift that requires a fundamental change in the way things are governed and
managed, as well as in the way services are delivered.

1.4 Learning from Past Experiences in Community-

Based Health Care

C
urrently, Kenya has a large number of well trained public health technicians
(PHTs) and enrolled community nurses (ECNs), many of whom are unemployed,
who can fulfil the extension role inherent in LEVEL ONE SERVICES. They will do
this by linking with households through community-owned resource persons (CORPs).
It would not make sense to train another lot of extension workers for LEVEL ONE
SERVICES, when these cadres are available if they can be hired. This model of CORPs
at sub-locational level being supported by a PHT or ECN was tested by CARE Kenya in
Siaya District with excellent results (Olewe, 2003). The main problem, as usual, was
lack of sustainability as it was donor dependent. If the scheme could be state
supported as provided for in NHSSP II, it would be a sure way of improving the health
status of Kenyans.
The effectiveness of community health services and community health workers
(CHWs) has been shown in a number of studies and projects. In Democratic Republic
of Congo (DRC), CHWs were found to be effective in administering timely and
effective treatment of presumptive malaria attacks (Kidane and Murrow, 2000). Since
CORPs are also local community members, they are, in principle, always accessible to
the villagers. On the other hand, large centrally managed CORP programmes have
failed, whilst true community-based ones work well (Friedman et al., 2004).

4 Taking KEPH to the Community

 In Kenya the effectiveness of CORP-based programmes has been demonstrated in
districts throughout the country: Kakamega, Busia, Siaya, Bondo, Kisumu, Kisii, Nyeri,
Kirinyaga, Meru, Embu, Machakos and Kwale, to cite a few, be it on pilot and small
scale. Many lessons can be gleaned from these experiences, as summarized below.
First, it is possible to build capacity at village level to manage community-based
activities effectively. Communities can be organized into functional units such as
villages or sub-locations that are linked to or part of the legal structures of the
country, for effective action for health. Health committees and resource persons
elected by these structures can be trained for effective actions for health at the
village level. These structures work best when linked to administrative structures as
well as the health facilities’ catchment areas, and when they are in control of
tangible decisions, guided by clear guidelines defining their roles. Linkage to other
sustainable local structures such as schools, churches and women’s groups may be
better than introducing a new structure. The communities need facilitation and
support from the formal system.
Second, the CORPs as volunteers can provide services at the household level that
include a community-based information system, dialogue based on information,
health promotion, disease prevention, simple curative care using drugs supplied
through a revolving fund generated from users, and a referral system established by
local health committees. The main problem is that CORPs elected by their own
communities, without any guiding criteria, may not be adequately literate to
undertake all the tasks assigned. Even though CORPs are nominated by the
communities, the criteria for selection can be jointly agreed between the community
and the health system. These could include ability to read and write, being a
permanent resident of the community, and having demonstrated attitudes valued by
the community.
Third, because incentives are lacking, it is difficult to sustain the morale and
motivation of CORPs for long. They therefore fall prey to agents whose agendas may
not be consistent with those of either the community or the Ministry of Health, and
who may thus disrupt operations towards set objectives. Incentives tend to be limited
to uniforms, protective wear, drug kits, reimbursement of direct costs and periodic
rewards for excellent performance. Whatever the incentives are, they seem to be
best if handled by the local committees rather than being paid for centrally. There
are experiences of allowances paid by village governments but not regularly
(Tanzania). Elsewhere local government revenue, grain and labour from villagers used
to pay CHWs, as well as possibilities for career development to professional health
worker, seem to work well (in Sudan, for example, as reported by Erasmas et al.,
2003). The majority of the CORPs, however, are dissatisfied with the community
compensation system, which leads to demotivation and internal conflict and demands
for regular salaries. There is no reason why they should not be paid a stipend based
on work actually done. What is important is that the cash should be paid through a
local committee to enhance loyalty and accountability to the people served.
Factors that appear to influence the motivation and work behaviour of CORPs
include:
• Hopes for a better life through continuous development of life skills and
opportunities.
• Personal interests (values, characteristics), giving reason for volunteerism.
• Community factors (acceptance, understanding, involvement).
• Political and policy environment (creation of supportive structures).

Taking KEPH to the Community 5

 • Administrative environment (government regulations, laws, procedures, conditions,
support, logistics, supplies available for the work, leading to greater satisfaction).
• The strength of the governing structures linking the community with the health
system.
• Training of health workers, supervisors and managers in participatory skills.
• Supportive supervision by a multidisciplinary team of professionals.

Fourth, community health extension workers (CHEWs) tend to be recruited by the

health system and assigned to the local structures. This seems to work well in Malawi
in terms of retention of workers, but has yet to be evaluated in Ethiopia. In both
cases the impact on health outcomes has not yet been demonstrated. The approach
addresses the problem of attrition that affects the effectiveness of volunteer CORPs
However, it may not address the problem of loyalty to the community as
was experienced with a similar cadre in Kenya, the family health field
Given an educator (FHFE), which was eventually discontinued.
adequate level of Fifth, effective community health services require well thought out
transparency in theoretical and practical training modules and programmes. Most
decision making, training activities for CORPs take place in the community but with
the community periods of practice at various facilities up to the sub-district level. The
can play a leading initial training covers community organization, community entry and
role in processes situation analysis, the community information system, community
of joint action for dialogue for behaviour change, and first aid. This is followed by three
health and the days a month to cover community-based integrated management of
management of childhood illnesses (C-IMCI), reproductive health (RH), malaria, acute
funds. respiratory infections (ARIs), water and sanitation, community nutrition,
business management, record keeping, drug management and
counselling, agribusiness, poultry keeping, and project implementation, monitoring
and evaluation. Some CORPs are trained on recognition (using algorithms),
classification and action. They are then supervised and supported by a trainer (a
health extension worker) at the sub-locational level, linked to a health facility. CORP
training starts with an initial period of two to six weeks, but continues essentially life
long, emphasizing problem-based experiential approaches, based on learning needs.
The health extension personnel, on the other hand, are trained for periods ranging
from one to three years at a training institution.
Sustainability is promoted when community-based activities are built into existing
initiatives and based on available resources. Given an adequate level of transparency
in decision making, the community can play a leading role in processes of joint action
for health and the management of funds. Thus, six, health actions can be self-
sustaining if properly governed by the community, but systems of accountability and
transparency must be established and practised. Ways of enhancing resource
generation may include sale of drugs, which can be done at low prices affordable to
the community through a social franchise set up to maintain standards. Communities
can participate in cost-sharing if they are in control of the money they contribute and
can see tangible results. External contributions can be added to their account to
cover gaps in costs as well as households that are unable to pay. Communities are
thus able to maintain a regular supply of preventive and curative materials, such as
medicines and water treatment chemicals. They realize that without adequate
accountability, free health services prove to be even more expensive to them than
cost-sharing because of informal payments and inefficiency.

6 Taking KEPH to the Community

 Finally, critical to the success of the community approach are coordinating
structures that bring together key players at national and provincial levels to
organize and guide the implementation of policy guidelines and key activities. Such
structures are necessary to ensure consistency, the joint assessment of progress and
enhanced learning from various sites. Periodic forums for disseminating results and
sharing experiences enable sustainability of momentum as well as mutual
accountability. In addition, the use of indigenous knowledge is promoted,
incorporated and shared for wider consumption. At the local level, village health days
once a month are effective in sustaining improvement in health outcomes. Formal
cooperation between the Ministry of Health and a non-government organization (NGO)
with particular experience in CBHC works well in achieving and sustaining results. A
formal contractual agreement enhances efficiency of collaboration, as well as
adherence to set standards.

1.5 The Key Role of Households and Communities as

Partners in LEVEL ONE SERVICES

K
enya’s dismal health status has arisen in part because the formal health care
system has exhibited limited effectiveness in changing the behaviour of
households, hence the urgency of promoting effective linkages with the formal
system rather than the integration of LEVEL ONE SERVICES into the formal sector. The
two systems must become partners in action for health, with due respect for and
recognition of the importance of the community/household-based system. The CORPs
thus need to be fully part of the community-based system, and partially part of the
formal health system, while the CHEWs would be fully part of the formal health
system but partially community-based.
Under this system, the households have important responsibilities for addressing
health needs at all stages in the life cycle. Among these are:
• Health promotion:
„ Ensuring a healthy diet for people at all stages in life in order to meet
nutritional needs.
„ Building healthy social capital to ensure mutual support in meeting daily needs
as well as coping with shocks in life.
„ Demanding health and social entitlements as citizens.
„ Monitoring health status to promote early detection of problems
CORP training
for timely action.
starts with an
„ Taking regular exercise.
initial period of
„ Ensuring gender equity.
two to six
„ Using available services to monitor nutrition, chronic conditions
weeks, but
and other causes of disability.
continues
essentially life
• Disease prevention:
long,
„ Practising good personal hygiene in terms of washing hands,
emphasizing
using latrines, etc.
problem based
„ Using safe drinking water.
experiential
„ Ensuring adequate shelter, and protection against vectors of
approaches,
disease.
based on
„ Preventing accidents and abuse, and taking appropriate action
learning needs.
when they occur.

Taking KEPH to the Community 7

 „ Ensuring appropriate sexual behaviour to prevent transmission of
Communities sexually transmitted diseases.
realize that
without • Care seeking and compliance with treatment and advice:
accountability, „ Giving sick household members appropriate home care for illness.
free health „ Taking children as scheduled to complete a full course of
services prove to immunizations.
be even more „ Recognizing and acting on the need for referral or seeking care
expensive to them outside the home.
than cost-sharing „ Following recommendations given by health workers in relation to
because of treatment, follow up and referral.
informal payments „ Ensuring that every pregnant woman receives antenatal and
and inefficiency. maternity care services.

• Governance and management of health services:

„ Attending and taking an active part in meetings to discuss trends in coverage,
morbidity, resources and client satisfaction, and giving feedback to the service
system either directly or through representation.

• Claiming rights:
„ Knowing what rights communities have in health.
„ Building capacity to claim these rights progressively.
„ Ensuring that health providers in the community are accountable for effective
health service delivery and resource use, and above all are functioning in line
with the Citizen’s Health Charter.

8 Taking KEPH to the Community

 2: Service Provision at Level 1

B
efore proceeding, some clarification is perhaps in order. According to KEPH,
LEVEL ONE SERVICES intend to provide basic community health services
(promotive, preventive and simple curative) to Kenyans. One level 1 service
“unit” is designed to serve 5,000 people and will work with volunteer CORPs
identified by the community and trained and supported by the community health
extension worker (CHEW). This strategy paper uses the term “CORP” to include any
type of community health workers who are willing to work on voluntary basis. All of
them must be taken into consideration and mechanisms of vetting, licensing and
control worked out – with their participation – to ensure acceptable standards. Since
one of the tasks of the CORP is data gathering it is essential that they be able to read
and write. Other characteristics should include permanent residence in the
community served and commitment to the service of neighbours as evidenced by their
track record. Nominations or volunteers should be vetted by the community at an
open meeting before they are recruited by the health team from levels 2 and 3 and
the district team.

2.1 Norms and Services at Level 1

T
he Ministry of Health’s newly articulated Norms and Standards for Health
Service Delivery sets out the specific services that should be offered at
different levels as well as the minimum human resources, infrastructure and
commodity requirements. Accordingly, the implications of norms and standards for
the community services is that:
• One CORP will serve 20 households or 100 people.
• One health extension worker (retrained PHT or any other similar cadre) will
supervise and support 25 CORPs.
• One level 1 unit will serve 5,000 people and will require
„ 50 CORPs
„ 2 community health extension workers (CHEWs).

For the CORPs to be effective they need the support of the trained community
health extension worker – the CHEW, whose main roles include training and continued
support for the CORPs according to the felt needs of the community. The CHEWs are
based at a health facility but assigned to work within a specific sub-location to ensure
acceptable standards of care at level 1. They provide continuing training to CORPs
through demonstration and instruction based on immediate learning needs. They thus

Taking KEPH to the Community 9

train the CORPs on the job as they provide services at level 1. This is why the CHEWs
are referred to in this document as “coaches” of the CORPs. This is the essence of the
community system.
The CHEWs will be formal employees of the health system hired and paid through
the local Health Facility Management Committee. The CORPs, as volunteer part time
workers, may be reimbursed for direct costs incurred in level 1 service provision and
provided with protective clothing, bags to carry working materials, and an essential
care package supplied and replenished by the CHEW. The CORPs may receive a
certificate of recognition after five years of service. Moving away to take up
opportunities that may arise should be appreciated, not discouraged and condemned,
and the CORP replaced.
On the basis of the lessons learnt from previous experiences in Kenya and
elsewhere, the guiding principles in providing LEVEL ONE SERVICES are the following:
• Communities to be organized into functional units of 20 households.
• CORPs to be voluntary, but paid a stipend on the basis of work actually done, and
this payment to be made through the local committees to enhance loyalty and
accountability.
• CORPs to be nominated by the communities on the basis of predefined criteria.
• CHEWs to be on government payroll and facilitated (e.g., transport).
• Community to play a leading role in joint health actions.
• A strong coordination structure to be established to bring in all actors at all
levels.
• Communication to be strengthened through advocacy, social mobilization and
interactive dialogue.

2.2 Definition of Services Provided at Level 1

N
HSSP II aims to improve the health and well being of all Kenyans, based on a
life-cycle approach for ensuring that each age cohort receives health services
according to its needs. The plan expects to achieve that goal through selective,
highly cost-effective service package interventions for each age cohort that are likely
to result in health improvement in the overall population. This strategy takes the
NHSSP II objectives to the community level by mobilizing communities towards their
active and dynamic involvement in implementing the interventions that contribute to
their own health and socio-economic development, to release themselves from the
vicious cycle of poverty and ill-health.
The Kenya Essential Package for Health (KEPH) is designed as an integrated
collection of cost-effective interventions that address common diseases, injuries and
risk factors, including diagnostic and health care services, to satisfy the demand for
prevention and treatment of these conditions. Using an evidence-based plan, health
committees organize actions for health grounded in their own capacities. The
conditions identified and included in their plan are those in which the LEVEL ONE
SERVICES can make the most significant contribution to the improvement of the
health and well being of Kenyans.
Community level activities focus on effective communication aimed at behaviour
change, disease prevention, and access to safe water and basic care. LEVEL ONE
SERVICES activities organized by the committees may include:
• Disease prevention and control to reduce morbidity, disability and mortality
„ Communicable disease control: HIV/AIDS, STI, TB, malaria, epidemics

10 Taking KEPH to the Community

 „ First aid and emergency preparedness/treatment of injuries/trauma
„ IEC for community health promotion and disease prevention

• Family health services to expand family planning, maternal, child and youth
services
„ MCH/FP, maternal care/obstetric care, immunization, nutrition,
C-IMCI The Kenya
„ Adolescent reproductive health Essential Package
„ Non-communicable disease control: Cardiovascular diseases, for Health
diabetes, neoplasms, anaemia, nutritional deficiencies, mental defines six life-
health cycle cohorts:
„ Other common diseases of local priorities within the district, ♦ Pregnancy and
e.g., eye disease, oral health, etc. the newborn
„ Community-based day-care centres (first 2 weeks
„ Community-based referral system, particularly in emergencies of life)
„ Paying for first-contact health services provided by CORPs ♦ Early childhood
(2 weeks to 5
• Hygiene and environmental sanitation years)
„ IEC for water, hygiene, sanitation and school health ♦ Late childhood
„ Excreta/solid waste disposal (5 to 12 years)
„ Water supply and safety, including protection of springs ♦ Adolescence
„ Food hygiene (13-24 years)
„ Control of insects and rodents ♦ Adult (25-59
„ Personal hygiene years)
„ Healthy home environment: environmental sanitation, ♦ Elderly (over
development of kitchen gardens 60 years)
„ Organizing community health days

This package has to be incorporated into comprehensive district health plans

organized by cohorts to enable districts to properly utilize available scarce resources.
Similarly, the filtered health service delivery packages targeted at community level
should be incorporated into the community-based health plans. Table 1 summarizes
the different services provided to the six life-cycle cohorts.

Table 1: Service activities and requirements at level 1, by cohorts in a

population of 5,000
Cohort Service activities Minimum kit Human resource
All cohorts § Sensitize, mobilize and organize § Preventive materials § 1 CHEW
community to ensure leadership and supplies (ITNs, § 50 CORPs
support and awareness of rights and water guard)
responsibilities in health § Health promotion
§ Promote early service seeking supplies (IEC
behaviour materials)
§ Promote health awareness through § Drugs/supplies for
IEC on control and prevention of treatment of common
common diseases, particularly ailments (anti-
malaria malarials, analgesics,
§ Promote disease prevention and first aid supplies)
control through environmental § Referral guidelines
sanitation, safe water supply and
good personal hygiene Continued

Taking KEPH to the Community 11

Table 1, continued
Cohort Service activities Minimum kit Human resource

§ Promote HIV/AIDS control § Communication and

§ Provide first aid and treatment of transport support,
common ailments including bicycles
§ Make referrals § Stationery and supplies
§ Develop and help maintain a such as forms,
community-based information household registers,
system chalkboards
Pregnancy, § Provide exclusive breast feeding § Safe delivery kit § 1 CHEW
delivery education § Antenatal care § 50 CORPS
and § Provide IEC on current KAP on safe equipment
newborn pregnancy and delivery of a § IEC with key messages
(first 2 healthy newborn to promote early
weeks of § Advocate for community leadership childhood care
life) support for safe pregnancy and § Preventive materials
delivery of a healthy newborn and supplies (ITNs,
§ Promote safe delivery through nutritious foods)
pregnancy monitoring, § FP pills, condoms
establishment and timely referral
§ Disseminate key messages to
support safe pregnancy and
delivery of a healthy newborn
§ Promote or provide professional
supervised home delivery
Early § Promote C-IMCI activities § Expanded programme § 1 CHEW
childhood § Conduct de-worming of immunization (EPI) § 50 CORPS
(2 weeks to § Mobilize and organize for early equipment § Trained
5 years) childhood development (ECD) § Intermittent residual caregivers
§ Disseminate key ECD health spray equipment
messages § Essential drugs and
§ Support nutrition awareness and supplies for common
support for orphans and vulnerable conditions, e.g., anti-
children (OVC) malarials, ORS, de-
§ Promote food and nutrition worming tablets
security § Nutritious food
§ Monitor growth and development supplements
Late § Promote gender responsive school § IEC materials with key § 1 CHEW
childhood: health activities messages on healthy § 50 CORPS
5 to 12 § Equip the children with knowledge lifestyles § Trained
years and skills to promote a healthy teachers
(school- lifestyle including psycho-social § Trained parents
age) development
§ Train teachers and orient parents
in school health services
§ Promote child-to-child approach to
healthy lifestyles
Adolescence § Equip the youth (in and out of § Training curriculum for § 1 CHEW
and youth school) with knowledge and life the youth on life skills § 50 CORPS
13–24 years skills, and facilitate a supportive including psycho-social § Trained
environment to enhance adoption issues, reproductive teachers
of a healthy lifestyle for health, drug and § Trained parents
themselves and the community substance abuse, etc.)
Continued

12 Taking KEPH to the Community

Table 1, continued
Cohort Service activities Minimum kit Human resource
§ Initiate comprehensive community- § Preventive materials
based, youth-friendly centres in such as condoms
collaboration with other arms of
government, NGOs, etc.
§ Raise awareness on disease
causation, control and prevention,
in particular STI/HIV/AIDS
§ Provide family life education

Adults 25– § Conduct C-DOTS activities and § Health learning § 1 CHEW

59 years defaulter tracing materials § 50 CORPS
§ Raise awareness of non- § Preventive materials
communicable disease control (ITNs, condoms)
§ Care for chronically ill § Drugs and supplies
§ Equip adults with knowledge and for first aid,
skills for health and key health treatment of simple
messages to promote adoption of a common conditions
healthy lifestyle and care seeking
§ Assist with ensuring household food
security
§ Promote participation in actions for
health
Elderly § Equip elderly persons, the § Key health messages § 1 CHEW
persons community and health care and health learning § 50 CORPS
(Over 60 providers with relevant knowledge materials
years) about common old age diseases, § Preventive materials
impairments and disabilities; how to § Drugs and supplies
improve quality of life; and sources for first aid,
of care treatment of simple
§ Advocate for the development of common conditions
social support systems for the
elderly
§ Develop community home-based
care for elderly persons with chronic
illnesses

2.3 Supportive Supervision

T
he health system should be able to provide supportive supervision to the LEVEL
ONE SERVICES frontline personnel. Multidisciplinary supervisory teams having an
appropriate skills mix will ensure that standards of quantity and quality of work
are met during service delivery. Multi-sector coordination and collaboration and team
work at various levels in creating a supervisory system will be encouraged. Regular
performance appraisals based on checklists will be carried out to measure
performance, promote good communication and discussions, and determine
appropriate rewards to CORPs.
Supervisory teams will be established at national, provincial and district levels.
They will be trained in supportive supervision and oriented on tools for peer review
and performance. The composition of the teams could be as follows:
• National: Epidemiology, MCH, administration, finance, environmental health,
health promotion, human resource and training.

Taking KEPH to the Community 13

• Provincial: Disease prevention and control, public health, MCH, administration
and finance, health promotion, and training.
• District: Public health, public health nursing, environmental health, health
education.

During supervisory visits, the team should:

• Discuss with CHEWs and CORPs the aim of supervision and the content and use of
checklists
• Discuss with committees and consumers issues for attention.
• Observe performance based on job descriptions; guide, direct and encourage.
• Check recording and data systems.
• Check stocks of supplies, note gaps.
• At end of mission, provide feedback to CORPs (positive and negative findings),
and wind up with an agreed plan of action based on displayed community-based
information system (CBIS) and facility-based information system (FBIS) data.

The team would then prepare a field report and send it to the location
development committee (LDC)/health facility committee (HFC) and the district health
management team (DHMT) for follow up and needed action. Such actions may
include: in-service training, continuing education, and improvements in the supply of
materials provided by the health centre (HC) or District Health Office.

2.4 Communication Strategy at Level 1

C
ommunity-based communication is the hub of level 1 health care provision. It
facilitates the transfer of knowledge and skills on health matters between
individuals and families to make informed choices and decisions for behaviour
change. It also creates demand for better health services and builds mutual
understanding and trust among key actors within the community. The communications
component of this strategy is designed to facilitate behaviour change of individuals at
family/household level supported through advocacy and social mobilization. It
intends to maximize the use of traditional and multi-media channels as opportunities
to effect behaviour change.
District Health Management Teams (DHMTs) and health personnel at levels 2 and 3
have an important role in creating awareness among the community on the
importance of LEVEL ONE SERVICES in their respective villages. They should also build
the capacity of community leaders and extension workers on IEC techniques for
sustaining the process of sensitizing and educating communities on health and health-
related problems and related social concerns.
The strategies for effective communication include: advocacy, social mobilization
and interactive communication. Each of these categories has its specific purpose but
they also overlap.

2.4.1 Advocacy
Advocacy efforts will be intensified, as a means of communication that focuses on
policy and decision making processes, to influence support or action on LEVEL ONE
SERVICES at village, location, district and national levels. The DHMT will advocate for

14 Taking KEPH to the Community

support by religious, government and political leaders, other influential people, and
NGOs and CBOs for resource mobilization and allocation for LEVEL ONE SERVICES
activities at community level. A variety of advocacy channels, including direct
contacts, meetings, group discussions and popular theatre, will be used to this end.
This process will involve:
• Promoting political and social commitment, mobilizing resources, and stimulating
development of supportive policies.
• Explaining the role of the community and other influential people in the LEVEL
ONE SERVICES strategy.
• Informing leaders and other influential individuals about the aims, objectives,
strategies and activities of the LEVEL ONE SERVICES strategy.

2.4.2 Social Mobilization

Effective social mobilization activities will be carried out to ensure that community
interest is created, and that community members are motivated and influenced to
take action or to support initiatives that are beneficial for themselves – taking
children for immunization, organizing referral preparedness, etc. Social mobilization
will be carried out through village gatherings, village health days, seminars, popular
theatre, youth groups, women’s groups, and print and electronic media. The DHMT
will make sure that CORPs and other extension workers are equipped with knowledge
and skills for carrying out their functions in social mobilization and sensitization of
the community.
Social mobilization is about sensitizing and motivating social partners to work
together in raising awareness and pooling resources, targeting interested
organizations, individuals and health related sectors, along with CBOs, NGOs,
professional associations and the private sector. Concerted effort will go into:
• Identifying and recruiting partners to play a role in the implementation of LEVEL
ONE SERVICES.
• Identifying roles and responsibilities for various partners in the implementation of
LEVEL ONE SERVICES.
• Maintaining partnerships and ensuring active partner participation, by engaging
them in the planning, implementation, monitoring, evaluation and feedback
process.

2.4.3 Interactive/Participatory Communication for LEVEL ONE SERVICES

Interactive communication will be promoted for imparting specific knowledge and
skills towards positive change of behaviour and attitudes. Direct interaction involving
reflection based on identified limits to the fullness of life will be one mode of
operation. This will help to inform and motivate major target groups and bring about
desired change in key household practices, targeting caregivers, community leaders
and service providers. Activities will include the following:
• Promoting self-directed problem identification.
• Developing relevant cost-effective behaviour change messages.
• Strengthening mutual learning.
• Promoting community initiatives for behaviour change.
• Enhancing household capacity to initiate and maintain household behaviour
change.

Taking KEPH to the Community 15

 3: Implementation Framework
and Process

D
efining the norms and standards and the services to be provided through
LEVEL ONE SERVICES is not a sufficient condition for implementing an
effective community strategy. The implementation mechanism needs to be
elaborated. The mechanism should includes the organizational and
coordination structures, entry steps to roll out the strategy, planning and
management of operations, and linkages with facility-based health systems. This
section highlights these issues.

3.1 Organizational Structures and Coordination

Framework

I
ntegrating LEVEL ONE SERVICES into the normal health care system will initially
require a concerted effort to oversee its take-off until it becomes a functional
component of the health system countrywide. Task forces to oversee the
implementation process will be established at national, provincial and district levels.
Further, the task forces will be provided with orientation to develop common
approaches to the facilitation and management of service provision at level 1. The
orientation of the task forces at all levels will be immediately followed by the launch
of activities at district and community levels, including community entry and
recruitment and training of the CHEWs and CORPs who will be at the frontline of the
services.
The programme will be initiated in at least four districts in each province, to be
identified on the basis of local interest and likelihood of success. This will form a
solid foundation and good experience for scaling up, and it is expected that the
programme would then be able to touch all the districts in the country by the end of
the second year.
Highlighting the sector-wide approach to the implementation of NHSSP II, and the
principles of the health sector reform, an experienced partner will be identified in
each province to support the implementation of this initiative. This partner would
collaborate with the provincial health team in the processes of mobilization,
organization, planning, training, monitoring and evaluation of level 1 activities. The
idea is to build on existing experiences and strength, instead of starting from scratch.
The various structures and necessary actions to support the introduction and
implementation of LEVEL ONE SERVICES are summarized in Table 2.

16 Taking KEPH to the Community

Table 2: Levels of action to support level 1 services
Structure Summary of activities
Household, § Plan, implement, monitor, evaluate and provide feedback on activities
village, school, § Mobilize and manage resources
congregation § Undertake health promotion, hygiene, lifestyle and care seeking
initiatives
Sub-location, § Provide health status information (systems)
parish, dispensary § Plan, implement, monitor, evaluate and provide feedback on activities
§ Mobilize and manage resources
§ Support, provide and protect water sources at village level
§ Manage community-based information system
§ Provide technical support, supportive supervision and coaching
§ Train CORPs and village leaders on LEVEL ONE SERVICES
§ Establish and maintain working links, including monitoring) of NGOs and
CBOs
§ Train and conduct social mobilization on rights for health to all
communities
Division, health § Plan, implement, monitor, evaluate and provide feedback on activities
centre for continuous improvement
§ Provide training and supportive supervision
§ Coordinate, collaborate, network, exchange ideas and pool resources

District, diocese, § Carry out comprehensive district planning, implementation, monitoring,

hospital evaluation and feedback, budgeting, and supervision
§ Identify and increase the utilization of existing community organizations
and structures and sensitize them on rights for health
§ Strengthen Health Boards
§ Build capacity of villages on safe water supply, sanitation facilities
§ Train extension staff and leaders on LEVEL ONE SERVICES
§ Facilitate M&E of NGO and CBO activities in the district
§ Facilitate community capacity for providing technical and material
support
§ Coordinate input of development partners/NGOs/CBOs

Province § Build capacity of districts for implementation of LEVEL ONE SERVICES

and assure quality, including rights
§ Provide technical and material support on planning, implementation,
monitoring, evaluation and feedback
National § Formulate and review the LEVEL ONE SERVICES guidelines in relation to
national health policy
§ Build capacity of districts for the assessment, reflection, planning and
action process
§ Ensure multi-sector and donor coordination in health and resource
allocation
§ Ensure that the community-based information system is part of the
health management information service (HMIS)
§ Ensure equity of health services, quality assurance, and technical
support

Taking KEPH to the Community 17

3.2 The Entry Steps

T
he implementation of this strategy is anticipated to take a structured, step-by-
step approach that involves awareness creation, formation of district level
working groups and training teams, and establishment of a formal monitoring
and evaluation mechanism, all of which precede the actual entry into the community.
More details of the planned training are provided in Section 5, but the entry process
is expected to involve the following actions:

1. Define a clear implementation guideline: This will include the development of

comprehensive message materials, the consolidation of the commodity kit, and the
training needs, curriculum and manual for both CORPs and CHEWS.

2. Create awareness among district leaders, including the District Commissioner

(DC), the District Development Committee (DDC) and relevant line ministries: The
facilitating team should ensure adequate knowledge of the district situation as part of
this early step. Among the tools to be used might be an orientation workshop (1–3
days) for the leaders to introduce the LEVEL ONE SERVICES strategy.

3. Form and equip district-level multi-sector working groups and training team:
The teams will be trained as trainers for the LEVEL ONE SERVICES strategy. In each
district this may involve a ten-day course (to be determined in conjunction with the
development of the training manual) in two phases of five days each, in order to
launch the programme:
• The first phase will cover the introduction of LEVEL ONE SERVICES concepts, entry
process, participatory assessment and household registration, feedback and
planning (two days), and service delivery by cohort (two days) reinforced by field
practice (one day). The participatory assessment and household registration
provide information for planning as well as an evidence base for documenting
change in key family practices.
• The second phase would cover competency-based training, to prepare the working
groups/teams as trainers. The idea is that the actual LEVEL ONE SERVICES strategy
with households should be undertaken by CORPs, who share the same context.
Thus the action linked training and implementation are repeated at all the levels
in a continuous spiral of action focusing on successful sites. The training can be
carried out in a cascade, so that the first phase of training is taken all the way to
the village level, and then the second phase, in the same way until each set of
actors is fully trained and equipped for their role.

4. Follow up, monitor and evaluate: Once training is completed the CHEWs – as
coaches – follow up to monitor activities, provide supportive supervision, assess
progress and solve problems. The training with follow up forms the main part of the
introduction and establishment of the programme in a district. Scaling up of this
intervention is assured through the multi-sector working group, building on existing
programmes. This is strengthened by iterative rapid assessment, planning and action
reinforced by regular health days.

5. Launch the programme in the communities: Effective community entry will be

based on a process of engagement that recognizes the need for the health system to

18 Taking KEPH to the Community

negotiate its way into the community agendas as an alternative for addressing their
livelihood, health and development issues. The steps will involve:
• Exploration: This step entails a relatively low-key fact finding mission to enable
the service providers coming into the community to gain as much knowledge and
understanding of the community’s situation as possible. The findings should be
written up and shared with the community.
• Protocol: This step entails identifying the gatekeepers (formal and informal
leaders) in order to enter through them to formalize the process and gain
authority to work with the community. The facilitators introduce the LEVEL ONE
SERVICES idea to the leaders in order to involve them in the rest of the community
process. Together the group clarifies the objectives and identifies the target
groups to ensure that they are included. This process should lead to identification
of task groups to spearhead detailed assessment and planning.
• Participatory assessment: This process starts with discussions with the key
individuals at every level and control point down to the household level. This
ensures that the introduction of the new idea takes full cognisance of what is
going on in the community. The new idea has to be negotiated through the
gatekeepers at every level, down to the level of individuals concerned.

The assessment is carried out to determine the current situation and the course of
action. The community must be involved in defining the issues to be included in the
assessment. The assessment, in turn, should be built into the community-based
information system to assist the community to continuously assess and analyse their
situation. The process enables the community to see where they are now and where
they wish to be. In other words, it allows for the identification of gaps, issues,
resources and capacity in order to set objectives for making desired changes.
The assessment task force will define indicators/key questions and identify
sources of reliable information, target groups and the most appropriate methods of
information gathering for the assessment. These will be used as the basis for
developing information gathering tools (checklists, interview guides,
etc.). Once the community members and the team agree on methods to
The assessment
be used, the facilitating team, including selected community members,
process enables
will go through specific training on how to use the tools effectively to
the community to
ensure standardization and improve the accuracy and validity of
see where they
findings. The scope of the assessment should include:
are now and
• The population where they wish
• Community structures and processes of governance and to be. Information
management from the
• Any existing community information system assessment, in
• Resource availability, access, management (money, manpower, turn, should be
material) built into the
• Service delivery and the minimum package of care and support community-based
• Communication strategy, networking, collaboration and linkages information
• Coping mechanisms, innovations and best practices system to assist
• The status of health and well being, based on agreed indicators the community to
• The status of food security and nutrition, based on agreed indicators continuously
assess and
• Care seeking behaviour
analyse their
• The environment (water, sanitation, shelter, soils, vegetation,
situation.
infrastructure)

Taking KEPH to the Community 19

• Identified issues, concerns, ideas, technologies, best practices, models, tools,
techniques and approaches
• Identified dialogue centres and groups (religious institutions, schools, civic
leaders, youth groups and other sectors), their roles and responsibilities

Assessment methods may include: transect walks, direct observation, mapping the
availability of and access to resources, a seasonal calendar of happenings, activities,
diseases, food availability, etc., daily activities by gender, Venn diagrams, key
informant interviews of individuals from the community, and focus group discussions.

3.3 Feedback and Participatory Planning of Level 1

Service Activities

F
indings of the assessment are to be presented to the rest of the community at a
general meeting open to all community members. The community validates the
findings and identifies striking themes, expressed with emotion such as anger,
frustration, fear or excitement. Such themes are effective in generating energy for
community action for health.
The community participants summarize the findings in terms of strengths,
opportunities, weaknesses and threats. Strategic action points are based on strengths
and opportunities and can be in three categories:
• Actions that can be taken with communities’ own resources.
• Actions requiring additional support from local partners.
• Actions requiring external support.

The community participants reflect on the future they want (their vision/dream of
the way things ought to be) and agree on the main action points. Identified task
forces or interest groups are assigned to prepare plans that are collated and
presented to the whole group for consideration and adoption. The process allows for
all partners to explore what coping mechanisms are in place and their effectiveness
and to add options that are lacking.
Felt needs from different interest groups (e.g., pregnant women, parents of
under-fives, parents of school age children, adolescents, adults and the elderly,
differently-abled persons) are harmonized into one village plan. These plans are then
presented and negotiated at the village meeting, which brings all the plans together
into one village plan. After the priorities have been set for the consolidated list, a
draft village plan is formulated and monitoring and evaluating indicators identified.
The CHEW, CORPs, and local NGOs and CBOs within the village provide technical
assistance throughout this process of assessment and planning.
The integrated village plan is submitted to the health facility committee. The
draft village plans are then collated and reviewed in relation to resource
implications, village capacity and the technical support required for their effective
implementation. Finally, the village plans are consolidated into one integrated
locational/sub-locational health plan for level 1 activities.

20 Taking KEPH to the Community

 4: Linkage between Community and
Health Facility and Sustainability

A
clear organizational structure with well defined roles and responsibilities of
all actors at all levels is necessary to ensure the success of LEVEL ONE
SERVICES. These structures will be built on the existing ones to avoid the
creation of unsustainable parallel systems and processes.

4.1 Structures and Their Functions in Supporting

Services at Level 1

F
igure 1 illustrates the overall health sector structure. At level 1 the governing
structures will be based as much as possible on using location, sub-location and
village structures, all linked to the local health facilities within them, so that
each structure is responsible for a geographically discrete unit based on an
administrative division. The implementation of LEVEL ONE SERVICES requires the
formation of linkage committees at these levels that would have specific
responsibilities based on the respective levels.

Figure 1: Suggested organizational linkages and structures

Level 6 NATIONAL

Level 5
ˆ
PROVINCIAL

ˆ
Level 4 DISTRICT

ˆ
Levels 3, 2 HFC HFC HFC HFC HFC
ˆ
Representation at the HFC
ˆ
Level 1 VHC VHC VHC

HFC = Heath facility committee VHC = Village health committee

Taking KEPH to the Community 21

 The intention of the decentralization policy is to enable the community to
participate effectively in decision making processes related to matters of health at
the community level, as well as at the interface between level 1 and levels 2 and 3.
The lower levels of care (levels 2 and 3) are more or less consistent with the
administrative and development nodes within the community (although sometimes
their catchment population may not correspond to administrative
Decentralization boundaries), and can therefore be robust and sustainable. Health
intends to committees at divisional, locational, sub-locational and village levels
enable the can be expected to provide citizens with sufficient representation and
community to voice in all issues affecting service provision at level 1. There is thus a
participate need to establish effective linkages between the community and the
effectively in health system through linking structures. The health facility in-charges
decision making (supported by the DHMT), CHEWs, CORPs, village elders, chiefs and
processes other extension workers are the sinews that bind these structures and
related to enable sustained community leadership in addressing health problems.
matters of Health facility management committees, made up of community
health at the representatives and the facility in-charges, should meet at least
community monthly. The committees will review progress from the indicators and
level. baselines generated through the CBIS and FBIS and make decisions for
continued actions for health, at facility, community, household, political
and administrative levels. The coordinator of CHEWs at the facility level
should collate the data obtained from the CHEWs and the health facility in-charge,
together with own information, then share the information with the other sectors by
displaying it on boards, disseminating summaries and presenting the summaries at
stakeholder forums.

4.1.1 District Level

Within the district, the organization and management of the LEVEL ONE SERVICES
activities should be integrated into the health sector and local government reform
frameworks. The DHMB and DHMT will provide governance and technical support,
respectively, to level 1 activities that includes planning, implementation, monitoring
and supervision. These structures would take responsibility for:
• Providing technical and administrative support to LEVEL ONE SERVICES delivery at
levels 1 to 4 to ensure effectiveness at community level.
• Facilitating recruitment and training of trainers, CHEWs and CORPs.
• Training and preparing coaches and trainers of trainers that are based at the
district levels.
• Ensuring that resources reach level one services to implement their village health
plans
• Coordinating, monitoring and evaluating the implementation of activities,
compiling monitoring data, and producing periodic reports.
• Convening experience sharing forums, preparing and submitting reports to MOH
and stakeholders in the district, and organizing evaluation and review meetings.
• Selecting, updating and distributing IEC and health learning materials.
• Facilitating collaboration with stakeholders and securing resources for the
programme.
• Organizing and conducting capacity building sessions, including in-service training.

22 Taking KEPH to the Community

4.1.2 Divisional Level (and Level 3 Health Facility)
If there is no health centre committee, a divisional level subcommittee will be
established that will be responsible for health services in the whole division. The
subcommittee will also function as the health centre committee where there is a
corresponding health centre. The CHEW at this level should provide technical support
to level 1, with responsibility for facilitating LEVEL ONE SERVICES activities, reporting
to the health centre committee, and providing day-to-day support of CORPs in their
service provision. The CHEW would also compile data and reports to the health centre
committee for discussion, decision making and action, after which the reports would
be submitted to the district. Specifically, the health centre committee, in addition to
what is given in the guidelines for facility committees, should:
• Oversee the functioning of the health centre in support of level 1 service
provision.
• Oversee the functioning of the different level 1 units to be established under the
committee.
• Receive and interpret policy guidelines and follow up their implementation.
• Obtain and distribute standard formats for data collection and reporting.
• Coordinate CBIS and FBIS and divisional experience sharing and dialogue forums.
• Communicate information to the relevant District Offices.
• Strengthen collaboration with divisional level stakeholders.
• Mobilize resources for development of the health facility as well as supporting
outreach and referral activities.
• Organize quarterly Divisional LEVEL ONE SERVICES Days.

4.1.3 Locational/Sub-Locational Level (and Level 2 Health Facility)

This is the level of first direct contact with level 1 and will carry out activities
relating to LEVEL ONE SERVICES. This level should have a dispensary committee with
representation from locational and sub-locational structures as detailed in the
decentralization guidelines and would therefore form the main linkage between the
health system and the community. The dispensary committee should be
linked with and report to the locational/sub-locational development
committees on matters of health. The technical resource persons at this
Community
level would include the CHEW, trained to train, coach and support
structures work
CORPs. The committee, in addition to the formal roles assigned to it
best when linked
through the various guidelines, should:
to administrative
• Plan, implement, monitor, evaluate and provide feedback on LEVEL structures as
ONE SERVICES activities. well as the
• Mobilize resources for development of the health facility as well as health facilities’
supporting outreach and referral activities. catchment
• Facilitate regular dialogue between the community and the health areas, and when
service providers based on available information. they are in
• Organize the community for health action. control of
• Strengthen community involvement in decision making. tangible
• Promote inter-sector collaboration. decisions,
• Oversee the processing of CBIS and FBIS, display and discuss the guided by clear
data for action – addressing facility-based and community-based guidelines
issues causing gaps indicated in the data – by sub-locations to ensure defining their
specificity of responsibility. roles.

Taking KEPH to the Community 23

• Facilitate planning, budgeting, budget controls and accountability, to ensure
availability of all the resources needed for LEVEL ONE SERVICES.
• Establish the link between the health system and the community by helping to
market the health facility to enhance its credibility based on quality of care and
thus promote a culture of good health promotion at the community level.
• Use the services as the place of first choice when in need of care.
• Listen to and address complaints of clients.
• Coordinate the recruitment of CORPs and CHEWs.
• Convene monthly Community Health Days for joint health action.

4.1.4 Village Level (Level 1)

The village health committee will oversee the operations of LEVEL ONE SERVICES in
the village and will therefore serve as the link between the village and the household.
Through the committee, the Chair will mobilize community resources and undertake
social mobilization for implementation, reporting to the Dispensary Committee in
matters of LEVEL ONE SERVICES. The CORPs will report to the Chair on their day-to-
day activities, with the technical support of the CHEW. The functions of the village
structure include:
• Representing the villagers in various health committees at other levels.
• Endorsing the recruitment of the health workers (CHEW and CORPs).
• Planning, implementing, monitoring, evaluating and giving feedback on level 1
service provision, encouraging the implementation of key household practices by
all, while voicing any concerns barring them from accessing their rights in matters
of health.
• Mobilizing resources for health activities including outreach and referral.
• Facilitating regular dialogue within the community based on the CBIS and FBIS.
• Organizing the community for collective health actions and addressing priority
problems.
• Ensuring community involvement in decision making.
• Gathering community-based health information for use at the community level
and sharing with the different levels where possible.
• Encouraging and using existing appropriate household-based care.
• Listening to and addressing complaints of clients, for example by reporting to the
CORPs or higher level service providers.
• Taking control of development processes, decisions and priorities, and initiating
interventions, based on capacity.
• Facilitating provision of specific education on LEVEL ONE SERVICES.
• Making contacts with partners for technical support and resource mobilization
while at the same time retaining control over the use of resources.
• Promoting equal opportunities for decision making and control of resources at
village level.
• Promoting gender equality and the empowerment of women.

Since health status depends on factors beyond the health sector, coordinated
action across sectors at the community level will increase efficiency in improving
health outcomes. This includes economic empowerment and transformation,
enhancing access to the means of production and marketing, and paying attention to
the social determinants of health. The village health committee will work in
partnership with different sectors of the community in:

24 Taking KEPH to the Community

• Planning for departments and sectors to work together with a common vision at
community level.
• Lobbying and advocating to gain political support and commitment based on a
common stronger voice for change.
• Conducting IEC and training.
• Promoting networking through regular communication and the sharing of
information, skills and experience through open forums for dialogue.
• Developing and using common guidelines in working with the community.
• Ensuring the pooling and better use of resources to increase efficiency and
effectiveness by reducing duplication of efforts.
• Strengthening the economic capacity of households through professionally
managed initiatives to expand options.
• Maintaining joint information systems to enable regular reporting of
progress and success and thus enhance commitment.
Service provision
4.1.5 Household Level at level 1 is
The household consists of individuals associated with and usually organized in
headed by the household head. It is the members of households and three tiers
families who are the primary targets and implementers of level 1 starting with
service provision. They are responsible for the day-to-day upkeep of household-based
household affairs as well as participating in community-organized caregivers, adult
health activities. They have contacts with the CORPs and the formal members of the
health system where they seek and utilize health services. The household who
household forms the first level of care that is universally available. provide the
essential
4.2 LEVEL ONE SERVICES Sustainability elements of care
for health in all

S
dimensions and
ustaining LEVEL ONE SERVICES greatly depends on the degree of
across life-cycle
community ownership, participation and involvement, supported
cohorts These
by political will shown in resource allocation for action by the
household-based
state. Communities will be empowered to manage own resources in
caregivers are
addition to external support necessary for facilitation of LEVEL ONE
normally
SERVICES activities. The Government through MOH will mobilize
supported
additional resources from external partners and allocate resources from
directly by the
the government budget for the sustainability of this initiative.
CORPs.
Any investments made at the community level will focus on enabling
the community to be self-reliant, within the limitations of their
situation.

4.3 Strengthening Rights to Health Aspects of LEVEL

ONE SERVICES
Human rights for health are tools that empower those who are not in a position to
assert and defend their claim to equitable, quality health care. It is critical to protect
members of the community such as children, women, disabled persons, orphans and
others (differently-abled) who may be exposed to jeopardy but are unable to protect
their rights. In this way their needs differ from the more advantaged groups in the

Taking KEPH to the Community 25

 community and they should be given due consideration supported by transparent,
accessible and effective mechanisms.
The objective of rights for health in the context of LEVEL ONE SERVICES is to
enable CORPs, community leaders and communities as a whole to understand and
acknowledge their health rights and the reasons some community members are
deprived of their rights. Community members should be able to identify
Districts, and discuss the main challenges and find solutions. Equally important,
locations and they should be able to analyse the roles and responsibilities of
village structures individuals, family members, the community, the Government, NGOs/
including CORPs CBOs, religious bodies and the donor/international community in
are responsible ensuring equitable access to care. They should address power
for raising and relationships with regard to resource utilization and decision making.
maintaining Moreover, they should identify mechanisms for voicing, receiving and
awareness on handling complaints on issues differentially denying the most vulnerable
rights for health members of the community their right to good health care services.
with every It is the responsibility of the districts, locations and village
member of the structures including CORPs to raise and maintain awareness on rights for
community. health with every member of the community. This entails ensuring
accessibility to KEPH with special attention to marginalized and
disadvantaged groups across cohorts. Communities, through
participatory processes, should therefore assess their situation, analyse problems and
find solutions to address the existing rights-related issues.

26 Taking KEPH to the Community

 5: Recruitment and Training of
Service Providers for Level 1
Service Provision

K
enya will need a total of 255,000 CORPs (50 per sub-location for 5,100 sub-
locations), to be trained, supervised and supported by 5,100 CHEWs.
Achieving a cadre that size and in good time presents an enormous
challenge. As indicated earlier, this strategy envisions a cascade approach to
the development of an adequate, competent community-based human resource
necessary for effective implementation of level 1 of KEPH. The cascade will begin
with trainers trained at national level and flow downward all the way to the
community.

5.1 Training Trainers of Service Providers at Level 1

B
eing newly recognized by the health system as a level of care, level 1 requires
innovation in the identification and training of appropriate service providers.
The training of trainers is intended to result in a core multi-sector team of
trainers charged with the responsibility of training CHEWs and CORPs for service
provision at level 1.

5.1.1 Selection of Trainers

A multidisciplinary team of trainers of trainers (TOTs) will be constituted at the
district level. The team will be made up of four to five people drawn from health and
related sectors such as water, education, agriculture and community development
who will train divisional level trainers in KEPH principles and services. Similarly at the
divisional level, the selection of trainers will be expected to include the relevant
sectors where they have extension staff. These divisional trainers will train actual
service providers at sub-location levels.
The national level, in collaboration with the provinces, will facilitate capacity
development of the district teams of trainers. These teams will, in turn, train the
divisional and sub-locational level trainers to train CHEWs and CORPs.
It is estimated that the training duration for the district and divisional TOTs will be
two weeks; for the health extension workers it will be four months, starting with an
introductory one-month session linked to implementation activities. The actual
durations will be determined after the development of the training content and
manual. For CORPs, training will begin with four weeks of basic training followed by
on-the-job training, essentially life long. The course should be in the community with
field and health facility practice elements. Refresher training will be undertaken from
time to time, according to need, but at least every quarter.

Taking KEPH to the Community 27

5.1.2 The Tasks of CHEWs as Trainer-Coaches
The CHEWs, as the trainers and coaches of CORPs, will need to be familiar with all
the tasks of the CORPs plus the additional management, supervisory, training and
clinical tasks required to support CORPs properly. Their tasks will therefore include:
• Training CORPs using problem-based learning methods in service contexts.
• Implementing NHSSP II and the KEPH at level 1.
• Organizing and facilitating community animation and mobilization.
• Carrying out evidence-based management of service delivery at level 1, grounded
in a continuous improvement strategy.
• Supporting CORPs in recognition and classification of health problems and action
to resolve them.
• Promoting inter-sector action for health, working with various extension workers.
• Facilitating health promotion through advocacy, social mobilization and
interactive communication to improve key household practices for health.
• Functioning as link person between communities and the health system.
• Carrying out immunization, family planning, antenatal care, home delivery,
disease surveillance, treatment of common conditions, prevention and control of
HIV/AIDS, STI, TB, and promotion of school health.
• Managing resources, and storing and distributing commodities and supplies for
CORPs.
• Mobilizing communities and their leaders on LEVEL ONE SERVICES to enable them
to take appropriate action.
• Facilitating assessment, planning, implementation, monitoring and evaluation of
LEVEL ONE SERVICES.
• Establishing and managing community- and facility-based information systems, to
include data collation, storage, analysis, interpretation and utilization, in
dialogue for continuous improvement.
• Carrying out baseline survey and analysing data.
• Keeping records of daily activities of services delivered and producing and
submitting reports.
• Organizing documentation and filing system.

5.1.3 Training Content

Based on the tasks required of trainer-coachers, the training content will include:
• Concepts in health and development
• Components of NHSSP II, focusing on the KEPH strategy
• Community process
• Community-based education and competency-based training
• Communication strategy, which contains advocacy, social community mobilization
and interactive/participatory communication.
• Community- and facility-based information systems, including data collection,
storage, analysis, interpretation and utilization in continuous improvement.
• Evidence-based management of LEVEL ONE SERVICES.
• Clinical updates (safe motherhood, IMCI, malaria treatment, prevention and
control).

28 Taking KEPH to the Community

5.2 Recruitment and Training of CORPs

C
ORPs are at point in the delivery of KEPH at level 1 and as such they should be
able to accompany the households in their struggle for health improvement.
This is possible when the providers overlap adequately with the target
community in terms of experience and context. Since the core of level 1 service
provision rests on key household practices, CORPs are likely to be more effective in
dialoguing with households for actions for health as they share a common context and
experience. And because communication is essential to their effectiveness, the
selection criteria for those to be trained as CORPs should include literacy in the local
language, along with respectability in the community and a “good heart”. Those
interested in being trained should be encouraged to offer themselves if they satisfy
the literacy criterion, but they would have to be voted for by members of the village
under the leadership of the village elders.

5.2.1 Recruitment
The village, sub-location and district teams should collaborate in recruitment of the
CORPs and their coaches (CHEWs) for training, one for each village, according to
recruitment guidelines set by the communities. The coaches, depending on their area
of expertise, should be hired by the location development committee or the health
facility committee. They could be at the level of a PHT or ECN, but financed through
a financial allocation by the state. The same fund should be used to compensate the
CORPs for work actually done and costs incurred.
It is envisaged that the training would take place in the respective contexts of
those to be trained, and be done in phases to reduce the time that people are taken
away. Since they are volunteers, prolonged training away from their base may disable
the livelihood mechanisms they depend on. Thus, although the training would
eventually cover nine months, the course would be spread in phases over three years.
Each phase of the training would be linked to specific implementation activities to
enable the programme to take off. The outcome of the training should be a team of
competent community-based providers for service provision at level 1.

5.2.2 The Scope of Training

The course would equip the CORPS with the skills they need to undertake the tasks
assigned to them, such as:
• Recognizing a health problem, classifying it and deciding on appropriate action.
• Promoting inter-sector action for health, working with various extension workers.
• Facilitating good health promotion through advocacy, social mobilization and
interactive communication.
• Functioning as link person between communities and the health system.
• Developing and maintaining household registers, collecting data from households
regularly as a method of health promotion, collating data on chalkboards, and
using it for dialogue at household and village levels.
• Educating and motivating community members on key household practices based
on agreed communication strategy, such as safe motherhood, C-IMCI, adolescent
health, screening for chronic conditions.
• Carrying out immunization, family planning, antenatal care, disease surveillance,
treatment of malaria, prevention and control of HIV/AIDS and STIs, monitoring TB
treatment, promoting school health, and ensuring continuity of services.

Taking KEPH to the Community 29

• Providing first aid treatment for minor illness and injuries, and referring patients
to health facilities.
• Managing resources and storing and distributing commodities and supplies.
• Raising awareness through appropriate IEC and behaviour change interventions on
disease causation, control and prevention, environmental sanitation, safe water
supply, housing, hygiene, community IMCI (nutrition, maternal care,
immunization, malaria, etc.).
• Mobilizing communities and their leaders on LEVEL ONE SERVICES to take
appropriate action.
• Facilitating and participating in planning, implementation, monitoring and
evaluation of LEVEL ONE SERVICES.
• Carrying out baseline survey, compiling survey data.
• Registering households, keeping population and household data of the villages,
and recording events based on regular household visits.
• Keeping records of daily activities of services delivered, producing reports and
submitting them to LDC/HFC.
• Organizing documentation and filing system.

Where there are ECNs as CHEWs, they could conduct home deliveries with the
support of traditional birth attendants (TBAs). The content of the various levels of
training is summarized in Table 3 by category and required skills.

Table 3: Summary of training content by category and tasks

Category Required skills/Tasks Training content
trained
The national § Programme development and § Concepts in health and development
and provincial management § NHSSP II, KEPH, LEVEL ONE SERVICES
managers/ § Resource mobilization and and the life-cycle approach
trainers allocation § Programme development and
§ Development of guidelines, management
training materials § Resource management (human,
§ Training of managers and trainers financial)
§ Planning § Evidence-based planning,
§ Development and testing of implementation, monitoring,
models evaluation, feedback
§ Networking, dissemination, § Communication strategy, dialogue for
advocacy behaviour change
§ Competency based training

The district and § Policy dissemination and § Concepts in health and development
sub-district implementation § (including rights based approach)
trainers and § Programme management § NHSSP II, LEVEL ONE SERVICES and the
supervisors § Community, entry, mobilization, life-cycle approach
organization § Governance, management and
§ Participatory planning leadership
§ Monitoring and evaluation § Planning, implementation,
§ Advocacy and dialogue for change monitoring, evaluation, feedback and
§ Training of the health extension the wheel of change
workers and supporting them in § Community-based management
training CORPs information system
§ Development of learning aids
Continued

30 Taking KEPH to the Community

Table 3, continued
Category Required skills/Tasks Training content
trained
§ Supervision of extension workers § Community-based education and
§ Logistical support competency-based training
§ Ensuring accountability and § Communication strategy, dialogue for
integrity change
§ Leading change, support to § Management of resources and
governance activities

CHEWs § Community entry, mobilization, § Concepts in health and development

organization and sensitization § NHSSP II, LEVEL ONE SERVICES and the
§ Establishing the information system, life-cycle approach
and the planning, implementation, § Community partnership (entry, etc.)
monitoring, evaluation and § Community-based education and
feedback process competency-based training
§ Report writing § Updates on recognition and
§ Training of committees and CORPs classification of disease and taking
§ Recognition and classification of appropriate action based on KEPH
common conditions and decision for (treatment or referral)
action (treatment or referral) § C-IMCI, handling essential drugs and
§ Home visiting supplies
§ Communication through evidence- § Nutrition, growth monitoring
based dialogue § Home care, home visiting
§ Growth monitoring § Counselling
§ Supervision § Recordkeeping, data gathering and use
§ Planning, implementation,
monitoring, evaluation, feedback
§ Communication strategy and dialogue
§ Health and management information
system
§ Planning for community-based health
initiatives

CORPs § Community entry, organization, § LEVEL ONE SERVICES

sensitization § CBIS
§ Registering households, data § Community dialogue for change
gathering § Recognition and classification of
§ Collation of data on chalkboards common conditions and decision for
§ Community dialogue for change action (treatment or referral)
§ Record keeping and report writing § Home visiting
§ Health promotion § Keeping drugs and supplies
§ Recognition and classification of
common conditions and decision for
action
§ Home visiting
§ Training and supporting home
caregivers

Taking KEPH to the Community 31

 6: Monitoring and Evaluation

I
n the development of structures for the district health plans, which in future will
be based largely on the intelligence developed at level 1, we defined monitoring
and evaluation – M&E – as a continuum of observation, information gathering,
analysis, documentation, supervision and assessment. This applies equally at
community level. The purpose is to keep activities on track towards goals and
objectives and to support decision making. Effective M&E thus contributes to
accountability on current activities (reporting and assessing impact) and helps
improve planning and implementation of future activities.

6.1 Issues in Monitoring and Evaluation

T
o carry out monitoring and evaluation activities, the critical issues are goals,
clear objectives, targets, inputs, outputs and indicators. Monitoring is the
process of regularly reviewing achievements and progress towards the goal. In
this context monitoring is the process of measuring, coordinating, collecting,
processing and communicating information on the implementation of
the planned KEPH activities. It also involves tracking the use of
Effective M&E
resources to support management and decision making by the
contributes to
stakeholders. In a word, it involves comparing what is actually
accountability on
happening with what was planned.
current activities
Evaluation itself implies judging and appraising. It can take place
(reporting and
during or after implementation. It involves determining the worth,
assessing impact)
merit, value or quality of ongoing or completed activities in terms of
and helps
relevance, effectiveness, efficiency and sometimes impact. In a
improve planning
nutshell, evaluation asks whether we succeeded or failed, whether we
and
used resources appropriately, and whether our actions will have long-
implementation
term results.
of future
An effective M&E system needs monitoring structures with
activities.
appropriate staff, a good information network system, and appropriate
reporting formats/registers and procedures. Fundamentally, monitoring
should be established from the beginning as part of the planned
activities. The purpose is to ensure that KEPH activities are implemented according to
the set plan, that lessons are derived from the way the programme is implemented,
and that health extension programmes are effectively implemented.

32 Taking KEPH to the Community

6.2 Implementing Monitoring and Evaluation

M
&E methods derive from the key issues that inform the process. These include
the quality of the information used for tracking progress, changes in
objectives/activities, timeliness of programme/project activities, timeliness/
effectiveness of communicating results, and the capacity of the
implementers and managers of the activities. To facilitate M&E, there
should be regular collection and analysis of data that are directly Monitoring
relevant to programme objectives and management. involves
comparing what is
6.2.1 M&E Methods actually
Monitoring and evaluation should be participatory and built into happening with
community processes. The community should be guided to take control what was
of activities. Feedback should always be given to the community for planned.
monitoring progress and for re-planning programme activities.
Both qualitative and quantitative methods can be used to evaluate
health programmes. Qualitative methods are used to measure success in
participation, collaboration, changes in views of people, policy development and
implementation. Qualitative data provide crucial information on values, norms,
knowledge, attitudes, behaviours, experiences, practices and social interactions in
the implementation of the health extension package. Tools or techniques used in
collecting qualitative data include observations, in-depth interviews, and group or
focus group discussions.
Quantitative methods provide precise measurements of activities and services –
how many, how often, how much. Quantitative tools include large surveys for
programme evaluations. Both quantitative and qualitative data are used together to
give a clearer picture of the situations about the performance of the programme.

6.2.2 Community-Based Information System

It is critical that the management of health action be evidence-based, beginning at
the community level. Yet at present most of the information used in health services
delivery is derived from health facilities at levels 2, 3 and 4. Health and health-
related information and data generated in the communities are rarely linked with
those higher levels. This makes health reports less comprehensive than they should
be and inadequate for effective monitoring, evaluation and planning.
At community level, the evidence is grounded in the community-
based information system, which refers to information required, Evaluation asks
gathered, analysed and used by the community and other levels for whether we
planning, monitoring and decision making related to KEPH at the succeeded or
community level. The system enables the community to follow up on failed, whether
the progress of implementation of planned activities, to determine their we used
success and constraints in achieving their objectives. Because there is resources
not likely to be an elaborate management information system in very appropriately,
many communities, it is important that a system be designed and and whether our
established for the collection, analysis, reporting and use of realistic actions will have
health and health-related information. In order to make this long-term
information complete there is a need to establish reasonably uniform results.
community-based information systems across the sector. Similar efforts
must be taken to link or integrate this information to the present HMIS

Taking KEPH to the Community 33

in the health facility. Table 4 summarizes the categories and types of information to
be collected at community level, and identifies possible sources of the information.
There are a number of steps that can be taken to link the community and health
facility information systems. Members of the health facility committees, community
leaders, CHEWs and CORPs should be trained on the importance of data collection,
analysis, storage and utilization. The DHMT should facilitate the availability of data
collection tools. The committee should be responsible for the overall management of
their community-based information system (CBIS).
CORPs, with the support of the village elders, are expected to be responsible for
collecting routine/day-to-day data in the services they provide using the available

Table 4: Types of health information to be collected in community by category

and source
Category Types of data Collection/Source
Demographic § Population by age and sex § Village register
§ Births and deaths (with cause) § Birth and death register
§ Migration in and out § Village health worker

Nutrition § Under one year registered weight § Under-five register

§ One to five years registered weight
§ Moderate and severe malnutrition

Immunization § Under one year registered, § Under-five register

vaccinated against BCG, DPTHB § Household survey
§ Polio (3 doses), measles, fully § Visit form, registers
immunized children § National immunization
§ Women protected against tetanus
with at least 3 doses of tetanus
toxoid
Malaria § Under five sleeps under ITN § Village register, survey

Reproductive and § ANC visits, ANC referrals, causes of § ANC register

child health referrals § Delivery register
§ Deliveries, referrals during delivery, § Family planning register
complications § Household/catchment area
§ Mother and child outcome, deaths survey form
and causes
§ New and current family planning
users by method
§ IEC/BCC session conducted
Health status § Under-fives with fever, diarrhoea, § Household survey/visit form
measles, chest tightness, HIV/AIDS
Environmental § Latrines, housing type, safe waste § Household survey/visit form
sanitation/Water disposal methods, safe water sources
School § School visits, health education, § School visit form
health screening on disease
conditions, immunization status, first
aid, guidance and counselling,
referral system, safe water, latrines,
school meals, mass treatment, class
one enrolment by gender, dropouts
by gender
Socio-economic § Number of orphans, disabled children § Household visit form
exempted

34 Taking KEPH to the Community

CBIS tools, e.g., village registers and household visit forms. The collected data are
presented to the CHEW and Assistant Chief, or entered in the sub-locational
chalkboard.
Health facility in-charges should use the information as a basis for discussion
during their review and planning meetings. They should provide immediate feedback
to CHEWs and CORPs during supervisory visits and meetings. CHEWs and CORPs and
other leaders should use the information to monitor progress of planned LEVEL ONE
SERVICES. In addition, data are used for monitoring, identifying vulnerable
households, targeting outreach services and deciding appropriate health education
lessons.
Feedback to the village will be ensured through representation by CORPs and
elders in the health facility committee meetings. The District M&E officer should be
responsible for processing and analysing data by sub-location and disseminating at the
district level. Data can also be obtained from other institutions such as schools,
churches and mosques.

Taking KEPH to the Community 35

 7: Activities and Inputs for
Implementing the Community
Strategy

T
he implementation process will kick off with the identification and
establishment of task forces at national, provincial and district levels. The
national team of managers drawn from both national and provincial levels
will go through a five-day orientation workshop followed by commencement
of activities at the district and community levels. Each province will be required to
start off with a minimum of four districts with the most enthusiastic champions and
partners to encourage early success stories. In this way it should be possible for the
programme to reach all the districts in the country by the second year.
The following sections provide an outline of the tasks, outputs and expected
inputs in introducing LEVEL ONE SERVICES [Link] 5, at the end of the
section, provides a timetable for pulling together all the pieces detailed in the
previous sections.

7.1 Assembling Key Implementation Partners

E
xperienced partners identified in each province could spearhead mobilization,
organization, planning, training, monitoring and evaluation activities. Such
partners could be contracted by the MOH for the task.

7.1.1 Specific Tasks

• Carry out a rapid inventory of agencies and individuals with experience in
community-based approaches to health care and development by province and
district.
• Identify key partners and champions and convene them into task forces at
national, provincial, district and community levels for LEVEL ONE SERVICES
implementation.
• Identify lead partners with proven capacity to spearhead the implementation of
LEVEL ONE SERVICES at national and provincial levels.
• Hold a five-day national orientation workshop followed shortly by provincial
orientation workshops, but building on existing initiatives and processes.
• Establish national and provincial secretariats and identify a district focal person
for LEVEL ONE SERVICES.
• Establish coordination and collaboration mechanisms/committees at national,
provincial and district levels to spearhead evidence-based planning, monitoring
and evaluation (quarterly meetings at each level).

36 Taking KEPH to the Community

• Hold annual LEVEL ONE SERVICES meetings for review, as well as share
innovations, discuss progress and find solutions to problems.
• Run training workshops on emerging critical elements.
• Recognize excellence, celebrate progress and publish results.

7.1.2 Expected Outputs

• An inventory of experienced LEVEL ONE SERVICES agencies and champions
undertaken and a report presented to the LEVEL ONE SERVICES task force.
• A national task force convened and oriented through a five-day workshop
attended by national and provincial managers sector-wide.
• A lead partner identified at national level and in all provinces and contracted to
spearhead LEVEL ONE SERVICES.
• All eight provinces hold orientation workshops attended by all district teams,
sector-wide.
• Coordinating committees meet quarterly.
• Secretariats established and focal point persons identified at the three levels.
• All districts submit LEVEL ONE SERVICES plans, 30 in the first year and 50 in the
second year.

7.1.3 Required Inputs

• National, provincial and district managers assigned to spearhead operations as
counterpart facilitators alongside the expert facilitators from contracted partner
agencies.
• The identified lead agencies provide two experienced facilitators to facilitate
activities at national and provincial levels.
• Transport and travel for fieldwork, orientation workshops and coordination meetings.
• Daily subsistence allowances for fieldwork, orientation workshops and
coordination meetings.
• Stationery and other workshop materials.
• Report production at national, provincial and district levels.

7.2 Building the Human Resource

P
eople are the foundation of LEVEL ONE SERVICES, and we considered earlier some
of the issues of recruitment and training of the large cadre of service providers that
will be required. Here we apply that discussion to recap the specific tasks, outputs
and inputs.

7.2.1 Specific Tasks

• Identify and train the national team of trainers, with all provinces represented.
• Identify and train provincial teams, with all districts represented.
• Recruit the team of health extension workers, animators, CHEWs and CORPs.
• Train the health extension workers as they initiate the LEVEL ONE SERVICES
implementation steps, supported by trainers, applying the partnership approach
to health personnel education.
• Identify trained CORPs and orient them to LEVEL ONE SERVICES on the basis of
their learning needs.
• Work with the community structures to identify and train additional CORPs based
on the number of households per sub-location, one CORPs for 20 households.
• Develop a training curriculum and training materials based on the learning needs.

Taking KEPH to the Community 37

7.2.2 Expected Outputs
• 32 national trainers trained, all in the first year.
• 400 provincial trainers trained (5 from each district), at least 150 in the first year.
• 5,100 CHEWs (PHTs, ECNs or equivalent) recruited and trained, one for each sub-
location: 2,000 recruited and commence their action linked training in the first
year, the rest recruited and started on training by the second year.
• 225,000 CORPs (who can read and write but nominated by their communities)
trained: 50,000 trained in the first year in 30 districts and the rest identified and
trained in the second year, therefore covering all the districts.

7.2.3 Required Inputs

• National (8), provincial (400) and district trainers.
• The identified lead agencies provide two experienced trainers to accompany the
MOH teams at national and respective provincial levels.
• Transport and travel for fieldwork supervision, follow up and training workshops.
• Daily subsistence allowances for fieldwork, supervision, follow up and workshops.
• Curriculum and training materials development.
• Stationery and other training materials.
• Report production at national, provincial and district levels.
• 5,100 CHEWs (PHTs, ECNs or equivalent) and 225,000 CORPs (50 per sub-location).

7.3 Introducing and Sustaining Service Delivery at

Level 1

T
he launching of service provision at level 1 should follow the community entry
and participatory planning process described earlier, as well as the training of
CHEWs and CORPs. The actual package and hence the content of the sub-
location kit should be worked out by the DHMT in consideration of prevailing local
diseases/conditions. The health facility committees should be responsible for the
provision of the kits including regular replenishment of drugs and supplies therein.

7.3.1 Specific Tasks

• Establish the level 1 service package for each implementing district on the basis
of community plans collated into the district master plan.
• Distribute supplies according to guidelines and controls.
• Promote early service seeking behaviour.
• Facilitate health promotion: IEC on control and prevention of common diseases
(particularly malaria and HIV/AIDS) using the dialogue method at household and
community levels to ensure disease prevention and control.
• Facilitate environmental sanitation and safe water supply and encourage good
personal hygiene.
• Provide first aid and treatment of common ailments.
• Establish a referral mechanism and identify and refer clients.

7.3.2 Expected outputs

• Level 1 service package established for each implementing district.
• Equipment, drugs and supplies distributed according to the package, guidelines
and controls to 5,100 sub-locations.
• 900,000 household visits for health promotion, disease prevention, care and
support, and data collection.

38 Taking KEPH to the Community

• 600,000 packets of IEC materials distributed to CHEWs, CORPs, schools and
worship sites on control and prevention of common diseases (particularly malaria
and HIV/AIDS).
• 1,800,000 people receive treatment.
• 1,200,000 people referred.
• 900,000 women cared for and referred to health facility to deliver; 600,000 cared
for but delivered at home.

7.3.3 Required Inputs

• Preventive and promotive materials and supplies (ITNs, water guard, condoms,
contraceptives).
• Health promotion supplies (IEC materials according to priorities, e.g., C-IMCI, safe
motherhood, community nutrition and supplements).
• Drugs and supplies for first aid and treatment of common ailments (first aid kit and
supplies, anti-malarials, analgesics, de-worming medicines, oral rehydration salts).
• Referral mechanism, e.g., communication and transport (phones, air-time,
bicycle, forms).
• 5,100 CHEWs, 225,000 CORPs, trained caregivers, trained teachers, trained
parents.
• Antenatal care equipment and supplies.
• Indoor residual spray equipment and supplies.
• Expanded programme of immunization equipment.
• Home delivery kits.
• Growth monitoring equipment and cards.
• Gender and age sensitive recreation facilities, including comprehensive
community-based youth-friendly centres.
• Home-based care equipment and supplies.

7.4 Strengthening Linkage between the Health System

and the Communities

F
undamental to KEPH is the recognition that at the community level people do
not access health facilities, for a variety of reasons ranging from cost to
questions about service and quality of care. A trip to a formal sector health
facility may be made only as a last resort and frequently when it is too late for
effective treatment – thus contributing to the spiral of discontent. This has a major
impact on the health status at community level. One purpose of KEPH is to renew
services on the ground and restore people’s confidence in the formal health sector. It
is therefore critical to build and strengthen linkages between the two avenues of
health care.

7.4.1 Specific tasks

Following orientation and training workshops, participants with the support of
facilitators will:
• Create awareness among the district leaders by written communication followed
by a visit and leaders workshop.
• Carry out community entry starting at the district level and continuing down to
the community (sub-locational level).
• Disseminate the relevant portions of the NHSSP II and LEVEL ONE SERVICES
guidelines to all key stakeholders.

Taking KEPH to the Community 39

• Orient key stakeholders on LEVEL ONE SERVICES and launch the initiative in 30
districts in the first year and the rest in the second year.
• Support interested health committees to strengthen the health facility community.
• Develop guidelines and procedures to promote evidence-based governance,
management and service delivery to translate policies, plans and human capital
into long-term health improvement.
• Sensitize, mobilize and organize the community, and enhance leadership support,
for rights and responsibilities for health.
• Bridge the gap between health workers and the communities they serve, seeking to:
„ Improve communication and relations with communities.
„ Show genuine respect and concern for community problems and aspirations.
„ Work with communities to promote health and improve their health status.
„ Increase availability of health workers to the communities.

7.4.2 Expected Outputs

• Entry process undertaken in all 80 districts in Kenya, 30 of which will be done in
the first year covering a minimum of 1,000 sub-locations, and the rest in the
second year.
• 300 copies of LEVEL ONE SERVICES guidelines distributed in all 80 districts in the
country.
• Orientation for key stakeholders on LEVEL ONE SERVICES and launch of the
initiative in 30 districts in the first year and the rest in the second year.
• 2,000 community-based structures reviewed and briefed for involvement in LEVEL
ONE SERVICES.
• Orientation for 5,000 village health committee members on their LEVEL ONE
SERVICES functions and relevant policy documents made accessible to them.
• 80 districts will have LEVEL ONE SERVICES plans, at least 30 of them in the first year.
• Health facility committee guidelines reviewed and re-oriented in the light of
LEVEL ONE SERVICES in 80 districts, 30 covered in the first year, with 20% of level
2 and 3 health facilities.
• Linkage mechanisms (committees, staff and CORPs) established in at least 30
districts in the first year and the rest in the second year.
• 400 facilities have plans including LEVEL ONE SERVICES with at least 100 in the
first year, and the rest to be done by the second year.
• 400 facilities monitoring and discussing client satisfaction, with 100 commencing
in the first year.
• 400 committees with established referral mechanism, with 100 in place the first year.
• 400 committees holding evidence-based discussions regularly, with 100 having
started in the first year and 20% of facility committees involved in the practice of
displaying and discussing information to inform improvement.

7.4.3 Required Inputs

• Transport and subsistence allowance for team conducting entry process in 80
districts, and 5,100 sub-locations.
• 5,000 copies of LEVEL ONE SERVICES guidelines.
• Three-day orientation workshops for 50 participants per district in 80 districts.
• Transport and subsistence for two-day dialogue sessions at district level quarterly
in each district (320 sessions).
• Transport and subsistence for one-day evidence-based dialogue sessions at health
facility level quarterly in each district (3,200 sessions).

40 Taking KEPH to the Community

• Stationery and supplies for the linkage structures for 1,000 health facility
committees.

7.5 Monitoring and Evaluating Level 1 Activities

T
o be effective, M&E must be built into a programme from the very beginning,
and that is the case here. Specific timetables, deliverables and budget lines for
tracking and assessing LEVEL ONE SERVICES will ensure that the community
process is ingrained into the implementation of service delivery.

7.5.1 Specific Tasks

• Carry out assessment and baseline surveys, as well as identify structures for
inclusive participation in evidence-based dialogue at community level.
• Establish evidence-based participatory planning, implementation, monitoring and
action for health, starting with initial district implementation plan for LEVEL ONE
SERVICES followed by quarterly reviews.
• Register and map households by villages and sub-locations.
• Establish CBIS with chalkboards at strategic sites for local collation and use of data.
• Hold monthly local health days for collective action as well as evidence-based
dialogue for health, with supervisory support.
• Hold quarterly divisional health days for sharing, recognition and celebration
through situation analysis, participatory planning and action for health.
• Establish regular evidence-based dialogue, planning, implementation, monitoring,
evaluation and feedback meetings, based on the CBIS and HMIS at all levels.

7.5.2 Expected Outputs

• Household registration and baseline surveys in at least 30 districts and aiming to
cover 20% of the sub-locations in the first year. The rest of the districts would be
covered in the second year.
• 80 districts launch quarterly evidence-based dialogue sessions based on CBIS and
HMIS, building on the baseline survey data, with at least 30 districts covered in
the first year and the rest in the second year and at least 1,000 sub-locations
reached in the first year.
• 1,000 chalkboards functioning and the same number of facilities displaying data
on immunization and maternity delivery, based on the KEPH assessment
framework.
• Regular evidence-based dialogue, planning, implementation, monitoring,
evaluation and feedback meetings, based on the CBIS and HMIS, at all levels in 30
districts in the first year and scaled up to the rest in the second year.

7.5.3 Required Inputs

• District assessment and survey teams to cover 30 districts in the first year and 50
districts in the second year (10 research assistants and 15 enumerators for six days
per district).
• Data cleaning, entry and analysis.
• Report production at national, provincial and district levels.
• 5 computers per district to facilitate data processing.
• 80 statisticians.

Taking KEPH to the Community 41

Table 5: Programme timetable, April 2006 – March 2009

Activities Apr-Jun06 Jul-Sep06 Oct-Dec06 Jan-Mar07 Apr-Dec07 Jan-Dec08 Jan-Mar09

1. Launching LEVEL ONE SERVICES implementation countrywide
Carry out a rapid
inventory of
agencies, individuals
& programmes **

Convene national
& provincial task forces * * * * *** **** *

Identify and contract

lead partners *

Hold national &

provincial orientation
workshops *********
Establish national &
provincial secretariats
and focal persons for
LEVEL ONE SERVICES ***** ****
Hold annual LEVEL
ONE SERVICES meetings * * *
Conduct training
workshops for updates * * * * *** ****
Assess & recognize
performance * *
Publish results * *

2. Training service providers’ and the community for LEVEL ONE SERVICES implementation

Develop training
curricula & materials **

Identify & train the

national team of trainers *

Identify & train

provincial teams ***** ***

Recruit & train

CHEWs ** *** *** *** *** ***

Identify & train

CORPs ** *** *** *** *** ***

3. Strengthening the linkage between the health system and communities for LEVEL ONE SERVICES
implementation

Create awareness
at district level *

Carry out community

entry ** ***
Disseminate LEVEL
ONE SERVICES
guidelines ** **
Continued

42 Taking KEPH to the Community

Table 5, continued
Activities Apr-Jun 06 Jul-Sept06 Oct-Dec06 Jan-Mar 07 Apr-Dec 07 Jan-Dec08 Jan-Mar 09

Carry out assessment

& baseline surveys ** ***** **
Register and &
households ** ***** ***** *****
Establish CBIS ** ***** ***** *****

Monthly health days *** ******* ********* ******* ******* ******* ***
Hold quarterly
divisional health days * * * * *** **** *
Establish evidence-
based planning, imple-
mentation, monitoring,
evaluation & feedback * * * * *** **** *
Strengthen HMIS ** ***** ***** ***** ***** *****

Monitor client
satisfaction *** ******* ********* ******* ******* ******* ***

4. Providing services at level 1

Carry out home visiting

regularly *** ******* ********* ******* ******* ******* ***

Provide preventive,
promotive & simple
curative care on demand *** ******* ********* ******* ******* ******* ***
Assess performance of
households quarterly * * * * *** **** *
Conduct dialogue
sessions at barazas,
churches, mosques
& schools *** ******* ********* ******* ******* ******* ***
Hold divisional
community days * * * * *** **** *
Hold regular dialogue
sessions *** ******* ********* ******* ******* ******* ***
* = Number of weeks required to complete the task.

Taking KEPH to the Community 43

 8: Budget

T
his section contains two separate approaches to the financial data. Following
a statement of the assumptions behind the budget allocations, the section
first presents a budget organized according to objectives and activities. This
is followed by a summary budget for LEVEL ONE SERVICES calculated on an
annual basis.

8.1 Budget Parameters

B
udget allocations are estimated according to the parameters detailed below.
These relate to contracting and consultants, drugs and supplies, transport and
travel, office space and equipment, documentation and publication, training,
and workshops and meetings.

1. Contracting and consultants: The identified lead agencies provide experienced

facilitators for national and provincial level activities, including assembling key
partners, recruiting and training personnel, strengthening linkages between health
facilities and the community, and conducting baseline surveys. All human resources
required for these activities, except in the case of government staff involvement, will
be paid for under the contracting and consultants budget line. A detailed analysis of
consultancy cost and daily subsistence allowance (DSA) for each activity is contained
in the budget.

2. Drugs and supplies: These will include:

• Preventive and promotive materials and supplies (ITNs, water guard, condoms,
contraceptives)
• Health promotion supplies (IEC materials according to priorities, e.g., C-IMCI, safe
motherhood, community nutrition and supplements)
• Drugs and supplies for first aid and treatment of common ailments (first aid kit
and supplies, anti-malarials, analgesics, deworming medicines, oral rehydration
salts)
• Referral mechanism, e.g., communication and transport (phones, air-time,
bicycle, forms)
• Antenatal care equipment and supplies
• Indoor residual spray equipment and supplies
• Expanded programme on immunization equipment
• Home delivery kits

44 Taking KEPH to the Community

• Growth monitoring equipment and cards
• Equipment for gender and age sensitive recreation facilities
• Home-based care equipment and supplies

3. Transport and travel: Transport and travel will include hired vehicles for project
and consultant staff travels, bus fares, taxi hires and bicycle hires, among other
travel means that will be applicable.

4. Office space and equipment: Office space will include cost for hire of space
where government may not have space for the coordination of activities at provincial
levels. Communication costs including telephones, e-mails, fax, etc., are budgeted
under this line. Equipment will include procurement of office equipment such as
computers, printers, and telephone and fax equipment among other small office
machines.

5. Documentation and publication: This will include the cost of documenting and
publishing the project results and best practices arising there from. The cost of
circulating copies to all stakeholders is also included under this budget.

6. Training Costs: These will include costs for

• Transport and travel for fieldwork supervision, follow up and training workshops
• Daily subsistence allowances for fieldwork, supervision, follow up and workshops
• Curriculum and training materials development
• Stationery and other training materials
• Report production at national, provincial and district levels

7. Workshops and meetings: Three types of budget lines are covered here:
community process and governing structures development; planning, implementation,
monitoring, evaluation, feedback and information systems; and dissemination
workshops and meetings. The costs will include:
• Transport and travel
• Daily subsistence allowances
• Materials development
• Stationery and other materials
• Report production for national, provincial and district levels

8.2 Budget by Objectives and Activities, 2006–2009

Table 6: Summary of budget by objectives and activities, 2006–2009 (in US$)
Output Inputs Unit cost Total
1. Launching LEVEL ONE SERVICES implementation countrywide
Carry out a rapid inventory Inventory of A consultant, 2,500 20,000
of agencies, individuals and community-based travel, daily
programmes programmes, people subsistence
and agencies allowance
undertaken in 8 (DSA),
provinces stationery

Convene LEVEL ONE 9 task forces meet Transport, 6,000 540,000

SERVICES task forces at quar-terly (25 members travel, DSA
national & provincial levels each attend 10
meetings) Continued

Taking KEPH to the Community 45

Table 6, continued
Output Inputs Unit cost Total

Contract agencies to 8 agencies contracted 16 consultant 216,000 1,728,000

spearhead LEVEL ONE advisors
SERVICES implementation
Hold national & provincial 9 workshops attended Transport, travel, 8,000 72,000
LEVEL ONE SERVICES by 30 participants DSA
orientation workshops each

Establish national and 9 secretariats Staff, computers, 108,000 972,000

provincial LEVEL ONE established stationery,
SERVICES secretariats & a communication
focal person facilities

Convene annual LEVEL ONE 3 annual meetings held Staff, stationery, 150,000 450,000
SERVICES meetings communication
facilities

Conduct training workshops 3 refresher workshops Staff, facilitators 50,000 150,000

on emerging issues on emerging issues stationery,
communication
facilities

Assess & recognize 30 people recognized Awards for 2,000 60,000

performance excellence
Publish results 3 monographs Editing, printing 35,000 105,000
published, 1,500 copies
Subtotal 4,097,000
2. Training health providers and community leaders for LEVEL ONE SERVICES implementation
Develop training curricula 3 sets of curricula & 2 consultants, 6,000 18,000
& training materials materials developed stationery,
printing
Identify/train national 32 trainers trained Transport, travel, 2,000 64,000
team of trainers stationery,trainers
Identify/train provincial 400 trainers trained Transport, DSA, 1,500 600,000
teams stationery,trainers
Recruit/train community 5,100 CHEWs trained Transport, DSA, 400 2,040,000
health extension workers, stationery,trainers
animators, coaches
Identify/train CORPs 110,000 CORPs trained Transport, DSA, 100 11,000,000
stationery,trainers
Subtotal 13,722,000

3. Strengthening linkages between the health system and communities for LEVEL ONE
SERVICES and the provision of services at level 1
Create awareness at 80 districts reached Animators, facili- 3,000 240,000
district level through tators, transport,
contact and workshop DSA, stationery
Carry out community Entry process under- Animators, facili- 30,000
entry taken in 80 districts tators, transport, 2,400,000
and 5,000 sub-locations DSA, stationery
Continued

46 Taking KEPH to the Community

Table 6, continued
Output Inputs Unit cost Total
Disseminate LEVEL ONE 300 copies of Transport 50 15,000
SERVICES guidelines guidelines distributed
Carry out assessment and Assessment and follow- Facilitators, tran- 10,000 1,600,000
baseline surveys up surveys in 80 sport, enumera-
districts tors, stationery,
data analysis, DSA,
Brief & orient community 5,000 committee Animators, facilita- 50 250,000
leaders members orient on tors, transport,
policy documents DSA, stationery
Develop district LEVEL 80 districts have LEVEL Facilitators, 100 8,000
ONE SERVICES plans ONE SERVICES plans transport, DSA,
stationery
Establish evidence-based 20,000 dialogue Animators, 10 200,000
planning, implementa- sessions (4 per site) facilitators,
tion, M&E and feedback transport, DSA,
and quarterly reviews stationery
Register and map 25,000 households Staff, CHEWs, 50 250,000
households by villages registered in 5,000 CORPs, GIS,
and sub-locations sub-locations stationery
Establish CBIS with 2,000 chalkboards & Chalkboards, ani- 100 200,000
chalkboards at strategic facilities displaying mators, facilita-
sites progress data tors, transport,
DSA, stationery
Hold monthly local health 50,000 local health Animators, 10 500,000
days days transport, DSA,
stationery
Hold quarterly divisional 1,200 divisional health Facilitators, 400 480,000
health days days transport, DSA,
stationery
Restructure health 800 committees Animators, 100 80,000
committees to strengthen restructured transport, DSA,
community linkage stationery
Establish evidence-based Established at 800 Animators, 100 80,000
planning, implementa- health facilities transport, DSA,
tion, M&E and feedback stationery
at committee levels
Orient key stakeholders 800 committees Animators, 1,000 800,000
on LEVEL ONE SERVICES trained transport, DSA,
and launch the initiative stationery
Distribute CHEW & CORP 187,500 kits Antimalarials, ITNs, 556.8 104,400,000
kits according to distributed Vit. A, worm
guidelines and controls tablets, water
guard, etc., in kit
Hold regular evidence- 5,000,000 reached CORPs, bag, 3 15,000,000
based dialogue with learning materials
households

Subtotal 161,303,000

Grand total 179,122,000

Taking KEPH to the Community 47

8.3 Annual Budget Summary for LEVEL ONE SERVICES
Table 7: Summary yearly budget for LEVEL ONE SERVICES, 2006–2009 (in US$)
Item 2006 2007 2008 2009 Total
1. Contracting &
consultants 2,800,500 3,734,000 3,734,000 933,500 11,202,000
2. Drugs & supplies 26,100,000 34,800,000 34,800,000 8,700,000 104,400,000
3. Transport &
travel 150,000 600,000 600,000 300,000 1,650,000
4. Office space
& equipment 900,000 934,500 394,500 202,000 2,431,000
5. Community process
& governing
structures devel-
opment 1,000,000 1,000,000 960,000 - 2,960,000
6. Planning, imple-
mentation,
monitoring,
evaluation,
feedback &
information
systems 1,333,000 1,000,000 500,000 500,000 3,333,000
7. Documentation
& publication 20,000 20,000 20,000 30,000 90,000
8. Workshops &
meetings 800,000 2,200,000 600,000 1,000,000 4,600,000
9. Training 5,000,000 5,000,000 3,000,000 872,000 13,872,000
Grand total 38,103,500 49,288,500 44,608,500 12,537,500 144,538,000
Note: Budget period is April 2006 to March 2009.

48 Taking KEPH to the Community

 References

Ariga, E., J. Opiyo, M. Reta, J. Odoyo, E. Muga and D. Kaseje. 2003. Community
Empowerment for Food and Income Security through Partnership Agriculture: An
Approach to Sustainable Food Security in Abom Sub-Location in Bondo District, Kenya.
Tropical Institute of Community Health and Development (TICH) Publication, Kisumu,
Kenya.
Baily, K. 2003. Participation of Communities in Nutrition Screening in Ethiopia. African
Church Information Service. TICH Publication, Kisumu, Kenya.
Chatora, Rufaro, 2003. “An overview of the traditional medicine situation in the African
region”. African Health Monitor, World Health Organization Africa Regional Office (AFRO).
Erasmus, V., B. King and D. Kaseje. 2003. Planning and Managing Community Based Health
Care in a Chronic Emergency Situation: The Case of South Sudan. TICH Publication,
Kisumu, Kenya.
Friedman, I., R. Lehmann and D. Sandors. 2004. “Review of utilization and effectiveness of
community health workers In Africa”. Technical Report, Social Science and Medicine,
43(5).
Kasilo, O. 2003. “Enhancing traditional medicine research and development in the African
region”. African Health Monitor. WHO Africa Regional Office (AFRO).
Kidane, G. and R. Morrow. 2000. “Teaching mothers to provide home treatment of malaria in
Tigray, Ethiopia: A randomized trial”. The Lancet, 356: 550–5.
Kyeyune, P., D. Balaba and J. Homsy. 2003. “The role of traditional health practitioners in
increasing access to HIV/AIDS prevention and care: The Ugandan experience”. African
Health Monitor, WHO Africa Regional Office (AFRO).
Olewe, M. 2003. Integrated Management of Childhood Illnesses (IMCI): The Case of Siaya
District, Kenya. TICH Publication, Nairobi, Kenya.
Oule, J. 2004. “The role of traditional health practitioners in health care provision in Nyanza,
Kenya”. Unpublished. TICH in Africa, Box 2224, Kisumu, Kenya.
Simba, D., D. Kaseje and G. Kiangi. 2003. Community Based Health Care: The Case of Mufindi
District, Tanzania. TICH Publication, Kisumu, Kenya.
Taylor, T. and C. Taylor. 2002. Just and Lasting Change: When Communities Own Their
Futures. The Johns Hopkins University Press, Baltimore, Maryland USA.
UNICEF/WHO. 1978. Alma Atta Declaration. WHO, Geneva, Switzerland.

Taking KEPH to the Community 49

50 Taking KEPH to the Community
 Reversing the trends
The Second
Republic of Kenya
NATIONAL HEALTH SECTOR
Strategic Plan of Kenya

Taking the Kenya

Essential Package
for Health to the
COMMUNITY
A Strategy for the Delivery of
LEVEL ONE SERVICES

Ministry of Health
June 2006
Taking the Kenya Essential Package for Health to the Community:
A Strategy for the Delivery of LEVEL ONE SERVICES

Communities are the central focus of affordable, equitable and effective

health care. Representing the first level of health care, they are the core of
the Kenya Essential Package for Health defined in Kenya’s second National
Health Sector Strategic Plan. The goal of this strategy is to enhance
community access to health care in order to improve productivity and thus
reduce poverty, hunger, and child and maternal deaths, as well as improve
education performance across all the stages of the life [Link]
provision at level 1 is organized in three tiers starting with household-based
caregivers, adult members of the household who provide the essential
elements of care for health in all dimensions and across life-cycle cohorts.
These household-based caregivers are supported by volunteer community-
owned resource persons - CORPs - who are in turn supported and managed by
a range of community structures to be established or strengthened through
the implementation of this strategy. It is anticipated that the community
focus will reach the entire country, district by district, within two years.

Ministry of Health
Health Sector Reform Secretariat
Afya House
PO Box 3460 - City Square
Nairobi 00200, Kenya
Email: secretary@[Link]
[Link]