For 11 years, Jackline Vugutsa has been a community health promoter (CHP) in Banja Ward, Vihiga County, Western Kenya, bridging the gap between health facilities and communities. Ahead lies a winding road, etched into the hilly terrain of Banja Ward in Vihiga County, Western Kenya. Jackline Vugutsa adjusts the red pack securely on her back, its weight a familiar companion. For 11 years, Jackline has trodden these paths, crossing valleys and villages, guided by a singular purpose: to bring health closer to her people. As she arrives at the first household of the day, warm greetings are exchanged.
But today, she's equipped with a new, powerful tool-a smartphone and the electronic Community Health Information System (eCHIS), a platform for collecting, analyzing, and reporting data on community health activities and outcomes.
Jackline Vugutsa, a community health promoter in Kenya, uses eCHIS to improve healthcare delivery.
The Role of eCHIS in Transforming Community Health
With seamless efficiency, Jackline uses the eCHIS to update information about household members. The eCHIS prompts her, ensuring no detail is missed. As she enters data, the system becomes her ally, alerting her to probable malaria cases needing urgent referral to health facilities for confirmation. eCHIS also shares the information with the nearby health facility. When the family arrives at the facility and presents the referral card Jackline provided, their history is waiting-a lifeline to timely malaria treatment.
Jackline says: "Lastly, with the phone, you can send messages to households whom you’re planning to visit so that they prepare themselves accordingly. This saves time and ensures you get all the relevant information, as clients have time to prepare themselves and avail all the required documents."
Until this point, community health workers are reporting manually, filling in registers that are handed to their supervisors and then to the District Health Records Officer to digitize. The eCHIS will integrate the work of each individual into a wider system by enabling workers to enter information on their mobile phone wherever they are, removing a lot of the reporting burden.
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Combating Malaria: A Key Focus
Three quarters of Kenya’s 51 million people are at risk of malaria, a serious disease that can cause disability and death. However, in the past decade, Kenya has increased the scope of malaria prevention interventions, resulting in significant reductions in morbidity and mortality. For example, the number of children who die before they turn five years old has declined by more than half in Kenya, from 115 out of every 1,000 babies born from 1999 through 2003 to 52 out of every 1,000 babies born from 2010 through 2014. The country has prioritized scaling up malaria case management at the community level in targeted areas.
The eCHIS technology helps CHPs provide better health services, especially for malaria prevention and treatment.
Kenya Community Health Strategy 2020-2025
Addressing Gaps Through Digitalization
Despite Kenya’s remarkable results in malaria prevention and control, the country still faces challenges in providing high-quality and affordable health care services to all its people, especially in remote and underserved areas. Kenya has responded to this challenge by adopting digital health to enhance its health system and outcomes. As a pioneer of digital health in East Africa, Kenya has implemented innovative technologies and established supportive policies and laws for its digital health initiatives. However, despite the progress and significant investments already made in digital health, community health still lags in digitalization; many of its reporting systems remain paper based, which makes them prone to errors and inefficiencies.
To address this gap, Kenya launched the Community Health Digitalization Strategy in March 2021. This initiative aims to scale up the use of digital tools and systems by CHPs-such as Jackline in Vihiga County-across the country. The strategy also involves enhancing the implementation and sustainability of eCHIS. The government has to date kitted around 95,000 CHPs with a smartphone for eCHIS use across all the 47 counties in Kenya, though not all of them have been trained to use the system.
Jackline is one of the many champions who are using eCHIS to combat malaria and enhance health in their communities. She is among the 95,000 CHPs that the government of Kenya has empowered with smartphones and digital tools, thanks to political goodwill and the Afya Nyumbani pledge to achieve health for all. Jackline notes: "In addition, I am able to send one message at once to all my CHPs from the system instead of sending them individual SMSs."
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Collaborative Efforts and Impact
To support Kenya’s digital community health efforts, the US President’s Malaria Initiative (PMI), the United States Agency for International Development (USAID), and the Bill & Melinda Gates Foundation partnered with Digital Square, a global initiative led by PATH that supports digital health innovations and collaborations. PMI and Digital Square conducted a comprehensive assessment of the community digital ecosystem in Kenya, as well as in 26 other partner countries, to understand the needs, challenges, and opportunities for digital community health.
Based on the assessment results and recommendations, PMI and Digital Square are working with the USAID mission in Kenya, the Ministry of Health, and other stakeholders to implement and scale up eCHIS and other digital tools for malaria management by CHPs. A key activity of the Digital Square partnership is the collaboration with the government of Vihiga County, which started in 2022. The goal of this collaboration is to improve community malaria health services in Vihiga County by using eCHIS for data and intervention accountability. The partnership provides support for the implementation of eCHIS in terms of infrastructure (including mobile phones, tablets, and data bundles) and capacity strengthening (training, supervision, and feedback) for CHPs and health managers. The partnership also monitors and evaluates the impact of eCHIS on malaria indicators, such as case detection, testing, treatment, and referral.
The partnership between PMI and Digital Square has had a positive impact on both the health strategy and malaria response of Kenya’s digital community. By using eCHIS and other digital tools, CHPs like Jackline are improving the quality and timeliness of data collection and reporting, which is informing decision-making and resource allocation. Moreover, eCHIS is interoperable with other digital health systems in Kenya; that is, it can securely exchange data so that health workers and managers at all levels of the health system have access to the appropriate level of data.
This capacity to communicate with other systems has enhanced the delivery and coordination of malaria interventions-including diagnosis, treatment, prevention, and surveillance-at the community level. As a result, the partnership is strengthening the health system and improving the health outcomes of Kenyans, especially those who are underserved by the health system and hard to reach.
Kenya Community Health Strategy 2020-2025
The Kenya Community Health Strategy 2020 - 2025 (KCHS 2020 - 2025) was developed to build on the Community Health Strategy 2014 - 2019. The development of the KCHS 2020 - 2025 is based on the lessons learnt from the implementation of the Community Health Strategy 2014 - 2019 and findings of a situational analysis of community health in Kenya that was undertaken towards the end of the implementation on the Community Health Strategy 2014-2019. That situational analysis noted several aspects of community health systems that need to be strengthened and scaled to unlock the outsized potential of community health in Kenya. For instance, major gaps were identified in the distribution and coverage by the community health workforce across counties. Coverage ratios across the counties ranged from as low as 17% to as high as 90%, showing poor distribution of the workforce. Additionally, funding for community health was a key lesson gathered from the previous strategy. During the implementation, community health did not have an independent line in the budget for Ministry of Health.
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The KCHS 2020 - 2025 was developed through a multi-stakeholder and multi sectoral participatory process led by the Ministry of Health and in collaboration with County Governments, Civil Society, Development Partners, and other stakeholders.
One of the most important priorities of the KCHS is encouraging communities to own their health challenges and, where possible, to suggest local solutions. To do this, you need the right governance structures in place. The consistent compensation of CHWs has long been a challenge at the heart of Kenyan healthcare policy, with different counties taking different approaches. The KCHS calls for consistent and fair compensation structures for CHWs across Kenya, in order to boost motivation, attraction and retention.
While the CHU4UHC Platform has already done significant work to strengthen community health data management, the KCHS aims to address the gaps that still exist. This includes developing and implementing a digital community health information system (eCHIS), which in turn will help enhance the capacity of CHWs to collect, collate and report on their work.
There are multiple organizations involved in community health in Kenya and so the KCHS hinges on the establishment of a strong health partnership framework. Moving forward with a shared vision and commitment to change will be vital to transform the strategy from a static document into transformative action.
The launch of the Kenya Community Health Strategy 2020-2025 is a key step in getting us to where we want to be regarding community healthcare. The focus now is on supporting the Ministry of Health and other partners to implement it.
Community Health Units and Skilled Birth Delivery
Despite the widespread application of the community health strategy (CHS) in Kenya and evidence of its effectiveness in reducing health outcomes at the household level, data from Kakamega County, of which Lurambi sub-county is part of, still showed that skilled birth delivery was at 47% against the national estimateof 62% and a target of 90%.
The study was undertaken in Lurambi Sub County in Kakamega County of Western Kenya. The study focused on all 38 Community Health Units within the Lurambi sub-county. The Community Health Extension Workers (CHEWs) were the respondents for the CHU assessment. The Community Health Units were assessed based on their functionality concerning 5 parameters: Training, Community Health committees, Community Based Health Information System (CBHIS), Community Dialogue and Community Action Days.
Ager et al developed a Community Health Unit (CHU)functionality scorecard and categorised CHUs as functional, Semi-functional, or Non-Functional. A set of 17 indicators are used in the scoring and percentage score are generated. A positive score is assigned 1 and a negative score is assigned 0. The scores are then summed up and expressed as a percentage out of 17 indicators per CHU.
The study established that most of the community health units (68.6%) in Lurambi Sub County meet at least 80% functionality assessment scores of the strategy and are fully functional while the rest of the CUs are semi-functional. This shows higher levels of implementation compared to report on community health services in Kenya conducted in Turkana, Kibera, and Machakos which established that only 28% were fully functional and the majority were semi-functional.
The study has also established that mothers living within fully functional CUs were more likely to have skilled delivery than those from semi-functional CUs.
Pregnant women were more likely to have skilled deliveries in fully functional CUs than semi-functional CUs (OR=1.3; 95% CI=1.1-2.4; p-value<.001). 2 out of 3 community units were fully functional, and functionality was associated with increased uptake of skilled delivery. In a fully functional CUs, Community Health Volunteers provided health education through regular visits and they were able to provide a referral to health facilities for the pregnant women.
The Community Strategy had set an ambitious target of reaching 16 million Kenyans (3.2 million households) being enrolled by 2009 which was yet to be achieved by 2017. The strategy also aimed at strengthening community participation and encouraging communities to take action towards their health through functional community units and linked health facilities.
The Kenya Community Health Strategy is a vital framework for enhancing healthcare accessibility and outcomes. Digital innovations like eCHIS, coupled with collaborative partnerships, are instrumental in achieving universal health coverage and addressing critical health challenges such as malaria. Continued efforts to strengthen community health systems and support community health workers are essential for realizing the strategy's ambitious goals.
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