Introduction and Background

Communities 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). 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.

Community strategy was introduced in Kenya in the year 2006 as a function of the NHSSP II
2005-2010 where the KEPH was envisaged to be delivered through the community approach.
Over the years the trends were dwindling as far as maternal mortality and infant mortality is
concerned. The need to reverse the trends birthed the need of doing things differently as opposed
to the curative approach which focused on facilities.

The community strategy became the modality of shifting the paradigm from curative to
preventive. The operational unit for implementing the community health strategy is the
Community unit which is synonymous to the administrative unit known as the sub location. Each
sub location consists of several villages and each village is served by several Community Health
Volunteers (CHVs). Thus there may be as many as 25 CHWs in one community Unit) CU.

Objectives of Community Health Strategy

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There were four objectives captured as detailed below though after seven years in 2013, there
was need to revise the community health strategy documents, thus seven strategic objectives
were coined to fit into the Kenya Health Policy framework also detailed herein.

1. To provide tier one services for all cohorts and socioeconomic groups, taking into account
their needs and priorities

2. To establish and build capacity of tier one human resource capacity to provide services

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3. Strengthening health facility community linkages through effective decentralization and
partnership for the implementation of level one services

4. Strengthening the community to progressively realise their rights for accessible and quality
care and to seek accountability from facility based health services

NOTE

Poverty compounds powerlessness and increases ill health, as illhealth increases poverty. Both
have become progressively worse since the 1990s.

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 determining their own health priorities and to link them with the formal health
system in order to reflect their decisions and actions in health plans. In addition, people
themselves would also participate in resource mobilization, allocation and control. This approach
is well articulated in NHSSP II and supported by local government reforms that would ensure the
effectiveness of decentralization, as power is shifted to the councils, and governing structures
that enhance transparency and accountability. The community-based approach, as set out in this
strategy, is the mechanism through which households and communities take an active role in
health and health-related development issues. Initiatives 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
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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.

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Strategic Objectives

The 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 and priorities.

• Building the capacity of the community health extension workers (CHEWs) and community-
owned resource persons (CORPs) to provide services at level 1.

• Strengthening health facility–community linkages through effective decentralization and

partnership for the implementation of LEVEL ONE SERVICES.

• Strengthening the community to progressively realize their rights for accessible and quality
care and to seek accountability from facilitybased health services.

Justification for the Community-Based Approach

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
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providers tend to be uprooted from their socio-cultural contexts. This leads to loss of trust as
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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

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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 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 effectiveness
in improving health conditions. The people have learnt through experience that they should not
rely only on the conventional service providers. There is therefore an overwhelming need to
negotiate with people and households as partners in health care, giving them a chance to
influence the way care is delivered and thus restore their confidence in the health system.
Meeting this need means focusing attention on enhancing the capacity of households to play their
role in action for health effectively. Through continued respectful dialogue, we will be able to
enlarge their choices as we seek to support them in making rational, evidence-based decisions
concerning their health needs across all stages in the human life cycle, and thus reverse the
trends in health indicators. Turning the competing systems 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
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are delivered.

The Key Role of Households and Communities as Partners in LEVEL ONE SERVICES

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

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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 for timely action. Taking regular
exercise. Ensuring gender equity. Using available services to monitor nutrition, chronic
conditions and other causes of disability.

• Disease prevention: Practising good personal hygiene in terms of washing hands, using latrines,
etc. Using safe drinking water. Ensuring adequate shelter, and protection against vectors of
disease. Preventing accidents and abuse, and taking appropriate action when they occur.
Ensuring appropriate sexual behaviour to prevent transmission of sexually transmitted diseases.

• Care seeking and compliance with treatment and advice: Giving sick household members
appropriate home care for illness. Taking children as scheduled to complete a full course of
immunizations. Recognizing and acting on the need for referral or seeking care outside the home.
Following recommendations given by health workers in relation to treatment, follow up and
referral. Ensuring that every pregnant woman receives antenatal and 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
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these rights progressively. Ensuring that health providers in the community are accountable for
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effective health service delivery and resource use, and above all are functioning in line with the
Citizen’s Health Charter.

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Norms and Services at Level 1

The 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 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
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essential care package supplied and replenished by the CHEW. The CORPs may receive a
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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.

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 • 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.

Definition of Services Provided at Level 1

NHSSP 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
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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

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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 Adolescent reproductive health
Non-communicable disease control: Cardiovascular diseases, diabetes, neoplasms, anaemia,
nutritional deficiencies, mental health Other common diseases of local priorities within the
district, e.g., eye disease, oral health, etc. Community-based day-care centres Community-based
referral system, particularly in emergencies Paying for first-contact health services provided by
CORPs

• Hygiene and environmental sanitation IEC for water, hygiene, sanitation and school health
Excreta/solid waste disposal Water supply and safety, including protection of springs Food
hygiene Control of insects and rodents Personal hygiene Healthy home environment:
environmental sanitation, development of kitchen gardens 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.

The Kenya Essential Package for Health defines six lifecycle cohorts: ♦ Pregnancy and the
newborn (first 2 weeks of life) ♦ Early childhood (2 weeks to 5 years) ♦ Late childhood (5 to 12
years) ♦ Adolescence (13-24 years) ♦ Adult (25-59 years) ♦ Elderly (over 60 years)
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Service activities and requirements at level 1, by cohorts in a population

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All cohorts

Service activities

Sensitize, mobilize and organize community to ensure leadership support and awareness of rights
and responsibilities in health

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§ Promote early service seeking behaviour § Promote health awareness through IEC on control
and prevention of common diseases, particularly malaria

§ Promote disease prevention and control through environmental sanitation, safe water supply
and good personal hygiene. Promote HIV/AIDS control

§ Provide first aid and treatment of common ailments § Make referrals § Develop and help
maintain a community-based information system

Minimum kit

§ Preventive materials and supplies (ITNs, water guard) § Health promotion supplies (IEC
materials) § Drugs/supplies for treatment of common ailments (antimalarials, analgesics, first aid
supplies) § Referral guidelines§ Communication and transport support, including bicycles §
Stationery and supplies such as forms, household registers, chalkboards

Human resource §

1 CHEW § 50 CORPs

Pregnancy, delivery and newborn (first 2 weeks of life)

Service activities

§ Provide exclusive breast feeding education

§ Provide IEC on current KAP on safe pregnancy and delivery of a healthy newborn

§ Advocate for community leadership support for safe pregnancy and delivery of a healthy
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newborn
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§ Promote safe delivery through pregnancy monitoring, establishment and timely referral

§ Disseminate key messages to support safe pregnancy and delivery of a healthy newborn

§ Promote or provide professional supervised home delivery

KITTY

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§ Safe delivery kit § Antenatal care equipment § IEC with key messages to promote early
childhood care § Preventive materials and supplies (ITNs, nutritious foods) § FP pills, condoms

HUMAN RESOURCE

§ 1 CHEW § 50 CORPS

Early childhood (2 weeks to 5 years)

Service activities

§ Promote C-IMCI activities

§ Conduct de-worming

§ Mobilize and organize for early childhood development (ECD)

§ Disseminate key ECD health messages § Support nutrition awareness and support for orphans
and vulnerable children (OVC)

§ Promote food and nutrition security § Monitor growth and development

SUPPLIMENTS

§ Expanded programme of immunization (EPI) equipment

§ Intermittent residual spray equipment

§ Essential drugs and supplies for common conditions, e.g., antimalarials, ORS, deworming
tablets
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§ Nutritious food supplements

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HUMAN RESOURCE

§ 1 CHEW § 50 CORPS § Trained caregivers

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Late childhood: 5 to 12 years (school age)

Service activities

§ Promote gender responsive school health activities

§ Equip the children with knowledge and skills to promote a healthy lifestyle including psycho-
social development

§ Train teachers and orient parents in school health services

§ Promote child-to-child approach to healthy lifestyles.

§ Initiate comprehensive communitybased, youth-friendly centres in 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

KITTY

§ IEC materials with key messages on healthy lifestyles

HUMAN RESOURCE

§ 1 CHEW § 50 CORPS § Trained teachers § Trained parents

Adolescence and youth 13–24 years

Service activities

Equip the youth (in and out of school) with knowledge and life skills, and facilitate a supportive
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environment to enhance adoption of a healthy lifestyle for themselves and the community
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KITTY§

Training curriculum for the youth on life skills including psycho-social issues, reproductive
health, drug and substance abuse, etc.)

HUMAN RESOURCE

§ 1 CHEW § 50 CORPS § Trained teachers § Trained parents

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Adults 25– 59 years

Service activities

§ Conduct C-DOTS activities and defaulter tracing

§ Raise awareness of noncommunicable disease control

§ Care for chronically ill

§ Equip adults with knowledge and skills for health and key health messages to promote
adoption of a healthy lifestyle and care seeking

§ Assist with ensuring household food security

§ Promote participation in actions for health

KITTY

Health learning materials § Preventive materials (ITNs, condoms) § Drugs and supplies for first
aid, treatment of simple common conditions

HUMAN RESOURCE

§ 1 CHEW § 50 CORPS

Elderly persons (Over 60 years)

Service activities

§ Equip elderly persons, the community and health care providers with relevant knowledge about
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common old age diseases, impairments and disabilities; how to improve quality of life; and
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sources of care

§ Advocate for the development of social support systems for the elderly § Develop community
home-based care for elderly persons with chronic illnesses

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KITTY

§ Key health messages and health learning materials

§ Preventive materials

§ Drugs and supplies for first aid, treatment of simple common conditions

HUMAN RESOURCE

§ 1 CHEW § 50 CORP

Communication Strategy at Level 1

The strategies for effective communication include: advocacy, social mobilization and
interactive communication.

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.

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.
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Social Mobilization
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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

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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.

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.

The Entry Steps

The implementation of this strategy is anticipated to take a structured, step-bystep approach that
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involves awareness creation, formation of district level working groups and training teams, and
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establishment of a formal monitoring and evaluation mechanism, all of which precede the actual
entry into the community.

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.

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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
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of the programme in a district. Scaling up of this intervention is assured through the multi-sector
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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 tonegotiate 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

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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
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agree on methods to be used, the facilitating team, including selected community members, will
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go through specific training on how to use the tools effectively to ensure standardization and
improve the accuracy and validity of findings. The scope of the assessment should include: • The
population • Community structures and processes of governance and management • Any existing
community information system • Resource availability, access, management (money, manpower,
material) • Service delivery and the minimum package of care and support • Communication
strategy, networking, collaboration and linkages • Coping mechanisms, innovations and best
practices • The status of health and well being, based on agreed indicators • The status of food

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security and nutrition, based on agreed indicators • Care seeking behaviour • The environment
(water, sanitation, shelter, soils, vegetation, infrastructure)

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.

Linkage between Community and Health Facility and Sustainability

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.

Linkage of the Community with the health system

The community level is where people live. This is the level at which most health promotive and
disease prevention activities can take place because these are strongly related to the behaviour of
people hence a healthy population. When people are healthy, the load on health facilities is
reduced and therefore health facilities work more efficiently and effectively. This is why the
community level is the foundation of the health system. If health services at the community level
are strong, the health facilities and the national health system will be strong.

Key health actors at the community level

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1. Individuals and households in the communities

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2. Leaders and various groups in the community like the religious groups, special interest groups
such as women, persons with disabilities, youth and people leaving with HIV/AIDS.

3. The local administration representing the government

4. The link health facility and the health management teams

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5. Development partners working in the area

6. The Community Health Committees, Community Health Extension Workers and the
Community Health Workers

Role of CHEWS

1. Visiting homes to determine health situations and dialogue

with household members

2. Supervise and train CHVs

3. Identifying and sensitizing communities on health interventions

4. Identifying common ailments and minor injuries at

community level collecting health data at household level for
analysis

5. Distribution of information education communication materials,

mosquito nets and other commodities to households

6. Maintaining and updating health data using health registers and

keeping records

7. Identifying and referring health cases to appropriate health

facilities

8. Monitoring growth of children under the age of five years

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9. Identifying defaulters of health interventions and referring them

to appropriate health facilities
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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 healthrelated information and data generated in
the communities are rarely linked with those higher levels. This makes health reports less

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comprehensive than they should be and inadequate for effective monitoring, evaluation and
planning. At community level, the evidence is grounded in the communitybased information
system, which refers to information required, gathered, analysed and used by the community and
other levels for planning, monitoring and decision making related to KEPH at the community
level. The system enables the community to follow up on the progress of implementation of
planned activities, to determine their success and constraints in achieving their objectives.
Because there is not likely to be an elaborate management information system in very many
communities, it is important that a system be designed and established for the collection,
analysis, reporting and use of realistic health and health-related information. In order to make
this information complete there is a need to establish reasonably uniform community-based
information systems across the sector. Similar efforts must be taken to link or integrate this
information to the present HMIS 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 availableCBIS 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
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meetings. CHEWs and CORPs and other leaders should use the information to monitor progress
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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.

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Activities and Inputs for Implementing the Community Strategy

The 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 countrywide.

Assembling Key Implementation Partners

Experienced 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.

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
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secretariats and identify a district focal person for LEVEL ONE SERVICES. • Establish
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coordination and collaboration mechanisms/committees at national, provincial and district levels

to spearhead evidence-based planning, monitoring and evaluation (quarterly meetings at each
level).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.

Strengthening Linkage between the Health System and the Communities

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Fundamental 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.

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.

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
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health workers to the communities.

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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

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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.

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

OTHER NOTES
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The following are workers in the community:

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Community Health Volunteer (CHV): Volunteerworkersprovidelevel1servicesandsupport

community for their initiatives to improve their health status

Community Health Committee (CHC): Governance body for CU consists of

representatives from different groups and villages provide leadership for managing level 1
services and activities in CU and build partnership with stakeholders. They are usually 9-13

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members. Community Health Extension Worker (CHEW): Health or development workers
support CHVs and CHC technically through supervision and mentoring and strengthen linkage
between CU and higher health systems.

Services delivered at Tier one

Facilitate individuals, households and communities to carry out appropriate health behaviours,
provide agreed health services like education concerning health problems and methods of
preventing and controlling then, promotion of food supply and proper nutrition, supply of safe
water and basic sanitation, maternal and child health care, including family planning,
immunization against infectious diseases, prevention and control of endemic diseases, treatment
of common diseases and injuries, provision of essential drugs and community based
rehabilitation. Finally, recognize signs and conditions requiring referral and manage the referrals.

10. Convening and coordinating monthly community meetings,

quarterly and action days
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