Factors Affecting of Health Services by Community Health Units

Health is a major component in the socio-economic development of any community. Promotion of good health at different levels of the society is the responsibility of all individuals, families, households, and communities [1]. Implementing community health services is a top priority of the Ministry of Public Health and Sanitation (MOPHS), and its partners in Kenya. This is well articulated in the Ministry of Health Joint Programme of Work and Funding, 2006/2007–2009/2010, the MoPHS strategic plan 2008-2010 and the second National Health Sector Strategic Plan (NHSSP II) of 2005–2010 [2]. The Kenya Essential Package for Health (KEPH) introduced six life-cycle cohorts and six service delivery levels. One of its key innovations is the recognition and introduction of level 1 service, which aimed at empowering Kenyan households and communities to take charge of improving their own health (Ibid). Community strategy which forms basis to achieve this is an approach which aims at empowering individual communities at household level to take control of their own health issues through community health units. The community forms the foundation in the provision of affordable, equitable and effective health care [3].


Introduction
Health is a major component in the socio-economic development of any community. Promotion of good health at different levels of the society is the responsibility of all individuals, families, households, and communities [1]. Implementing community health services is a top priority of the Ministry of Public Health and Sanitation (MOPHS), and its partners in Kenya. This is well articulated in the Ministry [2]. The Kenya Essential Package for Health (KEPH) introduced six life-cycle cohorts and six service delivery levels. One of its key innovations is the recognition and introduction of level 1 service, which aimed at empowering Kenyan households and communities to take charge of improving their own health (Ibid). Community strategy which forms basis to achieve this is an approach which aims at empowering individual communities at household level to take control of their own health issues through community health units. The community forms the foundation in the provision of affordable, equitable and effective health care [3].

Objectives of the Study
To identify factors affecting implementation of health services by community health units, identify income generating activities of the community units and to determine the capacity of the community units.

Methodology
This was a descriptive cross sectional study conducted in May 2016 in nine community health units in Matuga sub-county. The study focused on collecting data on factors affecting implementation of health services by community health units. Matuga sub-county is in Kwale County and covers an area of 1,031 km 2 which is divided into two administrative divisions, namely Matuga and Kubo divisions [4]. The population projection of Matuga sub-county based on 2009 census was estimated to be 183,156 persons (Ibid). In terms of climate, the sub-county is hot and dry from January to March and relatively cool from June to August. Rainfall pattern is bimodal with long rains normally occurring between mid-March and June while the short rains occur between October and December [5].
Subsistence farming of food crops including maize, cowpeas and cassava is done mainly for domestic consumption. Coconuts, oranges, mangoes and cashew nuts are also grown for both domestic consumption and as cash crops. The main livestock kept include cattle, goats, ducks and chickens (Ibid). The protocol for this study was reviewed and approved by the sub-county health management team. Oral informed consent was obtained from study participants.

Sample size
The sample size was determined by the use of survey Monkey sample size calculator. A population of 450 forming nine community health units at 95% confidence level with 5% margin of error gave 208 as the sample size Stratified simple random sampling was used to select 208 respondents who were distributed proportionately within the nine community units. A yes and No piece of papers were used to select the respondents, only those who picked yes were interviewed after they had given written consent. The interviews were guided by a structured questionnaire.

Data management and analysis
Descriptive statistics were used to analyze the data. Data were double-entered into a computer using Ms Access and after validation analyzed using Spss version 17.0.

Results
Nine community units participated in the study involving 208 respondents (community health volunteers). Most of the community health volunteers (85%) knew what community strategy is with slightly above 90% of the respondents saying community strategy is relevant in health service delivery system. About 86% said community strategy helps in health service delivery by acting as a link between the health system and the community. More than 84% of the respondents didn't know their roles as community health volunteers only about 11% of the respondents knew most of their roles. There was no association between knowledge on community strategy and knowledge on the roles of community health volunteers (p=0.577). Most of the community health volunteers (68%) managed 20 households, the required number of households per community health volunteer and the rest (32%) managed 25 and above households. Slightly above 30% of the community health volunteers said it's not easy to manage 20 households citing lack of motivation in terms of allowances, transport, and long distance between households, illiterate community making it hard to understand health messages and also challenging questions asked by the community members. Other reasons given were; they (community health volunteers) were not recognized by ministry of health staffs, lack of equipments like the reporting tools, hardship areas and lack of cooperation from the community members.
On source of funding, slightly above 50% do not get funding from any agency but get their funding through member contributions the rest get their funding from the partners (Aphia plus -an NGO) and Ministry of health. Again about 41% of the respondents have farming as their source of income, 25% did business and the rest didn't have any source of income. Majority of the respondents (80%) felt good to work as community health volunteer but 20% said they had no alternative. Given alternative, 84% of the respondents said they would still work as community health volunteers and 16% said they would not. About 50% of the community health volunteers had dropped citing various reasons; no payment, marriage, employment elsewhere, harsh community, doing business, family issues, movement to other areas and others had no apparent reasons to drop.
About 60% of the respondents had income generating activities ranging from farming, keeping chicken, utensils for hire, hotel, and selling of firewood and catering services. Others respondents didn't have any income generating activity but relied on partners and other agencies for funding.

Discussion
The findings of this study revealed that not all community health volunteers who were trained on community strategy understood what community strategy is as. About 15% could not define community health strategy though majority agreed that community health strategy is relevant in the ministry of health, a fact which the ministry of health and other stakeholders can capitalize on to improve on the health indicators. Though majority knew and agreed that community strategy linked the community and the health system, only 11% knew most of their roles. This means that there is a need for a refresher training of the community health volunteers. Again the findings of this study suggests that there is no association between knowledge on community strategy and knowledge on the roles of community health volunteers in community health strategy (p=0.577) as such these variables needs to be handled independently, a community health volunteer having knowledge on community strategy did not necessary mean he or she had knowledge on their roles. Majority of the community health volunteers had no source of income, and we can therefore speculate that this could be contributing factor why there is high attrition rate (50%) of the community health volunteers in Matuga Sub County. The high dropout rate suggests there could have been misconception of community health strategy approach, it could have been misunderstood to mean employment of community health volunteers. There is therefore need for creating community awareness that it is a volunteering work and people need not to expect to be paid. The study findings also suggested that majority of the respondents felt good to work as community health volunteers and are willing to remain community health volunteers even if given another alternative. This is a fact that the ministry of health can take advantage of. If the challenges facing the community health volunteers are addressed there is probability health indicators can improve. Income generating activities appears to be an important factor which keeps the cu together and needs to be encouraged as this will reduce attrition rate.

Recommendations and Conclusion
• The ministry of health should do refresher trainings to the community health volunteers from time to time. • .The Cus need to be encourage to start income generating activities. • The Ministry of health and other health stakeholders to support the Cus with bicycles, (increase the number of bicycles) to facilitate movement of the community health volunteers. • The Ministry of health should organize to give community health volunteers identification cards for ease identification when in the field. • Partners and Ministry of health to provide the Cus with reporting tools. • The Ministry of health should come up with guidelines which will guide the operation of Cus in Matuga Sub County to avoid partners supporting some Cus. • The community need to be mobilized on the importance of community health volunteers in the community. • The ministry of health Kwale should address the challenges raised by community health volunteers.
The major limitation in this study is illiteracy of some respondents (community health volunteers) were interviewed during the study.