Background: Global interest and investment in close-to-community health services is increasing. Kenya is currently revising its community health strategy (CHS) alongside political devolution, which will result in revisioning of responsibility for local services. This article aims to explore drivers of policy change from key informant perspectives and to study perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change.Methods: We conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives, including those who will influence or be influenced by CHS policy change in Kenya (policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members) in two purposively selected counties: Nairobi and Kitui. Qualitative data were digitally recorded, transcribed, translated and coded before framework analysis.Results: There is widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas for change identified include: lack of clear supervisory structure including provision of adequate travel resources, current uneven coverage and equity of community health services, limited community knowledge about the strategy revision and demand for home-based HIV testing and counselling.Conclusion: This in-depth analysis which captures multiple perspectives results in robust recommendations for strategy revision informed by the Five Wonders of Change Framework. These recommendations point towards a more people-centred health system for improved equity and effectiveness and indicate priority areas for action if success of policy change through the roll-out of the revised strategy is to be realized.

Objectives The objective of this study is to identify enablers and barriers in access of HIV and sexual reproductive health (SRH) services among adolescent key populations (KP) in Kenya. Methods A cross-sectional study using qualitative methods was conducted between October 2015 and April 2016. A total of 9 focus group discussions and 18 in-depth interviews were conducted with 108 adolescent KPs in Mombasa, Kisumu and Nairobi Counties of Kenya. Data were recorded digitally, translated, transcribed and coded in NVivo10 prior to analysis. Results Adolescent KPs preferred to access services in private health due to increased confidentiality, limited stigma and discrimination, access to adequate amount of condoms, friendly and fast-tracked services. Negative health provider attitudes made adolescent KPs dislike accessing health care in public health facilities. There was a lack of adolescent key population's policies and guidelines on HIV and SRH. Conclusions The study has demonstrated existing enablers and barriers to provision of HIV/SRH services for an at-risk population for which limited data exist. The results provide a basis for program redesign involving the adolescent KPs to minimize barriers for access to HIV/SRH services. Keywords Adolescents Á Adolescent key populations Á People who inject drugs Á Sex workers Á Men who have sex with men (MSM) This article is part of the special issue ''Sexual and reproductive health of young people-Focus Africa''. The Rudolf Geigy Foundation (Basel, Switzerland) funded the open access publication of this article.

Background Close-to-community (CTC) providers of health care are a crucial workforce for delivery of high-quality and universal health coverage. There is limited evidence on the effect of training supervisors of this cadre in supportive supervision. Our study aimed to demonstrate the effects of a training intervention on the approach to and frequency of supervision of CTC providers of health care. Methods We conducted a context analysis in 2013 in two Kenyan counties to assess factors that influenced delivery of community health services. Supervision was identified a priority factor that needed to be addressed to improve community health services. Supervision was inadequate due to lack of supervisor capacity in supportive approaches and lack of supervision guidelines. We designed a six-day training intervention and trained 48 purposively selected CTC supervisors on the educative, administrative and supportive components of supportive supervision, problem solving and advocacy and provided them with checklists to guide supervision sessions. We administered quantitative questionnaires to supervisors to assess changes in supervision frequency before and after the training and then explored perspectives on the intervention with community health volunteers (CHVs) and their supervisors using qualitative in-depth interviews. Results Six months after the intervention, we observed that supervisors had shifted the supervision approach from being controlling and administrative to coaching, mentorship and problem solving. Changes in the frequency of supervision were found in Kitui only, whereby significant decreases in group supervision were met with increases in accompanied home visit supervision. Supervisors and CHVs reported the intervention was helpful and it responded to capacity gaps in supervision of CHVs. Conclusion Our intervention responded to capacity gaps in supervision and contributed to enhanced supervision capacity among supervisors. Supervisors found the curriculum acceptable and useful in improving supervision skills.

Background Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi’s equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. Methods We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Results Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. Conclusions If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.

BackgroundPower imbalances are a key driver of avoidable, unfair and unjust differences in health. Devolution shifts the balance of power in health systems. Intersectionality approaches can provide a ‘lens’ for analysing how power relations contribute to complex and multiple forms of health advantage and disadvantage. These approaches have not to date been widely used to analyse health systems reforms. While the stated objectives of devolution often include improved equity, efficiency and community participation, past evidence demonstrates that that there is a need to create space and capacity for people to transform existing power relations these within specific contexts.MethodsWe carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from across the health system in ten counties, 14 focus group discussions with community members in two of these counties and photovoice participatory research with nine young people. We adopted an intersectionality lens to reveal how power relations intersect to produce vulnerabilities for specific groups in specific contexts, and to identify examples of the tacit knowledge about these vulnerabilities held by priority-setting stakeholders, in the wake of the introduction of devolution reforms in Kenya.ResultsOur study identified a range of ways in which longstanding social forces and discriminations limit the power and agency individuals can exercise, but are mediated by their unique circumstances at a given point in their life. These are the social determinants of health, influencing an individual’s exposure to risk of ill health from their living environment, their work, or their social context, including social norms relating to their gender, age, geographical residence or socio-economic status. While a range of policy measures have been introduced to encourage participation by typically ‘unheard voices’, devolution processes have yet to adequately challenge the social norms, and intersecting power relations which contribute to discrimination and marginalisation.ConclusionsIf key actors in devolved decision-making structures are to ensure progress towards universal health coverage, there is need for intersectoral policy action to address social determinants, promote equity and identify ways to challenge and shift power imbalances in priority-setting processes.