This systematic review study synthesizes the available academic literature that interrogates the interrelationship between households and community health services in accelerating primary healthcare delivery. The study was conducted to inform on-going research on the structural linkages between households and community health services in the acceleration of primary healthcare delivery that is focusing on Kisumu County, Kenya.

For purpose of this study, structural linkages refers to the inter-relationship, roles and interventions between the households and community health Volunteers (CHVs) who are responsible for the delivery of community health services for better health outcome. The structural linkages are seen from the lenses of the interplay between the existing community health structures and the beneficiary households in optimizing the primary healthcare delivery in Kisumu County, Kenya for the achievement of Universal Health Coverage (UHC).

Why the focus on Kisumu County, Kenya? This is mainly for two reasons reinforced by the notion of positive experiences of the County in promoting primary healthcare delivery using CHVs. Secondly, the choice of Kisumu County is driven by the county’s heavy disease burden evidenced by a high prevalence of communicable diseases such as HIV and malaria. Some of the county’s critical health indicators, adapted from the Kisumu County Integrated Development Plan (2018 – 2022) and Kenya Demographic Health Survey (DHS, 2022) show a high infant mortality rate of 40/1000 live births compared to national average of 32/1000 liver births; a maternal mortality rate of 495/100,000births compared to the national average of 362/100,000 births, and under-5 mortality rate of 79 per 1000 live births. Communicable diseases such as HIV/AIDS and tuberculosis remain a major challenge to the health with HIV prevalence rate of 14.6%. The Kisumu County Health Sector Strategic and Investment Plan (KCHSSIP) (2013-2017) forms the main framework/strategy for the roll-out of the community health services under which the community health volunteers (CHVs) and community health extension workers (CHEWs) play an important role as intermediaries of CHS. However, the community health strategy model has been hampered by the weak linkages between households, village and community healthcare systems, which is key to accelerating PHC.

The provision of community health services (CHS) is critical in accelerating primary health care (PHC) delivery to the most vulnerable and deprived populations. According to the World Health Organization (WHO), ¹ community health workers (CHWs) have been widely used to deliver key health care and health promotion interventions in under-served populations in resource-limited settings and communities. In fact, The Alma Ata Declaration signed in 1978 declared PHC as the official health policy of member states. It defined PHC as ‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community or country can afford to maintain at every stage of their development in the spirit of self-reliance and self- determination’. ²

This notion of PHC was further reinforced by the 2008 WHO report entitled ‘PHC: Now, more than Ever’, which underscored the case for universal health coverage (UHC) as an instrument to improve health equity, health systems strengthening, being people-centred and purposed to promote and protect the health of communities. The 2008 report of the WHO Commission on Social Determinants of Health ³ underlined that social determinants such as income, education and political conditions of countries and societies are critical for health improvement. ⁵ Today UHC has become a critical policy imperative to advance the ideas of social justice, human rights, and equity.

At the global level, the policy imperative for PHC and the role of community health system is anchored on the Alma Ata Declaration and most recently on the 2018 Astana Declaration in marking the 40th Anniversary since the Alma Ata. The Astana Declaration provides an opportunity to take stock of the global progress in supporting community health systems and to rekindle global interest on PHC and the centrality of community health systems to achieving UHC. Held under the banner “From Alma-Ata towards Universal Health Coverage and the SDGs”, it calls for the strengthening of PHC to be inclusive, effective and efficient to realize a sustainable health system that guarantees the achievement of UHC and health-related Sustainable Development Goals (SDGs).

Agarwal et al ⁴ observe that the Astana Conference provides a shift from whether CHW programmes are effective to identifying what makes the CHW programmes effective. Regretfully, world governments have been slow in formulating national policies, strategies and plans of action to launch and sustain PHC, especially in developing countries, as part of a comprehensive health system. ³ Underlining this argument is the notion that the success of PHC will, among others, be driven by empowering individuals and communities through their participation in the development and implementation of policies and plans impacting on health outcomes.

Africa has an enormous task to achieve an inclusive and transformation growth unless it invests in sustainable health systems. The WHO estimates that investing an additional $21 to $36 per capita per year over the next five years in Africa would save 3.1 million lives, out of which 90% would be mothers and children. It would also prevent 3.8 million to 5.1 million children from stunting with anticipated economic gains in five years amounting to $100 billion from additional investments in health. ⁵³ According to Rifkin, ⁵ it is estimated that by 2030, nearly 9 out of 10 of the extreme poor will be found in sub-Saharan Africa. The WHO ⁶ gives an even more stark picture, pointing out that while the African region constitutes 11% of the world population, it has 60% of people living with HIV/AIDS and constitutes 300-500 million malaria cases occurring every year globally. The continent faces many other health challenges such as polio, rising cases of non-communicable diseases (NCDs), and high maternal and child mortality rates. Most countries did not meet the health-related Millennium Development Goals (MDGs) by 2015 and are not on track to achieve SDG3 on good health and well-being.

The dwindling fiscal space for health financing in Africa has further accentuated the challenge of meeting the health goals. Most countries are failing to meet the 2001 Abuja Declaration target of allocating 15% of total government expenditure to the health sector, and only five countries (Botswana, Rwanda, Zambia, Madagascar and Togo), have met the Abuja target so far. ⁵³ Data from the World Bank ⁷ shows a significant increase in out-of-pocket expenses in almost all countries, and the regional average peaked from US$15 per capita in 1995, to US$38 in 2014. This translates to 11 million Africans falling into poverty every year due to high out-of-pocket payments. The fragility of Africa’s health system provides for a policy imperative to strengthen CHS to give impetus to the role of CHWs to accelerate PHC delivery and reduce disease burden. The Third Global Forum on Human Resources held in 2013 recognized that CHWs programmes could play a critical role in accelerating MDGs/SDGs and achieving UHC. ⁸ The WHO Africa region has argued the case for increased scale up of access to PHC services and progress towards UHC by promoting the expansion and implementation of CHW programmes. ⁸ This position is in fact a build up to the 1987 Bamako Initiative adopted by the African Ministries of Health on increasing access to essential drugs and other health care services by strengthening the PHC services ⁹ and that of the African Union of deploying 2 million CHWs across sub-Saharan Africa. ¹⁰

In Kenya, both the 2010 Constitution and the Vision 2030 policy blueprint commit to improving the health of the population by declaring health as a basic human right, and have now devolved health services to the counties. In addition, The Kenya Health Policy (2014-2030) seeks to achieve UHC by 2030. ¹¹ Despite this policy articulation and existence of robust strategies, the country is far from achieving the health goals. Available data, show that maternal mortality rate remains as high at 362 per 100,000 births, malaria incidence per 1000 population stood at 225, while infant and under-5 mortality remains high at 39 per 1000 live births and 52 per 1000 live births, respectively. Kenya is also grappling with communicable diseases such as HIV/AIDS and tuberculosis, with new HIV infections per 1000 infected estimated at 146 despite a drop in prevalence rate from 6.7% in 2003 to 5.9% in 2015. ¹² Tuberculosis incidence per 1000 population stood at 90 in 2015. NCDs are increasingly becoming a burden to the health system with rising cases of cancer causing an estimated 21,000 deaths annually. ¹³

To improve health outcomes, especially for poor and vulnerable populations, the Government of Kenya prioritized a community health strategy. The second National Health Sector Strategic Plan (NHSSP II) (2005-2010) adopted the Kenya Essential Package for Health (KEPH), which underlined the policy imperative for community health. The KEPH was operationalized in 2006 as a package for the community health strategy – “Taking the Kenya Essential Package for Health to the Community: A Strategy for the delivery of Level One Services” and further revised in 2014 into the current Community Health Strategy (2014-19). The community strategy is geared towards enhancing community access to health care as an intervention to improve productivity and address poverty in Kenya. The communities have the responsibility to manage their own health while PHC provides the basis for CHS as a fundamental human right, social justice and equity. The implementation of the CHS in Kenya has been less than optimal and the CHWs and volunteers who form the bulk of the workforce for the level one services have weak linkages with households/wards and communities.

Most written studies on challenges facing the CHS have narrowly focused on skill development for CHWs. Therefore, this research study looks at some of the functional and behavioural gaps, the structural linkages between households and CHS delivered by the CHWs, the health-seeking behaviour of the households demanding the CHS, and examines some of the successful community health models with a view to proposing a functional model of community health for PHC delivery in Kenya.

This systematic literature review study provides a comprehensive synopsis of empirical studies that could inform a primary research on two main questions as follows: (a)

How does the interaction between households and CHWs affect utilization of CHS to promote equity and right to health in Kisumu County?

The systematic review targets both qualitative and quantitative conceptual and empirical studies. The study applies a descriptive approach by using narrative review ²² to provide context and substance to the two main research questions: (1)

How does the interaction between households and CHWs affect utilization of CHS to promote equity and right to health in Kisumu County?

For purposes of searching the literature, the study used the operational terms “CHW/V” defined as ‘members of the community selected from the area with the task of improving the community’s health and well-being and linking the people to primary care services’ and “CHS” operationally defined as ‘provision of community healthcare services to a client or patient usually at home or residential setting’.

The process of the selection of the studies involved an electronic search identified 366 records, from which 21 studies were retained ( Figure 1). The 21 studies included 19 qualitative and 1 mixed-methods and one randomised control trial. The studies were conducted in India, Cambodia, Uganda, Ethiopia, Burkina Faso, South Africa, Ghana and Kenya. Table 1 lists all studies included in this study.

The quality of the studies was good in terms of providing evidence and application of the methods though the authors offer a critique in terms of relevance to the research questions to determine a research gap. Hence it is important to underline that most of these studies have been narrow in scope and limited to analysing the role of CHWs in the health system and less on community and systemic issues that impact on their performance. The studies have also not focused on the contextual relations between the health volunteers and communities they serve especially from the perspective of the recipient of the services in this case the households. ²⁴

This systematic review has explored the structural linkages between community/households and the CHS by examining some select studies from the global, regional and local level to understand the interaction between households and CHWs. The systematic review has examined two dimensions that affect this linkage in terms of how the interaction between households and CHWs affect the uptake of CHS and how the health-seeking behaviour of households influence their choices of CHS being delivered by CHWs in the acceleration of PHC services. Evidence from the 21 selected studies show that improving this structural linkage is critical for the uptake of the CHS and towards subsequent acceleration of PHC delivery. The achievement of the SDG3 on good health, and well-being target 3.8 to achieve UHC will depend on the acceleration of PHC for poor and vulnerable populations.

Evidence from the studies show that the relationship between household/communities and CHWs is important in strengthening the interaction and optimize the utilization of CHS. ³¹ Important factors that impact on this relationship includes the social determinants of health, socio-cultural influences, importance of trust and confidentiality, and building on the social capital. A study conducted in Odisha, India, for example, observed that trust-building with the community is a critical determinant on utilization of CHS. This was also corroborated by the outcome of similar studies conducted in Kenya, Malawi, Mozambique and Ethiopia by Kok et al ⁴⁶ on factors shaping the relationship between households/community, CHWs and the health sector. These authors observed that this relationship is particularly important since CHWs act as intermediaries with the health facilities given their understanding and familiarity of the socio-cultural context. The findings from this particular empirical study re-affirms the importance in the trusting relationship for CHW/Vs as key to performance and also establishes that the bond of relationship between CHW/Vs and their supervisors’ impact on their relationship with the communities.

Trust and confidentiality are very important in fostering strong linkage between the households/community and CHWs and this has an impact on the uptake of the community health services. Most of the selected studies underlined the role of perception and attitudes that influence the interaction. This is corroborated in the study by Rachlis et al ²⁸ on community perceptions of CHWs specifically for HIV, tuberculosis and hypertension patients in western Kenya. Their findings showed that some participants’ perceptions of CHWs act as an impediment in the management of chronic diseases, especially issues related to lack of confidentiality or information/knowledge on the subject matter. A study by Grundy & Annear ²⁹ in Kwa-Zulu-Natal, South Africa, on the role of CHWs in delivering maternal and child health services, observed that the lack of trust and confidentiality was perceived to be the most singular barrier to CHW acceptability and those CHWs with reputation of confidentiality were trusted by the individuals, households and communities. Evidence from the studies also observed that the interaction between the households and CHWs was in some instances influenced by the ability or inability to provide extra resources, especially to needy households. Some poor households see the CHWs not just as a medical aide support but that they should be able to meet their financial needs. ^{27 , 43 , 44}

This systematic review of the studies shows that health-seeking behaviour of household and communities influence their health care preferences. ³⁴ This is important for the poor and vulnerable communities who suffer from catastrophic health expenditure and rely on CHWs as their best preference. Using the Pathways model developed by Ref. 38, the social and cultural factors affect the steps of the process from the detection of symptoms to choosing health care services. A study by Mushtaq et al ³⁵ in Pakistan provides evidence to show that issues of gender and NCD burden are critical in influencing the health-seeking patterns of households.

Studies are also showing that women are disadvantaged due to cultural reasons from making health choices for themselves and their children without the consent of the head of household. ^{32 , 35} In some contexts, the limited number of female health workers limits the women’s access to health care and accounts for the growing burden of the NCDs, such as hypertension. This is also corroborated in a qualitative study conducted in North Eastern Kenya by N’Gbichi et al, ³⁶ which observed that women will prefer home-delivery by a skilled attendant if there are no female nurses to attend to them in a hospital facility. This buttresses the point that while delivery in a health facility is the preferred choice, culture could act as a disincentive against using the facility and home delivery is preferred to avoid male nurses or doctors.

The households/community perception on issues of trust and confidentiality does affect the choices they make on whether to utilize the CHWs. ⁴¹ Other factors that influence the uptake of the CHS include distance to reach communities, infrastructure of geographical location, credibility, lack of awareness of the CHW services or poor engagement amongst the community. ^{41 , 45}

Community health services are critical for the acceleration of PHC delivery amongst vulnerable and deprived populations. It forms an important pathway for the achievement of UHC, which is an outcome of SDG3 on health. Fostering strong structural linkages between the households/wards and CHS being provided by the CHWs/Vs would therefore accelerate the achievement PHC delivery.

The findings from this systematic review study have demonstrated that PHC delivery is critical for better health outcomes and to achieve UHC. The studies have revealed that CHS could significantly contribute to the acceleration of PHC and the agency role of CHW/Vs is paramount at a community level. There is an imperative for strengthening the linkages between households/community and CHW/Vs to foster the uptake of CHS. Evidence from the systematic study pinpoints that understanding the health-seeking behaviour of the households is critical as this influences the choices households make on whether to utilize the health services provided by the CHW/Vs.