As long as you have engaged Community Health Promoters, no one cares if you have involved the CHCs or not”: Factors influencing community health committees in performing their community participation roles in a devolved health system in Kenya

Community participation is an essential process that entails empowering lay community members to actively engage in the decision-making, planning and evaluating the delivery of primary health care (PHC) services. In Kenya, Community Health Committees (CHCs) are mechanisms for lay community members to participate in overseeing the delivery of basic health services at the household and community levels. There is limited research or programmatic evidence on the impact and functionality of CHCs. This thesis defines CHC functionality as the extent to which CHCs provide a platform for lay community members to participate in leadership, planning, mobilizing and managing resources, and evaluating the delivery of community health services in their communities. The research questions are: i) What factors influence the functionality of CHCs as mechanisms of community participation in sub-Saharan Africa and in Kenya specifically? ii) How do CHCs’ relationships and communication with outside stakeholders and within the CHC influence the functionality of CHCs as mechanisms of community participation in Kenya? iii) How does the implementation of community/ CHC-related health policy influence the functionality of CHCs in Kenya? This research was conducted within the scope of Health Systems and Policy Research (HPSR) using a descriptive qualitative design. Data were collected between 2017 and 2021 using a combination of interviews, document reviews, and focus group discussions. Key lessons: i) There is a disproportionate focus on the delivery of community health services by health professionals over community participation through CHCs. When service delivery takes precedence, health professionals invest more time and resources in CHPs, who are perceived as more valuable in helping to achieve service delivery targets compared to CHCs. ii) Power asymmetry in CHCs affects their functionality. Power asymmetry is driven by uneven access to information and resources. Health professionals who work with CHCs exert their power by stereotyping lay community members in CHCs and excluding them from decision-making and planning processes. Lay CHCs members who are also CHPs have more access to information and resources from health professionals and other actors, such as NGOs, compared to non-CHPs. iii) Inter-role conflict among CHAs and CHPs, who are also CHC members, arises due to the dual responsibilities of providing community health services while also overseeing the delivery of those same services. Inter-role conflict influences the functionality of CHCs because CHAs and CHPs tend to focus more on meeting service delivery targets at the expense of playing their designated oversight roles as CHC members. iv) Health professionals often select CHC members they find it easier to work with. They prefer to work with elite members in relatively affluent communities and have a higher educational status than other community members. The process of selecting these members often needs to be more transparent and participatory, which erodes the trust and legitimacy of CHCs among their constituents. While CHC members may not resemble vulnerable and marginalized persons in their communities, they often stand for the interests of those they represent. While elite community members use their gravitas to advance the representative agenda of CHCs, there is a risk of elite capture in the decision-making processes. The findings and reflections in this thesis contribute to a better understanding of the complex contextual factors and interpersonal interactions that influence the functionality of CHCs in Kenya. This research also provides practical insights for health managers and policymakers in other low and middle-income settings on how to strengthen community participation through CHCs. In conclusion, the analyzed CHCs exhibited limited functionality in fulfilling their role as mechanisms for community participation, due to power imbalances within CHCs, inadequate policy guidance, insufficient awareness of roles and responsibilities, and suboptimal teamwork.