The fact that iCCM policy potentially affected the interests of so
many different departments and units, appeared to be one of the reasons
why such a consultative approach to policy formulation had
been employed, but was also clearly a factor slowing decision-making.
Most respondents in the Ministry recognized that while community
health policy all came to a ‘head’ at the CHW, there were multiple
vertical programs that did not necessarily have aligned interests.
... .you see when you integrate and you still remain vertical, that
is what hampers the whole thing because we say ok if we want it
to be integrated then why can’t it be under one house? ... ..
Because what I get from there will not score me much. ... are you
getting me? (02-Govt Official, non-Child Health)
Finally, one further factor that may have contributed to impetus for
the strengthening the community strategy was the establishment of
the MOPHS separate from the MOMS. The existence of MOPHS
and its focus on promotive and preventive health services may have
helped strengthen community level services.
Relationships with international actors
Policy development in relation to community-level child health
interventions emerged from both a global push and local recognition
of the problem, with most respondents feeling that the iCCM policy
agenda was driven in good part by the global push to address the
main issues contributing to child morbidity and mortality, and the
need to achieve the MDGs.
It’s based on the child health indicators, they were too poor and
we were really struggling to catch up with the MDG targets. You
know whenever the president reports the progress of MDGs in
Geneva every year, we have that difficulty especially with the
child health indicators... .. our indicators have been poor and
we have to improve them. That is what triggers the policy (007,
Govt official, Non-Child Health)
The existence of global evidence and recommendations on successful
childhood interventions at community level shaped the thinking
around the iCCM agenda among government actors. Various
national level meetings were held between 2010 and 2012 to discuss
iCCM and related issues. Of particularly importance were the issues
around use of zinc and antibiotics at the community level and the integration
of iCCM in the overall community strategy. Development
partners pushed for acceptance of use of antibiotics and zinc by
higher-level decision makers.
Participants emphasized WHO and UNICEF, in addition to the
Ministry of Health, as being the most powerful actors who had been
strongly supportive of iCCM in the country.
these two agencies [WHO and UNICEF] have really been drivers
of child survival both at global, regional and country level. And
maybe they feel that as a ministry we are not moving fast enough
to start adopting these policies. For them, this should have happened
yesterday. (01-Govt Official, Child Health)
Although respondents widely acknowledge the influence that international
actors had brought to bear on iCCM policy debates, there
remained a lack of clarity on the financing and sustainability of a
potential iCCM policy. Several donors mentioned intentions to support
the scale up of community interventions, but their commitments
to iCCM were not very specific and the funding that was
available appeared to be for relatively small scale pilots rather than
nationwide scale up:
We have resources for child health but they are limited and we’re
gonna have to make some very difficult choices on what we can
do with those resources. We do ask our partners on the ground
to leverage on other sources of funding ... ... you get a mix of
the resources and see whether you can get a greater effect. But
really our resources, what is available, is not enough to provide a
huge coverage for ICCM. 05-International Org/Donor
At no stage in the Kenyan case was a substantial amount of money
made available by donors for iCCM implementation (in contrast
e.g. to Mozambique, Burkina Faso and Niger). Thus although international
actors had clearly been influential in iCCM policy debates,
there appeared to be relatively lower dependency on them for
financing child health programs than in other contexts.
Political stability and support
Finally we note that concerns about political stability did not enter
into debates about iCCM policy formulation in Kenya. Although
there was high-level political concern regarding the country’s trajectory
to achieve MDG 4 on child survival, and this created a window
of opportunity for iCCM policy, the policy itself did not appear to
be of sufficient significance to garner political support.