Presentation given by Maryline Mireku at the CHW Symposium in Kampala, 21-23 February 2017

1. Referral to Health Facilities in Kenya – Factors that
support Community Health Volunteers in Linking
the Community and Health System
Maryline Mireku
1st
International Symposium on Community
Health Workers
21 -23 Feb 2017
Kampala, Uganda
.

2. Background
•CHWs are key in achieving universal health coverage
•CHW referral enhances access to formal health care system
2

3. Importance of
CHW Referral
•Enhances uptake of skilled services at the facility
•Enhances coordinated care between facility and community
•A successful community referral process motivates CHVs
Sources: (Oliver et. al, 2015; Mireku et.al, 2014, Crigler et.al,
2014, Brooks et.al,2014; Ministry of Health Kenya, 2013)

4. Study Aim
To explore factors influencing CHWs referral during provision of
community health services.

5. CHW Work
Structure in Kenya
Source: Ministry of Health, Kenya. Strategy
for Community Health (2014-2019)

6. Methods
Participants:
•98 Community members; 46 CHVs; 10
Community Health Committee members; 11
CHV Supervisors
Data Collection
•Qualitative (IDI and FGDs) – Referral
process, logistics, and uptake
•Quantitative – Assessment of referral
uptake
Nairobi
Kitui

7. CHW Factors
• Presence of a standardized
referral process
• Availability of logistics – referral
tools
• Regular Supportive Supervision
(educative, supportive,
administrative)
• Knowledge of available services
• Motivation
CHV supervision
meeting_ Kitui

8. Client Factors
• Low cost of referral uptake
• Perceived attitude of facility health workers
• CHV escort to facility
• Illness-related stigma
• Type of relationship with CHV*

9. Facility Factors
• Distance from community
• Cost of care
• Availability of services
• Limited waiting time
Gatikwera
Community Unit

10. Selected quotes
…come back the next day, it
was lunch time and people
were on lunch break and at
2 they are not found in
their offices. This really
disturbed me when my leg
was unwell, God healed my
leg (FGD_Kitui_Community)
…you don't have the money
to pay for the test, so you just
go back home and keep quiet
and you look like someone
who received no help at all
because you will not go back
to them and tell them that
you don't have the money to
pay for the test and they
themselves are as poor as
you are, so you just keep
quiet.
(FGD_Nairobi_Community).
they think if they get there
(facility) you will
investigate them and want
to know what they are
suffering from and they do
not want to tell the disease
they have
(IDI_CHV_Nairobi)

11. Conclusion and
Recommendations
• Lack of logistics is a threat to referral uptake in
community health service provision
• Strengthening bi-directional feedback between CHWs
and health facility can improve uptake of referrals
• There is need for clarification and management of
community expectations of the referral process

12. Co-authors
1. Lillian Otiso (LVCT Health)
2. Linet Okoth (LVCT Health)
3. Nelly Muturi (LVCT Health)
4. Robinson Karuga (LVCT Health)
5. Miriam Taegtmeyer (Liverpool School of Tropical Medicine)
6. Rosalind McCollum (Liverpool School of Tropical Medicine)

13. Maryline Mireku
Research Officer
LVCT Health
MMireku@lvcthealth.org
merylinem@gmail.com
www.lvcthealth.org
www.reachoutconsortium.org
REACHOUT is funded by the European Union Seventh
Framework Programme ([FP7/2007-2013] [FP7/2007-2011])
under grant agreement n° 306090