Background

Community health is a flagship initiative of Kenya’s Vision 2030 and is recognised as the first level of facility care in the Kenya Health Act of 2017. As such, the Kenya Community Health Policy 2020-2030 provides the framework for community health services. Kenya has further adopted primary health care to achieve Universal Health Coverage (UHC), as outlined in the Kenya Primary Care Strategic Framework 2019-2024, which places emphasis on community-based primary health care.

To increase demand for primary health care, the Government of Kenya recognised the need for social accountability to balance the demand and supply of service provision. To this end, the government set out to empower individuals and households to understand and realise their right to equitable, high-quality health care and to demand services through the third edition of the Community Health Strategy 2020-2025.

To accelerate the realisation of this aspiration, Kenya started implementing the community scorecard in 2021, following the development of the Kenya Community scorecard Guidelines for Social Accountability in Primary Health Care to ensure coordinated implementation nationwide.

Kenya started implementing the community scorecard in 2021

How community scorecards work

Quality of care community scorecards are participatory tools used to:

• Collect feedback from community members to assess the quality of care
• Increase accountability
• Inform actions to improve local health services
• Enhance community ownership and engagement

Each community scorecard is made up of several indicators used to assess the quality of health services offered at the local health facility or catchment area. Examples include the:

• Availability of medicines
• Cleanliness of the facility
• Patient waiting times

To-date, the community scorecard has been rolled out in 15 counties, among them Kakamega County. Located in the western part of Kenya, about 30 km north of the equator, Kakamega County consists of 12 sub counties (subregions). The county is home to a population of approximately 1,867,579 people (Kenya Population and Housing Census, 2019) and has 425 Community Health Units (CHUs) (Kakamega County Health Sector Strategic and Investment Plan, 2018-2023) with 4,250 Community Health Promoters (CHPs) distributed across the 12 sub counties.

Adoption and utilisation of the community scorecard

The Community scorecard rollout in Kakamega County began with a pilot project in 2021, focusing on Khwisero sub-county, which already had an established community health unit with consistent dialogue and action days. Due to the pilot’s remarkable performance in bringing the community’s voice to service delivery, the African Leaders Malaria Alliance (ALMA) supported the expansion of the Community Scorecard in 2022 to all 12 sub-counties in Kakamega County, targeting one community health unit in each sub-county.

Gladys Wafula, a public health officer in Matungu Sub-County, was one of those training participants on the Community scorecard alongside community strategy coordinators from 12 sub-counties. “This tool is designed to improve health services by actively involving the community in identifying challenges and implementing effective solutions,” she explains.

After the training, Gladys led the Community Health Promoters (CHPs) linked to Matungu Sub-County Hospital in collecting feedback on the facility’s health service delivery. The assessment revealed three major issues in Quarter 2 of 2022 – the cleanliness of the facility, the availability of drugs and diagnostic services, and the need for respectful and compassionate care.

Community members raised significant concerns about the cleanliness of their local health facility. A facility visit confirmed the assessment report – overgrown bushes, scattered litter, and maternity waste were found across the compound, in the pit latrines, and in the outdoor bathrooms. This created discomfort and significantly lowered hygiene standards. Furthermore, the pit latrines were at capacity, and handwashing facilities were absent. Particularly alarming was the state of the maternity wing, which lacked dedicated toilets and bathrooms. Mothers in labour and those who had just delivered were forced to use the same lavatory facilities as everyone else, compromising their privacy and hygiene.

Community members further raised concerns about the availability of drugs and commodities, citing frequent shortages that often forced them to pay out of pocket for prescriptions.

Community members expressed dissatisfaction with the treatment they received at the facility. Expectant mothers reported poor reception upon arrival to deliver, and harsh language further contributed to their negative experiences. This challenge extended to outpatient services, where patients often felt lost and unwelcome due to the absence of a customer care desk. The reception from nurses was frequently perceived as unkind, adding to the patients’ discomfort.

Taking corrective measures

Determined to make a change, the Health Facility Management Committee at Matungu Sub-County Hospital took action to address the issues raised by community members:

To improve the client/ patient experience, the health facility conducted training for all healthcare workers at the hospital. With budgetary support of about Kshs. 270,000 from a partner- Boresha Jamii, this training focused on handling a diverse range of patients, including outpatient, inpatient, and maternity cases and a customer care desk installed to offer direction to patients. As a result, there has been a notable improvement in how community members perceive the quality of services offered at Matungu Sub-County Hospital.

To address the hospital’s cleanliness and hygiene, the sub-county Health Management Team (HMT) allocated funds (Kshs.70,000) from the county to purchase a lawnmower for cutting grass and clearing bushes, a task previously reliant on borrowing equipment from other facilities. Additionally, the Public Health Officer in charge of the facility successfully petitioned the construction of new latrines and bathrooms to the county government, which was promptly funded to the tune of Kshs. 350,000. The county also facilitated renovations of the maternity wing, creating a dedicated unit that ensures privacy and easy access to sanitation facilities. Furthermore, new pit latrines and bathrooms were constructed for post-natal and inpatient clients, and handwashing facilities were installed, significantly improving the level of hygiene for all patients. Notably, the construction project saw the active involvement of community members. Among them was Hamisi Kawale, a resident of Matungu Sub-County and a construction contractor.

On the front of drug supply, Matungu Sub-County hospital has successfully strived to secure a steady supply of drugs. To address emergencies, such as the frequent cases of low blood levels among expectant mothers, the hospital has taken proactive measures to purchase essential drugs when stock runs low. This initiative is complemented by the larger supplies awaited from the county level.

• Training: The health facility conducted training for all healthcare workers at the hospital
• Funds: Various funds were mobilised to improve the health facility
• Supplies: The availability of various supplies was improved

I was called to support the construction of a new lavatory and bathroom facility. When I came, the situation was quite dire—expectant mothers struggled a lot due to the lack of a dedicated facility. Furthermore, the state of the facilities made my work difficult at the beginning, but I forged on. Now, the hospital is clean. Community members who brought this issue up and the Health Facility Management Committee that addressed this concern have given the hospital a huge turnaround. Today, the hospital is what it should be, and as a member of the community whose family also relies on Matungu Sub-County Hospital for our health needs, I am glad to have contributed to this change. The community is now happy to come to the facility and is proud of Matungu Sub-County Hospital.

Hamisi Kawale

Judith Nyongesa, the Community Health Services Coordinator for Kakamega County, notes that the challenge of drug supply extends beyond Matungu sub-county Hospital and affects all 12 Sub-Counties in County. This issue identified as a cross-cutting challenge through the Community scorecard is rooted in inadequate health budgets. In response, the county operationalised the Facility Improvement Fund (FIF) in early 2024. The FIF model incentivises health facilities to generate more funds, with a percentage allocated back to them. This initiative enables facilities to address critical gaps, such as the absence of essential drugs and pending bills and facilitates urgent stock replenishments while awaiting national government supplies. The initiative has significantly improved drug availability and overall healthcare delivery at Matungu Sub-County Hospital and across the county.

Community impact

Mildred Malala, a community member, mother of four, and farmer, has sought health services from Matungu Sub-County Hospital since 2014. As her primary healthcare provider, the hospital has been essential for her antenatal care, child deliveries, immunisations, and regular checkup for her children. Additionally, she and her husband turn to the hospital for their own health needs due to its proximity.

Mildred reflects on her past experience at the facility. “When I first started coming here and for a long time thereafter, there was litter everywhere, including medical waste, especially from the maternity wing. Women, especially after delivery, faced challenges accessing clean bathrooms, which were quite far and unclean. This poor hygiene increased their risk of infections.”

However, Mildred notes a significant turnaround over the past year. “There was a community dialogue where feedback on why people were avoiding the hospital was gathered. Cleanliness was a major concern, and this feedback was taken seriously by the Health Facility Management Committee. During my recent visit, I saw the positive changes firsthand. New latrines have been built and are well maintained, and there is now a dedicated bathroom in the maternity wing. Women no longer have to struggle to find a clean facility outside. This has made a huge difference in how we experience care here.”

Mildred is hopeful for continued improvements.

The hospital is getting better and better, and the number of people coming here for services has increased. I encourage my fellow community members to visit the hospital because the services have truly improved.

Mildred Malala – Community Member

A mother of two and small business owner, Dora Ambeyi equally relies on Matungu Sub-County Hospital for her family’s healthcare needs. Her involvement in community feedback sessions has been instrumental in driving improvements at the facility.

Reflecting on her past experiences, she describes the changes she has witnessed at the facility.

“Previously, our main challenges were the availability of drugs and the unhygienic conditions in the maternity wing. The lavatories and showers were particularly bad. I was actively involved in raising these concerns during community dialogues. We told health workers and Community Health Promoters (CHPs) that if a hospital is dirty, we were better off and safer at home. We urged them to improve the hygiene standards to reduce the number of home deliveries and also highlighted issues with drug availability and staffing levels.

Since those discussions, the improvements have been evident. Drug shortages have been addressed; now, instead of buying medication ourselves, we can get what we need directly from our CHPs, whether it is deworming medication or oral rehydration salts (ORS) for children with diarrhea.

The changes in the maternity wing have been especially significant. Previously, women had to endure using distant and dirty washrooms, and sometimes even gave birth outside due to the lack of proper facilities in close proximity. Now, the hospital is clean, accessible washrooms within the facility, and there is a dedicated, well-maintained space for women post-delivery.

I remember bringing my own bucket for self-cleaning after giving birth, only to be pleasantly surprised in March 2023 when a nurse showed me the clean, functional shower facilities. I felt incredibly safe and comfortable compared to my experience in 2020.

Dora Ambeyi, community member

These improvements have made a huge difference, and I am confident that the hospital will continue to enhance its services. It is reassuring to see the progress.

Conclusion

The implementation of the community scorecard in Kakamega County has significantly improved the delivery of health services. Through focused corrective measures and active community engagement, the county has addressed key issues in cleanliness, drug availability, and patient care, leading to enhanced health outcomes and increased community trust in local health services where the scorecard is implemented. This demonstrates the effectiveness of community-driven approaches in enhancing health care delivery and achieving better health outcomes.