Background

Community participation has been emphasized internationally as a way of enhancing accountability, as well as a means to enhance health goals in terms of coverage, access and effective utilization. In rural health facilities in Kenya, initiatives to increase community accountability have focused on Health Facility Committees (HFCs). In Coast Province the role of HFCs has been expanded with the introduction of direct funding of rural facilities. We explored the nature and depth of managerial engagement of HFCs at the facility level in two rural districts in this Coastal setting, and how this has contributed to community accountability

Methods

We conducted structured interviews with the health worker in-charge and with patients in 30 health centres and dispensaries. These data were supplemented with in-depth interviews with district managers, and with health workers and HFC members in 12 health centres and dispensaries. In-depth interviews with health workers and HFC members included a participatory exercise to stimulate discussion of the nature and depth of their roles in facility management.

Results

HFCs were generally functioning well and played an important role in facility operations. The breadth and depth of engagement had reportedly increased after the introduction of direct funding of health facilities which allowed HFCs to manage their own budgets. Although relations with facility staff were generally good, some mistrust was expressed between HFC members and health workers, and between HFC members and the broader community, partially reflecting a lack of clarity in HFC roles. Moreover, over half of exit interviewees were not aware of the HFC's existence. Women and less well-educated respondents were particularly unlikely to know about the HFC.

Conclusions

There is potential for HFCs to play an active and important role in health facility management, particularly where they have control over some facility level resources. However, to optimise their contribution, efforts are needed to improve their training, clarify their roles, and improve engagement with the wider community.