Understanding what factors influence community health worker involvement in hypertension service delivery in Kenya: applying a community health system lens.

The systematic involvement of community health workers (CHWs) in hypertension management can improve outcomes and achieve blood pressure control. However, much of this evidence is from effectiveness trials conducted under ideal conditions, with little evidence from programmes operating in routine conditions. In Kenya, recent policy changes have expanded CHW roles to routinely incorporate non-communicable disease (including hypertension) service delivery. We undertook an exploratory descriptive qualitative study in one county, examining what CHWs now referred to as community health promoters (CHPs) do in relation to hypertension service delivery, influences on their involvement, and considerations for sustainability. We found ad hoc and fragmented CHP involvement in practice despite policy guidance for community-level hypertension service delivery. Drawing on the extended health systems building blocks framework, we identified multiple capacities that can support expanded CHP roles in hypertension care, including the pre-existing community health service structure and societal partnerships, as well as their level of motivation. Policy provisions for CHP professionalization (payment of stipends, provision of CHP kits with varied commodities and training) create an enabling environment. However, sustained adoption of the new CHP roles may be impeded by (i) challenges in meeting the financial and supply chain obligations for stipend payments and commodities, respectively; and (ii) inadequate sensitization of communities and frontline-providers concerning expanded CHP roles and implications for facility-level hypertension care. To effectively implement recent policies, strengthening coordination and communication across all community and health system actors is needed, as well as clarity and deliberation on long-term financing for the community health system.