TABLE 4.
Human-Centered Design Insights Generated From Research on Community Health Volunteer Use of Supply Chain Tools, 2 Counties in Kenya
| Relevance to Design | Illustrative Quotes | |
|---|---|---|
| Behavioral Insights | ||
| Nomadic migration has dramatically declined due to the need for education, health, and demarcation of land. | Migration was less of an issue than originally assumed and some simple design considerations were required for resupplying CHVs during migration. | “People move in search of pastures and water. They move within the sub-county and rarely outside.” —County Health Management Team member, Wajir “Communities here no longer migrate, land is being partitioned and allocated to the community.” —CHV, Samburu |
| In some communities, only men move with their animals, leaving their women and children behind. | As women and children were left behind, CHVs will also remain. | “I usually migrate and leave my wives in this home. When I migrate I take 1 wife …, I usually take the wife that doesn't have any young children. I haven't migrated for 5 years.” —Husband of women of reproductive age, Samburu |
| Members from the community do visit nearby centers to trade and get basic supplies. | In many situations, CHVs within these nomadic communities will have access to health facilities to collect supplies even if migrating. | |
| Mobile phones are the main mode of communication between the people that move and the ones that are left behind. | The use of mobile phones is increasingly common and important for these communities. | |
| Supply Chain Insights | ||
| Health facilities, which will be or are responsible for resupplying CHVs, have stock-outs and overstocks. | Stock imbalances at facilities will result in stock imbalances with CHVs. | “Sometimes they make a blind order when they are in town.” —Subcounty Pharmacist, Samburu |
| Health facility staff do not routinely use data (demand data) to calculate supply requirements. | Health facilities need to have access and include CHV data in calculating their requests. | |
| Insufficient county level budget allocations result in an undersupply of commodities to facilities. | A current lack of data visibility does not support transparency and accountability. | “There is too little allocation of funds to commodities, and this is demoralizing to health care workers” —Subcounty health management team member, Samburu |
| Family planning products are supplied to the counties from the national medical stores even though demand is low, resulting in overstocking and expiries. | When counties do not request commodities, it can result in national level programs pushing out commodities. | “The uptake of FP is not high. We do not have supply chain issues for FP. We are generally overstocked rather than understocked” —Subcounty health management team member, Wajir |
| Information System Insights | ||
| Lack of standardized supply chain reporting forms has resulted in ad hoc processes. | Standardized recording and reporting of supply chain data is critical for making data available to higher levels. | “I record commodities like condoms in a notebook, but other reports I do are MOH 513, 514, and MOH 100.” —CHV, Samburu |
| Service-related forms were in place but poorly used due to their complexity and unavailability. | Reporting forms must be suitable for low literacy CHVs to ensure complete and timely reporting. | “Some of the CHVs know how to read and write. The ones that don't know how come to me, and I do it for them (reporting) like their end of month report.” —CHV supervisor, Wajir |
| Some county and subcounty level but very few facility-level staff have skills to visualize and analyze data. | Facility staff need to be trained to use the data reported by CHVs to inform resupply and ensure CHVs get the commodities they need. | |
| Human Resource Insights | ||
| CHVs have inadequate supervision due to lack of logistical support for supervisors to travel. | The use of mobile phones is one way to overcome some of the challenges associated with providing one-on-one supervision. | “I do supervision based on priority or challenges like availability of motorcycle or fuel. It's only my own initiative. I just support myself.” —CHV supervisor, Samburu |
| Lack of support throughout the system demotivates CHVs, leading to high attrition. | If CHVs are demotivated, it is essential to design a solution that makes their job easy and more rewarding. Also, take into consideration that if attrition is high, supply chain tools must be simple so new staff can be easily trained. | “We started with 20 CHVs but only 2 of them are active.” —CHV, Wajir |
| Service Delivery Infrastructure Insights | ||
| Mobile clinics are designed to be located at strategic points such as the watering points; however, they are not operational or fully utilized due to inadequate funding and support. | Mobile clinics are being strengthened and could possibly resupply CHVs in the future. | “The nomadic clinics go to static settlements where there are no dispensaries. If they were designed differently, they would reach the nomads.” —Subcounty health management team member, Wajir |
| Meetings are held regularly and with high turnout throughout the system in one county but not the other. | Monthly meetings should be strengthened as part of the supply chain strategy to improve communication, data use, and local problem solving. | “During the monthly CHV meeting we plan and schedule all activities of the month since it is a challenge to send SMS in between.” —CHV supervisor, Samburu |
| Connectivity Insights | ||
| Lack of connectivity and lack of power to charge phones hinders CHVs' communication among themselves and with their supervisor. | The design must consider that CHVs will likely not have their phones charged and have network at all times. Therefore, use of phones should be limited as much as possible to one report per month. | “Most [CHVs] have feature phones because of the battery life. Some use solar powered charges. They send 1 rep to town to charge all the phones.” —Partner, Wajir |
| Few CHVs had smartphones issued by partners, but struggled to use them for anything other than voice communication with family and friends. | Smartphone availability is increasing but capacity among CHVs to use them is still low. cStock should be designed for the future of smartphones. | “There is no connectivity here in the hospital, not even Safaricom or Telkom. If you want Telkom you go for about 500 meters to access it, for Safaricom you have to go to that hill (about 1 KM).” — Health facility in-charge, Samburu “Although CHVs have smartphones we usually (and they prefer too) sending SMSs”—Health facility staff, Samburu |
Abbreviations: CHV, community health volunteer; MOH, ministry of health; SMS, short message service.