Juma Pamela A, Owuor Karen, Bennett Sara
African Population and Health Research Center,
Kenya Medical Research Institute, Centre for Global Health Nairobi, Kenya and.
Health Policy Plan. 2015 Dec;30 Suppl 2:ii65-ii73. doi: 10.1093/heapol/czv094.
There has been a re-emphasis recently on community health workers to provide child health care services including integrated community case management for childhood illness (iCCM). This research analysed iCCM policy development in Kenya and in particular the types of decision-making criteria used by Kenyan policy-makers in considering whether to advance iCCM policy.
Data were collected through document reviews (n = 41) and semi-structured interviews (n = 19) with key stakeholders in iCCM policy including government officials, development partners, bilateral donors, and civil society organizations. Initial analysis was guided by the policy triangle with further analysis of factors affecting policy decision-making drawing upon a simple framework developed by Grindle and Thomas (Policy makers, policy choices and policy outcomes: the political economy of reform in developing countries. 1989; Policy Sci 22: :213-48.).
Policy development for iCCM has been slow in Kenya, compared with other Sub-Saharan African countries. At the time of the study, the Government had just completed the Community Health Training Manual which incorporated iCCM as a module, but this was the only formal expression of iCCM in Kenya. We found technical considerations, notably concerns about community health workers dispensing antibiotics to be a key factor slowing iCCM policy development, but this also overlapped with bureaucratic considerations, such as how the development of community health worker cadres may affect clinicians, as well as initial concerns about how an integrated approach might affect vertically oriented programs. International actors through agreements such as the Millennium Development Goals helped to get child survival onto the national policy agenda and such actors were active promoters of iCCM policy change. However international funders had not committed funding to scale-up iCCM policy, and this probably constrained their influence over iCCM policy debate.
Kenyan actors' concerns about iCCM underline the importance of adapting global policies to local conditions, and also generating local evidence to inform decision-making.
最近，社区卫生工作者再次受到重视，要求其提供儿童保健服务，包括针对儿童疾病的综合社区病例管理（iCCM）。本研究分析了肯尼亚的iCCM政策制定情况，特别是肯尼亚政策制定者在考虑是否推进iCCM政策时所使用的决策标准类型。
通过文件审查（n = 41）和半结构化访谈（n = 19）收集数据，访谈对象为iCCM政策的关键利益相关者，包括政府官员、发展伙伴、双边捐助者和民间社会组织。初步分析以政策三角为指导，并借鉴格林德尔和托马斯开发的一个简单框架（《政策制定者、政策选择和政策结果：发展中国家改革的政治经济学》。1989年；《政策科学》22卷：213 - 48页）对影响政策决策的因素进行进一步分析。
与其他撒哈拉以南非洲国家相比，肯尼亚的iCCM政策制定进展缓慢。在研究之时，政府刚刚完成将iCCM作为一个模块纳入其中的《社区卫生培训手册》，但这是iCCM在肯尼亚唯一的正式体现。我们发现技术考量，尤其是对社区卫生工作者发放抗生素的担忧是减缓iCCM政策发展的关键因素，但这也与官僚主义考量相重叠，比如社区卫生工作者队伍的发展可能如何影响临床医生，以及最初对综合方法可能如何影响垂直项目的担忧。国际行为体通过诸如千年发展目标等协议，帮助将儿童生存问题提上国家政策议程，并且这些行为体是iCCM政策变革的积极推动者。然而，国际资助者尚未承诺为扩大iCCM政策提供资金，这可能限制了他们对iCCM政策辩论的影响力。
肯尼亚行为体对iCCM的担忧凸显了使全球政策适应当地情况以及生成当地证据以供决策参考的重要性。
