Care as repair, but whose responsibility? Front-line health workers’ resourcefulness in implementing a PMTCT tracing policy in Kenya

Defaulter tracing policies for Prevention of Mother-to-Child Transmission (PMTCT) services are vital for achieving the global goal of zero new HIV infections. However, little is known about their implementation. This qualitative study explores the role of tracers—community volunteers, retention workers, and mentor mothers—in implementing such policy across six facilities in Western Kenya. It uses the conceptual lens of 'repair work' to unveil their ‘everyday work in keeping systems going’ ensuring care delivery to women and their infants. Data were collected through 31 semi-structured interviews with tracers and PMTCT managers, observations, document reviews, and analyzed using thematic network analysis. Our findings reveal significant variability in policy implementation, influenced by integration of PMTCT services to maternal and child health clinics and facility resources. Tracing and retaining women in PMTCT care heavily relied on tracers’ adaptive strategies and ingenuity to compensate – through repair work – for systemic shortcomings, resulting in the delivery of differentiated, person-centered care using social networks, personal funds and improvisations. Key challenges included inadequate remuneration, lack of institutional resources and support, and insufficient information and evaluation systems. Our results highlight the social nature of health systems and demonstrate the relevance of 'repair work' for health systems research, used in our paper to unveil the often-unrecognized efforts of tracers in maintaining PMTCT care continuity. To ensure sustainable and effective translation of policy into practice, policymakers, donors and program managers must allocate sufficient resources, and provide formal employment to tracers rather than relying on repair work to keep systems going.