Final Report for PROJECT FOR IMPROVEMENT OF ...i Final Report for PROJECT FOR IMPROVEMENT OF HEALTH...

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Final Report for PROJECT FOR IMPROVEMENT OF

HEALTH SERVICE WITH A FOCUS ON SAFE MOTHERHOOD IN

KISII AND KERICHO DISTRICTS

March 2008

Submitted by

HANDS

(Health and Development Service)

� � � �

Report No. HANDS/ XIII / 2008 Period covered from 24th March 2005 to 31st March 2008

Final Report SAMOKIKE March 2008

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CONTENTS

INTRODUCTION..........................................................................................................................................�MAPS ..............................................................................................................................................................�PROJECT SITE .............................................................................................................................................�PROJECT PHOTOS......................................................................................................................................�LIST OF ABBREVIATONS .........................................................................................................................xi

EXECUTIVE SUMMARY............................................................................................................................1

CHAPTER 1. OVERVIEW OF THE PROJECT .......................................................................................3

� 1.1 Background................................................................................................................................... 3 � 1.2 Target Population, Implementation Period, and Activities ...................................................... 3 � � 1.2.1 Target Population.................................................................................................................. 3 1.2.2 Implementation Period ................................................................................................................. 4 1.3 Organizational Structure................................................................................................................. 5 1.3.1 Project Counterpart ...................................................................................................................... 5 1.3.2 Office Management ....................................................................................................................... 6 1.3.3 Networking..................................................................................................................................... 8

Chapter 2. Project Achievements..................................................................................................................10

2.1 Survey Conducted by the Project ...........................................................................................................10 2.2 Outputs of the Project ............................................................................................................................11 2.2.1 Output 1 .................................................................................................................................................12 2.2.2 Output 2 .................................................................................................................................................18 2.2.3 Output 3 .................................................................................................................................................29 2.2.4 Output 4 .................................................................................................................................................32 2.2.5 Output 5 .................................................................................................................................................37 2.3 Project Input.............................................................................................................................................39 2.3.1 Expenditure of Project..........................................................................................................................392.3.3 Provision of Equipment ........................................................................................................................40 2.3.4 Facilities .................................................................................................................................................41 2.4 Achievement of Overall Goal ..................................................................................................................42 2.4.1 Factors Contributed to Achieve the Project Purpose.........................................................................42 2.4.2 Achievement of Project Purpose ..........................................................................................................43 2.4.3 Towards the Achievement of Overall Goal .........................................................................................43

Chapter 3. Recommendations and Lessons Learned for Future ...............................................................44

3.1 Recommendations and Lessons Learned ...............................................................................................44 3.2 Way Forward............................................................................................................................................45

Chapter 4. History of Project Design Matrix...............................................................................................47

Chapter 5. Appendices...................................................................................................................................49


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INTRODUCTION�

Health and Development Service (HANDS) in collaboration with the Japan International Cooperation Agency(JICA) and the Ministry of Health (MoH) of Republic of Kenya, initiated the “Project for Improvement of Health Services with a Focus on Safe Motherhood in Kisii and Kericho Districts”; SAveMOthers in KIsii and KEricho (SAMOKIKE Project). The Project was implemented for three years from March 2005 to March 2008.

Under its “National Health Sector Strategic Plan (1999-2000)”, the MoH had aimed to establish the referral system from the primary health facilities such as Health Centre (HC) to the secondary health facilities such as District Hospitals. Then, the MoH planned “The Second National Health Sector Strategic Plan (2001-2005)” to reducing the maternal mortality rate, increasing the skilled birth attendance rate, and improving the antenatal care with emphasis on the primary health facilities near the community. In Japan, on the other hand, “Healthcare and Development Initiative (HDI)” was announced in June 2005 emphasizing MDGs relating health. This was aimed to support the development of infrastructure for healthcare management, with special emphasis on strengthening the healthcare system, developing and strengthening of the healthcare facilities, and assisting the capacity building of health workers.

Since 2000, JICA has been extending support to western Kenya such as rehabilitation program at District Hospitals and HCs. SAMOKIE project has been positioned as the extension of JICA initiatives mentioned above to strengthening the healthcare services.

The Project can be distinguished from other technical assistance projects by several characteristics. First, this is a PROTECO (Proposed-Type Technical Cooperation Project�that incorporates strength of both JICA and NGO creating synergy between the government policy and the grass-root activity. In addition, this Project has attempted to achieve the synergy by combining the horizontal approach of improving HC system and the vertical approach of improving maternal care services.

It has been a challenge to achieve these broad goals in three years. The social confusion after the presidential election of December 2007 had significantly affected SAMOKIKE project activities in its final phase. Still, in the final evaluation, lessons learned from the Project were strongly recommended as meaningful to the foregoing policy-making in the community-led improvement of the quality of healthcare system.

Next year, Kisii and Kericho District Hospitals are scheduled to be renovated for better functionality financially supported by JICA donation. We believe further activities creating synergies will continue towards the future.

Tamayo Haraguchi Chief Advisor

JICA/HANDS/MOH SAMOKIKE Project


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MAPS


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Project Site

Map: Kisii District, Nyanza Province

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Map: Kericho District, Rift Valley Province �


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Project Photos

1. Maternal Care

1. HC Renovation�Supplying water tanks � � � �

Ibeno HC, Kisii��

2. Provision of medical equipment�Adult weighing scaleChepkemel HC,Kericho�

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3. Essential Obstetric Care Training�Professionalmaternal care trainings for midwife (Kisii DH)

4. Kakamega Study Tour�Studying referral system in Kakamega District

5. Partners Workshop�Group work of HC staff, community representativesKisii�

�Partners Workshop�Pregnant woman experienceKericho��


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2. Health Centre Management

1. Provison of multi-purpose vehicles to Kisii and Kericho districts

2. Study tour to TanzaniaMorogoro region�participated by DHMT members of Kisii and Kericho districts

3. Monitoring of 5S1K impelmenation by DHMT member (Riana HC, Kisii�

4. 5S1K Workshop at pilot HC (Chepkemel HC, Kericho�

5. Utilizaion of HIS Board Riana HC, Kisii�

6. Supervison to HCs for HIS improvement by DMRIOsSigowet HC, Kericho�


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3.Community Activities

1. Community Activity Meeting�Discussion of Action Plan by HC staff and Community RepresentativesKericho�

2. Community Led Community Meetings at HCRiotanchi HC, Kisii�

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3. Community Campaign�Procession(Kipkelion HC, Kericho��

4. Community Campaign � A man wearing Maternity Jacket (Riana HC, Kisii�

5. Community phones managed by the communityRiotanchi HC, Kisii�

6. IGA�Planting corn within the empty space of the HC (Kipkelion HC, Kericho�


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� LIST OF ABBREVIATONS

ANC Antenatal Care CDC Centers for Disease Control and Prevention CHANIS Child Health and Nutrition Information System CORP Community Resource Person DCO District Clinical Officer DH(s) District Hospital(s) DHAO District Health Administration Officer DHEO District Health Education Officer DHMT District Health Management Team DMO District Medical Office DMOH District Medical Officer of Health DMRIO District Medical Record and Information Officer DPC District Project Coordinator DPCC District Project Coordination Committee DPHN District Public Health Nurse DPHO District Public Health Officer DRH Division of Reproductive Health EPI Expanded Program of Immunization FIF Facility Improvement Fund FS Facilitative Supervision HANDS Health and Development Service HC(s) Health Centre(s) HCMC Health Centre Management Committee HIS Health Information System HM Health Management IGA Income Generation Activities JICA Japan International Cooperation Agency JNPSC Joint National Project Steering Committee KEMSA Kenya Medical Supply Agency KEPI Kenya Expanded Programme on Immunization MC Maternal Care MoH Ministry of Health NTWC National Technical Working Committee PDM Project Design Matrix PHO Public Health Office PMTCT Prevention of Mother-To-Child Transmission of HIV PNC Postnatal Care PROTECO Proposed-Type Technical Cooperation Project RH Reproductive Health SAMOKIKE Save Mothers in Kisii and Kericho SMG Safe Motherhood Group TBA Traditional Birth Attendant TOT Training of Trainer


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Executive Summary

The overall goal of the Project was to improve the health condition, particularly the maternal health in the Kisii and Kericho Districts. The Project purpose was to improve the maternal care in the project areas with a focus on health centres (HCs) and communities and the Project activities were planned to achieve the following five outputs; � Output 1: Maternal care services at the HCs are upgraded. � Output 2: Management support in the HCs is improved � Output 3: District Health Management Teams (DHMTs)’ system for their supportive

supervision for HCs is strengthened. � Output 4: Maternal care at the community level is improved � Output 5: A referral system is arranged and functioning between communities, HCs and �

District Hospitals (DHs).

In order to achieve broad aspects of outputs, the Project activities was implemented within three different target levels; District Medical Office (DMO), HC, and community. Through the three-year activities, we conducted minor renovation of HC facilities, provided medical equipment for maternal care, and built the capacity of health staff. In addition, SAMOKIKE project strengthened cooperation among community and health facilities, organizing role building at the three target levels. As a result, it has led to achieve improved health care service at HCs and communities focusing on maternal care.

Especially, implementation of Partners Workshop, 5S1K trainings at HCs, and Community Campaign were the activities that have achieved highest impacts. For example, Partners Workshop was epoch-making that it has provided training opportunity simultaneously to both HC workers and the community, resulting in strengthening mutual understanding and coordination between community and HC staffs. Staffs of DMO, DH, and HC learned together the basic methodology of 5S1K as a tool for understanding basic management of healthcare system, and its activities were implemented at all HCs under the supervision of DMO. In addition, through the series of community activities, HC staff and community members cooperated and organized successful Community Campaign in the final year.

In the final evaluation, SAMOKIKE project results was highly regarded for creating positive impacts among different levels, which lesson can be disseminated to other projects. However, the Project did not have enough time and resources to fully achieve all the various goals set up in PDM. Especially, the supervision of DMO and the improvement of referral system remain unfulfilled because of limited human resources in health facilities and government budget.

Unfortunately, the Project in its last half of the final year was affected by the social confusion after the presidential election. Western Kenya, project’s target region, was restricted from transportation, and Japanese staff could not operate. As a result, dissemination seminar was cancelled which was aimed to promote impacts of the achievements of the Project to other region in order to maintain its sustainability. Despite the influence of external conditions, however, SAMOKIKE project produced a technical report on


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the achievements and lessons learned and conducted Dissemination Preparation Training so that when the confusion is resolved, the MOH may utilize and take initiative to conduct dissemination seminars.


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CHAPTER 1. OVERVIEW OF THE PROJECT

1.1 Background

Western Kenya (Nyanza province and part of Rift Valley Province) is challenged by high prevalence of infectious diseases including malaria and HIV/AIDS, low social capital compared to a large population, and the deterioration of health facilities. Under these conditions, Kenyan government established “The National Health Sector Strategic Plan 1999-2004”. This Plan prioritized on decentralization and appropriate allocation of human resources, aiming to improve health service at the regional level by establishing referral system from the primary health facilities such as Health Centres (HCs) to the secondary health facilities such as District Hospitals (DH), as well as strengthening management capacity of medical supplies and equipment usage.

The maternal mortality rate in Kenya is reported to be 1,000 per 100,000 births (WHO, UNICEF, UNFPA. 2000), among the highest in the world. The causes of high maternal mortality rate result from pregnancy-related complication such as postpartum hemorrhage. These are due to the inappropriate awareness of a pregnant woman or a traditional birth attendant (TBA) to detect danger signs, lack of basic maternal care (MC) service or referral system at the primary health facilities such as HCs, and the inability of the hospitals to offer speedy and appropriate maternal care.

No data on the maternal mortality rate of the project target region is available, but data indicates that in-facility delivery of the two target Provinces is 36.0%, which is lower than the national average of 40.1% (Kenya Demographic and Health Survey 2003). Given that more than 50% of deliveries take place at home, the need is high in increasing the delivery rate at the facility attended by medical certificate holders (doctors, clinical officers, and nurses/midwives) and in strengthening the linkage between communities and primary health facilities.

SAMOKIKE Project was initiated in western Kenya (Kisii District, Nyanza Province and Kericho District, Rift Valley Province) to improve maternal care in the target regions through strengthening HC management, upgrading maternal care at the HC and community levels, and encouraging community involvement, thereby ultimately contributing to the health of pregnant women and their community.

1.2 Target Population, Implementation Period, and Activities

1.2.1 Target Population

The total population of Kisii and Kericho Districts was approximately 1,000,000 (Kisii 500,000, Kericho 500,000). In particular, SAMOKIKE project targeted 7 HCs in each District, total of 14 HCs, and surrounding residents of approximately 260,000.

In 2007, some of the target HCs became under the administrative rule of new Districts due to a governmental


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rearrangement, however the project activities continued upon the request of the Ministry of Health (MOH) (Refer to Table 1-1).

Table 1-1�Targeted HC 2005�2006 2007�2008

District HC District HC Iranda� HC Iranda� HCKiogoro HC Kiogoro HC Marani HC Marani HC Ibeno HC

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CentralKisii� Ibeno HC

Riana HC Riana HC Riotanchi HC

SouthKisii Riotanchi HC

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Kisii�

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� Ibacho HC Masaba Ibacho HC Ainamoi HC Ainamoi HC Sosiot HC Sosiot HC Sigowet HC Sigowet HC Kabianga HC Kabianga HC Chepkemel HC

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Kericho�

� Chepkemel HC Kipkelion HC Kipkelion HC

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Kericho�

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� Fort Tenan HC Kipkelion

Fort Tenan HC

1.2.2 Implementation Period

As show in Table 1-2, SAMOKIKE Project was structured in 4 implementation phases. Each phase has been proceeded with the reflection of the previous phase(s) so that the lessons can be utilized in the new phase.

The 1st phase focused on the office preparation and baseline survey, constructing individual activity plans that reflected the local reality and needs. Through the 2nd phase, the basic facility improvement was achieved by means of HC renovation and the maternal care-related equipment provision. The 3rd phase sought to lay a foundation of human resource development and collaboration with the community members through the training of HC staff and involvement of community for maternal care. The 4th phase continued with building the capacity of health workers, promoting community involvement, and strengthening referral system. Also, following the mid-term review of October 2006, the PDM was reviewed, revised, and approved. The final evaluation was conducted in November 2007.

Although SAMOKIKE project had planned to organize dissemination seminars for relevant stakeholders in the later half of the 4th phase, the Project had to change the contract because the social confusion after the presidential election of December 2007 was considered a serious external factor. Accordingly, SAMOKIKE project produced a technical report on the achievements of and lessons learned from the Project and conducted Dissemination Preparation Training, so that when the confusion is resolved, the MOH may utilize


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and lead conducting dissemination seminars.

Table 1-2�Phases and Major Activities of the Project

Phase Period Major Activities

1st March - December 2005 -Conduct the HC assessment and Community Baseline Study

- Renovate HC facilities and provide equipment - Select model HCs for community activities, start to

2nd January - March 2006 -Continue to implement each activity 3rd June 2006 - March 2007 -Continue to implement each activity

- Implement a trial activity at the model HCs to other HCs

4th May 2007 - March 2008 - Continue to implement each activity and strengthen referral system

- Conduct Community Impact Assessment Study - Final evaluation by JICA - Produce technical report and conduct Dissemination

Preparation Training

1.3 Organizational Structure

1.3.1 Project Counterpart

The Kenyan counterpart of SAMOKIKE project has been the MOH, within which the Reproductive Health Office has been the point division to coordinate among Department and District/Province. (Refer to Figure 1-1�


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Figure 1-1�Relationship of Kenyan and Japanese Stakeholders

1.3.2 Office Management

1�OfficeSAMOKIKE project had an office in each District of Kisii and Kericho. In Kisii, DMO as the Project counterpart had provided the office space nearby DHMT’s office since the 1st phase. In Kericho, sufficient office space was not provided initially, but after a series of negotiations with DMO and the MOH, new office was constructed in early-December 2006.

2�Office Staff At HANDS Tokyo, two program officers coordinated works in Japan.

Ministry of HealthDept. of Preventive and Promotive Health

Director of Medical Service

Division of Reproductive Health

Medical Officer of Health (MOH)

Medical Superintendent in District Hosp.

District Health Management Team(DHMT)

District Health Office/District Hospital/HC

Community People

HANDS Kenya

JICA Kenya

HANDS

- Implements the project

JICA

- Supervises the project - Ensures / supports smooth

implementation of the project

Kisii and Kericho Districts (Project Site)

Kenyan Stakeholders

Japanese Stakeholders

Nyanza Provincial Health Office

Rift Valley Provincial Health Office

Communication

� Collaboration

Relationship between HANDS and JICA


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In Kisii office, in addition to one Japanese coordinator since the 2nd phase, there was four to five Kenyan staff. In Kericho office, there was a total of five to six Japanese staff including a chief advisor, an administrative coordinator, and three or four technical experts, and four to six Kenyan staff. (Refer to Table 1-3, Figure 1-2�

Two technical assistants who were seconded to this Project each from DMO of Kisii and Kericho continued their duties at the Project offices while Japanese experts did not reside.

In the small cities of Kisii and Kericho where recruitment was usually difficult, SAMOKIKE project extended hiring efficient staff from the previous phase for the smooth project implementation.

In each phase, the Kenyan Labor Law was respected in every step of the hiring process with every employee, with the assistance from the legal team of JICA Kenya in reviewing employment agreements. Two of these employees had been seconded from DMO of Kisii and Kericho since the 1st phase.

Table1-3�List of HANDS Kenyan Staff Total Number of Staff

Position1st Phase 2nd Phase 3rd Phase 4th Phase

Kericho Office - Technical Assistant 1 1 3 3 - Secretary 2 1 1 0 - Assistant Coordinator 0 0 0 1 - Driver 1 2 2 2 - Technical Assistant on Community

Phone0 0 0 1

Kisii Office - Technical Assistant 1 1 2 2 - Secretary 1 1 1 1 - Driver 1 1 1 1 - Technical Assistant on Community

Phone0 0 0 1


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Figure 1-2�Project Team Organization

1.3.3 Networking

As mentioned before, SAMOIKIE project worked in a partnership with the MoH. The Project had organized Project Steering Committee together with the MoH for information sharing and discussions to organize, plan, and implement the Project (Refer to Appendix 1-3). In each phase, the Project presented its plan and activity report to the MoH, whose opinions were reflected to the next phase (Refer to Appendix 6). After 2007, amidst the decentralization movement, the Project sought to strengthen the coordination with

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the Districts and started producing Project Monthly Report in the 4th phase and visiting MoH office at Provincial and National level regularly. In Nyanza Province, the Stakeholder Meeting requested the Project to present its activities, contributing to the dissemination of the Project achievements.

1) Meeting led by the MoH a)� Joint National Project Steering Committee (JNPSC): 5 times

-A committee to discuss mainly management and policy issues. -Members consisted of the Ministry of Finance, Permanent Secretary in MoH, Director of

Medical Service, Head of Promotion and Prevention department, Head of Division of Reproductive Health, JICA representative, and HANDS representative

b)� National Technical Working Committee (NTWC): 6 times -A committee to discuss mainly planning of project implementation. -Members consisted of Head of Promotion and Prevention Department, Head of Division of

Reproductive, Provincial Medical Officer of Health (Nyanza Province, Rift Valley Province), District Medical Officer of Health (Kisii Districts, Kericho Districts), JICA project manager, and HANDS project staff

2) Meeting led by the Project a)� District Project Coordination Committee (DPCC): 12 times

� -A committee to discuss mainly project activities. -Members consisted of DHMT (Kisii Districts, Kericho Districts), and HANDS project staff

HANDS also established a strong network with other organizations and have built capacity development through conducting trainings facilitated by local NGOs such as Aga Khan Health Services and Engender.


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Chapter 2. Project Achievements

SAMOKIKE Project used the Project Design Matrix (PDM) to design goals to which activities were planned and implemented. This chapter first gives the overview of the surveys SAMOKIKE project conducted (Refer to session 2-1). Next it describes for each targeted output as follows; a) summary of relevant activities, b) achievements of indicators, c) review and recommendations (Refer to session 2-2). Then, the list of equipment and facilities that SAMOKIKE project provided are mentioned (Refer to session 2-3).Finally, achievements of the Project’s overall goal and purposes are discussed (Refer to session 2-4).

2.1 Survey Conducted by the Project

SAMOKIKE project conducted surveys at the 1st phase and at the middle-to-end of the 4th phase on each area of Maternal Care (MC), Health Management (HM), and Community Activities (CA). Major surveys were as shown in Table 2-1. The results of these surveys were very useful when it was necessary to review and evaluated activities of SAMOKIKE project.

Table 2-1�Summary of Project Surveys

Year Survey Content Target/Method

Maternal Care Related 2005 � HC Assessment

Survey� Types of services � Amount and condition of

medical equipments

� Amount and condition of storage

� Maternal record keeping

� Visits by HANDS experts � Interview with HC staff by

HANDS experts.

� Interview with DHMT members

2007 � Assessment on Emergency Preparedness

� Delivery kit maintenance at HC delivery room

� Visit by HANDS experts, Kenyan staffs

2007 � Assessment on staff allocation

� Number of staff at each HC

� HC staff completing a survey form� Interview with DPHN

2007 � Maternal care Follow up

� Maternal care training evaluation

� Delivery kit maintenance at HC delivery room

� Campaign evaluation

� Visit by HANDS experts, Kenyan staffs, and DPHN

2007 � Case study on Referral cases

� Utilization and evaluation of referral form

� Review of referral form at DH/HC and interview with nurse

Health Management Related

2005 � HC Assessment � HC Generally � Visit by HANDS experts


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2007 Survey � HC facilities generally � HCMC activities � Referral generally � HIS status at HC � Maintenance of drug and

medical supplies

� Status of DHMT supervision

� Interview by HANDS experts with HC staff

� Interview with DHMT members

2007 � 5S1K Performance Assessment

� Status of 5S1K within HC using checklist

� Visit by DPHN to HC � Visit and interview by DPHN with

HC staff

2007 � HISPerformance Assessment

� Quality of 5 Monthly Reports using checklist

� Status of HIS at HC (mainly filing, utilization of HIS board and referral stamp)

� Confirmation of DMRIO report using checklist

� Visit HC by DMRIO

Community Activity Related

2005 � Community Assessment Survey

2007 � Community Impact Assessment Survey

� Opinion and knowledge of community member on delivery and child care

� Satisfaction on ANC, delivery service at HC and utilization

� Ability towards SMG by other community members, capacity ability of HC

� Interview with key informant � Household interview � Focus group discussion � Direct observation

(By Almaco Management Consultants Ltd�

2007 � Interview on HCMATERNAL CARE and SMG

� Status of HCMC, SMG, activities,

� changes before and after SAMOKIKE project

� Interview by HANDS experts, with HC staff and HCMC

2.2 Outputs of the Project

The following sections summarize the Project’s outputs, their relevant activities, achievements, and review and recommendations. Refer to Appendix 1 for details about the program and the number of participants for the training, workshop and meetings. (Appendix 1-1.“Training and Workshop”, Appendix 1-2. “Community Meeting and Campaign”, Appendix 1-3. “Maternal Care and Stakeholder Meeting”). 2.2.1 Output 1


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Output 1 “Maternal Care at the HCs are Upgraded” Indicators�� Increase in the number of HC and HC staff (rate) providing skilled delivery attendance � Number of Maternal Death Review (MDR) � Number of staff completed training within each HC � Number of follow-ups, staff receiving follow-ups, and evaluation of work performed by trained

staff.� Communities satisfaction level of the quality of care � Number of HC maintaining facilities and equipment 1and 2 years after their installation � Number of staff attended maintenance training and the frequency of regular maintenance Related Project Activities�� HC Renovation � Medical equipment provision � Essential obstetric care training (National Package training) � Maternal care training (Partners Workshop) � Medical equipment training

Summary of related activities 1) HC Renovation1st and 2nd phases�SAMOKIKE project renovated 10 out of 14 HCs which had not been renovated previously by JICA. The renovations included reconstructions of broken walls, making drainage trenches, supplying water tanks and generators. These renovations were essential for providing maternal care especially delivery services. The Project involved Community Representatives, who monitored the process of the renovations.

2) Providing medical and non-medical equipment (2nd phase) Medical equipment necessary for maternal care was provided to the targeted HC and DH, including diagnostic set (sphygmomanometer, thermometer, weighing scale, and fetoscope), delivery set (kidney dishes, forceps, cord scissors), and other equipment (delivery bed, sterilizer, and oxygen concentrator). The type and amount of equipment were decided on the result of the baseline survey and discussions with DHMT members.

3) Essential Obstetric Care Training (National Package Training) (3rd phase) SAMOKIKE project conducted the training in collaboration with Reproductive Health Team (RHT) members from central, provincial and district levels. Central MOH provided the training materials such as Power Point (PPT) and textbooks, and the representative of RHT members from two provinces and two districts facilitated the training. The training was held for 10 days covering broad maternal care skills including ANC, delivery care, PNC, neonatal care, management of complications of pregnancy, and infection prevention (including HIV/AIDS). Totally 24 midwives from 14 HCs, District Hospitals and Sub District Hospitals were trained.


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4) Maternal Care Training(Partners Workshop�(2nd, 3rd, and 4th phases) Partners Workshop is a new approach to provide training opportunity to both health care workers and the community to learn together and discuss the specific needs and issues involving maternal care in the communities. Partners Workshop is separated into two parts: i) training on basic maternal care (first 2.5 days) and ii) training on professional maternal care (last 2.5 days) (Refer to Figure 2-1). SAMOKIKE project had planned and implemented 3sessions of Partners Workshop in collaboration with RHT members.

i�Basic Maternal Care In the first 2.5 days of Partners Workshop, midwives from each 7HCs of Kisii and Kericho, Health Centre Management Committee (HCMC), and Safe Motherhood Group (SMG) member participated. Training contents were selected from high priorities regarding the maternal health and maternal care service of the community selected by DPHN and project staff, which includes contents such as customer care, community maternal care, ANC, emergency of pregnancy, emergency transportation, and record of maternal death. The participants not only learned about basic maternal care but also deepened mutual understanding through spending time together. Also, at the end of the training, participants created an action plan for their community which they brought back and implemented it in their community.

Figure 2-1�Concept for Partners Workshop

ii�Professional Maternal Care After the first 2.5 days of basic maternal care training, midwives continued to stay to learn professional maternal care, which includes contents such as management of ANC, delivery, PNC, neonatal care, infection prevention, obstetric emergency preparedness.

In particular, as a preparation for starting delivery service at all HCs, the training had put the highest emphasis on management of delivery preparedness to make ready the required items in delivery room in addition to the skills to support normal delivery. After the training, DPHN and project staff visited HC for

Community

Midwife

Basic Maternal care for the Community

Professional Maternal care at the HC

2.5 days

5 days

Concept for Partners WorkshopConcept for Partners WorkshopPartners Workshop is a new approach to provide a training opportunity

simultaneously to both health care workers and the community.


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follow-ups.

5) Medical Equipment Training (4th phase)In the 2nd phase, SAMOKIKE project provided medical equipment required for maternal care to each HC and DH. In addition, in the 4th phase, the Project conducted training on equipment which requires maintenance such as adult and child weighing scale, oxygen concentrator, autoclave, sphygmomanometer (BP machine) and electric fetoscope The Project invited a facilitator from a company based in Nairobi (CROWN Health Care) from which SAMOKIKE project bought these equipment. The training covered purposes, basic usage, and maintenance of equipment.

Achievement of indicators 1) Number of HC and HC staff (rate) providing skilled delivery attendanceThere were 5 HCs that began to provide delivery services during the Project, and now all 14 HCs are ready to provide delivery services. In addition, 13 out of 14 HCs presently are capable of 24 hour delivery service. According to pre and post test from all three Partners Workshop conducted, every participant (HC midwives) got higher score compared to the pre test. (Refer to Table 2-2). In addition, the number of skilled midwives in the 4th phase increased from the average of 4.8 to 5.1 in Kisii and remained flat at 3.6 in Kericho from the survey. Despite the increase in Kisii, this number far lags the minimum of 8 staff per HC which the Kenyan government specifies and further improvement is required. (Refer to Table 2-3).

Table 2-2�Results of Pre-post tests of Partners Workshop (Professional Maternal Care)


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�� ID 1 2 3 4 5 6 7 8 9 10 11 12 Average Highest Lowest

Pre % 49 39 44 50 59 50 63 59 61 44 56 54 52 63 39Post % 75 70 66 76 71 71 68 77 82 74 80 79 74 82 66Balance 26 31 23 26 12 20 5 18 21 30 24 25 22 19 28Pre % 51 63 54 56 59 40 51 61 50 60 54 56 54 63 40

Post % 67 71 79 66 71 74 62 78 65 88 79 75 73 88 62Balance �0 1 -2 �� 3 34 �� 5 �2 -1 -2 �6 �1 -2 --

-��ID 1 2 3 4 5 6 7 8 9 10 11 12 Average Highest Lowest

Pre % 0� 0- 17 5� 46 04 51 01 24 21 0- 53 65 80 49Post % 79 77 85 84 82 80 80 78 67 68 77 77 78 85 67Balance 18 14 5 13 33 16 2 9 13 11 14 4 13 5 18Pre % 52 46 53 -6 34 51 53 22 24 20 24 57 78 29

Post % 51 17 54 07 25 64 52 06 5� 55 5- 73 94 57Balance 3 3� � 3� -3 �0 - �4 �5 -� �1 �0 �0 -1

3��ID 1 2 3 4 5 6 7 Average Highest Lowest

Pre % 57 22 26 42 07 07 51 0� 51 42Post % 14 50 10 1- 13 1- 60 14 60 50Balance �4 -� -5 35 -3 -- �1 -3 �1 3�Pre % 63 77 56 33 65 56 21 55 33Post % 75 85 71 56 78 78 54 12 20Balance �- 1 �2 -3 �3 -- �0 1 -3

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Table 2-3�Number of Midwife at Target HC

Kisii Kericho

2005 2007 Increase or decrease 2005 2007 Increase or

decrease Ibacho HC 3 4 � Ainamoi HC 6 6 �Ibeno HC 7 6 � Chepkemel HC 3 3 �Iranda HC 3 5 � Fort TernanHC 2 2 �

Kiogoro HC 4 5 � Kabianga HC 1 2 �Marani HC 8 7 � Kipkelion HC 3 2 �Riana HC 6 5 � Sigowet HC 6 6 �

Riotanchi HC 3 4 � Sosiot HC 4 4 �average 4.8 5.1 � average 3.6 3.6 �

2) Maternal Death Review (MDR) At Partners Workshop, SAMOKIKE project addressed MDR to HC staff and community members. Although it was difficult to assess death at the community, the staff of HANDS and DPHN visited the area of reported maternal death and discussed with HC staff and community members.

3) Number of staff completed training within each HC The number of midwives who attended maternal care trainingNational Package, Partners Workshop�was 22 from each District and total of 44. Based on the survey, these numbers were equivalent to 61% midwives in Kisii and 88% midwives in Kericho (Refer to Table 2-4). Due to relocation of HC staff, some midwives who attended training may have had to move away from the target HC.


16

Table 2-4�Number of Staff who attended Maternal Care Training of the Project

Kisii Kericho Number of staff

who attended training

2005-2007�

Number of total staff

(2007)

Number of staff who attended

training(2005-2007)

Number of total staff

(2007)

Ibacho HC 4 4 Ainamoi HC 4 6Ibeno HC 2 6 Chepkemel HC 3 3Iranda HC 4 5 Fort TernanHC 2 2

Kiogoro HC 2 5 Kabianga HC 2 2Marani HC 5 7 Kipkelion HC 3 2Riana HC 5 5 Sigowet HC 5 6Riotanchi

HC5 4 Sosiot HC 3 4

Total 22 36 Total 22 25

4) Follow-ups SAMOKIKE project did follow-ups after each Maternal Care Training. For midwives who could not attend training, the Project staff visited them with the material and trained them individually. As a result, all HCs became capable of providing delivery services.

5) Communities satisfaction level of the quality of maternal care Satisfaction level of mothers with a child under 12 months who had visited HC for ANC was 96.5% in Kisii and 97.6% in Kericho, improving although from already high 90%-plus in both District when the Project started in 2005. (ALMACO, Community Baseline Study in 2005 and Community Impact Assessment in 2007) (Refer to Table 2-5).

Table 2-5�Satisfaction Level of Mothers below-12 months old who attended ANC at target HC

� % Satisfied with ANC services % change between 2005 and 2007

KISII 2005 (n=140) 91.42007 (n=143) 96.5

5.1

KERICHO 2005 (n=150) 92.72007(n=127) 97.6

4.9

Source: ALMACO2005: Community Baseline Study 2007: Community Impact Assessment Study�


17

Also, the survey in 2005 resulted in satisfaction levels of delivery at HC as low as 12.9� in Kisii and 42.1� in Kericho, which improved significantly in the survey in 2007 as high as 98.7� in Kisii and 97.3� in Kericho. (Refer to Table 2-6)

Table 2-6�Satisfaction Level of Delivery at Target HC

�% Satisfied with delivery

services last delivery % change between 2005 and

2007

KISII 2005 (n=139) 12.92007 (n=143) 98.7

85.8

KERICHO 2005 (n=159) 42.12007 (n=139) 97.2

55.1

Source: ALMACO, 2005: Community Baseline Study 2007: Community Impact Assessment Study�

6) Number of HC maintaining facilities and equipment 1and 2 years after their installation All HCs could offer services using the provided equipment, however, some equipment could not be used temporarily because HC ran out of fuel of the generator or battery for the electric fetoscope. Currently, all HCs in Kericho and Kisii have one or more Income Generating Activities (IGA) going on, hence, we expect the community to continue to better manage its HC by supplementing the necessary equipments from IGA.

7) Number of staff attended maintenance training and the frequency of regular maintenance A total of 27 staff from both Districts attended the Medical Equipment Training. In addition, technicians from DH who are in charge of maintenance for HC equipment participated. Although regular maintenance at HCs was not conducted, technicians from DH provided services to HC when requested.

Discussion and lesson learnt 1) Setting up better environment for qualitative improvement in maternal care services After implementation of three year project, all HCs could provide delivery service now and the level of community satisfaction has risen. However, the average number of skilled midwives at each HC is 5.2 in Kisii and 3.6 in Kericho, which far lags the minimum of 8 per HC that the Kenyan government specifies. Also, dormitories are not sufficiently established for health staff at HC and better environment are necessary to be provided. In the aspect of the qualitative improvement in maternal care services, SAMOKIKE project recommends increase number of midwives and improvement in the HC environment such as staff dormitories.

2) Involving community and HC staff in the management of HC facility and medical equipment SAMOKIKE project has involved community to HC renovation and such community involvement will


18

continue to be the key to maintaining and managing HC. In addition, supplies such as fuel and batteries for medical equipment should be afforded by funds raised through IGA. It is desirable that HC staff coordinate with the community to maintain and manage the facilities and medical equipment.

3) Enhancing collaboration between community and HC SAMOKIKE project has involved community to many of its activities. In particular, Partners Workshop was epoch-making that it provided training opportunity simultaneously to both HC workers and the community. As a result, Partner Workshop and other various activities resulted in strengthening mutual understanding and coordination between community and HC. SAMOKIKE project highly recommends disseminating these activities to the other regions.

2.2.2 Output 2

Targeted Output 2 “Management support in the HCs is improved” Indicators�� Number of HC in-charge who received training related to health management � Increased level of community satisfaction on MCH regarding health management at HCs Related Project Activities�� Facilitative Supervision (FS) and Quality Improvement Training � 5S1K workshop (workshop and follow up) � 5S1K competition

Summary of related activities Project activities for the improvement of HC management consisted mainly of 1) capacity building of facilitative supervision to HCs, 2)5S1K workshop (including follow up training), and 3)5S1K competition (HIS will be described in targeted output 2-2). Summaries of each activity are as follows;

1) Facilitative Supervision (FS) and Quality Improvement Training (3rd phase) The Project invited a lecturer from EngenderHealth to implement this three-day training. The training goals were to help staff understand the meaning of quality management, assess their facilities, and conduct an action plan for improvement. The target participants were DHMT members responsible for supervising HC and HC in-charge responsible for the management of the target HC. The training was held jointly for Kisii and Kericho participants. The training covered a) basic quality control, b) basic quality management method, c) quality management in practice, d) infection prevention in practice, and e) creation of action plan. The participants brought back their action plans to their community to implement for quality improvement of their facilities. A total of 14, one from each 14 target HC, participated in this training, and the pre-post-test resulted in improvements by all the participants.

2) 5S1K training (4th phase) Prof. HANDA Yujiro, Project Formulation Advisor (Health Sector), Regional Support Office for Eastern


19

and Southern Africa JICA the 5S1K training so that 5S1K would be practiced in all 14 HCs in Kisii and Kericho, help improve HC management (in particular, drug and waste management), and build the managerial skills of DHMT members. The Project organized three different types of training (Table 2-7) for gradual and effective implementation of 5S1K as shown in Table 2-8. Introductory Meeting and Training for Pilot HC were held on the same day. One month later, 5S1K workshops for other HC were held on the basis of experiences at pilot HC. One staff member was invited for this workshop (HC in-charge from Kericho and nurse from Kisii) from each target HC. After this 5S1K workshop, the participants were given a certificate of “5S1K manager” and become a leader of 5S1K implementation at their HC. For 5S1K implementation at Pilot HCs, Project staff and the staff from DHMT visited Pilot HCs regularly to review progress of implementation and give appropriate advice to guide implementation.

Table 2-7�Three different types of training for 5S1K implementation in the districts Types of Training

Target Facilitators Contents

IntroductoryMeeting

DHMT member Prof. HANDA Yujiro Introduction of 5S1K, discussion

5S1Ktraining for pilot HC

DHMT member and pilot HC staff

Prof. HANDA Yujiro Introduction of 5S1K, site inspection of the facility, choice of the place for 5S1K implementation

5S1Kworkshopfor HC

Staff of 14 target HCs

DHMT member, representative of pilot HC, HANDS staff

Introduction of 5S1K, pilot HC case study, site inspection of pilot HC, action plan

3) 5S1K Competition: Follow up training in the form of competition (4th phase) Three months after the 5S1K workshop and HC implementation, DHMT members and Project staff visited each HC and assessed the implementation of 5S1K using the “5S1K Performance check list” developed by the Project. Using the assessment results, a follow up training was organized in the form of competition. The competition invited from each HC the 5S1K manager who had participated in the previous workshop. The photos which were taken during monitoring and evaluation visits were used in the feedback by DHMT to explain the impact of 5S1K activities, highlight areas that required further improvements, and to compare the performance of different facilities. The experiences from different facilities were also shared through the discussions among the participants.

Achievement of indicators 1) Number of HC in-charge who received training related to health management There were more than 42 participants in aggregate who attended the 5S1K workshop and Facilitative Supervision (FS) and Quality Improvement Training. According to the survey after the 5S1K competition, all participants believed their work environment has improved, indicating the impact of 5S1K implementation. Also, 91% responded that they had an idea or plan to further improve their HC using 5S1K (9% responded that they did not). Many of these plans were immediately executable, and some


20

getting a hint from other HC during the training. These indicate HC managers’ growing skills and confidence as a result of the training that the Project organized.

2) Increased level of community satisfaction on MCH regarding health management at HCs Interviews with HCMC: representative in communities, and Assistant Chief (Refer to Table 2-8) resulted in increased level of satisfaction on maternal care service related to community management.

Table 2-88Results of Interview with Community Representatives9HCMC and Assistant Chief:

Y 2005 Y 2007 Availability of facility 65.6% 46.9%Medicine and medical

supply 37.5% 9.4%

Appropriateness of facility

37.5% 9.4%

Healthcare education 34.3% 28.1% Water supply 15.6% 3.1%

Electricity supply 12.5% 0% Services 6.2% 0%

*Rate of respondents who though they needed an improvement (the lower percentage indicates an improvement)

Source8Almaco 2007

In the improved areas (availability of facilities, appropriateness of facilities), in addition to contribution by training and Project’s equipment provision, it is also important that HC management generally improved as facilities are properly being managed. Also, the improved supply of service can be seen to be in turn contributing to the improvement of management capacity.

Discussion and lesson learnt 1) Introducing and implementing 5S1K gradually To improve the management skills of HC managers, the Project first hosted workshop on basic concept of HC management in the 3rd phase, and as an advanced step conducted more practical 5S1K workshop in the 4th phase. It could be recognized that achievements of the training were put into the practice, owing to such process of training implementation. Such gradual implementation not only increased knowledge of HC staff but also improved HC management in practice. These results are recognized by community representatives and would lead to further utilization of HC.


21

2) Capacity building of HC managers Although leaving a room for improvement, the Project has succeeded in laying the groundwork for building the skills of HC managers. It is most important for the managers to continue to work on their skills and recognize that they can improve further. The Project recommends HC staff and DHMT as supervisor of medical facilities generally to continue to support HC managers.

Targeted Output 2-2�Health Information System (HIS) and record keeping system at HCs is functioning and is utilized for service and management at the HCs Indicators�� Number of training sessions for HIS and trainees � Efficiency of recording and reporting � Use of HIS for care and management at HCs and DHMT � Use of HIS for monitoring and evaluation � HIS study tour (for DMRIO) � HIS training and follow up training � HIS Board and Referral Stamp � HIS competition

Summary of related activities Health Information System (HIS) is essential to any program for improvement of health management. Project activities for the improvement of HIS included; 1) The study tour for capacity improvement of District Medical Record and Information Officer (DMRIO), 2) HIS training and follow-up training, 3) Introduction of HIS Board and Referral Stamps as tools for practical use of HIS; and 4) Competition for sustainable HIS improvement.

1) HIS Study Tour (3rd phase) The Project organized a study tour to Mombasa District, Coast Province in Tanzania, for Kisii and Kericho DMRIO for HIS improvement. In Mombasa, The Aga Khan Health Services, in collaboration with Provincial Health Office was operating the HIS and Health Report Improvement project which has shown some positive improvement of HIS in the province. The tour was organized with site visits in the project area and discussions with project related personnel. By this study tour, DMRIOs could acquire practical knowledge to identify and analyze the main challenges and also how to address them in Kisii and Kericho.

2) HIS training (3rd phase) and follow up training (4th phase) After the study tour to Mombasa, HIS training was conducted by DMRIOs with technical support from Aga Khan Health Services for 2.5 days. The main targets for this training were HC staff responsible for health information reports from HC to the districts in both Kisii and Kericho. One HC staff (Recording officer or Nurse) was invited as a participant from each target HC. Management Information System Consultant from Aga Khan Health Services invited as a trainer to facilitate the whole training with DMRIOs. The following contents were covered during the training.


22

- Overview of HIS - Detailed guidelines for Monthly Summary Reports from HC to the Districts - Discussion on importance o HIS and quality of data and information - Discussion on how to overcome challenges of HIS, especially quality of data

HIS follow up training was conducted in the 4th phase as one-day training and was meant to follow up HIS related activities at HCs and to identify ways to improve HIS. In preparation for this training, DMRIOs assessed the 5 monthly summary reports which were submitted to the district by HC.

3) Introduction of HIS Board and Referral Stamp (4th phase) HIS Board and Referral Stamps were for the purpose of improving HIS at HC and particularly to facility management improvement.

HIS Board was purchased by the project. This was a white board which had a hard, smooth, white surface used for writing on with markers.

Table 2-9 shows the detailed contents of HIS Board which was made especially for HC use. The HIS Board was designed for monthly data (number of clients, tests, revenue and expense of the Facility Improvement Fund, number of immunization programs) to be shown to possible stakeholders of HC, such as community members, clients, health centre staff and other visitors. To make it into a HIS Board, the frame and contents were painted by a local painter. The contents were decided by DMRIO and HC staff based on discussions and then distributed to HC.

The main aims for introducing the Referral Stamps were to identify the clients/patients who were referred to upper level of health facility and to acquire accurate data regarding to number of referred clients/patients at HC by applying the stamp to “patient registration record” and “patient note”. Stamps were produced by the Project and distributed to each target HC. Stamps were introduced because there had been barely any record of referrals from HC to DH (record in Kisii were inaccurate) and was difficult to assess the referral in practice.


23

Table 2-9�HIS Board in Kisii and Kericho for HC

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CCCCCCCCCCCCCCCCCCCCCCCCC+��F

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4) HIS Competition: Follow up training in the form of competition (4th phase) The Project organized HIS competition as a wrap up event to the above activities 1) to 3) and to motivate participants for continued improvements of HIS. The competition was participated by all 14 HC (7 in Kisii and 7 in Kericho). Over the three months after the HIS follow up training, the competition assessed the five types of Monthly Summary ReportsOPD, Workload, CHANIS, EPI, RH�and evaluated the quality of reporting/data collection and practical use of HIS board and Referral Stamp at the facility.

“HIS Performance Checklist” (produced by the Project and DMRIO) used for evaluation was designed to product quantitative output that can be clearly compared with that of other HC. DMRIOs visited each target HC to assess their HIS performance by using the Checklist. The competition was held in one day and the DMRIO held a seminar to provided feedback to the HC staff after the assessment.

Achievement of indicators 1) Number of training sessions for HIS and trainees The Project held HIS training six times, including one study tour for DMRIO for HIS improvement, one 2.5-day training for HC managers (jointly for Kisii and Kericho), a follow up training each in Kisii and Kericho, and an HIS competition seminar each in Kisii and Kericho. In aggregate, 40 HC staff participated from the target HC (including the competition participants).

2) Efficiency of recording and reporting The Project could not achieve much in efficient recording and reporting. However, HIS Board provided opportunity for sharing HC’s information with community members and at the same time, it makes HC


24

staff to review the health information even after monthly reports were submitted to the district (before introducing HIS Board, most of HC staff did not have interest for own HC’s information and never review the data which was submitted to the district).The Referral Stamp made it much easier to count the number of referred patients. In these respects, the Project made some contribution to efficient recording and reporting.

3) Use of HIS for care and management at HCs and DHMT HC only recently started utilizing HIS such as HIS Board, and it is too soon to evaluate its impact on the improvement of facility management and services. The Project considers HIS Board the first step. Also, as DMRIO builds up capacity, DHMT members started to share monthly information with each other. Improvements are gradual if not sufficient. For example, in the month of a maternal death at one HC, DHMT shared this information among its members and appropriately followed up with this HC (Refer to Maternal Death Review).

4) Use of HIS for monitoring and evaluation The Project considers that more time was needed for HIS to have meaningful impact on monitoring assessment. Still, the Project believes it succeeded in building the foundation for future HIS utilization by conducting a series of trainings and capacity building programs for DMRIO and HC staff. The Project recommends supporting a long-term activity of HIS improvement for HIS to be applied to monitoring assessment.

Figure 2-2� Changes in HIS Conditions and Situation (2005 – 2007) (p42) Number of HCs which were judged ‘good’ or answered ‘yes’ for each criteria

7

�

-

3

4

2

0

5

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

�� !(�� !��%�� <�� ! � �� <��@��,��"#>��

-772

-775

Source:� HC Assessment Survey 2005 and 2007

Discussion and lesson learnt 1) Comprehensive approach towards HIS improvement Due to limited data, it was difficult to clearly evaluate the improvement of HIS at HC. However, for an overall improvement, the Project believes its comprehensive approach was effective: develop the capacity


25

of DMRIO as leaders of HIS improvement in their District; train HC staff; offer follow up training; introduce HIS Board as a new tool; introduce Referral Stamp; and evaluate results and reflect to future planning. The Project believes such comprehensive approach was effective towards the direction of overall improvement.

2) DMRIO to lead further HIS improvement Since the 4th phase, DMRIO has taken initiatives of interventions and trainings. DMRIO has developed a capacity to lead activities in their District for HIS improvement. The Project recommends DMRIO to continue to work on HIS improvement at target HC or other medical facilities such as dispensaries. Budgeting should be discussed for these purposes.

3) Challenges while promoting HIS Kisii District (Nyanza Province) was in the process of implementing a new pilot system of HIS while Kericho District (Rift Valley Province) was not. Such discrepancy made it difficult to execute a joint training for these two Districts, which was one of the most difficult issues to resolve.

Targeted Output 2-3:�Management capability for drugs and medical supplies at the HCs are improved.”

Indicators�� Reduced stock-out time for drugs and medical supplies. � Improved basic drug and medical supplies management of HCs. � Rational use of medicines based on guidelines at HCs

Relevant Project Activities�� Drug management training � 5S1K training � 5S1K competition

Summary of related activities 1) Drug management training (3rd phase) HANDS technical advisor led the training on drug management for HC staff to learn the basic knowledge about drug management. Training was held for three days each in Kisii and Kericho, and one participant (nurse, HC in-charge) from each HC, or a total of 13 participants, were invited. This training also introduced the basic concepts of 5S1K, which was more formally introduced in the 4th

phase.

2) 5S1K trainings, 5S1K competition: Please refer to output 2-1.

Achievement of indicators 1) Reduced stock-out time for drugs and medical supplies (records and condition of drugs and medical supplies) Drug management training resulted in some improvement; however, improvements varied from one HC to


26

another. After the 5S1K training and competition of the 4th phase, HC showed significant improvements.

Also, according to the HC Assessment Survey that compared 2005 with 2007, both Kisii and Kericho improved in all assessment areas including space, alignment, darkness, shelves, and security (Refer to Figure 2-3).

� � �

Photo�� Store room before (left) and after (right) 5S1K; Chepkemel HC, Kericho

Figure 2-3�Pharmacy Store Management Change (2005 - 2007) (p31) Number of HCs which was judged ‘good’ for each criteria

7

�

-

3

4

2

0

5

��

!(�� /�� "��,�� !��%�� !��

-772

-775


2) Decrease in shortage of medical supply inventory 2007 HC Assessment Survey results show that as of December 2007, there were fewer days of medical supply store shortages (from the high of 43 days on average in 2005 to the low of 20 days on average in 2007).However, this seemed to have resulted from the change in supply system (formerly central to district to HC; now central to HC), and not fully explained by the impact of the Project activities.

3) Rate of prescriptions based on HC treatment guidelines There is no data on the rate of prescriptions that were based on HC treatment guidelines. However, Table 2-10 shows that more guidelines were used at HC in 2007 compared with 2005 in both Kisii and Kericho.


27

Apparently, guidelines were used effectively for treatment. However, these guidelines were not a tool that the Project provided and encouraged, and therefore this cannot be seen as an achievement of the Project. However, it can be said that the various Project training helped HC staff develop skills to utilize these guidelines.

Table 2-10� Number of Guidelines Used at HC (Average)

2005 2007 Kisii 2.57 3.57

Kericho 2 3

Average 2.29 3.29


Discussion and lesson learnt1) Positive impact of external conditions on drug management Generally, medical supply management has improved. There were changes in external conditions that contributed to this progress (e.g. Change in supply system).The Project contributed much to the improvement in store management. The improvements varied across different HC, so the Project recommends DHMT to regularly support less developed HC to work hard to catch up.

2) Promoting 5S1K as preparation for the transitioning of the medical supply system The MOH is planning to transition from its current PUSH system to a PULL system regarding the medical supply distribution. Prior to 5S1K, store management was barely functioning (see Photo), and HC could not have appropriately managed supply if converted to a PULL system. Most, if not all, HC have improved store management and started to record supply more properly. In these respects, the Project recommends introducing 5S1K as preparation for the change to the PULL system and for further improvement in medical store management in medical facilities of Kisii and Kericho that had not been the target of the Project.

Targeted Output 2-4: “To improve waste management system.” Indicators�� Number of HC staff who received the basics of waste management � Number of HCs which undertake waste management according to the MOH standard � Improvement behavior regarding waste management among HC for improvement Relevant Project Activities�� 5S1K training� 5S1K competition

Summary of related activities Interventions for waste management improvement were also attempted through 5S1K activities which led to cost-effective improvements in facility environment improvement as well as sanitary conditions by such instructions as burning rubbish regularly, separating refuse purposely, and fencing the refuse pit. Proper


28

way of using Safety Box was also given to HC staff. For other relevant activities, please refer to targeted output 2-1.

Achievement of indicators 1) Number of HC staff attending waste management training In aggregate, over 30 participated in the waste management training as a part of 5S1K training and competition.

2) Number of HC that follows the MOH waste management guidelines Since the MOH has not standardized the requirements for waste management at HC level, the Project cannot make this assessment quantitatively. However, 2007 HC Assessment Survey results showed improvements in the use of refuse pit and Safety Box as shown in Figure 2-4.Safety Box has become available in all 14 target HCs. More HCs in Kisii responded refuse pits were “good”, but there was no change in the response from HCs in Kericho.

3) Improvement in attitude and behavior of staff towards waste management For general waste, the Project had since its inception believed that each HC should have its own incinerator to prevent infection and improve sanitary conditions. However, purchasing a new incinerator was financially not possible either at HC or by the MOH; therefore, this need was converted into making another effort within available resources, such as burning rubbish regularly (around two times per week) using paraffin and managing the capacity of a refuse pit. Such improvements were seen in almost all HCs (both in Kishii and Kericho). Also, pits were properly fenced for the safety measure for children.

Figure 2-4� Waste Management Change (2005 - 2007) Number of HCs which was judged ‘good’ for each criteria

7

�

-

3

4

2

0

5

��

!�� @�) >��(�

-772

-775



29

� � �

Photo:� � Refuse pit before (left) and after 5S1K (right)

Discussion and lesson learnt 1) Improvement in waste management Project has observed improvements in waste management, which has a room for further improvement. In particular for Safety Boxes, burning those in a refuse pit by using paraffin won’t be sufficient for both reasons; infectious prevention and environment protection. Those are needed to be burned in an incinerator. However, in current circumstances, there is no fund to set incinerator at each HC and no system to collect Safety Boxes from each HC to burn those at District Hospital. Accordingly, a new standard needs to be established to determine and promote appropriate levels of waste management given the distant locations and limitations in purchasing an incinerator. In these respects, the Project recommends that DHMT guides HC.

2.2.3 Output 3

Targeted Output 3 “District Health Management Teams(DHMTs) system for their supportive supervision for HCs is strengthened”

Indicators�� Number of DHMT members involved in supervision of HCs. � Number of v supervision at each HC. � Level of satisfaction by HC in charges with supportive supervision Relevant Project Activities�� Supervision check list � Study tour to Tanzania � DPCC meetings� Provision of Multi Purpose vehicles: one for Kisii and one for Kericho � Other joint activities

Summary of related activities 1) Supervision check listDue to the lack of comprehensive and standardized check list on DPCC, Supervision to HC by DPCC was insufficient and lack of consistency each HC. The Project developed the supervision check list through the discussion with DPCC. In the 2nd phase, DPCC revised it with HC managers.


30

2) Study tour to Tanzania (3rd phase) A study tour to Tanzania was aimed at enhancing the knowledge base of DHMT members through technical discussions with the Ministry of Healthcare of Tanzania and The Project for Strengthening District Health Services in Morogoro Region (Morogoro Health Project).This one-week tour was participated by DMOH and DPHN of both Districts of Kisii and Kericho. The tour members actively discussed with the Project for Strengthening District Health Services in Morogoro Region (Morogoro Health Project), which was a project in many ways similar to the SAMOKIKE Project that worked to improve health system of Tanzanian districts and provinces.

3) DPCC meetings (1st to 4th phase) DPCC (District Project Coordination Committee) has promoted information sharing and discussion between Kisii and Kericho for the purposes of effective Project management and capacity building of DHMT members. DPCC meetings were organized as shown in Table 2-11.

Table 2-11�DPCC held in each phase

Number of DPCC meetings

Phase 1 5Phase 2 2Phase 3 3Phase 4 2

In the 4th phase, DPCC met twice because the first half of this phase was devoted to follow up trainings and because DPCC had to cancel its scheduled meeting in the second half due to the turmoil after the presidential election.

4) Provision of Multi Purpose Vehicles: one for Kisii and one for Kericho (1st phase) The Project provided one vehicle to each Kisii and Kericho in the middle of the 1st phase. These were Multi Purpose cars that were used for ambulance to strengthen the referral system or for building the capacity of DHMT to support and supervise HCs. At each DPCC meeting, the status of the usage of the vehicles was updated and maintenance and other related issues were discussed. Nowadays, the Multi Purpose cars are used as not only a referral but also regular supervision by DHMT.

5) Other joint activities The Project had aimed for a sustained development of its activities and to this goal coordinated all Project activities with DHMT. In particular, the Project organized DHMT-led training and other activities and contributed to build the capacity of DHMT members.


31

6) Dissemination Preparation Training The Project planned Dissemination Seminar in the last half of 4th phase, however, political and social confusion in Kenya affected by the result of Kenyan presidential election made it impossible to be held it in the phase. Therefore, the Project rearranged the four-day training for the purpose of reviewing and sharing the project achievements and planning the continued activities with DHMT members. The training included the session of the preparation of dissemination seminar, (when safety condition become better) as a part of technical transformation.

Achievement of indicators 1) Number of DHMT who supervised each HC The members of District Health Office who supervised each HC included District Medical Officer of Health (DMOH), District Public Health Nurse (DPHN), District Clinical Officer (DCO), District Public Health Officer (DPHO), District Medical Record and Information Officer (DMRIO), District Health Administration Officer (DHAO), together with other members as necessary. The total team members were between eight and ten in Kisii District and normally between four and five in Kisii District, who visited their relevant HC for supervision.

2) Number of visits to HC for supervision In Kisii, normally two days of a week were regular visit days, but this was subject to change due to scheduling conflicts. Also, the target HC of the Project was only few of the all HC that DHMT supervised. As a result, actual visits to each HC were 1-3 times per month. There were no regular visit days in Kericho. However, HC recognized more number of visits by DHMT members than before. The new DMOH (in position since March 2007) has initiated building a new system, which progress the Project expects to continue.

3) Level of satisfaction of HC managers for DHMT supervision The level of satisfaction of HC managers for DHMT supervision has improved from “rather dissatisfied to satisfied” (average) of 2005 to “satisfied to very satisfied” (average) of 2007 (HC Assessment Survey). The reasons for the improvement were 1) DHMT members gave advance notices to HC before a visit, 2) DHMT members were more cooperative than before, 3) DHMT members identified issues unnoticed by HC staff and helped solve problems, and 4) DHMT members were more attentive to HC requests.

Discussion and lesson learnt 1) Strengthening support and supervision for medical facilities The Project in its 1st phase developed the checklist for medical facility supervision to improve the quality of support of HC by DHMT. However, in reality, the check list had not been utilized because DHMT could not allocate resources and because DHMT could not financially afford to establish means of transportation to visit HC. Later, DHMT better recognized the effectiveness of the checklist after the implementation of 5S1K and HIS competitions, which gave opportunities for DHMT members to learn how to assess HC conditions using tools similar to the checklist. It is desirable that each Kisii and Kericho develops its own methods – e.g. incorporating 5S1K concepts as a standard of support/supervision of medical facilities – to


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improve their system. The Project recommends each District to ensure budget and staff allocations for further progress and improvement in quality (e.g. more frequent visits, accurate recording of advice, etc).

2.2.4 Output 4

Targeted Output 4 “Maternal Care at the community level is improved” Indicators�� Number of community people seeking maternal care services in target health facility. � Increased knowledge regarding maternal care among people � Number of maternal care health learning sessions held and its participants regarding maternal care. � Number of peer learning workshops and exchange visits � Number of communities replicating activities Relevant Project Activities�� Monitoring HC renovation � Selecting pilot HC � Involvement of community (e.g; Community Activity Meeting, Community Campaign)

Summary of related activities SAMOKIKE project adopted a “two-way approach” in implementing community activities since we believe that the interaction between the HC and the community is the key to improve health service at the HCs as well as to promote the health of the community. This principle was applied for conducting following activities during the Project.

Figure 2-5�“Two-Way approach” between HC and Community Activities

1) Monitoring HC renovation (1st and 2nd phases) SAMOKIKE project considered HC renovation an opportunity to strengthen the relationship between the

SAMOKIKE

DHMT

Health Centre Community

• Monitoring process of the HC renovation

• Attending the same workshop e.t.c…


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HCs and communities by involving the Community Representatives in the process of renovations. Community Representatives made a team and monitored the process of the renovations by local agencies. In addition, Community Representatives reported the progress of the renovations to HC staff, HANDS staff, and DHMT and issues that each party found were shared together.

2) Selecting model HC (2nd phase) The Project selected Chepkemel HC (Kericho district) and Iranda HC (Kisii district) as a model HC. The following three points were considered as criteria for selection; a) the extent of community participation to HC (especially women’s participation), b) appropriateness of recording and record-keeping of the minutes of meetings and c) relationship between the HC and community. SAMOKIKE project in its 1st phase provided to these pilot HC generators that enabled them 24 hour delivery service. Upon providing the generators, the Project conducted management training for maintenance to the Community Representatives.

3) Involvement of community (Community Activity Meeting, community Campaign) (2nd, 3rd, and 4th

phase)SAMOKIKE project implemented the following activities towards improving maternal care and healthcare in Kisii and Kericho districts: a) Conducted Community Activities Meetings (CAM): Trainings for Community Representatives, b) Held Community led Community Meetings at HCs: Trainings for Community Leaders, and c) Implemented Community Campaigns.

a) Community Activity Meeting (CAM) The overall purpose of Community Activity Meeting was to provide an opportunity for discussions between HC staff and Community Representatives and to encourage them working together. CAM invited three participants; 1 staff from HC (normally clinical officer), 1 HCMC member and 1 SMG members each from all targeted HCs. Every year CAM was held and agenda� was decided according to current demands. During the 2nd phase, the meeting focused on reporting the progress of HC renovation, sharing the issues still to be solved. In the 3rd phase, action plan to promote HC involvement was developed, and action plan to organize Community Campaign was discussed in the 4th phase.

b) Community Led Community Meeting at HC (2nd, 3rd, and 4th phases)Community Led Community Meeting at HC was organized in second year of the project and 3meetings at each HC were conducted during the Project. While CAM was mainly organized by SAMOKIKE project and DHMTs, Community Representatives (HCMC and SMG members) mainly organized Community Meetings. In the 3rd phase, the main objectives of the meeting were to provide basic information about Safe Motherhood to other community members and to prepare for Community Campaigns in the 4th phase. Each meeting helped involve more community people to the community activities and SAMOKIKE project succeeded in improving the knowledge of maternal care at the community.


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Figure 2-6�Four Main Actors of SAMOKIKE Community Activities

SMG

Mem

bers HC Staff

HCMC

Mem

bers Comm

unity

lead

ers

COMMUNITY ACTIVITIES

SMG

Mem

bers HC Staff

HCMC

Mem

bers Comm

unity

lead

ers

SMG

Mem

bers HC Staff

HCMC

Mem

bers Comm

unity

lead

ers

COMMUNITY ACTIVITIES

c) Community Campaign (4th phase) SAMOKIKE project organized Community Campaign to raise further awareness to promote Safe Motherhood in its 4th phase. In order to reach mass population, two approaches were used: a) the first campaign targeting community people “broadly”, and b) the second campaign targeting pregnant woman and mothers “specifically”.

i�First Campaign (Mass Campaign) The first Campaign was targeted to community people aimed a)to promote importance of community support in saving mothers and newborns and b)to inform community about the importance of father’s participation. Campaigns were held for a half day to one full day, mainly organized by Community Representative and Community Leaders who had attended Campaign Pre-Meetings at each HC. The details of the Campaign was unique at each HC, including a) procession by Community Representatives and Community Leaders and HC staff who wore the campaign T-shirts and carried the campaign banner within the catchment area of HC, b) getting together at an open space in the community providing entertainments such as dramas and songs prepared by local school children and women’s group and c) promotion of the key message “Mama Mwenye Afya Jamii Yenye Afya (Healthy Mothers, Healthy Community)” which emphasize the importance of Safe Motherhood in the community. In addition, comments from mothers who had experienced delivery at HC helped community to understand services at HC.

ii�Second Campaign The second Campaign was aimed to educate pregnant women about Safe Motherhood and to promote the importance of ANC and PNC at HCs. Brochures were provided to encourage attendance of ANC at least 4 times, to get assistance of skilled midwife at delivery, and to promote the importance of attending PNC. Afterwards, baby shawls were given as presents to women who gave birth at HC and to those who wanted to deliver at HC but could not for specific reasons. (Refer to Table 2-12 for detail).


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Table 2-12�Two Approaches for Safe Motherhood Community Campaigns

1st Compaign 2 nd Campaign

Specific messagesa) Importance of communiy supportin saving mothers and newbornsb) Importance of fathers participation

a) Safe delivery(Skilled care)b) Importance of ANC and PNC

Contents

a) Campaign processionb) Entertainment(Dramas and Songs)c) Promotion of the keny messages

a) One-on-one education at the timeof ANC and PNC at HCb) Giving out a blanket to a motherwho delivered at HC, and who hadcome to ANC(at least twice).

TargetsFamilies, Community Members,Fathers, etc. (Mass)

Mothers, Clients

Duration One day Three months

Location Cathchment area of each HC Each HC

Principal organizersHCMC, SMG, HC staff and about 40community members

HC staff

Supporters DHMT, HANDS DHMT, HANDS

Toolsa) IEC/BCC(filer, radio)b) T-shatsc) Bannerd) Maternity experiencejackets

a) Baby blankets(distributed incorrdination with DPHN)b) IEC/BCC(brochure)

Achievement of indicators1) Number of community people seeking maternal care services in target health facility. According to community survey, more women came to HC to give birth or attended ANC and PNC than before SAMOKIKE project started (Refer to Table 2-13).

Table 2-13� Number of Women who came to HC for ANC, Delivery, and PNC (Monthly Average)

� 2005 2007Rate of increase

(times) ANC (total) 92.5 100.7 1.1

Delivery 11.5 19.1 1.7 Kisii

PNC(Total) 5.9 25.0 4.2 ANC (total) 33.6 42.9 1.3

Delivery 2.0 13.6 6.8 Kericho

PNC(Total) No data 42.8 �

Source: ALMACO, 2007 Community Impact Assessment Study

2) Increased knowledge regarding maternal care among people SAMOKIKE project succeeded in raising the awareness by conducting campaigns and educating community through IEC/BCC such as brochures filers, and radio advertisements. Total of 3,700 people joined Community Campaigns. Also, increase in the numbers of visitors to HC and observation of men escorting women and children visiting HC seems to reflect improved awareness of the community.


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3) Number of maternal care health learning sessions held and its participants regarding maternal care.

SAMOKIKE project conducted a total of 6 maternal care health learning sessions (Partners Workshop), 3 times in each District. A total of 140 people or 70 people in each District attended. Also, the Project organized Community Led Community Meetings at each HC to discuss maternal care with Community Representatives

4) Number of peer learning workshops and exchange visits During Partners Workshop, the program introduced particularly active HC and its communities. For example, the Workshop highlighted one community that made an empty space of HC a farm for IGA

5) Number of communities replicating activities Currently, all 14HCs are implementing IGA. Activities such as SMG escorting pregnant women in labor to HC are reported. In addition, within 3 targeted HCs, new midwives were hired by the community to resolve shortage of staffing issue.

Discussion and lesson learnt 1) Sustainability of the ongoing community activities SAMOKIKE projects believe that active involvement of community is crucial to effectively improve maternal care of the community. Better achievements were observed after active community involvement; therefore, the Project recommends encouraging community involvement to sustain further improvement. In particular, we believe that IGA by the community will continue to help improve maternal care services at each HC. Also, community involvement is necessary to extend catchment area for promoting maternal care of the community.

2) Promoting participation of family, husband, and men Promoting women to come to HC requires understanding of social, financial, cultural, and geographical conditions surrounding women. SAMOKIKE project organized activities to educate men about assisting pregnant mothers, which effort will need to be continued. It is expected that men who joined these activities will proactively support pregnant women and mothers.


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2.2.5 Output 5

Targeted Output 5 “A referral system is arranged and functioning between communities, HCs and District Hospitals” Indicators�� Number of appropriate referral cases of maternal complications � Types and number of record of communication, transportation and maintenance � Utilization of referral guidelines � Number of meetings reviewing referral cases Relevant Project Activities�� Kakamega study tour � Installation of community phones � Implementation of referral form and provision of referral stamp � Training and Refresher Course on Referral

Summary of related activities 1) Kakamega Study Tour (3rd phase) SAMOKIKE project organized a three-day tour to Kakamega District in Western Province of Kenya, where a maternal healthcare project had been implemented, to study their referral forms. The contents of the program were about expenses, communication and transportation tool, recording and management system of their referral system. Photocopies of Kakamega District’s referral forms were brought back for discussions with DHMT of Kisii and Kericho, and these forms were revised and implemented at all HCs and DH.

2) Installation of community phones (4th phase) Given the importance of timely referral in case of obstetric emergency, SAMOKIKE project installed community phone (Simu Ya Jamii) and other accessories to all target HCs. Community phones can be a source of IGA as 45% of the charge of the usage will be received by the phone owner. Such profit is expected to be utilized for emergency purposes within the community. HCMC was appointed as a manager of community phones, and methods to manage community phones were decided at each HC. Community phones were used mainly for emergency at night time but were placed in a convenient location for community people to utilize during the day and to promote as IGA. The Project conducted technical training to the manager, HCMC, and HC staffs, and introduced the installation and its benefits to the community during Community Campaigns.

3) Implementation of referral form and provision of referral stamp (3rd and 4th phases) Referral forms are necessary for effective information sharing between the facilities when transporting patients in emergency. Photocopies of Kakamega’s referral forms were brought back for discussions with DHMT of Kisii and Kericho, revised and implemented after the training with midwives. Referral Stamp had been introduced to HC for tracking the record of patients and pregnant women referred from HC to DH (Refer to Session 2-2).


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4) Trainings and Refresher Course (Follow-up) on Community Phone (4th phase) Trainings on procedure and management of community phones and Refresher Course were held after the installation. During the Refresher Course, technical training was conducted for midwives who require sophisticated skills in times of emergency. The technical training covered knowledge about management of obstetric emergency such as pregnancy induced hypertension (PIH), obstructed labor, fetal distress and postpartum hemorrhage which are typical obstetric emergency.

Achievement of indicators 1) Number of appropriate referral cases of maternal complications The multi-purpose vehicle provided by SAMOKIKE project in its 1st phase enabled effective transportation of patients in emergency. As a result, the percentage of referral cases at all HCs rose from the low of 13% (13 out of 101patients) in August 2006 to the high of 19% (28 out of 144 patients) in August 2007. There is not enough information to evaluate the appropriateness of referral; however, referral forms and delivery records had been utilized properly to record diagnosis and referral case such as saving lives of both mothers and babies had been reported.

2) Types and number of record of communication, transportation and maintenance Although the frequency of the usage of community phone vary depending on HC and its number of delivery, community phones are used approximately one to four times every month at each target HC. In addition, HCs and DHs have been utilizing referral forms which were introduced in the 4th phase to manage an emergency case effectively.

3) Utilization of referral guidelines In the 4th phase, SAMOKIKE project implemented technical training for midwives, covering management of obstetric emergency such as Pregnancy Induced Hypertension (PIH), obstructed labor, fetal distress, and postpartum hemorrhage. The participants brought back copies of the training material to their HC to put into practice. Also, guidelines to promote the procedure in referral case such as ways to contact DH, to complete referral form and register book were distributed to each HC. It has been reported that they are now implementing the procedures.

4) Number of meetings reviewing referral cases At DPCC, SAMOKIKE project reviewed referral cases with member of DHMT of Kisii and Kericho using actual referral forms and delivery records of DH. Also, all cases that was required to be shared was discussed with DHMT.

Discussion and lesson learnt 1) External factors and community involvement SAMOKIKE project had faced difficult challenges such as poor geographical conditions (e.g., unpaved roads) and financial issues (e.g., cost of fuel for transportation and maintenance of multi-purpose vehicle) against its goal of strengthening referral system from HC to DH. Although these hurdles were too


39

significant to be resolved in three year project, supporting community-led emergency support system (e.g.,human resources, expense support, or lending of vehicles) enabled to strengthen the network of the community. Through sustaining community involvement, we hope such external factors will be resolved step by step.

2) Preparedness for emergency at HC Not all HCs are actually prepared for emergency at HC. In addition to normal delivery, HC should develop capacity for dealing with obstetric complications. SAMOKIKE project recommends that DPHN as supervisor of HC continue to review referral cases and level up the skill and knowledge of each midwives.

3) Preparedness of DH There were occasions in which patients were referred from HC to DH but DH could not fully accommodate to an emergency due to shortage of ambulance or fuel for transportation. Also, HC may not always afford an escort of its nurse or midwife due to capacity limitation. In regards for strengthening effective referral system, the Project recommends to establish support system where escort support from the DH would be provided.

2.3 Project Input

2.3.1 Expenditure of Project

The following table summarizes the contracted amount of SAMOKIKE project over three years.

Table 2-14�Contract amount of the SAMOKIKE Project (by phase) 1st Phase 2nd Phase 3rd Phase 4th Phase Total

Contract amount (yen) 94,102 33,033 80,687 89,523 297,345

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � In 1000 yen�

2.3.2 Dispatch of Japanese Experts The list of Japanese experts (HANDS project members) is shown in Table2-15


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Table 2-15�Dispatch of Japanese experts (HANDS project members) March 2005 – March 2008�

Input M/M Title

1st phase 2nd phase 3rd phase 4th phase

Chief Advisor 7.33 2 4.4 8

Project Coordinator 1(Kisii Office) � 1.37 7.4 7.43

Project Coordinator 1(Kericho Office) 7.83 2 8.2 7.53

Midwife (Technical Advisor on MATERNAL CARE)

7.47 2 7.97 6.43

Technical Advisor on Health Management 1 (Technical Advisor on Medical Equipment Management)

� � 2 �

Technical Advisor on Health Management 2

5.9 2 5 6.5

Technical Advisor on Community Health 2 2 2 6

Total 30.53 11.37 36.97 41.89

2.3.3 Provision of Equipment

Total amount of equipment SAMOKIKE project spent is 14,034 yen for “Equipment Provision” and 11,181 yen for “Other Equipment Provision”. (Refer to table 2-16 for expenditure in each phase.) Lists of equipment and facilities are in the end of this report (Refer to Appendix 2-2, 2-3). Expense in the 1st phase was the largest because of the purchases of four vehicles and procurement of equipment for the Project to start up. Expenses in the 3rd and 4th phases were for the purchases of community phones.

Table 2-16:�Equipment Provision (by phase) Expense/Phase 1st Phase 2nd Phase 3rd Phase 4th Phase Total (yen)

equipment provision 12,047,400 1,740,010 246,820 14,034,230other equipment provision 7,269,551 3,363,376 548,490 11,181,417� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � In 1000 yen�

The main equipment SAMOKIKE project provided are as follows:

1) Medical equipment for HC Total� 1,256,407 yen

SAMOKIKE project conducted baseline surveys at each HC in 2005, discussed with the MOH, and


41

decided a list of equipment to provide. The list covered minimal requirements for maternal care services at HC (ANC, delivery, PNC), and equipment was provided to each HC by February 2006. Equipment can be categorized as maternal care purpose, record keeping purpose, and drug and medical supply management purpose. For details, refer to Appendix 2-2 “List of Equipment provided to Kisii and Kericho through JICA” and 2-3 “List of Equipment provided to Kisii and Kericho through HANDS”.

2) Community phone for HC Total� 1,986,830 yen

To strengthen referral system, community phones powered by solar-panel battery were provided to 14 HCs. In the 3rd phase, main components were procured, and additional equipment was gathered, assembled, put to training, and installed in the 4th phase,.

3) Vehicles for District Medical Office Total� 12,047,400 yen

In the 1st phase, SAMOKIKE project provided to each District Health Office of Kisii and Kericho a multi-purpose vehicle for their supervision of HC, referral transportation, and delivery of medical supplies. The vehicles were utilized flexibly during the implementation of SAMOKIKE project. In addition, two 4WD vehicles were purchased for the project activities that were provided to DMO of Kisii and Kericho after the closure of SAMOKIKE project.

2.3.4 Facilities SAMOKIKE project conducted the following facility construction and renovation:

1) HC renovation Total� 7,603,864 yenKisii�5,120,824�Kericho�2,483,040�

Based on the results of baseline surveys on the facilities of targeted HCs in the 1st phase, SAMOKIKE project renovated 4HCs in Kericho and 6HCs in Kisii. Renovation covered facilities, water supply, fences, space for medical supply and health record keeping. For details, refer to Appendix 2-4 “Cost of Health centre renovation in Kisii and Kericho through JICA.”

2) Construction of Kericho office Total�1,000,000 KESKenya Schilling) � 1,728,000 yen

SAMOKIKE project had temporarily used a storage space of Kericho DH as office space since the 1st

phase. In the 3rd phase, a new office was constructed within Kericho DH. This construction was fully financed by the MOH. In addition, the Project offered 1 million KES (1,728,000 yen) for security replenishment (e.g., fencing, window, etc�.


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2.4 Achievement of Overall Goal

Overall Goal : “Health condition, particularly the maternal health, in Kisii and Kericho Districts is improved ”

Indicators�� Maternal mortality (rate) in the Districts � Case fatality rate due to maternal complications � Infant mortality rate and malaria fatality rate Project Purpose�“Maternal care in the Project are with a focus on HCs and communities is improved” Indicators�� Skilled birth attendance rate of in the Districts � Delivery rate and ANC rate at HCs � Success rate in meeting the needs of women with maternal complications � HC utilization rate and client satisfaction

2.4.1 Factors Contributed to Achieve the Project Purpose

To achieve the Project Purpose of “Maternal care in the Project are with a focus on HCs and communities is improved”, SAMOKIKE project implemented the following three approaches: a) upgrading maternity care (targeted outputs 1, 2, 5); b) strengthening HC management (targeted outputs 2, 3); and c) encouraging community involvement (targeted output 4). These three approaches were interdependent and only together could achieve SAMOKIKE project’s overall goal. Japanese Experts worked together to coordinate these approaches to pursue the goal of the Project.

Figure 2-7:�SAMOKIKE Project Approach

Upgrading Upgrading MaternityMaternity CareCare

Encouraging Encouraging Community Community InvolvementInvolvement

Strengthening Strengthening Health Centre Health Centre ManagementManagement

Where good maternity care at Where good maternity care at HC should beHC should be


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2.4.2 Achievement of Project Purpose

As discussed section 2-2, most targeted outputs were achieved to a large extent even not perfectly. In this respect, it can be expected that the Project Purposes were reasonably fulfilled. However, SAMOKIKE project could not obtain data on “Skilled birth attendance rate of in the Districts”, which was one of the indicators of Project Purpose that SAMOKIKE project could not evaluate. However, the number of ANC and deliveries at the target HCs increased significantly after SAMOKIKE project compared to before (Refer to Table 2-13), which should be considered as a positive impact of the Project. In addition, the level of community’s satisfaction towards HC services has improved (Refer to Tables 2-5 and 2-6). SAMOKIKE project was reported several cases of successful treatments meeting the needs of pregnant women with complications. In particular, at meetings reviewing referral cases, participants have started to report more cases including a referral from HC to DH that utilized a multi-purpose vehicle of SAMOKIKE project and saved the lives of both the mother and the child.Refer to Section 2-2-5�

2.4.3 Towards the Achievement of Overall Goal

The Overall Goal of SAMOKIKE project was “Health condition, particularly the maternal health, in Kisii and Kericho Districts is improved”. The indicators measuring Overall Goal were maternal mortality rate in the Districts, case fatality rate due to maternal complications, infant mortality rate, and malaria fatality rate. Unfortunately, accurate and comparable data could not be obtained at the end of SAMOKIKE project, since these indicators need to be observed and compared in a longer span of 5-10 years. However, factors for achieving the Overall Goal and Project Purpose– “upgrading maternal care”, “strengthening HC management”, “encouraging community involvement” - were mostly achieved and therefore SAMOKIKE project can be considered to have succeeded in building the foundation for a further achievements.


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Chapter 3. Recommendations and Lessons Learned for Future

3.1 Recommendations and Lessons Learned

1) Basic investments for improving maternal care services To improve maternal care, it is most important to strengthen the capability of facilities nearest to community, which means building HC’s capability to provide normal delivery services.� To this goal, SAMOKIKE project recommends promoting ANC and investing facilities capable of 24-hour normal delivery services at the HC level.

2) Strengthening relationship between community and HC SAMOKIKE project resulted in the increased number of people coming to HC for maternal care thanks to the strong relationship between community and HC based on the key concept of Safe Motherhood. In particular, the following two factors contributed to the effective relationship building in the short-term:

First, there was a basis for building relationship between community and HC because it was widely recognized by people in Kenya that HCs are for community and managed and operated by community. SAMOKIKE project saw this as an example of government policy to effectively impact improvements at the grass-root level. Second, Partner’s Workshop was implemented as a unique method for capacity development, unlike TOT. This new approach was effective because community members spent days and nights with HC staffs (midwives) to not only learn the technical issues at the workshop but also to develop mutual understanding between each other.

3) Synergy effect of 5S1K in educating basic(minimal )health management 5S1K training as means to educate basic health management resulted in an additional impact of strengthening leadership skills among HC staff. Given the all-time shortage of resources, 5S1K is a concept easily understood and executed at all levels, well regarded by MoH in District as well as MoH in Province SAMOKIKE project recommends them to sustain disseminating the concept of 5S1K.

4) Role allocation of building referral system People tend to think that building referral system involves large scale initiatives such as infrastructure building, logistics, and strong management system by the government, although they are barely achievable. Therefore, collaboration between the public sector (central and local government) and the private sector (NGO, company, community, and community people) is essential. Under the limited resource, SAMOKIKE project recommended each community, HC, District Hospital, and District Health Office to proactively think and execute what each can do within their power to improve the referral system which we believe to continue to be a more practical approach.

5) Combining the horizontal approach with the vertical approach By combining the horizontal goal of improving health services with the vertical goal of improving maternal


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care, SAMOKIKE project enabled counterpart, HC staff and community to clearly understand the direction of the project, encouraged actions, therefore result in reaping an immediate impact. SAMOKIKE project recommends sustaining the development of basic health management focusing with the issue of maternal care at community.

6) Motivation programs at the HC level Organizing minimal HC management contest under the supervision of DHMT largely influenced the behaviors of HC staff. In particular, DHMT has reported that it has greatly contributed to the improvement of the environment of administration of HCs and changed HC staffs behaviors such as submitting HIS accurately and punctually. Certificate award of the contest is displayed at both the HC and the office of DMO and many HCs anticipate such contest to be continued every year to motivate their activities. SAMOKIKE project recommends similar programs as cost efficient means to motivate DMO people and to promote the supervision of HC.

7) Utilizing Safe Motherhood Group activities Safe Motherhood Group (SMG) who were educated through SAMOKIKE project are capable resources who could serve as role models for other communities. SAMOKIKE project recommends appointing SMG for educating Community Health Worker which is a part of the government strategy to develop community-led healthcare services.

8) Cost sharing activities of health service In some HCs, Community Representatives have approved to hire midwives to enable 24 hour delivery service using Facility Improvement Fund (FIF). Efficient utilization of FIF at the HC has greatly contributed to improve the health service of HC. We believe, at least, minimum cost sharing from the health service in the community will be necessary.

3.2 Way Forward

1) Budgeting gap to be resolved with the counterpart SAMOKIKE project had not been designed in the scope of annual budgeting of Kenya and therefore may not be financially sustainable. In the future, it is important to minimize the budgeting gap by reflecting the capacity of the counterpart from the initial project planning.

2) Predicting external factors � The social confusion in the final year of SAMOKIKE project was an external factor quite unexpected. In the future, it is important to predict and prepare for risks, especially those associated with tensions between different tribes.

3) PROTECO Despite rooms for improvements for both JICA and NGO, after three years of experience in PROTECO,


46

SAMOIKIKE project recommends PROTECO to progress as a collaborated program between JICA and NGO to each exercise their strength. This is expected to also create examples of synergy between the government policy and the grass-root activity. Since HANDS had committed since from the pre-project survey, SAMOKIKE project has benefited from building network with related Kenyan stakeholders from the beginning and presence of collaboration with JICA contributed hugely to appeal to Kenyan government. Furthermore, JICA’s presence helped SAMOKIKE project to be well recognized by the Kenyan government. We strongly believe that this indicates a possibility for a grass-root achievements to be reflected in government policy making.


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Chapter 4. History of Project Design Matrix

As a result of three changes in the policies of Health Program and after the review of the Project mid-term evaluation, the SAMOKIKE project needed to change its indicators and activities on the later half of 2006. Following the discussions at the NTWC meeting of July 2007, revised PDM was approved by the head of Reproductive Health Office, and finalized for M/M in September 2007.

First, indicators and activities related to drug and supply management was changed. This was due to the transition in the Kenyan drug and supply distribution system that had previously been PUSH system, in which MOH supply fixed amount of drug and supply. However, the system is now transitioning gradually at various District and Provincial levels to PULL system in which health facilities order the required amount. It is anticipated that some more time is required before the change to become effect at HC level.

Second, indicators and activities related to HMIS improvement was changed. This was because DANIDA (Danish International Development Agency) has started to test a new form of HMISHealth Management Information System�in certain Districts, which included one of SAMOIKIE project’s target District. However, it has not been decided whether the MOH might change its HMIS policy throughout all the Districts.

Third, indicators related to improvement in the capacity of Community Health Workers (CHWs) were changed. This was because the MOH announced its new guidelines regarding community healthcare activities in 2006, which clarified requirements, roles, and activities of CHWs.

After the mid-term evaluation, it was pointed out that the correlation of the SAMOIKE project’s activities and their outcomes were unclear. Therefore, the Project regrouped the target outputs and related activities so that hey are measurable. In addition, SAMOKIKE project added the activities of capacity building of HC managers and education on waste management to improve health management as based on the baseline surveys. Moreover, the mid-term evaluation team and NTWC had mentioned that the indicators were abstract and not easily measured in PDM0. Therefore, the amended PDM1 contains indicators that are more specific. Further details are shown in Appendix 4-3.�


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Chapter 5. Appendices

Appendix 1� Activity summary � Appendix 1-1� Training and Workshop � Appendix 1-2� Community meeting and Campaign � Appendix 1-3� Maternal care and Stakeholder Meeting Appendix 2� Donation list � Appendix 2-1� Equipment list � Appendix 2-2� List of Equipment provided through JICA � Appendix 2-3� List of Equipment provided through HANDS � Appendix 2-4� Renovation of facility Appendix 3� SAMOKIKE Project PO Appendix 4� PDM

Appendix 4-1� PDM02005�Appendix 4-2� PDM12007�Appendix 4-3� PDM changes

Appendix 5� IEC material Appendix 6� Minutes of JNPSC/NTWC meeting

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ount

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arks

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d Pr

omot

ive

Hea

lth S

ervi

ce, M

inis

try o

f Hea

lth

Targ

et G

roup

s: D

HM

Ts, H

ealth

car

e pr

ovid

ers,

HC

adm

inis

tratio

n st

aff,

and

com

mun

ities

in th

e K

isii

and

Ker

icho

Dis

trict

s B

enef

icia

ries:

Peo

ple

in th

e K

isii

and

Ker

icho

Dis

trict

s, pa

rticu

larly

wom

en o

f rep

rodu

ctiv

e ag

e.

PDM

0 (A

pril

2005

, Pro

ject

Doc

umen

t)N

arra

tive

Sum

mar

y O

bjec

tivel

y V

erifi

able

Indi

cato

rs *

1M

eans

of V

erifi

catio

nIm

port

ant A

ssum

ptio

ns[O

vera

ll G

oal]

Mat

erna

l mor

talit

y (r

ate)

in th

e D

istri

ct

Cas

e fa

talit

y ra

te d

ue to

mat

erna

l com

plic

atio

ns

Infa

nt m

orta

lity

rate

and

mal

aria

fata

lity

rate

[P

roje

ct P

urpo

se]

Skill

ed b

irth

atte

ndan

ce ra

te in

Dis

trict

Del

iver

y ra

te a

nd A

NC

rate

at H

Cs

HC

util

izat

ion

rate

and

clie

nt sa

tisfa

ctio

n [O

utpu

ts]

Com

pone

nt 1

. Mat

erna

l car

e in

the

Proj

ect a

rea

is im

prov

ed.

1%

of H

Cs p

rovi

ding

skill

ed b

irth

atte

ndan

ce (S

BA

)1.

Mat

erna

l car

e se

rvic

es a

t the

HC

s are

upg

rade

d.

% o

f clin

ical

staf

f mee

ting

the

defin

ition

of S

BA

1-1

Com

plet

ion

of tr

aini

ng w

orkp

lan,

No.

of s

taff

trai

ned

(into

tal a

nd b

y H

C),

No.

of f

ollo

w-u

ps fo

r tra

inin

g, N

o. o

fst

aff r

ecei

ving

the

follo

w-u

ps, E

valu

atio

n of

wor

kpe

rfor

med

by

train

ed st

aff,

Clie

nts s

atis

fact

ion

with

the

qual

ity o

f car

e.

Rec

ords

on

mee

tings

, Tr

aini

ngre

cord

s and

repo

rts, M

onito

ring

reco

rds

1-2.

No.

of H

Cs m

aint

aini

ng fa

cilit

y an

d eq

uipm

ent

prov

ided

1an

d 2

year

s afte

r ins

talla

tion,

No.

of s

taff

trai

ned

for

mai

nten

ance

.

Mon

itorin

g re

cord

s,C

omm

unity

surv

ey,

Mai

nten

ance

reco

rds

2. M

ater

nal c

are

at th

e co

mm

unity

leve

l is i

mpr

oved

. 2

No.

of C

OR

Ps tr

aine

d, N

o. o

f CO

RPs

atte

ndin

g A

NC

s and

deliv

erie

s in

pilo

t com

mun

ities

Patie

nt c

harts

at H

Cs a

ndH

ospi

tals

No.

of H

ealth

lear

ning

sess

ions

, No.

of p

artic

ipan

ts,

Cha

nges

in a

war

enes

s and

hea

lth b

ehav

iour

am

ong

peop

le.

For s

calin

g-up

to o

ther

com

mun

ities

, Tr

aini

ng re

cord

s/re

port

No.

of p

eer l

earn

ing

wor

ksho

ps a

nd e

xcha

nge

visi

ts

Com

mun

ity su

rvey

N

o. o

f com

mun

ities

repl

icat

ing

activ

ities

Cen

sus (

DH

S), M

DR

, Hea

lthSt

atis

tics

Patie

nt c

harts

at h

ospi

tals

and

HC

s, D

HS,

Hea

lth S

tatis

tics,

Com

mun

ity S

urve

ys, E

xit

Inte

rvie

ws

Hea

lth c

ondi

tion,

par

ticul

arly

the

mat

erna

l hea

lth, i

n th

e K

isii

and

Ker

icho

Dis

trict

s is i

mpr

oved

.

Mat

erna

l car

e in

the

Proj

ect a

rea

with

a fo

cus o

n he

alth

cen

tres a

ndco

mm

uniti

es is

impr

oved

.Su

cces

s rat

e in

mee

ting

the

need

s of w

omen

with

mat

erna

lco

mpl

icat

ions

No

sign

ifica

nt c

hang

es in

the

patte

rn o

f dis

ease

,M

OH

pol

icy,

or

econ

omic

or p

oliti

cal

cond

ition

s.

Trai

ning

reco

rds,

Rep

orts

by

train

ees

Rec

urre

nt c

osts

are

prov

ided

for h

ospi

tals

,H

Cs,

and

com

mun

ities

by

the

Ken

yan

side

.

71

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1

Mea

ns o

f Ver

ifica

tion

Impo

rtan

t Ass

umpt

ions

Com

pone

nt 2

. Man

agem

ent s

uppo

rt in

the

HC

s is i

mpr

oved

. 3

No.

of p

rope

r ref

erra

l cas

es o

f mat

erna

l com

plic

atio

ns

Cas

e re

view

reco

rdU

se o

f com

mun

icat

ion

& tr

ansp

orta

tion

Patie

nt c

hart

(Hos

pita

l, H

C)

No.

of t

rain

ing

sess

ions

for r

efer

ral a

nd N

o. o

f par

ticip

ants

U

se o

f ref

erra

l gui

delin

e N

o. o

f mee

tings

for r

evie

win

g re

ferr

al c

ases

4N

o. o

f tra

inin

g se

ssio

ns fo

r HIS

and

trai

nees

Com

mun

ity su

rvey

sR

edun

danc

y of

reco

rds a

nd re

porti

ng

Cas

e re

view

mee

tings

Use

of H

IS fo

r car

e an

d m

anag

emen

t at H

Cs

Adm

inis

tratio

n re

cord

s at H

Cs

Use

of H

IS fo

r mon

itorin

g an

d ev

alua

tion

Mon

itorin

g re

cord

sTr

aini

ng re

cord

s/re

ports

5St

ock-

out d

rugs

and

med

ical

supp

lies

Stoc

k/in

vent

ory

reco

rds

Use

of l

ogbo

oks f

or in

vent

ory

and

pres

crip

tion

Del

iver

y re

cord

sFr

eque

ncy

of d

rug

deliv

ery

to H

Cs

Logb

ooks

Rat

iona

l use

of m

edic

ines

bas

ed o

n gu

idel

ines

at H

Cs

Trai

ning

reco

rds/

repo

rtsPa

tient

cha

rts a

t HC

s Pr

escr

iptio

n re

cord

s6

No.

of D

HM

T m

embe

rs su

perv

isin

g H

Cs.

DH

MT

repo

rtsQ

ualit

y of

supe

rvis

ion

DH

MT

mee

ting

reco

rds

Qua

lity

assu

ranc

e of

HC

man

agem

ent

HC

C, H

FMT

mee

ting

reco

rds

4. H

ealth

Info

rmat

ion

Syst

em (H

IS) a

nd re

cord

kee

ping

syst

em a

t HC

sis

func

tioni

ng a

nd is

util

ised

for s

ervi

ce a

nd m

anag

emen

t at t

he H

Cs.

5. M

anag

emen

t cap

abili

ty fo

r dru

gs a

nd m

edic

al su

pplie

s at t

he H

Cs a

reim

prov

ed.

6. D

istri

ct H

ealth

Man

agem

ent T

eam

s (D

HM

Ts)'

syst

em fo

r the

irsu

ppor

tive

supe

rvis

ion

for H

Cs i

s stre

ngth

ened

.

3. A

refe

rral

syst

em is

arr

ange

d an

d fu

nctio

ning

bet

wee

n co

mm

uniti

es,

HC

s and

Dis

trict

Hos

pita

ls.

72

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1

Mea

ns o

f Ver

ifica

tion

Impo

rtan

t Ass

umpt

ions

(Act

iviti

es)

(Inp

uts)

Inpu

ts)

Out

com

e 1.

Mat

erna

l car

e se

rvic

es in

the

HC

s are

upg

rade

d.

Japa

nese

side

Ken

yan

side

A) T

o in

stitu

te a

trai

ning

syst

em fo

r mat

erna

l car

e [H

uman

Res

ourc

es]

[Ass

ignm

ents

of c

ount

erpa

rts]

1. P

repa

ratio

n (L

ong-

or sh

ort t

erm

exp

erts

or c

onsu

ltant

s)

Min

istry

of H

ealth

1) O

rgan

izin

g tra

inin

g te

am w

ithin

DH

MT

1. C

hief

Adv

isor

or T

echn

ical

Adv

isor

DR

H2)

Rev

iew

ing

info

rmat

ion

on tr

aini

ng n

eeds

for H

C st

aff

2. P

roje

ct M

anag

erO

ther

rele

vant

dep

artm

ents

3) E

stab

lishi

ng c

urric

ula

3. P

roje

ct C

oord

inat

orD

HM

T (K

isii

& K

eric

ho)

4) S

elec

ting

heal

th st

aff t

o be

trai

ned.

4.

Mid

wife

ryPM

O5)

For

mul

atin

g tra

inin

g w

ork-

plan

5. C

omm

unity

-bas

ed h

ealth

H

C st

aff

2. Im

plem

enta

tion

[Pro

visi

on o

f Equ

ipm

ent]

HFM

T (H

CC

)1.

Equ

ipm

ent f

or M

ater

nal c

are

at H

Cs

2. M

ater

nal c

are

equi

pmen

t for

trai

ning

at H

ospi

tals

[A

ccom

odat

ions

]3.

Fol

low

-up

or M

onito

ring

3. L

eani

ng m

ater

ials

nec

essa

ry fo

r tra

inin

g Sa

lary

for t

he st

aff

4. C

omm

unic

atio

n eq

uipm

ent

Faci

litie

s5.

Equ

ipm

ent f

or P

roje

ct O

pera

tion

Proj

ect O

ffic

e2)

Con

duct

ing

Mat

erna

l Dea

th R

evie

w (M

DR

)[F

acili

ty R

enov

atio

n ]

Off

ice

secr

etar

ies

i.e. W

ater

supp

ly fa

cilit

y at

HC

, Sol

ar sy

stem

for H

CD

river

sTr

aini

ng si

tes

1. P

repa

ratio

n

[Cou

nter

part

train

ing]

Trai

ning

in Ja

pan

and/

or th

ird c

ount

ries,

Acc

epta

nce

of tr

aine

es1.

Mid

wife

ry2.

Impl

emen

tatio

n 2.

Dis

trict

Hea

lth M

anag

emen

t 1)

Ren

ovat

ing

faci

litie

s and

pro

vidi

ng e

quip

men

t 3.

Oth

ers

2) D

evel

opin

g m

anua

ls fo

r ope

ratio

n an

d m

aint

enan

ce.

[Pro

ject

Ope

ratio

nal C

ost]

3. F

ollo

win

g-up

and

Mon

itorin

g 1.

Tra

inin

gC

ondu

ctin

g re

gula

r mai

nten

ance

for e

quip

men

t and

faci

litie

s 2.

Em

ploy

men

t of l

ocal

con

sulta

nts (

incl

udin

g su

b-co

ntra

ctin

g)

Tra

inin

g in

mat

erna

l car

e fo

r HC

staf

f, in

clud

ing

esse

ntia

l& e

mer

genc

yob

stet

ric c

are,

AN

C, P

AC

with

clie

nt-c

entre

d ca

re.

1) F

ollo

w-u

p fo

r the

trai

ned

staf

f with

on-

the-

job

train

ing

and

re-tr

aini

ngut

ilizi

ng C

ritic

al In

cide

nce

Ana

lysi

s *2

B) T

o es

tabl

ish

a sy

stem

for r

enov

atin

g fa

cilit

ies a

nd p

rovi

ding

equ

ipm

ent

with

thei

r mai

nten

ance

.

1) In

vest

igat

ing

the

curr

ent s

tatu

s of t

he fa

cilit

ies a

nd e

quip

men

t at e

ach

HC

.2)

Det

erm

inin

g th

e re

quire

d re

nova

tion

and

sele

ctin

g eq

uipm

ent f

orm

ater

nal c

are.

Dec

isio

ns o

n re

nova

tion

and

equi

pmen

t pro

visi

on w

ill b

e m

ade

base

d on

furt

her s

urve

ys, i

nclu

ding

an

asse

ssm

ent o

f the

cond

ition

of e

quip

men

t pro

vide

d by

Jap

anes

e G

rant

Aid

.R

ecur

rent

cos

ts fo

r ite

ms s

uch

as v

ehic

le fu

el a

nd e

quip

men

t

73

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1

Mea

ns o

f Ver

ifica

tion

Impo

rtan

t Ass

umpt

ions

Out

com

e 2.

Mat

erna

l car

e at

the

com

mun

ity le

vel i

s im

prov

ed.

3. O

ther

s 1.

Pre

para

tion

1) C

ondu

ctin

g co

mm

unity

and

hou

seho

ld su

rvey

s at c

andi

date

com

mun

ities

2)

Sel

ectin

g a

pilo

t com

mun

ity in

eac

h D

istri

ct

2. Im

plem

enta

tion

3. F

ollo

w-u

p or

Mon

itorin

g

Out

com

e 3.

A r

efer

ral s

yste

m is

arr

ange

d an

d fu

nctio

ning

bet

wee

nco

mm

uniti

es, H

Cs a

nd D

istr

ict H

ospi

tals

.1.

Pre

para

tion

1) A

sses

sing

the

curr

ent r

efer

ral s

yste

m

2) F

orm

ulat

e a

refe

rral

syst

em im

prov

emen

t pla

n

b) F

orm

ulat

ing

refe

rral

gui

delin

es fo

r the

HC

s and

Dis

trict

Hos

pita

ls

2. Im

plem

enta

tion

1) S

ettin

g up

com

mun

icat

ion

equi

pmen

t at D

istri

ct H

ospi

tals

and

HC

s.

3) T

rain

ing

HC

staf

f in

the

guid

elin

es3.

Fol

low

ing

up a

nd M

onito

ring

1) C

ondu

ctin

g m

aint

enan

ce fo

r com

mun

icat

ion

and

trans

porta

tion

2) C

ondu

ctin

g re

gula

r aud

its o

f ref

erra

l cas

es

3) Id

entif

ying

CO

RPs

*3 a

nd H

CM

C*4

mem

bers

in th

e co

mm

unity

and

form

ulat

ing

the

wor

kpla

n.

1) T

rain

ing

PHT

and

nurs

es a

t the

nea

rby

heal

th c

entre

and

dev

elop

ing

IEC

for a

war

enes

s and

refe

rral

2) T

rain

ing

CO

RPs

and

HC

MC

mem

bers

for c

omm

unity

aw

aren

ess a

ndre

ferr

al fo

r mat

erna

l car

e

a) F

orm

ulat

ing

a co

mm

unic

atio

n an

d tra

nspo

rtatio

n pl

an fo

r ref

erra

l at

Dis

trict

Hos

pita

ls a

nd H

Cs

2) A

ssis

ting

in se

curin

g tra

nspo

rtatio

n by

repa

iring

exi

stin

g ve

hicl

es o

rpr

ovid

ing

new

veh

icle

s at D

Hs

3) S

uppo

rting

CO

RPs

and

the

com

mun

ity to

org

aniz

e he

alth

lear

ning

grou

ps a

nd a

tran

spor

tatio

n sy

stem

with

com

mun

ity fu

nds

1) F

acili

tatin

g vi

sits

by

othe

r com

mun

ities

and

pee

r lea

rnin

g as

pilo

tco

mm

unity

act

iviti

es.

2) M

onito

ring

the

com

mun

ity h

ealth

act

iviti

es a

nd fo

rmul

atin

g m

odel

sfo

r bes

t pra

ctic

es.

3) S

uppo

rting

and

follo

win

g up

for t

he sc

ale-

up o

f act

iviti

es in

oth

erar

eas i

n D

istri

cts

74

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1

Mea

ns o

f Ver

ifica

tion

Impo

rtan

t Ass

umpt

ions

Out

com

e 4.

Hea

lth In

form

atio

n Sy

stem

(HIS

) and

rec

ord

keep

ing

syst

em a

t HC

s is f

unct

ioni

ng a

nd is

util

ised

for

serv

ice

and

man

a gem

ent a

t the

HC

s.1.

Pre

para

tion

1) A

sses

sing

the

curr

ent s

tatu

s of t

he H

IS a

t the

HC

s and

Dis

trict

Hos

pita

ls2)

For

mul

atin

g a

HIS

impr

ovem

ent p

lan

at th

e H

Cs

2. Im

plem

enta

tion

1) T

rain

ing

Dis

trict

MR

IO fo

r im

prov

emen

t pla

n fo

r HIS

2) T

rain

ing

HC

staf

f in

reco

rd-k

eepi

ng

3. F

ollo

win

g up

and

Mon

itorin

g C

ontin

uous

ly im

prov

ing

the

qual

ity o

f rec

ord-

keep

ing

at th

e D

istri

ctan

d H

C le

vels

Out

com

e 5.

Man

agem

ent c

apab

ility

for

drug

s and

med

ical

supp

lies

at th

e H

Cs a

re im

prov

ed.

1. P

repa

ratio

n1)

Sur

veyi

ng d

rugs

and

med

ical

supp

lies w

ith a

focu

s on

the

adeq

uacy

ofpr

ovis

ion

(del

iver

y), s

tock

, and

pre

scrip

tion

2) F

orm

ulat

ing

a dr

ug m

anag

emen

t im

prov

emen

t pla

n at

the

HC

s2.

Impl

emen

tatio

n1)

Intro

duci

ng lo

gboo

ks fo

r inv

ento

ry, s

tore

-kee

ping

and

pre

scrip

tion;

train

ing

HC

staf

f to

use

the

log

book

s2)

Tra

inin

g H

C st

aff o

n th

e ca

se m

anag

emen

t gui

delin

es a

t the

HC

s to

ensu

re th

e ra

tiona

l use

of d

rugs

3) M

aint

aini

ng a

nd st

reng

then

ing

the

logi

stic

s sys

tem

for d

rug

deliv

ery

in c

oord

inat

ion

with

HIS

3. F

ollo

win

g up

and

Mon

itorin

gC

ontin

uous

ly im

prov

ing

the

qual

ity o

f dru

g m

anag

emen

t.O

utco

me

6. D

istr

ict H

ealth

Man

agem

ent T

eam

s (D

HM

Ts)

' sys

tem

for

thei

r su

ppor

tive

supe

rvis

ion

for

HC

s is s

tren

gthe

ned.

1. P

repa

ratio

n 1)

Ass

essi

ng th

e D

HM

T's c

urre

nt sy

stem

for s

uper

visi

ng th

e H

Cs

2) F

orm

ulat

ing

thei

r pla

n fo

r HC

supe

rvis

ion

2. Im

plem

enta

tion

Impl

emen

ting

the

supe

rvis

ory

plan

3.

Fol

low

ing

up a

nd M

onito

ring

Mon

itorin

g th

e D

HM

T's s

uper

visi

on o

f the

HC

s with

feed

back

.

*2 C

ritic

al In

cide

nce

Ana

lysi

s: T

o as

sess

the

effe

cts o

f tra

inin

g by

exa

min

ing

reco

rds o

n th

e m

anag

emen

t of c

ases

han

dled

by

the

train

ees a

fter t

he tr

aini

ng.

*3 C

OR

Ps in

clud

e co

mm

unity

lead

ers,

tradi

tiona

l birt

h at

tend

ants

(TB

As)

and

com

mun

ity h

ealth

wor

kers

(CH

Ws)

. *4

The

Hea

th C

entre

Man

agem

ent C

omm

ittee

(HC

MC

) is a

com

mun

ity-b

ased

com

mitt

ee re

spon

sibl

e fo

r man

agem

ent o

f the

HC

s.

*1 T

he o

bjec

tivel

y ve

rifia

ble

indi

cato

rs u

sed

for t

he p

urpo

se a

nd o

utpu

ts a

re a

ccor

ded

to th

ose

esta

blis

hed

in th

e D

istri

ct P

lan.

Oth

erw

ise,

eff

orts

will

be

mad

e to

det

erm

ine

impo

rtant

indi

cato

rssu

ch a

s Mat

erna

l Mor

talit

y (r

ate)

in th

e ar

ea b

y ba

selin

e s

75

Proj

ect D

esig

n M

atrix

Pr

ojec

t Nam

e: P

roje

ct fo

r the

Impr

ovem

ent o

f Hea

lth S

ervi

ce w

ith a

focu

s on

Safe

Mot

herh

ood

in th

e K

isii

and

Ker

icho

Dis

trict

sPr

ojec

t Per

iod:

Mar

ch 2

005

to 2

008

(3 y

ears

)Im

plem

entin

g O

rgan

isat

ions

: Dis

trict

Hea

lth M

anag

emen

t Tea

ms (

DH

MTs

), D

ivis

ion

of R

epro

duct

ive

Hea

lth (D

RH

), D

epar

tmen

t of P

reve

ntiv

e an

d Pr

omot

ive

Hea

lth S

ervi

ce, M

inis

try o

f Hea

lth

Targ

et G

roup

s: D

HM

Ts, H

ealth

car

e pr

ovid

ers,

HC

adm

inis

tratio

n st

aff,

and

com

mun

ities

in th

e K

isii

and

Ker

icho

Dis

trict

s B

enef

icia

ries:

Peo

ple

in th

e K

isii

and

Ker

icho

Dis

trict

s, pa

rticu

larly

wom

en o

f rep

rodu

ctiv

e ag

e.

PDM

1 (M

ay 2

007)

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1M

eans

of V

erifi

catio

nIm

port

ant A

ssum

ptio

ns[O

vera

ll G

oal]

Mat

erna

l mor

talit

y (r

ate)

in th

e D

istri

ct

Cas

e fa

talit

y ra

te d

ue to

mat

erna

l com

plic

atio

ns

Infa

nt m

orta

lity

rate

and

mal

aria

fata

lity

rate

[P

roje

ct P

urpo

se]

Skill

ed b

irth

atte

ndan

ce ra

te in

Dis

trict

Del

iver

y ra

te a

nd A

NC

rate

at H

Cs

HC

util

izat

ion

rate

and

clie

nt sa

tisfa

ctio

n [O

utpu

ts]

Out

put 1

. Mat

erna

l car

e se

rvic

es a

t the

HC

s are

upg

rade

d.

Incr

ease

in th

e N

o. o

f HC

s pro

vidi

ng sk

illed

birt

h at

tend

ance

(SB

Incr

ease

in th

e N

o. o

f clin

ical

staf

f mee

ting

the

defin

ition

of S

BA

Rec

ords

on

mee

tings

, Tr

aini

ngre

cord

s and

repo

rts, M

onito

ring

reco

rds

Mon

itorin

g re

cord

s, C

omm

unity

surv

ey, M

aint

enan

ce re

cord

s

Out

put 2

. Man

agem

ent s

uppo

rt in

the

HC

s is i

mpr

oved

. 2-

1. T

o im

prov

e m

anag

emen

t cap

acity

of t

he H

C in

-cha

rges

HC

C,H

FMT

mee

ting

reco

rds

Mon

itorin

g re

cord

s,C

omm

unity

Sur

vey

(Exi

tin

terv

iew

s)D

HM

Tre

ports

No.

of t

rain

ing

sess

ions

for H

IS a

nd tr

aine

esTr

aini

ng re

ports

Use

of H

IS fo

r car

e an

d m

anag

emen

t at H

Cs a

nd D

HM

TU

se o

f HIS

for m

onito

ring

and

eval

uatio

n

2-2.

Hea

lth In

form

atio

n Sy

stem

(HIS

) and

reco

rd k

eepi

ng sy

stem

at H

Cs i

sfu

nctio

ning

and

is u

tilis

ed fo

r ser

vice

and

man

agem

ent a

t the

HC

s.G

ood

scor

e in

the

HIS

perf

orm

ance

che

cklis

t on

reco

rdin

g an

d re

porti

ngA

dmin

istra

tion

reco

rds a

t HC

sM

onito

ring

reco

rds

No.

of H

C in

-cha

rge

who

rece

ived

trai

ning

rela

ted

to h

ealth

man

agem

ent

Incr

ease

d le

vel o

f com

mun

ity sa

tisfa

ctio

n on

MC

H re

gard

ing

heal

th m

anag

emen

t at H

Cs

Effic

ienc

y of

reco

rdin

g an

d re

porti

ng

Cen

sus (

DH

S), M

DR

, Hea

lthSt

atis

tics

Patie

nt c

harts

at h

ospi

tals

and

HC

s, D

HS,

Hea

lth S

tatis

tics,

Com

mun

ity S

urve

ys, E

xit

Inte

rvie

ws

Hea

lth c

ondi

tion,

par

ticul

arly

the

mat

erna

l hea

lth, i

n th

e K

isii

and

Ker

icho

Dis

trict

s is i

mpr

oved

.

Mat

erna

l car

e in

the

Proj

ect a

rea

with

a fo

cus o

n he

alth

cen

tres a

ndco

mm

uniti

es is

impr

oved

.Su

cces

s rat

e in

mee

ting

the

need

s of w

omen

with

mat

erna

lco

mpl

icat

ions

No

sign

ifica

nt c

hang

es in

the

patte

rn o

f dis

ease

,M

OH

pol

icy,

or e

cono

mic

or p

oliti

cal c

ondi

tions

.

Trai

ning

reco

rds,

Rep

orts

by

train

ees

Rec

urre

nt c

osts

are

prov

ided

for h

ospi

tals

,H

Cs,

and

com

mun

ities

by

the

Ken

yan

side

.C

ompl

etio

n of

trai

ning

wor

kpla

n, N

o. o

f sta

ff tr

aine

d (in

tota

lan

d by

HC

), N

o. o

f fol

low

-ups

for t

rain

ing,

No.

of s

taff

rece

ivin

gth

e fo

llow

-ups

, Eva

luat

ion

of w

ork

perf

orm

ed b

y tra

ined

staf

f,C

lient

s' sa

tisfa

ctio

n w

ith th

e qu

ality

of c

are.

No.

of H

Cs m

aint

aini

ng fa

cilit

y an

d eq

uipm

ent 1

and

2 y

ears

afte

r the

ir in

stal

latio

n, N

o. o

f sta

ff tr

aine

d fo

r mai

nten

ance

.

76

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1M

eans

of V

erifi

catio

nIm

port

ant A

ssum

ptio

nsR

educ

ed st

ock-

out t

ime

for d

rugs

and

med

ical

supp

lies

Stoc

k / I

nven

tory

reco

rds

Del

iver

y re

cord

s/St

ore

arra

ngem

ent

Trai

ning

reco

rds/

repo

rtsPa

tient

cha

rts a

t HC

s Pr

escr

iptio

n re

cord

s/Lo

gboo

ks2-

4. T

o im

prov

e w

aste

man

agem

ent s

yste

mTr

aini

ng re

cord

s

HC

ass

essm

ent

Perf

orm

ance

ass

essm

ent

No.

of D

HM

T m

embe

rs in

volv

ed in

supe

rvis

ion

of H

Cs.

DH

MT

repo

rtsN

o. o

f sup

ervi

sion

at e

ach

HC

H

CC

, HFM

T m

eetin

g re

cord

sPr

ojec

t rec

ords

/repo

rts

Out

put 4

. Mat

erna

l car

e at

the

com

mun

ity le

vel i

s im

prov

ed.

HC

mon

thly

repo

rtC

omm

unity

surv

ey (E

xit

inte

rvie

ws)

Trai

ning

reco

rds/

repo

rts

No.

of c

omm

uniti

es re

plic

atin

g ac

tiviti

es

No.

of p

rope

r ref

erra

l cas

es o

f mat

erna

l com

plic

atio

ns

Type

and

No.

of u

se o

f com

mun

icat

ion

& tr

ansp

orta

tion

No.

of t

rain

ing

sess

ions

con

duct

ed fo

r ref

erra

l and

No.

of p

artic

ipU

se o

f the

refe

rral

gui

delin

eN

o. o

f mee

tings

for r

evie

win

g re

ferr

al c

ases

2-3.

Man

agem

ent c

apab

ility

for d

rugs

and

med

ical

supp

lies a

t the

HC

s are

impr

oved

.

Cas

e re

view

reco

rdPa

tient

cha

rt (h

ospi

tal,

HC

)

For s

calin

g-up

to o

ther

com

mun

ities

,N

o. o

f pee

r lea

rnin

g w

orks

hops

and

exc

hang

e vi

sits

Rat

iona

l use

of m

edic

ines

bas

ed o

n gu

idel

ines

at H

Cs

Leve

l of s

atis

fact

ion

byH

Cin

cha

rges

with

supp

ortiv

esu

perv

isio

n

No.

of H

C st

aff w

ho re

ceiv

ed th

e ba

sics

of w

aste

man

agem

ent

No.

of H

Cs w

hich

und

erta

ke w

aste

man

agem

ent a

ccor

ding

to th

eM

OH

stan

dard

Out

put 5

. A r

efer

ral s

yste

m is

arr

ange

d an

d fu

nctio

ning

bet

wee

nco

mm

uniti

es, H

Cs a

nd D

istr

ict H

ospi

tals

.

Out

put 3

. Dis

tric

t Hea

lth M

anag

emen

t Tea

ms (

DH

MT

s)' s

yste

m fo

rth

eir

supp

ortiv

e su

perv

isio

n fo

r H

Cs i

s str

engt

hene

d.

No.

of t

he c

omm

unity

peo

ple

seek

ing

mat

erna

l car

e se

rvic

es in

targ

et h

ealth

faci

lity.

Incr

ease

d kn

owle

dge

rega

rdin

g m

ater

nal c

are

amon

g pe

ople

.

No.

of h

ealth

lear

ning

sess

ions

, No.

of p

artic

ipan

ts

Impr

oved

bas

ic d

rug

and

med

ical

supp

lies m

anag

emen

t of H

Cs

Impr

oved

beh

avio

ur re

gard

ing

was

te m

anag

emen

t am

ong

HC

for

impr

ovem

ent

Com

mun

ity su

rvey

Proj

ect r

ecor

ds/re

ports

77

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1M

eans

of V

erifi

catio

nIm

port

ant A

ssum

ptio

ns(A

ctiv

ities

)(I

nput

s)In

puts

)O

utco

me

1. M

ater

nal c

are

serv

ices

at t

he H

Cs a

re u

pgra

ded.

Ja

pane

se si

deK

enya

n si

deA

. To

inst

itute

a tr

aini

ng sy

stem

for m

ater

nal c

are

[Hum

an R

esou

rces

][A

ssig

nmen

ts o

f cou

nter

parts

]A

-1. P

repa

ratio

n (L

ong-

or sh

ort t

erm

exp

erts

or c

onsu

ltant

s)

Min

istry

of H

ealth

1) O

rgan

izin

g tra

inin

g te

am w

ithin

DH

MT

1. C

hief

Adv

isor

or T

echn

ical

Adv

isor

DR

H2)

Rev

iew

ing

info

rmat

ion

on tr

aini

ng n

eeds

for H

C st

aff

2. P

roje

ct M

anag

erO

ther

rele

vant

dep

artm

ents

3) E

stab

lishi

ng c

urric

ula

3. P

roje

ct C

oord

inat

orD

HM

T (K

isii

& K

eric

ho)

4) S

elec

ting

heal

th st

aff t

o be

trai

ned.

4.

Mid

wife

ryPM

O5)

For

mul

atin

g tra

inin

g w

ork-

plan

5. C

omm

unity

-bas

ed h

ealth

H

C st

aff

A-2

. Im

plem

enta

tion

[Pro

visi

on o

f Equ

ipm

ent]

HFM

T (H

CC

)1.

Equ

ipm

ent f

or M

ater

nal c

are

at H

Cs

2. M

ater

nal c

are

equi

pmen

t for

trai

ning

at H

ospi

tals

[A

ccom

mod

atio

ns]

A-3

. Fol

low

-up

or M

onito

ring

3. L

eani

ng m

ater

ials

nec

essa

ry fo

r tra

inin

g Sa

lary

for t

he st

aff

4. C

omm

unic

atio

n eq

uipm

ent

Faci

litie

s5.

Equ

ipm

ent f

or P

roje

ct O

pera

tion

Proj

ect O

ffic

e2)

. Con

duct

ing

Mat

erna

l Dea

th R

evie

w (M

DR

)[F

acili

ty R

enov

atio

n ]

Off

ice

secr

etar

ies

i.e. W

ater

supp

ly fa

cilit

y at

HC

, Sol

ar sy

stem

for H

CD

river

sTr

aini

ng si

tes

B-1

. Pre

para

tion

[Cou

nter

part

train

ing]

Trai

ning

in Ja

pan

and/

or th

ird c

ount

ries,

Acc

epta

nce

of tr

aine

es1.

Mid

wife

ryB

-2. I

mpl

emen

tatio

n 2.

Dis

trict

Hea

lth M

anag

emen

t 1)

. Ren

ovat

ing

faci

litie

s and

pro

vidi

ng e

quip

men

t 3.

Oth

ers

2). D

evel

opin

g m

anua

ls fo

r ope

ratio

n an

d m

aint

enan

ce.

[Pro

ject

Ope

ratio

nal C

ost]

B-3

. Fol

low

ing-

up a

nd M

onito

ring

1. T

rain

ing

1). C

ondu

ctin

g re

gula

r mai

nten

ance

for e

quip

men

t and

faci

litie

s 2.

Em

ploy

men

t of l

ocal

con

sulta

nts (

incl

udin

g su

b-co

ntra

ctin

g)O

utco

me

2. M

anag

emen

t sup

port

in th

e H

Cs i

s im

prov

ed.

3. O

ther

s 2-

1. T

o im

prov

e m

anag

emen

t cap

acity

of t

he H

C in

-cha

rges

1. P

repa

ratio

n 1)

. Ass

essi

ng th

e cu

rren

t iss

ues r

egar

ding

the

man

agem

ent c

apac

ity o

f the

HC

in-c

harg

es2.

Impl

emen

tatio

n ).

Trai

ning

HC

in-c

harg

es o

n th

e he

alth

man

agem

ent

1). T

rain

ing

in m

ater

nal c

are

for H

C st

aff,

incl

udin

g es

sent

ial&

em

erge

ncy

obst

etric

car

e, A

NC

, PA

C w

ith c

lient

-cen

tred

care

.

B. T

o es

tabl

ish

a sy

stem

for r

enov

atin

g fa

cilit

ies a

nd p

rovi

ding

equ

ipm

ent w

ithth

eir m

aint

enan

ce.

1). I

nves

tigat

ing

the

curr

ent s

tatu

s of t

he fa

cilit

ies a

nd e

quip

men

t at e

ach

HC

.

2). D

eter

min

ing

the

requ

ired

reno

vatio

n an

d se

lect

ing

equi

pmen

t for

mat

erna

lca

re.

Rec

urre

nt c

osts

for i

tem

s suc

h as

vehi

cle

fuel

and

equ

ipm

ent

1). F

ollo

w-u

p fo

r the

trai

ned

staf

f with

on-

the-

job

train

ing

and

re-tr

aini

ngut

ilizi

ng C

ritic

al In

cide

nce

Ana

lysi

s *2

Dec

isio

ns o

n re

nova

tion

and

equi

pmen

t pro

visi

on w

ill b

e m

ade

base

d on

furt

her s

urve

ys, i

nclu

ding

an

asse

ssm

ent o

f the

cond

ition

of e

quip

men

t pro

vide

d by

Jap

anes

e G

rant

Aid

.

78

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1M

eans

of V

erifi

catio

nIm

port

ant A

ssum

ptio

ns2-

2. H

ealth

Info

rmat

ion

Syst

em (H

IS) a

nd r

ecor

d ke

epin

g sy

stem

at H

Cs i

sfu

nctio

ning

and

is u

tilis

ed fo

r se

rvic

e an

d m

anag

emen

t at t

he H

Cs.

1. P

repa

ratio

n 1)

. Ass

essi

ng th

e cu

rren

t sta

tus o

f the

HIS

at t

he H

Cs a

nd D

istri

ct H

ospi

tals

2). F

orm

ulat

ing

a H

IS im

prov

emen

t pla

n at

the

HC

s2.

Impl

emen

tatio

n 1)

. Tra

inin

g D

istri

ct M

RIO

for i

mpr

ovem

ent p

lan

for H

IS2)

. Tra

inin

g H

C st

aff i

n re

cord

-kee

ping

3.

Fol

low

ing

up a

nd M

onito

ring

1). C

ontin

uous

ly im

prov

ing

the

qual

ity o

f rec

ord-

keep

ing

at th

e D

istri

ct a

ndH

C le

vels

2-3.

Man

agem

ent c

apab

ility

for

drug

s and

med

ical

supp

lies a

t the

HC

sar

e im

prov

ed.

1. P

repa

ratio

n1)

. Sur

veyi

ng d

rugs

and

med

ical

supp

lies w

ith a

focu

s on

the

adeq

uacy

of

prov

isio

n (d

eliv

ery)

, sto

ck, a

nd p

resc

riptio

n2)

. For

mul

atin

g a

drug

and

supp

lies m

anag

emen

t im

prov

emen

t pla

n at

the

2. Im

plem

enta

tion

1). T

rain

ing

of H

C st

aff o

n th

e ba

sics

of d

rug

and

med

ical

supp

lies

man

agem

ent

2). T

rain

ing

HC

staf

f on

the

case

man

agem

ent g

uide

lines

at t

he H

Cs t

o en

sure

the

ratio

nal u

se o

f dru

gs3.

Fol

low

ing

up a

nd M

onito

ring

1). C

ontin

uous

ly im

prov

ing

the

qual

ity o

f dru

g m

anag

emen

t. 2-

4. T

o im

prov

e w

aste

man

agem

ent s

yste

m

1. P

repa

ratio

n 1)

. Ass

essi

ng th

e w

aste

man

agem

ent s

yste

m a

t the

HC

s2.

Impl

emen

tatio

n 1)

.Tra

inin

g H

C st

aff o

n th

e ba

sics

of w

aste

man

agem

ent

3. F

ollo

win

g up

and

Mon

itorin

g 1)

. Con

tinuo

usly

impr

ovin

g th

e w

aste

man

agem

ent

Out

com

e 3.

Dis

tric

t Hea

lth M

anag

emen

t Tea

ms (

DH

MT

s)' s

yste

m fo

rth

eir

supp

ortiv

e su

perv

isio

n fo

r H

Cs i

s str

engt

hene

d.1.

Pre

para

tion

1). A

sses

sing

the

DH

MT'

s cur

rent

syst

em fo

r sup

ervi

sing

the

HC

s2)

. For

mul

atin

g an

impr

oved

pla

n fo

r HC

supe

rvis

ion

2. Im

plem

enta

tion

1). I

mpl

emen

tatio

n of

the

supe

rvis

ory

plan

3. F

ollo

win

g up

and

Mon

itorin

g 1)

. Mon

itorin

g th

e D

HM

T's s

uper

visi

on o

f the

HC

s with

feed

back

.

79

Nar

rativ

e Su

mm

ary

Obj

ectiv

ely

Ver

ifiab

le In

dica

tors

*1M

eans

of V

erifi

catio

nIm

port

ant A

ssum

ptio

nsO

utco

me

4. M

ater

nal c

are

at th

e co

mm

unity

leve

l is i

mpr

oved

. 1.

Pre

para

tion

1). C

ondu

ctin

g co

mm

unity

and

hou

seho

ld su

rvey

s at c

andi

date

com

mun

ities

2)

. Sel

ectin

g a

pilo

t com

mun

ity in

eac

h D

istri

ct

2. Im

plem

enta

tion

3. F

ollo

w-u

p or

Mon

itorin

g

Out

com

e 5.

A r

efer

ral s

yste

m is

arr

ange

d an

d fu

nctio

ning

bet

wee

nco

mm

uniti

es, H

Cs a

nd D

istr

ict H

ospi

tals

.1.

Pre

para

tion

1). A

sses

sing

the

curr

ent r

efer

ral s

yste

m

2). F

orm

ulat

e a

refe

rral

syst

em im

prov

emen

t pla

n

b). F

orm

ulat

ing

refe

rral

gui

delin

es fo

r the

HC

s and

Dis

trict

Hos

pita

ls

2. Im

plem

enta

tion

1). S

ettin

g up

com

mun

icat

ion

equi

pmen

t at D

istri

ct H

ospi

tals

and

HC

s.

3). T

rain

ing

HC

staf

f in

the

guid

elin

es3.

Fol

low

ing

up a

nd M

onito

ring

1). C

ondu

ctin

g m

aint

enan

ce fo

r com

mun

icat

ion

and

trans

porta

tion

2). C

ondu

ctin

g re

gula

r aud

its o

f ref

erra

l cas

es*1

The

obj

ectiv

ely

verif

iabl

e in

dica

tors

use

d fo

r the

pur

pose

and

out

puts

are

acco

rded

to th

ose

esta

blis

hed

in th

e D

istri

ct P

lan.

Oth

erw

ise,

eff

orts

will

be

mad

e to

det

erm

ine

impo

rtant

indi

cato

rs su

ch a

s Mat

erna

l Mor

talit

y (r

ate)

inth

e ar

ea b

y ba

selin

e*2

Crit

ical

Inci

denc

e A

naly

sis:

To

asse

ss th

e ef

fect

s of t

rain

ing

by e

xam

inin

g re

cord

s on

the

man

agem

ent o

f cas

es h

andl

ed b

y th

e tra

inee

s afte

r the

trai

ning

.

*4 T

he H

eath

Cen

tre M

anag

emen

t Com

mitt

ee (H

CM

C) i

s a c

omm

unity

-bas

ed c

omm

ittee

resp

onsi

ble

for m

anag

emen

t of t

he H

Cs.

*3 C

HW

s who

are

Ex-

CO

RPs

incl

ude

com

mun

ity le

ader

s, tra

ditio

nal b

irth

atte

ndan

ts (T

BA

s) a

nd c

omm

unity

hea

lth w

orke

rs.

2). A

ssis

ting

in se

curin

g tra

nspo

rtatio

n by

repa

iring

exi

stin

g ve

hicl

es o

rpr

ovid

ing

new

veh

icle

s at D

Hs

3). S

uppo

rting

and

follo

win

g up

for t

he sc

ale-

up o

f act

iviti

es in

oth

er a

reas

inD

istri

cts

a). F

orm

ulat

ing

a co

mm

unic

atio

n an

d tra

nspo

rtatio

n pl

an fo

r ref

erra

l at

Dis

trict

Hos

pita

ls a

nd H

Cs

2). M

onito

ring

the

com

mun

ity h

ealth

act

iviti

es a

nd fo

rmul

atin

g m

odel

s for

best

pra

ctic

es.

2). T

rain

ing

CH

Ws a

nd H

CM

C m

embe

rs o

n co

mm

unity

aw

aren

ess a

nd re

ferr

alfo

r mat

erna

l car

e3)

. Sup

porti

ng C

HW

s and

the

com

mun

ity to

org

aniz

e he

alth

lear

ning

gro

ups a

nda

trans

porta

tion

syst

em w

ith c

omm

unity

fund

s

1). F

acili

tatin

g vi

sits

by

othe

r com

mun

ities

and

pee

r lea

rnin

g as

pilo

t com

mun

ityac

tiviti

es.

1). T

rain

ing

PHT

and

nurs

es a

t the

link

hea

lth c

entre

and

dev

elop

ing

IEC

for

awar

enes

s and

refe

rral

3). I

dent

ifyin

g C

HW

s*3

and

CH

IC*4

mem

bers

in th

e co

mm

unity

and

form

ulat

ing

the

wor

kpla

n.

80

→ Ori

gina

l Ind

icat

orR

evis

ed/C

hang

ed In

dica

tor

Out

put 1

Mat

erna

l car

e se

rvic

e at

the

HC

s are

upg

rade

dO

utpu

t 1M

ater

nal c

are

serv

ice

at th

e H

Cs a

re u

pgra

ded

Out

put 2

Mat

erna

l car

e at

the

com

mun

ity le

vel i

s im

prov

ed

Out

put 2

-1To

impr

ove

man

agem

ent c

apac

ity o

f the

HC

in-

char

ge

Out

put 3

A re

ferr

al sy

stem

is a

rran

ged

and

func

tioni

ngbe

twee

n co

mm

uniti

es, H

Cs a

nd D

istri

ct H

ospi

tals

Out

put 2

-2H

ealth

Info

rmat

ion

Syst

em (H

IS) a

nd re

cord

keep

ing

syst

em a

t HC

s is f

uctio

ning

and

isut

ilize

d fo

r ser

vice

and

man

agem

net a

t the

HC

s

Out

put 4

Hea

lth In

form

atio

n Sy

stem

(HIS

) and

reco

rdke

epin

g sy

stem

at H

Cs i

s fuc

tioni

ng a

nd is

util

ized

for s

ervi

ce a

nd m

anag

emne

t at t

he H

Cs

Out

put 2

-3M

anag

emen

t cap

abili

ty fo

r dru

gs a

nd m

edic

alsu

pplie

s at t

he H

Cs a

re im

prov

ed

Out

put 5

Man

agem

ent c

apab

ility

for d

rugs

and

med

ical

supp

lies a

t the

HC

s are

impr

oved

Out

put 2

-4To

impr

ove

was

te m

anag

emen

t sys

tem

Out

put 6

Dis

trict

Hea

lth M

anag

emen

t Tea

ms (

DH

MT)

syst

em fo

r the

ir su

ppor

tive

supe

rvis

ion

for H

Cs i

sst

reng

then

ed

Out

put 3

Dis

trict

Hea

lth M

anag

emen

t Tea

ms (

DH

MT)

syst

em fo

r the

ir su

ppor

tive

supe

rvis

ion

for H

Cs

is st

reng

then

ed

Out

put 4

Mat

erna

l car

e at

the

com

mun

ity le

vel i

sim

prov

ed

Out

put 5

A re

ferr

al sy

stem

is a

rran

ged

and

func

tioni

ngbe

twee

n co

mm

uniti

es, H

Cs a

nd D

istri

ctH

ospi

tals

Out

put 2

Com

pone

nt 1

Com

pone

nt 2

As a

orig

inal

, we

had

TWO

com

pone

nts.

Com

pone

nt o

ne w

as re

late

d to

mat

erna

l car

e an

d co

mpo

nent

two

was

rela

ted

to h

ealth

man

agem

ent.

How

ever

, the

revi

sed

one

spec

ifies

the

targ

ets o

f the

se tw

o co

mpo

nent

s.C

ompo

nent

one

is re

late

d to

mat

erna

l hea

lth sp

ecifi

cally

at H

C le

vel.

Com

pone

nt tw

o is

rela

ted

Hea

lth M

aneg

emen

t at H

C le

vel.

Com

pone

nt th

ree

is re

late

d to

Hea

lth M

anag

emen

t at D

istrc

t lev

el.

Com

pone

nt fo

ur is

rela

ted

to m

ater

nal c

are

at c

omm

unity

leve

l.C

ompo

nent

five

is re

late

d to

refe

rral

syst

em, w

hich

look

s at t

he li

nkag

e am

ong

thes

e co

mpo

nent

s, th

at is

, com

mun

ity/H

C a

nd D

istri

ct le

vels

.

81

→O

rigi

nal I

ndic

ator

Rev

ised

/Cha

nged

Indi

cato

rR

easo

n fo

r th

e ch

ange

N/A

No.

of H

C in

-cha

rge

who

rece

ived

trai

ning

rela

ted

to h

ealth

man

agem

ent

N/A

Incr

ease

d le

vel o

f com

mun

ity sa

tisfu

ctio

n on

MC

H re

gard

ing

heal

h m

anag

emen

t at H

Cs

Red

unda

ncy

of re

cord

s and

repo

rting

Effic

ienc

y of

reco

rdin

g an

d re

porti

ng

MO

H h

as b

een

revi

sing

the

reco

rdin

g sh

eets

. SA

MO

KIK

E PJ

T’s r

ole

was

to a

ssis

t the

DH

MT

and

HC

s to

unde

rsta

nd th

e im

porta

nce

of d

ata

colle

ctio

n an

d th

e us

e of

dat

a fo

rm

onito

ring

and

plan

ning

.SA

MO

KIK

E al

so p

rovi

ded

reco

rd k

eepi

ng a

nd st

orin

g to

ols s

uch

as c

alcu

lato

r, sh

elve

set

c. T

here

fore

it is

mor

e ap

prop

riate

to m

easu

re th

e pr

ojec

t out

com

e th

roug

h th

eef

ficie

ncy

of re

cord

ing

and

repo

rting

.

Use

of H

IS fo

r car

e an

d m

anag

emen

t at

HC

sU

se o

f HIS

for c

are

and

man

agem

ent a

t HC

san

d D

HM

T

The

SAM

OK

IKE

Proj

ect h

as b

een

invo

lvin

g th

e D

MR

IO fo

r the

impr

ovem

ent o

fhe

alth

reco

rd a

nd in

form

atio

n sy

stem

. The

refo

re it

is m

ore

appr

opria

te to

incl

ude

DH

MT

in th

e in

dica

tor.

Use

of l

ogbo

oks f

or in

vent

ory

and

pres

crip

tion

Impr

oved

bas

ic d

rug

and

med

ical

supp

lies

man

agem

ent o

f HC

s

Kis

ii an

d K

eric

ho d

istri

cts a

re a

t diff

eren

t sta

ge o

f int

rodu

cing

the

new

dru

gm

anag

emen

t sys

tem

(Pus

h →Pu

ll). G

iven

this

pro

cess

of t

rans

ition

, the

SA

MO

KIK

EPr

ojec

t cou

ld su

ppor

t onl

y th

e ba

sics

of t

he d

rug

man

agem

ent.

One

of a

ctiv

ities

was

the

train

ing

on d

rug

stor

age

man

agem

ent,

so th

at th

e dr

ugs a

re k

ept a

ppro

pria

tely

.

Freq

uenc

y of

dru

g de

liver

y to

HC

s(d

elet

e)Fr

eque

ncy

of d

rug

deliv

ery

to H

Cs i

s det

erm

ined

by

the

POH

/MO

H a

nd is

bey

ond

the

wor

k of

the

SAM

OK

IKE

proj

ect,

thus

it w

as e

xclu

de fr

om th

e or

igin

al P

DM

out

put

indi

cato

r lis

t.

N/A

(add

) No.

of H

C st

aff w

ho re

ceiv

ed th

eba

sics

of w

aste

man

agem

ent

N/A

(add

) No.

of H

Cs w

hich

und

erta

ke w

aste

man

agem

ent a

ccor

ding

to th

e M

OH

stan

dard

N/A

(add

)Im

prov

ed b

ehav

iour

rega

rdin

g w

aste

man

agem

ent a

mon

g H

C fo

r im

prov

emen

t

No.

of s

uper

visi

on a

t eac

h H

C

Leve

l of s

atis

fact

ion

by H

C in

-cha

rges

with

supp

ortiv

e su

perv

isio

n

Qua

lity

assu

ranc

e of

HC

man

agem

ent

(del

ete)

No.

of C

OR

Ps tr

aine

d, N

o. o

f CO

RPs

atte

ndin

g A

NC

s and

del

iver

ies i

n pi

lot

com

mun

ities

No.

of c

omm

unity

peo

ple

seek

ing

mat

erna

lca

re se

rvic

es in

targ

et h

ealth

faci

lity

Incr

ease

d kn

owle

dge

rega

rdin

g m

ater

nal

care

am

ong

peop

le

No.

of h

ealth

lear

ning

sess

ions

, No.

of

parti

cipa

nts

Use

of c

omm

unic

atio

n &

tran

spor

tatio

nTy

pe a

nd N

o. o

f use

of c

omm

unic

atio

n &

trans

porta

tion

The

orig

inal

indi

cato

r was

not

spec

ific

to m

easu

re th

e qu

ality

of r

efer

ral.

In o

rder

tom

easu

re th

e ar

rang

emen

t and

func

tioni

ng o

f ref

erra

l, de

tails

of c

omm

unita

tion

and

trans

porta

tion

use

wer

e ad

ded.

Dur

ing

the

heal

th a

ctiv

ities

, it w

as fo

und

that

the

was

te w

as n

ot a

ppro

pria

tely

man

aged

at s

ome

HC

s whi

ch c

ould

cau

se se

cond

ly in

fect

ions

. Giv

en th

e im

porta

nce

of p

rovi

ding

hea

lth se

rvic

e w

ith sa

fe a

nd p

rope

r env

ironm

ent,

the

new

out

com

e (to

impr

ove

was

te m

anag

emen

t sys

tem

) and

cor

resp

ondi

ng in

dica

tor a

re a

dded

.

Cur

rent

Com

mun

ity S

trate

gy o

f Ken

ya (J

une

2006

) int

rodu

ces t

he d

efin

ition

of l

evel

one

serv

ice

activ

ities

for a

ll si

x co

horts

. The

serv

ice

activ

ities

at t

he 1

st c

ohor

t(p

regn

ancy

, del

iver

y an

d ne

w b

orn)

incl

ude

prov

isio

n of

edu

catio

n an

d IE

C a

nddi

ssem

inat

ion

of k

ey m

essa

ges,

whi

ch is

exp

ecte

d to

rais

e aw

aren

ess a

nd c

hang

epo

sitiv

e be

havi

or a

mon

g C

HW

s as w

ell a

s com

mun

ity m

embe

rs. T

he re

vise

din

dica

tor i

s mor

e ap

prop

riate

with

the

new

ly d

efin

ed se

rvic

e ac

tiviti

es in

mea

surin

gm

ater

nal c

are

perf

orm

ance

at t

he c

omm

unity

leve

l. In

add

ition

, the

revi

sed

indi

cato

rsar

e m

ore

spec

ific

and

acco

unta

ble.

Qua

lity

of su

perv

isio

n

Out

put 4

Mat

erna

l car

e at

the

com

mun

ityle

vel i

s im

prov

edN

o. o

f Hea

lth le

arni

ng se

ssio

ns, N

o. o

fpa

rtici

pant

s, C

hang

es in

aw

aren

ess a

ndhe

alth

beh

avio

ur a

mon

g pe

ople

Out

put 3

Dis

trict

Hea

lth M

anag

emen

tTe

ams (

DH

MTs

)' sy

stem

for t

heir

supp

ortiv

e su

perv

isio

n fo

r HC

s is

stre

ngth

ened

.

Out

put 5

.A

refe

rral

syst

em is

arr

ange

d an

dfu

nctio

ning

bet

wee

n co

mm

uniti

es,

HC

s and

Dis

trict

Hos

pita

ls.

Out

put 2

-3M

anag

emen

t cap

abili

ty fo

r dru

gsan

d m

edic

al su

pplie

s at t

he H

Cs

are

impr

oved

Out

put 2

-4To

impr

ove

was

te m

anag

emen

tsy

stem

The

qual

ity o

f man

agem

ent s

yste

m sh

ould

be

mea

sure

d no

t onl

y by

the

effic

ienc

y of

syst

ems b

ut a

lso

by th

e ca

paci

ty o

f a k

ey p

erso

n w

ho is

to a

ssum

e a

supe

rvis

ing

role

in m

anag

ing

thos

e sy

stem

s. Th

eref

ore

the

man

agem

ent c

apac

ity o

f HC

in-c

harg

e an

dco

rres

pond

ing

indi

cato

rs a

re a

dded

.

Out

put 2

-1To

impr

ove

man

agem

ent c

apac

ityof

the

HC

in-c

harg

e

Out

put 2

-2H

ealth

Info

rmat

ion

Syst

em (H

IS)

and

reco

rd k

eepi

ng sy

stem

at H

Cs

is fu

ctio

ning

and

is u

tiliz

ed fo

rse

rvic

e an

d m

anag

emne

t at t

heH

Cs

82

→

Ori

gina

l Act

ivity

Rev

ised

/Cha

nged

Act

ivity

Rea

son

for

the

chan

ge

N/A

Ass

essi

ng th

e cu

rren

t iss

ues r

egar

ding

the

man

agem

ent c

apac

ity o

f the

HC

in-c

harg

es

N/A

Trai

ning

HC

in-c

harg

es o

n th

e he

alth

man

agem

ent

Intro

duci

ng lo

gboo

ks fo

r inv

ento

ry,

stor

e-ke

epin

g an

d pr

escr

iptio

n; tr

aini

ngH

C st

aff t

o us

e th

e lo

g bo

oks

Trai

ning

of H

C st

aff o

n th

e ba

sics

of d

rug

and

med

ical

supp

lies m

anag

emen

t

Kis

ii an

d K

eric

ho d

istri

cts a

re a

t diff

eren

t sta

ge o

f int

rodu

cing

the

new

dru

g m

anag

emen

t sys

tem

(Pus

h →Pu

ll). G

iven

this

pro

cess

of

trans

ition

, the

SA

MO

KIK

E Pr

ojec

t cou

ld su

ppor

t onl

y th

e ba

sics

of

the

drug

man

agem

ent.

One

of a

ctiv

ities

was

the

train

ing

on d

rug

stor

age

man

agem

ent,

so th

at th

e dr

ugs a

re k

ept a

ppro

pria

tely

.

Mai

ntai

ning

and

stre

ngth

enin

g th

elo

gist

ics s

yste

m fo

r dru

g de

liver

y in

coor

dina

tion

with

HIS

(del

ete)

Kis

ii an

d K

eric

ho d

istri

cts a

re a

t diff

eren

t sta

ge o

f int

rodu

cing

the

new

dru

g m

anag

emen

t sys

tem

(Pus

h →Pu

ll). G

iven

this

pro

cess

of

trans

ition

, the

SA

MO

KIK

E Pr

ojec

t cou

ld su

ppor

t onl

y th

e ba

sics

of

the

drug

man

agem

ent.

N/A

Ass

essi

ng th

e w

aste

man

agem

ent s

yste

m a

tth

e H

Cs

N/A

Trai

ning

HC

staf

f on

the

basi

cs o

f was

tem

anag

emen

t

N/A

Con

tinuo

usly

impr

ovin

g th

e w

aste

man

agem

ent

Iden

tifyi

ng C

OR

Ps*3

and

HC

MC

*4m

embe

rs in

the

com

mun

ity a

ndfo

rmul

atin

g th

e w

orkp

lan.

Iden

tifyi

ng C

HW

s*3

and

CH

IC*4

mem

bers

in th

e co

mm

unity

and

form

ulat

ing

the

wor

kpla

n.Tr

aini

ng C

OR

Ps a

nd H

CM

C m

embe

rsfo

r com

mun

ity a

war

enes

s and

refe

rral

for

mat

erna

l car

e

Trai

ning

CH

Ws a

nd H

CM

C m

embe

rs o

nco

mm

unity

aw

aren

ess a

nd re

ferr

al fo

rm

ater

nal c

are

Supp

ortin

gC

OR

Psan

dth

eco

mm

unity

to o

rgan

ize

heal

th le

arni

ng g

roup

s and

atra

nspo

rtatio

n sy

stem

with

com

mun

ityfu

nds

Supp

ortin

g C

HW

s and

the

com

mun

ity to

orga

nize

hea

lth le

arni

ng g

roup

s and

atra

nspo

rtatio

n sy

stem

with

com

mun

ity fu

nds

Out

put 2

-3M

anag

emen

t cap

abili

ty fo

r dru

gsan

d m

edic

al su

pplie

s at t

he H

Cs

are

impr

oved

The

qual

ity o

f man

agem

ent s

yste

m sh

ould

be

mea

sure

d no

t onl

y by

the

effic

ienc

y of

syst

ems b

ut a

lso

by th

e ca

paci

ty o

f a k

ey p

erso

nw

ho is

to a

ssum

e a

supe

rvis

ing

role

in m

anag

ing

thos

e sy

stem

s.Th

eref

ore

the

man

agem

ent c

apac

ity o

f HC

in-c

harg

e an

dco

rres

pond

ing

activ

ities

are

add

ed.

Out

put 2

-1To

impr

ove

man

agem

ent c

apac

ityof

the

HC

in-c

harg

e

Cur

rent

Com

mun

ity S

trate

gy o

f Ken

ya (J

une

2006

) int

rodu

ces t

hede

finiti

on o

f lev

el o

ne se

rvic

e ac

tiviti

es fo

r all

six

coho

rts.C

OR

Psar

e no

w o

ffic

ially

cal

led

"CH

Ws"

.

Out

put 4

Mat

erna

l car

e at

the

com

mun

ityle

vel i

s im

prov

ed

Out

put 2

-4To

impr

ove

was

te m

anag

emen

tsy

stem

Dur

ing

the

heal

th a

ctiv

ities

, it w

as fo

und

that

the

was

te w

as n

otap

prop

riate

ly m

anag

ed a

t som

e H

Cs w

hich

cou

ld c

ause

seco

ndly

infe

ctio

ns. G

iven

the

impo

rtanc

e of

pro

vidi

ng h

ealth

serv

ice

with

safe

and

pro

per e

nviro

nmen

t, th

e ne

w o

utco

me

(to im

prov

e w

aste

man

agem

ent s

yste

m) a

nd c

orre

spon

ding

indi

cato

r are

add

ed.

83

App

endi

x�5

Lis

t of I

EC

/BC

C m

ater

ials

pro

vide

d by

SA

MO

KIK

E p

roje

ct

No

IEC

/BC

CTa

rget

O

bjec

tive

Maj

or C

onte

nt

Dis

trib

utio

n M

etho

d

1

Post

er o

f Mod

el o

n

Goo

d C

usto

mer

Car

e

HC

staf

f To

im

prov

e cu

stom

er c

are

at

the

HC

s.

-

Idea

l atti

tude

of H

C st

aff t

owar

d cl

ient

s D

istri

bute

d on

e po

ster

for

eac

h

HC

.

MC

2

Post

er o

f R

efer

ral

Proc

edur

e on

Mat

erna

l

Emer

genc

y

HC

staf

f To

le

ad

the

HC

st

aff

to

appr

opria

te

refe

rral

pr

oced

ure

in c

ase

of e

mer

genc

y.

-

Ref

erra

l Pro

cedu

res

Dis

tribu

ted

one

post

er f

or e

ach

HC

.

3

5S a

pron

H

C st

aff

To sh

ow 5

S1K

prin

cipl

es to

ever

ybod

y in

HC

(Sta

ff,

clie

nts)

.

To g

et a

n at

tent

ion

abou

t 5S1

K

activ

ities

-5S

mar

k

-C

onte

nts

of 5

S1K

(So

rt, S

et,

Shin

e, S

tand

ardi

ze,

Sust

ain,

and

Kee

p it

up)

Giv

en

one

apro

n to

5S

1K

man

ager

on

the

day

of tr

aini

ng

4

5S1K

ToT

mat

eria

ls

HC

staf

f and

com

mun

ity m

embe

rs

To te

ach

5S1K

prin

cipl

es to

HC

staf

f and

com

mun

ity m

embe

rs

-Pu

rpos

e of

5S1

K

-M

eani

ng o

f 5S1

K

-Ex

ampl

e of

5S1

K a

ctiv

ities

-Ex

ampl

e of

5S1

K (b

efor

e an

d af

ter)

Giv

en o

n se

t of

mat

eria

l (1

0

slid

es w

ith la

min

atio

n) to

5S1

K

man

ager

(one

set p

er e

ach

HC

)

HM

5

5S1K

man

ager

badg

e

5S1K

man

ager

(HC

staf

f)

To e

ncou

rage

5S1

K m

anag

er to

act a

s man

ager

of 5

S1K

-N

ame

of th

e pe

rson

-M

eani

ng o

f 5S1

K

-Ph

oto

of th

e pe

rson

with

5S

apro

n

Giv

en o

n th

e da

y of

trai

ning

for

5S1K

man

ager

.

�

84

App

endi

x�5

6

Cam

paig

n Fl

ier

Mas

s (co

mm

unity

) To

pro

mot

e ut

iliza

tion

of H

C

and

supp

ort f

or p

regn

ant

wom

en

-Se

rvic

es a

vaila

ble

at H

C

-N

umbe

r of n

ewly

inst

alle

d co

mm

unity

pho

ne

-M

essa

ge to

fath

ers

-Ph

oto

of H

C st

aff w

elco

min

g to

HC

-Ph

oto

of a

fam

ily p

rom

otin

g m

ale

supp

ort f

or h

ealth

y

child

Dis

tribu

ted

on m

ass

cam

paig

n

day

7

Bro

chur

e Pr

egna

nt w

omen

To

serv

e as

edu

catio

nal

mat

eria

l for

pre

gnan

t wom

en

and

spou

ses t

o be

tter p

repa

re

for s

afe

deliv

ery

-Im

porta

nce

of sk

illed

car

e (A

NC

, Del

iver

y an

d PN

C)

-In

divi

dual

Birt

h Pl

an

-D

ange

r sig

ns

-R

ole

of sp

ouse

s/fa

ther

s

-N

utrit

ion

durin

g pr

egna

ncy

-Se

rvic

es a

t HC

-C

omm

unity

pho

ne n

umbe

r in

case

of e

mer

genc

y

Use

d an

d gi

ven

by H

C s

taff

at

the

time

of a

nten

atal

clin

ics

8

Cam

paig

n B

anne

r M

ass (

com

mun

ity)

-K

ey m

essa

ge o

f the

Cam

paig

n

-Pi

ctur

e of

hea

lthy

fam

ily

-N

ame

of H

C

Prov

ided

to

HC

on

the

day

of

1st c

ampa

ign

and

hand

ed it

ove

r

to H

C a

fter t

he c

ampa

ign

9

Cam

paig

n T-

shirt

M

ass (

com

mun

ity)

To p

rom

ote

key

mes

sage

of t

he

cam

paig

n an

d SA

MO

KIK

E

proj

ect

-K

ey m

essa

ge o

f the

Cam

paig

n

-Pi

ctur

e of

hea

lthy

fam

ily

Dis

tribu

ted

to

com

mun

ity

lead

ers

and

HC

sta

ff on

the

day

of 1

st c

ampa

ign

at e

ach

HC

CA

10

Rad

io

Mas

s (co

mm

unity

,

with

focu

s on

fath

ers)

To p

rom

ote

HC

util

izat

ion

for

skill

ed m

ater

nal c

are

-C

onve

rsat

ions

on

HC

util

izat

ion

and

its b

enef

its

On

air

for

thre

e m

onth

s (E

gesa

FM in

Kis

ii an

d R

adio

Inj

ili in

Ker

icho

) in

ve

rnac

ular

lang

uage

s.

11

Bab

y Sh

awl

Mas

s (co

mm

unity

) To

pro

mot

e sk

illed

car

e at

HC

s-

SAM

OK

IKE

and

JIC

A lo

go

Whe

n th

e w

oman

del

iver

ed a

t

HC

or m

eets

cer

tain

crit

eria

.

�

85

IEC

Imag

es

1.Po

ster

of M

odel

on

Goo

d C

usto

mer

Car

e2.

Pos

ter

of R

efer

ral P

roce

dure

on

Mat

erna

l Em

erge

ncy

3. “

5S a

pron

”

4. “

5S1K

ToT

mat

eria

ls “

5. 5

S1K

man

ager

bad

ges

6. C

ampa

ign

Flie

r

86

Appe

ndix

5

7. B

roch

ure

8. C

ampa

ign

Ban

ner

9. C

ampa

ign

T-sh

irt

11. B

aby

Shaw

l

87

Appendix 6

JOINT NATIONAL PROJECT STEERING COMMITTEE MEETING HELD ON 14/9/05 IN AFYA HOUSE.

Attendants.1. Mr. Zacharia Ogongo P/S MOH 2. Ms Naoko Fujita Hands chief advisor/project manager 3. Ms Masayo Nonoguchi Hands project coordinator 4. Dr Yasuhiko Kamiya Hands Technical Advisor 5. Dr Kemboi C.K DMOH –Kericho 6. Dr E.S Abunga DMOH-Kisii 7. Joseph N Neya DS/DIV-MOH 8. Ms Yumiko Igarashi JICA 9. Dr Willi Nyambati JICA Kenya office 10.Mr. Jiro Inamura DRR, JICA Kenya office 11.Dr Marsden Solomon Deputy Head, DRH 12.Mr. Daniel Sande DRH-National coordinator

ApologyDr Misore Head PPHS

The meeting started at 9.30am after handing over ceremony of two ambulances to Kisii and Kericho DMOHs.

Min 1/9/05: Welcome Remarks. The P/S chaired the meeting. He welcomed members and requested them to introduce themselves.

Min 2/9/05: Issues arising Office in Kericho is to be put up now awaiting AIE to avail funds, details of this will be reported in the next meeting by P/S office. The P/S requested for early ownership of the project by the concerned districts.

Min 3/9/05: Achievements April to August Operational and Technical achievements were presented. This was the project progress report in the last 4 months since its commencement in April 2005.

89

Appendix 6

The project has held several meetings at different levels, NTWC 2 meetings, DPCC 3 meetings in Kisii and Kericho, JNPSC it was the first meeting.Office set up in Kisii had been done. Fixing and ordering vehicles for the project (two ambulances for Kisii and Kericho have been handed over) Community Based Study had been done which included Dissemination workshop at Kericho on 12/8/05. Facility Based Study was done including feedback workshop 4 times, this necessitated rescheduling of some planned project activities.

Min 4/9/05: Constraints, Challenges and Concerns. Temporary project office issue in Kericho Project counterparts-budgetary and secondment issues. Coordination of the project with the District, GOK and JICA.

Min5/9/05: Progress report on HC renovation. HANDS decided minor renovations for 10 HCs based on the HC assessment. Total budget for renovation for the project Kshs.4, 060,000/= Renovation points include; water supply system, fencing and gate, drainage and partitioning. There is good community participation in monitoring the progress of HC renovation.

Min 6/9/05: Provision of medical equipments for maternal care. The process of procurement is as follows; HC assessment was conducted in june/july, and request for RH equipments from DRHT in Kisii and Kericho was received in August. The DRH gave standardized RH equipment list on 2/9/05.During HC assessment a lot of donated equips were found in good condition but not in use, while some HCs offering delivery services lacked equipments.

Min7/5/09: Procurement Policy. The project will;

- Provide medical equipments following the national guideline. - Consider making full use of existing facilities and equipments and

proper maintenance through the assistance of the two trained medical engineering personnel.

- Redistribution of donated equipments under supervision of DMOH in Kisii and Kericho-this will be realistically done at the end of the project.

90

Appendix 6

- Consider provision of other equipments as per HC individual needs. GOK funds in the two districts have been factored in the New District Health Plan to assist in procurement of equipments and renovations

Min 8/9/05 Any Other Business. HANDS/JICA expressed concern on counterpart funding from the MOH in relation to the project. In response, the PS said he would look into the matter and give feedback in subsequent meetings. It was agreed that there is need to enhance service demand seeking behavior by:--sensitizing the community on the services available. -enhancing quality maternal services -renovating of the existing HCs -strengthening referral systems (project ambulances in place) By addressing above issues members felt the communities’ confidence will be enhanced and this will increase number of client seeking behavior. The P/S emphasized on interaction and involvement of other community development projects i.e. CDF, LATIFA etc

There being no other business JICA country representative appreciated the presence of P/S who then thanked members for attending the meeting. Next meeting to be held on 16/11/05. Meeting closed at 11.30am

Sign………………….. Date…………………………….

Chairman.

Sign…………………. Date…………………………….

Secretary.

91

Appendix 6

MINUTES OF THE JOINT NATIONAL PROJECT STEERING COMMITTEE MEETING ON 16TH NOV, 2005 BETWEEN MOH AND JICA/HANDS AT AFYA HOUSE.

MEMBERS PRESENT. 1. Mr.Zachariah Ogongo Permanent Secretary-MoH –Chairman. 2. Dr Ambrose Misore Head PPHS-MoH 3. Dr Eric Abunga DMOH – Kisii 4. Dr Kemboi C K DMOH – Kericho 5. Dr M.M Solomon DRH –MoH 6. Mr J.M Gitonga PHO/D 7. Dr Were S.N ADMS, HSRS8. Mr Daniel Sande DRH-MoH 9. Ms Naoko FUJITA HANDS –Project Manager 10. Ms Yoko SUZUKI HANDS –Tokyo Officer 11. Dr Willie Nyambati Jica Kenya Office 12. Ms Yumiko Igarashi Jica 13. Mr Jiro Inamura Jica Kenya Office.

ABSENT WITH APOLOGY.1. Dr J.Nyikal DMS2. Dr I. Amira PMO Rift Valley 3. Dr J Gesami PMO Nyanza 4. Mr Charles Mutiso Rep.Ministry of Finance

The meeting started at 9.30am.

Min 1/11/05 Welcome Remarks Welcome remarks from the Permanent Secretary and self introduction of members.Remarks from Jica’s country representative and briefing on project progress to P/S and members.

Min 2/11/05 Achievements in the 1st term.HANDS representative took members through the projects’ achievements in the 1st term which included; Maternal Care –she told members preparation for the training for next year were on going, printing of the ANC/Delivery /PNC registers to be finalized in January 2006.

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JICAs’Kenya office in process of procuring equipments worth approximately Kshs. 4,500,000/= which will be distributed in Health Centers (HCs) in Feb 2006, HANDS Kenya has purchased equipments/materials worth approximately Kshs 1300, 000/= and had done distribution more distribution will be in Feb, 2006.

Health Management –procurement and handover of vehicles (two ambulances) to DHMT Kisii and Kericho had been done, procurement of drug storage and record keeping cabinet was in process. Printing of registers was in process and distribution will be early next year.

Health Centre renovation-Minor HC renovation had been done in 5 HCsin Kisii, 4 HCs in Kericho.Total renovation budget Kshs 4,060,000/=

Community Activities included involvement in the HC renovation, and establishment of women groups. Training of the community on maternal issues targeted both men and women.

Operational Achievements-this included office set up in Kisii and Kericho and hiring of staff. Construction of new office in Kericho to start early 2006. In summary effects of these years activities were geared towards improving Safe Motherhood(SM) services in HC and the community.

Plans for 2006 Jan-March included;Maternal Care-distribution of MC medical equipments, training of staff

and community members. Health Management –drug management plan development and training,

strengthening MC record keeping system and finalizing supervision list with DHMT,Community Activities-training of women and men in SM and

strengthening relationship between HC and community.

-HANDS /JICA to contribute Kshs300, 000/= towards Kericho office construction while GoK-MoH to fund the construction.

-consideration for spacious cabinets for drug storage during renovation to be done since the revised drug kit is bulky-there is need to lias with HC management during this activity. -consider purchasing solar panels in sunny areas since generators are costly.

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-Community involvement is important and that the process of strengthening HC management was underway where each HC is expected to open an account and revive HC management committees that are gender sensitive. -Male involvement in maternal health services is necessary. -Need to improve security and maintenance of HC through community involvement. Appropriate location and standardizing of drug stores is necessary. -Need to strengthen HC management since present health needs are demanding, it is necessary to know what modern health facility constitutes,ie hospital, HC or dispensary levels, and upgrading of facilities should be done appropriately.-Need to have close monitoring of drugs and other commodities through use of standardized tools/registers.

Min3/11/2005 Constraints and Challenges.Concerns on Counterpart budget –this was being worked on and it will be reflected in Feb/March 2006 revised estimates, since treasury had agreed to incorporate the 3 year JICA/ HANDS project

Staff shortage –there was on going recruitment and the head of PPHS promised to act through CNOs’ office depending on staff returns from the two districts.

-In Kericho staff redistribution was in process. -There is need to address post basic and other training related matters by the facility management i.e. by not allowing all staff to go for training at the same time, management to consider facility needs first.

Min 4/11/05 A O B -HANDS team leaves on 18/11/2005 to JAPAN for holidays, to be back mid January 2006 (project will continue running while they are away) -HANDS expressed need to have an office in Nairobi to assist in streamlining coordination of project activities. -Members agreed to have the national team visiting the project sites before the next meeting. -There is need to make arrangements for official handing over of the JICA and BELGIUM projects in Kisii and Nyamira districts. -Need to have deeper involvement in the project through emulatinglesions learnt in other facilities and replicating them in the project.

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-Need to have issues taken to the ground and involve the community while handling the matters rather than having issues handled in boardrooms

With no other business, the P/S thanked the JICA/HANDS team for there commendable work and wished them safe journey to Japan.

Next JNPSC 19/1/2006, DPCC 27/1/2006, NTWC date to be fixed. There will be project progress meeting on 9/3/2006 Meeting closed at 10.30am.

Chairman………………………….. Date……………………….

Secretary…………………………… Date………………………..

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MINUTES OF THE THIRD JOINT NATIONAL PROJECT STEERING COMMITTEE MEETING ON 29TH SEPT, 2006 BETWEEN MOH AND JICA/HANDS AT AFYA HOUSE

MEMBERS PRESENT 1. Mr.Hezron Nyangito Permanent Secretary-MoH –Chairman. 2. Dr S K Sharrif Head PPHS-MoH 3. Dr Josephine Kibaru Head-DRH –MoH 4. Dr Eric Abunga DMOH – Kisii 5. Dr Kemboi C.K. DMOH – Kericho 6. Mr F.M Ombwori Personal Assistant/PS 7. Prof.Handa Y Regional formulation Advisor, JICA 8. Mr. Daniel Sande DRH-MoH 9. Yumiko Kitagawa HANDS –Technical advisor MC 10. Mamoru Shimamoto HANDS –Project Manager 11. Kazuhiko Tokuhashi DRR-JICA Kenya Office 12. Ms Yumiko Igarashi JICA Project formulation Advisor 13. Keiko Takahashi HANDS. 14. Kiyomi Yamamoto HANDS 15. Yoshiki Ehare JICA Kenya 16. E Kinyangi JICA Prog. Officer

ABSENT WITH APOLOGY.1. DMS 2. PMO Rift Valley 3. PMO Nyanza 4. Rep. Ministry of Finance

The meeting started at 9.15am.

Min 1/9 Welcome Remarks - Welcome remarks from the Permanent Secretary and self introduction of

members.- Safe Motherhood is a key area in health and there is need to focus on it

due to challenges facing it. - He Called for duplication of Samokike Project in other parts of the country

and urged the involved parties to scale up the project - He commented on evaluation of the project and said it was crucial for the

purpose of prioritization of project activities, and emphasized on need for integration of health services.

- With maternal health being one of the MDGs, all efforts to improve the project outcome were welcome.

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Min. 2/9 Address from DRR JICA Office Kenya

- Thanked MOH for cooperation and mentioned achievements due to cooperation

- Emphasized on need to have strong health system to address health challenges; Malaria, HIV/AIDS, TB and said that with this in place safe motherhood will be achieved.

- Said JICA was willing to support MOH activities in other districts. - Mentioned JICA had sent 16 experts from HANDS to the project. - Commented on the trainings and the benefits to the HC staff and the

community.- He said that the project mid-term evaluation was one of the 3rd phase

agenda and he looked forward for cooperation/participation from MOH/JICA and HANDS. Prof. Handa would lead the evaluation team from JICA side.

- Called for support from MOH to the implementing organization HANDS.

Min: 3/9 Presentation on Mid-term Evaluation SAMOKIKE Project

- Emphasis on joint evaluation process and report writing MOH/JICA and HANDS was made.

- Role of evaluation was to acknowledge the evidence of project progress in terms of assessing how much more input was required and other positive project performance policy aspect and for betterment of health services.

- Members were shown and explained to the project design matrix format that was used in the project.

- 5 projects outputs were mentioned to members. - He mentioned that HANDS used integrated approach in implementation of

the 5 outputs and this was in collaboration with MOH (DMOH). - He mentioned expected efficiency based on the project outputs, with

emphasis to HC and communities. - More indicators were required for the evaluation process, which was being

worked on, and the outcome was necessary and essential evidence to be shown to MOH, JICA Kenya office and Japan Government.

- Evaluation report was necessary in determining project progress. - He said project design was relevant since it is in line with local demand,

the project goal being health issues especially maternal health is improved. - Members were reminded that no short comings in terms of efficiency in

the project activities had occurred. - He mentioned that there was effectiveness in the project, how the 5

outputs were contributing to the project outputs. - Despite staff shortage, the ones in health facilities were motivated

especially due to project works, and they require acknowledgement and support.

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- The project has a positive impact since it addresses maternal health care issues.

- On sustainability, he mentioned that retention of trained staff was crucial since it could assist in measuring project sustainability.

- He called for active participation and collaboration from Kenyan side both MoH/DMoH and locals (community),

- He had high expectation in the project as JICA/Japanese government would like to use the evaluation report in other sub-Saharan countries of Africa.

- The PS thanked Prof. Handa and assured him of total support and contribution in the project especially during mid-term evaluation.

- He added MOH was shifting its priorities towards community approach, and he looked forward to having the report as it could assist in improving the health status of the communities and else where.

DMOH – Kericho

- He commended the project especially the renovations in the 7 health centers. He added there was increase in maternal services due to improved services and availability of referral services. Supervision was being done in good time using the developed checklist and he looked forward to the mid-term evaluation exercise.

DMOH – Kisii

- Commended the project and said there was full community participation and involvement.

- Repairs were being done with focus to reproductive health. - Ambulance had improved referral services - Number of deliveries had increased through improved maternal care - Checklist was assisting in the joint supervision - Commented on the current staff training and added it was possible to

sustain the project. - On staff shortage he assured members of balancing staff in the health

centers following the recent MOH posting.

Min: 4/9 AOB- PS told the DMOHs to redistribute staff for balance - Members were informed of the uniqueness of the project as it was being

implemented by Japan NGO. - It is important that the evaluation should have the report and the costs of

the project as it was being implemented by NGO. - DPPHs emphasized on community participation, and that evaluation

should measure community involvement.

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- He called for additional indicators i.e. to address community and maternal care i.e. number of deliveries with skilled birth attendants.

- All activities done at community level that had led to increase to number of deliveries could be copied elsewhere as lessons learnt.

- It was important for the community people to be organized and educated by HC staff before the exercise.

- Evaluation was scheduled for October whereas report writing was scheduled for November.

- PS assured cooperation and support from MOH side.

With no other business, the meeting ended at 10.15 am.

Chairman………………………………….Date……………………….

Secretary…………………………………..Date……………………….

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MINUTES OF THE TECHNICAL COMMITTEE MEETING HELD ON APRIL 28, 2OO5

BETWEEN, MOH AND JICA (HANDS) AT AFYA HOUSE

MEMBERS PRESENT

1. Dr. A.O. Misore - Head, PPHS - Chairman 2. Dr. J. Kibaru - Head, DRH 3. Dr. E.S. Abunga - DMOH, Kisii 4. Dr. Kemboi C.K. - DMOH, Kericho 5. Kano Yoshiaki - Resident Representative, JICA 6. Nyambati Willie - JICA 7. Daniel E. Sande - DRH 8. Kanenawa Tomaki - JICA 9. Ehala Yoshiko - JICA 10.Fujita Naoko - HANDS 11.Kamiya Yasuniko - HANDS 12.Chiba Yoko - HANDS 13.Nonoguchi Masayo - HANDS

ABSENT WITH APOLOGY

1. Dr. James Nyikal - DMS

AGENDA

1. Welcome and introduction2. Review of the previous minutes 3. Matters arising 4. Any Other Business

� Dr. Misore who was chairing the meeting welcomed those present and asked them to introduce themselves.

� He thanked JICA and HANDS for their effort towards improving health care services in the two districts (Kisii and Kericho) focusing on Safe Motherhood and systems support for the 3 years they will be running the project.

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� JICA countries resident representative called for support from MOH and other teams working in the area and added that this will in turn encourage Japan Government’s effort in funding the project.

� Head, DRH gave an overview of the current maternal situation in the country. She mentioned causes of maternal death, direct and indirect causes contraceptives use, among women of reproductive age, in Kenya and mentioned that factors that led to increase in maternal death included poor referral system, poor infrastructure, inadequate health management and information systems, incompetent health provisions among other factors.

� She said, improving these factors would decrease maternal mortality in Kenya.

� HANDS Chief Advisor made a presentation on the overview of the project, its mission being working with people in improving their health status and added that it’s a non-profit making.

� MOH-Kisii made a presentation on the district plan, focusing on improving maternal health.

� He mentioned training activities for service health provider that will improve quality of care towards Safe Motherhood.

� Other matters discussed were: purchase of delivery equipments, PAC equipments and initiation of youth friendly activities.

� Improving communication both transport means and telephones� Need for clear policy from DRH on training of CORPS instead of TBAs. � Need to train Kericho DHMT on maternal health and prioritize community

activities. � Schedule of project was discussed and agreed that a project

implementation schedule should be made showing flow of activities. � It was agreed that regular meetings should be held in respect to the project.

Any Other Business

� Need to standardize equipment using rapid assessment tool was discussed and strict adherence to time frame to enable mid term evaluation of the project to be done at appropriate time.

� Proper arrangement be made to minimize interferance of the project with normal health services in the institutions owing to inadequate staff in the facilities especially in relation to training.

� Renovation and furnishing the Kisii/Kericho office was found necessary.

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� The committee agree that the National Steering Committee meeting be held on 25th August 2005 at 2.30 p.m. and Technical Committee meeting be held on 28th July 2005 from 9.00 a.m at Afya House.

� 1st District Committee meeting was scheduled on 6th May 2005 at Kericho Tea Hotel where head-DRH will chair the Meeting.

� With no other business Dr. Misore declared the meeting officially ended at 4.30 p.m.

Sign ……………………………………………… Date ………… Chairman

Sign ………………………………………………. Date………… Secretary

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NATIONAL TECHNICAL WORKING GROUP MEETING, MOH-JICA/HANDS SAFE MOTHERHOOD PROJECT IN AFYA HOUSE ON 4/8/2005.

IN ATTENDANCE

1. Dr. Kemboi C. K. DMOH/KERICHO 2. Dr. Josephine Kibaru Head – DRH/MOH 3. Adangah Ageism Policy & Planning Div. 4. Dr. E.S. Abunga DMOH Kisii 5. J. Inamura JICA Kenya 6. Tonoki Kanenawa JICA 7. Mamoru Shimamoto HANDS Kenya 8. Mayo Nonoguchi HANDS Kenya 9. Naoko Fujita HANDS Kenya 10.Yoko Chiba HANDS Kenya 11.Yauhiko Kamiya HANDS Kenya 12.Leonard Mauti DDPHN/ District Co-ord. 13.Mary Cheuiyot DDPHN/District Co-ord. 14.Mabwai Daudi HANDS 15.Sylvia Kimaru HANDS 16.Daniel Sande DRH/MOH

Absent with Apology1. Dr. Nyikal DMS

The meeting started at 9.00a.m.

Min. 1/8/05: Welcome Remarks

Dr. Misore chaired the meeting. He welcomed members, and requested them to introduce themselves. He took the group over the previous minutes. No issues arose after previous minute’s overview.

He introduced a new project member Mr.Shimamoto, and embarked on the agenda of the days meeting.

Min.2/8/05: Overall project progress This was the project progress report in the last 4 months since its commencement on 1st April 2005. Hands project manager took members through the overall project progress.

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Min. 3/8/05: Operational progress Staff recruitment for project operation had been done following advertisement on the daily newspaper though they (HANDS) require more staff to improve the project.Office set up for Kisii was done and completed in May 2005, though in Kericho they lacked a proper office and there is need to have a well-constructed office.She requested the MOH to construct a new building for them to get an office since the cost of renovating the current office was almost equivalent. She awaits feedback from MOH.

The hands project coordinator said on purchase of equipments including vehicles (2 ambulances and 2 project cars) said they were handling technical issues on importation. She said on 10th August the supervision vehicles will be at the Mombasa Port and will be in Nairobi by end of August. Supervision vehicle for hands will be available– end of September. She went ahead to show the group the type of vehicles they had purchased.

On networking a couple of meetings had been held previously and that meetings involving hands and local authority were on going.

Min. 4/08/05: Technical Progress

Facility assessment survey had been done by HANDS; these took one month.Community baseline study took 2 months, it was done by a private consultant firm (Almaco) ended July and that HANDS were expecting 1st draft of the report on baseline survey study in due course.

Members were shown major activity plan for 3 years with proper divisions, which included both original schedule vs. the re-schedule plan The said preparation period may take a bit longer than the expected, same to baseline survey and needs assessment – she said the delay was caused by the rescheduling of events/activities of the project.

Equipment purchase was in preparation period (September/October) since the equipments were already available in the country, while vehicles will be available by end of August.

Staff training is to be done next year2006 Health centre renovation was to be in 2006 but with re-scheduling, minor renovation will be commenced this year. Improving referral system and renovation of District Hospital will be done next year 2006. On community activities, the new project community technical adviser will work in collaboration with DHMT

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Monitoring and evaluation remains unchanged She reminded members that despite the alterations the project had not changed much.

Technical advisor on health management took the group on overall technical progressHe said the project had been divided in 4 phases and named them i.e.

(i)Introductory phase, (1st April-6th May) Involved;

– Introduction of Japanese Staff/DHMT –Introduction of the project

(ii) Preparatory phase (7th-30th May) – Involved confirmation of donors involvement in Kisii and Kericho

(iii) Health centre assessment phase (31stMay-12thJuly)–Involved Hands technical advisor and DHMT members in Kisii/Kericho

H/Cs(iv) Post H/C assessment phase(13th-July-Now)

- Involved data entry and analysis and schedule of meetings at various levels.

On health centre assessment findings he said two areas had been involved i.e. maternal care and Health management He discussed the findings of ANC, PNC, PMTC, FP and KEPI, and mentioned that TBAs practiced secretly by seeking help from private/mission hospitals.

He touched on facility equipment materials and spelled out some of challenges that exists i.e. lack of basic equipment and poor maintenance of existing equipments, poor record keeping, IP lacking etc He went ahead and showed pictures of H/C visited and renovated by JICA in 2003, and compared to the ones not renovated at all. The discrepancy was quite visible. From the assessment, it was found necessary to compare quality of service to quality of planning and management.

Other issues mentioned included need for proper renovations, availability of water supply and drainage systems, proper record keeping and management. DHMT supervision findings in health centers for both Kisii and Kericho were presented, and it emerged that most HCMCs were active.

Technical advisor on maternal care presented the community baseline study where she said improved maternal care at community level was the expected output from the community activities and that the purpose of study was to

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obtain people’s perspectives, knowledge, attitude and practice of pregnancy and childbirth. She said that ALMACO management consultants Ltd. Based in Nairobi had been subcontracted for the implementation of the project and that targeted communities were those ones within 1 kilometer from the 14 H/Centers targeted by the project.

She spelled out summary of observations and findings of community baseline study and gave out the way forward – that the project activities will be designed in collaboration with the representatives from the communities, H/Centre staff, DHMT members and HANDS TA on community activities.

Min. 5/8/05: Re-scheduling of project activitiesShe told members, that trainings were postponed since during assessment there was a problem with basic infrastructure therefore, DHMT/HANDS and communities found it necessary to start with renovations first.

This meant proper planning should be done before commencing the renovations. The current renovations were minor and that renovated H/Centers in 2002 by JICA were not to be considered.

She told members that 4M was available for the project and was to be spent by the end of October, 2005. Transparency of expenditure was mandatory and each H/Centre should write and handover proposal for renovation, regular reporting on progress and monitoring and evaluation by DHMT/HANDS will be continuous.

29/8/05 there will be a counterpart meeting for both districts, followed by regular meetings in Kisii and Kericho in respect to project progress. Members were shown procedures of H/C renovations and need for teamwork between H/Cs and the community. Responding to the presentations, the chairman told members that re-scheduling of project will not interfere with project process and that vehicles that are being purchased are not ambulances but for routine procedures.

He said there was need to find out basic equipments lacking in H/Cs and that some of donated equipments were not functioning but there was need to ensure proper maintenance of equipments the H/Cs are having. He assured members that there was adequate drug supply till September, 2006 and there was need to streamline drug use. He emphasized that currently drugs will be delivered to facilities not in the district depot allocation for the exercise is available.

He said money for Kericho hospital administration block was available and that further discussion on its utility was necessary before the construction works.

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He wanted to know what JICA/HANDS intended to do in Kericho in regard to construction/renovation, and cautioned the DMOH against giving out land to any other group since there is to save available land for expansion of the facility in future. He assured HANDS that Kericho would renovate one of the buildings to create an office for them.

Head-DRH wanted the vehicles to be modified to have all the facilities for ambulance services. She said registers were available i.e. ANC, PMTCT and PNC and suggested that the project can fund printing and distribution. On IP, she instructed DMOH Kericho to ensure that before equipments are purchased IP practice should be in place. Since government buys equipments for health facilities, HANDS should find out what’s lacking so that they don’t buy equipments already available.

The chairman wanted to know from HANDS whether the 4M was based on needs assessment findings and told members that each district has allocation of 6M for rural health facilities development and that HANDS should discuss with DHMT on necessary renovations, then with DHMT to choose the facilities that require renovation to enable merging of the funds in order to carry out reasonable work. He insisted on proposal submission by H/C and that only priority areas were to be chosen.

Min 6/8/05: Printed Estimates Head-DRH assured JICA/HANDS that their JICA project would appear on counterpart budget contribution by the MOH on the revised estimates of March 2006.Therefore the Kisii/Kericho DMOH should give their contributions.

JICA representative assure members that by end of this year the renovations will be done and that trainings will be on as from 2006.

Min.7/8/05: Project Collaboration On collaboration with counterparts, Technical advisor or maternal issues said the MOH staff lacked enough time to participate in working with them (HANDS) but after discussion the issues had been solved. She called for more MOH workers to assist with more information and organogram. Therefore there was need to second a DHMT member – Dr. Misore responded by urging the DMOH to expand activities in the district by allocating more staff from clinical area for these activities and proper coordination for office continuity. DMOH Kisii confirmed to members that he had already assigned a DHMT staff fully to the project and that DMOH Kericho was to do the same. The chairman urged members on prior planning of activities to avoid project activities clashing with normal daily activities.

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Min. 8/08/05: Schedule of other meetings � CBS – Dissemination by workshop 12/8/05 � 2nd JNPSC 25/8/05 2.30p.m. � 4th DPCC 16/9/05 � NTWC quarterly 3/11/05 subject to change

The chair thanked participants and said it was a good start with no other matters arising meeting ended at 11.30a.m.

Sign……………………………. Date………………………….

Chairman

Sign……………………………. Date…………………………..

Secretary.

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NATIONAL TECHNICAL WORKING COMMITTEE FOR MOH/HANDS/JICA SAFE MOTHERHOOD (SAMOKIKE) PROJECT ON 3

RD NOVEMBER, 2005

Members Present

1. Dr. J. Kibaru - Head DRH 2. Ms Naoko Fujita - HANDS Chief Advisor 3. Ms Yoko Chiba - HANDS Technical Advisor 4. Ms Masayo Nonoguchi - HANDS Project Coordinator 5. Ms Yoko Suzuki - HANDS Program Officer 6. Dr. Kemboi C. K. - DMOH Kericho 7. Ms. Yumiko Igarashi - JICA PA 8. Dr. E. S. Abunga - DMOH Kisii 9. Mr. Daniel Sande - DRH MoH 10. Dr. Willie Nyambati - JICA SPO 11. Mr. Jiro Inamura - PRR/JICA Kenya 12. Mr. Stephen Cheruiyot - Economist/Planning Officer – MoH

Absent with Apology Dr. A. O. Misore - Head PPHS

Meeting started at 9.00 a.m.

Min 1/11/05 Welcome Remarks Welcome and introductory remarks by DRH Head and Deputy Resident Representative, JICA Kenya Office.

Min 2/11/05 Presentation of Achievements in the 1st term

(March – November, 2005) HANDS

(i) Summary of achievements � Operational achievements included – Office setting

for Kisii and Kericho and staff recruitment/secondment. o Networking – meetings at National Level JNPSC

and NTWC at district level DPCC including meetings with other stakeholders and News letters.

o Technical achievements including baseline study and needs assessment, equipment provision, community involvement and HC renovations.

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(i) Achievement by each activity where issues on the following were discussed; � Maternal care at the health centres � Management at the health centres � District health management teams supervision � Maternal care at the communities

(ii) Provision of project equipment

� Multipurpose vehicles for districts use purchased and were handed over in September 2005 at Afya House other two project vehicles purchased for HANDS use in Kisii and Kericho. Details of multipurpose vehicles use explained.

� Medical equipment for Maternal care following guidelines from MoH-DRH, record keeping, and drug management were purchased, other equipments pending purchase by the SAMOKIKE budget while others by JICA.

(iii) Minor change on Project Design Matrix � Explanation on original project output and activities

against new project output and activities was given in details this included the old version i.e. Maternal Care Services at the Health Centres are upgraded against new version i.e. To improve maternal care at the health centres. This change came as a result of the Needs Assessment performed in the two districts (Kisii and Kericho).

Min 3/11/05 Constraints and Challenges

On office building in Kericho, the budgetary allocation of � 1.5M still pending awaiting financial release from the Ministry. On issues of counterpart budget, it was discussed that this budgetary allocation will be available by Feb/March 2006 approximately 10M. On weak participation by the DHMT members-it was discussed that prior activities planning and communication should be done on time while strengthening RH teams in the districts and delegation of duties will enhance full participation. On lack of H/C staff the MOH to address the issue.

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Min 4/11/05 Summary by DMOH � Establishment of supervision checklist for Kisii and

Kericho� Improvement of supervision activities in the health

facilities due to availability of supervision vehicles. � The SAMOKIKE project by HANDS is a ‘hands on’

project in comparison to other counterparts.

Presentation of Plan for 2nd term

Min 5/11/05 Plan of each activity

Outline of plans of each activity for the second phase was presented.

� Maternal care at the health centres, rough schedule of the SAMOKIKE project including training with proposed training program, delivery of donated equipments and joint meeting between HANDS and DRHT in Kisii and Kericho

Min 6/11/05 Brief Reports by DMOHS

� Health Centre management: - Management/staff/service issues in terms of the role of the district in improving management/staff/service issues.

� Maintenance of facility/equipment in terms of the district role in maintaining the facility equipment properly.

� Record keeping and the role of the district in provision of equipment and stationeries for record keeping

� Waste management following recommendation from the GoK guidelines

� Drug management � DHMT supervision. � Plan for community activity includes-training women group

leaders on SM with H/C staff o Installation of a generator to the model HC – Iranda HC o Follow up of the result of HC renovation o Collection of voices from community and reflection to

the SAMOKIKE Project.

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Min 7/11/05 AOB � HANDS and DRH can be accessed on internet through their

website www.hands.or.jp and www.drh.go.ke� DMOHs to have data of the project- will help in determine

project impact.� DMOHs to monitor the use of vehicles and equipment in the

districts. � HANDS presented (Logo mark design) meaning “lets work

together” this was approved by the DHMT in last 4th DPCC in Kericho

� Installation of generator in model H/C – Iranda, The DMOH/Community to agree on use, maintenance and fuelling this should be minuted.

� Through Rapid Result Initiative (RRI) the DMOHs of Kisii and Kericho should improve other SM issues especially FP uptake by improving their data through HMIS, distribution of commodities, supervision activities and other services in their districts with the presence of counterparts in their districts.

� District personnel to sustain the project while experts are away on holidays

� Need to share SM training schedule for the districts through the national coordinator.

� Need to integrate and coordinate activities in the districts-this will assist in identifying existing gaps in the districts that need to be addressed.

� For the purpose of project sustainability the GoK personnel need to participate fully rather than the community although the involvement of the community is important to enhance community ownership and uptake of services.

� Districts to order guidelines from DRH as other necessary arrangements for library are being mad- for the training models there is need to add others such as “madam Zoë” model.

With no other business meeting ended at 1 p.m. Next meeting date was scheduled for Feb. 2006.

Chairman --------------------------------------- Date ------------

Secretary --------------------------------------- Date ------------

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4TH NATIONAL TECHNICAL WORKING COMMITTEE MEETING FOR MOH/JICA/HANDS SAFE MOTHERHOOD (SAMOKIKE) PROJECT ON 15TH MARCH 2006

Members Present1. Dr. A. Misore -Head PPHS 2. Dr. J. Kibaru -Head DRH 3. Ms Yoko Chiba -HANDS Technical Advisor MC 4. Mr.Mamoru Shimamoto -Chief advisor HANDS Project 5. Ms Kyoko Koto -HANDS Program Officer 6. Dr. Kemboi C. K. -DMoH Kericho 7. Ms.Yumiko Igarashi -Project formulation advisor JICA 8. Dr. E. S. Abunga -DMoH Kisii 9. Mr. Daniel Sande -DRH MoH 10. Dr. Willie Nyambati -JICA SPO

Absent with Apology Mr. Kazuhiko Tokuhashi Deputy Resident Representative JICA


Min 1/03/06 Welcome Remarks Welcome and introductory remarks by Head PPHS.

Min 2/03/06 Address by DRR JICA. JICA Kenya office lost a member of staff hence Mr. Kazuhiko could not avail.

Min 3/03/06 Technical Activities in Second Phase Second phase had 60 days starting 22/1/2006 to 21/3/2006. Activities undertaken include office opening in Kisii and Kericho, highering of new local staff, holding of several meetings and implementing of activities including training of staff on matters concerning equipment and drug management, record keeping, follow ups and improving staff capacity in order to deliver quality MC services. All activities undertaken were based on action plan.

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Upgrading Maternal Care in HCs.One week orientation training on MC was contacted in Kisii and Kericho where service providers and 42 CORPS attended.

Improving management systems at HCs.Training curriculum already developed, training will be contacted in the 3rd phase, it includes waste management (Infection prevention and control)

Strengthening supervision capacity of the DHMTs. Supervisory checklist draft in place, management team working on the final supervisory checklist that will assist them during their supervisory visits in HCs.

Improving maternal care at the community. Orientation training of CORPS on MC, renovations of HCs and installation of generators in two model HCs in two 2 districts done.

Results of HC renovation. � Improved Water and Drainage systems, fence, gates, partitioning and

ceilings etc. Night duty in the two model HCs has improved due to operating generators installed by the project.

� Slides on training session and equipment handover were shown tomembers.

� Equipments included those purchased by JICA budget and HANDS, where HANDS provided training models, books, journals and registers to each district.

� Equipment distribution based on individual HC needs. � Water provided is tank water not piped. � Register printing was limited since DRH was in its final stages of

reviewing and standardizing the registers. � Madam Zoe is an essential training model for the two districts,

HANDS to include it in the models. � A comprehensive skills training for purposes of competency is

necessary after the orientation training. TOTs at divisional level should train CORPs using community orientation package.

� Participants during training session on full board booking to be provided with out of pocket (500/=), and that if the project cannot provide, the DMOH to source for funds else where for the participants allowances.

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� Project to continue its operations in the absence of experts and on their return, they will receive reports on equipment and commodity maintenance.

� Reflection of money spent by HANDS in the budget was necessary which is 100M although a 3o% budget cut was expected, since most of activities had been done.

Min 4/03/06 Plan of activities in the 3rd phase � HANDS promotion video was shown to members on maternal

services in Kisii, Kericho and other parts of the world and brief historical explanation on why JAPAN is working for SM in Kenya and other parts of the world given.

� Activities of 3rd phase were not mentioned due to anticipated budget cut by 30%. This would too result in having less HANDS technical staff.

� Although project was 3years,budget allocation was on yearly basis. � HANDS wished to continue working in Kenya after the project

term, and added that, often breaks and travels to Japan interfered with project operations. They called on MOH and GOK to negotiate for their continuous stay for the interest of the project, though it was clear that JAPAN Govt controlled their schedule in Kenya through JICA.

� Official project evaluation by JICA in cooperation with MOH will be done in Aug/Nov, 2006.

� There was need for discussions between MOH/JICA/HANDS on project consistence, expert’s breaks among other issues. Breaks cause wastage of time and resources. The frequent local staff highering and termination of their contracts had negative impact on the project, hence need to have them working in experts absence for the project continuity and sustainability.

� HANDS operation in Kenya would be possible after their project term ended only if they negotiated with GOK for registration licensing as an international NGO.

� DMOHS of Kisii and Kericho commented HANDS for the renovations, equipments and vehicles and added that health services had improved greatly. Communities were positive and supportive to the project. Although 2nd phase was short they promised to sustain the project during experts absence.

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� Availability of multipurpose vehicles made referral services effective, though there is need to strengthen communication by availing mobile phones and airtime to HC in charges.

� DMOHs were urged to ensure availability of functional kitchens, food and charcoal in HCs for mothers who seek delivery services.

� Construction of HANDS office in Kericho commenced in March, 06.JICA to contribute Kshs.300, 000/=towards the construction, in Kisii JICA will put up modern structures late this year to enable HANDS have a spacious office.

Min 4/03/06 AOB.� HANDS team to visit head of PPHS office before their departure to

Japan.� Project vehicles to be packed in Afya House compound while experts

are away. � There is need for project trends to be standardized since staff in the

two districts maybe transferred to other districts to offer similar services.

� HANDS requested DRH for official training proposal for district RH teams.

� Head PPHS thanked JICA/HANDS for their good work, and emphasized on community involvement with focus to reducing maternal mortality rates through offering preventive health services, rather than curative services and added that MOH would make follow up visits to facilities to assess utility. He hoped talks between HANDS and JAPAN govt will be done in goodtime to facilitate their early return.

� With no other business meeting ended at 11.30am.

Chairman…………………………………. Date…………………..

Secretary…………………………………. Date………………….

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5TH NATIONAL TECHNICAL WORKING COMMITTEE MEETING FOR MOH/JICA/HANDS SAFE MOTHERHOOD SAMOKIKE PROJECT ON 17TH

JULY 2006.

Members Present.

1. Dr J K Kibaru -Head DRH 2. Mr E Kinyangi -Programme Officer JICA 3. Dr E S Abunga -DMOH Kisii 4. Dr Kemboi C K -DMOH Kericho 5. Kiyomi Yamamoto -PC HANDS 6. Yumiko Kitagawa -MC Expert HANDS 8. Mamoru Shimamoto -PM HANDS 9. Daniel Sande -Programme Officer DRH MOH

Absent with apology Dr SK Sharrif HPPHS Mr. Kazuhiko Tokuhashi deputy resident Representative JICA Ms Yumiko Igarasshi Project Formulation Advisor JICA

Meeting started at 9.15am

Min 1/07/06 Opening Remarks.Welcome and introductory remarks by head-DRH

Min 2/07/06 Address from JICA DRR JICA Kenya office Mr. Kazuhiko Tokuhashi was unwell, while Ms Yumiko Igarashi was on leave. Mr. Kinyangi replaced Dr Willie Nyambati as JICA health representative.

Min 3/07/06 Introduction of new experts in the project New project members were introduced four long-term experts who were to stay during the project 3rd phase –Project Manager, Technical advisor on Maternal Care, Project coordinator for Kisii and Kericho. 5 short term experts were expected to the project-they were to go back to Japan before end of 3rd term.

Min 4/07/06 Review of previous activities in 2nd phase.Provision of equipments for maternal care to HCs Conducted SM training to service providers and community resource persons. Conducted DHMT supervision to HCs using checklist. Installation of generators to the two model HCs in Kisii and Kericho. Due to above activities, the number of deliveries in HCs had increased and clean water supply is adequate. Maternal emergencies are well addressed through improved communication and referral system.

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Two generators were purchased, although there was need for all HCs to have generators. For maintenance there is need to use other resources i.e. CDF and community involvement. The issue of solar use for power provision was raised, members felt it was important and needed to be discussed in subsequent meetings.

Min 5/07/06 Plan of activities in the 3rd phase 7/06 to 2/07 5 major activities to be undertaken.

� Upgrading MC in HCs through equipment maintenance, staff trainings, monitoring and evaluation activities and record keeping.

� Improving of management system in HCs � Strengthening supervision capacities of DHMTs � Improving MC in communities � Strengthening referral system

Nine trainings were to be carried out 3rd phase beginning with maternal care-2 week course in Essential Obstetric Care. Comments on trainings, -there is need to involve DHMT members in selection of participants in order to get the right staff and community members. Need to standardize the trainings by use of standardized training manuals. On essential obstetric training it was agreed that the DMOHs for the districts to provide funds for participants, out of pocket and facilitation fee for facilitators. This was to be discussed on 20th July 2006 in DPCC meeting in Kisii. HANDS wished to take four DHMT members for an exchange programme in Tanzania,-members discussed and it was agreed that HANDS was to meet all the costs involved.

Min 6/07/06 AOB There was need for HANDS experts to serve for longer period in the project. Construction of Kericho office was complete although the building had not dried up due to rains. Kisii office to be expanded in October 06, while JICA project in Kisii awaits design mission to give design report-this was expected in August 06. Mid term evaluation by Dr Handa to be done on 25-26 July 06, evaluation workshop to be held on 27-28 July 06 in Kericho.Evaluation will end in September 2006.MOH required early communication to enable participation in the evaluation exercise. MOH promised support to the project, HANDS urged to work closely with DMOHs to achieve better results. With no other issues arising members agreed that JPSC was to be held on 29/9/06 after projects’ midterm evaluation. Meeting ended 11am.

Chairman…………………………………………………Date……………………….

Secretary…………………………………………………Date………………………..

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Appendix 6

6TH MEETING OF THE NATIONAL TECHNICAL WORKING COMMITTEE (NTWC) FOR THE MOH/JICA-HANDS SAFE MOTHERHOOD (SAMOKIKE) PROJECT

DATE: 26/02/2007

VENUE: DRH BOARDROOM

Members Present: Organization 1. Dr. J. Kibaru Head-DRH 2. Yumiko Igarashi JICA 3. Adangah Agisu MOH 4. Elijah Kinyangi JICA 5. Daniel Sande DRH/MOH 6. Dr. F. S. Abunga DMOH - Kisii 7. Dr. A. K. Rotich DMOH – Kericho 8. MS. Junko Kato HANDS 9. Kiyomi Yamamoto HANDS 10. Dr. Kitetu R.N MOH/HSRS 11. Yumiko Kitagawa HANDS 12. Akiko Matsumoto HANDS

Absent with apology Dr. S K Sharrif HPPHS Deputy Country Representative-JICA

Meeting started at 10.15am

Min 1/02/06 Opening remarks Welcome and introductory remarks by the head-DRH.She called for feedback of the activities in 3rd phase of the project from the experts.

Min 2/02/06 Address from JICA DRR JICA Kenya office Deputy Country Representative sent apology. Igarashi – feedback report on Midterm evaluation to be released soon.

Min 3/02/07 Review of Technical Activities in the 3rd Phase Summary of activities: 3rd phase Had several training i.e.

� Maternal Care � Health facility management � Training included health personnel and community members

Summary of other trainings

� Health Centre drug management- basic training on drug management � Health Information System improvement training-used new tools in the training

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� Facilitative supervision done, which targeted Health Centers I/C in collaboration with Engender Health.

Activities in 3rd Phase - 3 study tours

� HIS program study tour to Coast Province � Technical exchange program visit to Morogoro Health project (MHP) � Observation of the referral system – Kakamega PGH supported the study tour (DHMT

Kakamega discussed referral system)

Community Activity in 3rd Phase

� Joint meeting, community and targeted health center staff � Community meeting at targeted health centers-had 956 participants for community

activities� Generators provided, delivery beds replaced in Kabianga H/C

Comments

� DMOH Kisii - The slight reduction in number of clients was due to lack of staff to cover night duty. With new staff employed the number is expected to rise.

� DMOH Kericho – Same as above, staff shortage resulted in reduction in number of clients.

� Dr. Kibaru –being a project district, skilled care is required to scale up the number of deliveries.

� New MOH strategy is to make use of the retired/unemployed midwives working in the villages, for them to give skilled delivery care-Can deliver women at home then bring them to post natal for care.

� Record keeping training will enable staff to report clearly

� Most women still make use of TBA but the retired midwives approach will improve delivery services as FP and immunization have picked up

� HMIS – partners to print standardized tools/registers for facilities. (DMOHs to facilitate the process)

� Training – as MOHs we need to use facilitators from the ministry for the purpose of standardizing the trainings, therefore provincial TOTs should be used in trainings.

� Study tours –all members were asked to submit their reports

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Min 4/02/07 Plan of Activities for the 4th Phase

� Need to conduct MC training and need for the staff to know how to care for mothers especially attitude – customer care

� Use of incentives i.e. provision of baby shawls to cover baby and cover materials for mothers.

� Focus on improving the referral system – will provide each health center with phone to enable them call the district hospitals and support referral system.

Comments – Dr. Kibaru

� Community dialogue for the purpose of scaling up the services – use of community RH package

� Need to have a broad approach and involve the men

� Community RH package to be applied in Kisii and Kericho

� Community health extension workers are part of the strategy and are being trained

� On sustainability of trainings offered to health workers, facilitators from the districts should use participants’ performance sheet which will be evaluated in the subsequent trainings.

� Need for Clinical Training Skills for the purpose of teaching. CTS for the district TOTs to be considered by HANDS.

� Mr.Kinyangi – elaborated on referral, roads status -need to have collaboration in terms of road repair – during community RH forums, issues of relationship between pregnant mothers and good roads should come up - advocacy to be done.

� Kisii referral improved – standby driver available

� Kericho- some parts not accessible arrangements in place to facilitate easy referral system.

� Need to have standby ambulances in the districts to facilitate easy referral.

� Need to improve capacity of the newly employed staff to enable them be able to run the health centers

� Tools to be printed and distributed to facilities in the project districts.

� Provision of drug management manuals to enable non-trained staff read and apply.

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Min 5/02/07 AOB

� Changes to be made on Project Design Matrix and indicators. � Need to focus on the MDGs to meet our objectives. � Baseline survey is required in Gucha and Nyamira districts and there is need to

develop TOR tools to support the selection of these districts. The purpose of the survey is to assess future expansion of the project.

� Results of final project evaluation report are expected.

Previous Meeting

� Counter part funds required for the purpose of supporting facilitative supervision activities in the districts (JICA to facilitate).

� Mid-term evaluation report required in the next meeting, it will enable DMOH/HANDS evaluate project progress.

� Need for a stakeholders forum to have feedback of mid-term report.

Sign…………………………. Date…………………………

Chairman.

Sign………………………….. Date………………………….

Secretary

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7TH NATIONAL TECHNICAL WORKING COMMITTEE MEETING FOR MOH/JICA/HANDS SAFE MOTHERHOOD (SAMOKIKE) PROJECT ON 17TH JULY 2007

Members Present1. Dr. S.K Sharif -Head PPHS 2. Dr. J. Kibaru -Head DRH 3. Ikuko Shimizu -HANDS 4. Tamayo Haraguchi -HANDS 5. Yumiko Kitagawa -HANDS 6. Dr. Ambrose K Rotich -DMoH Kericho 7. Ms.Yumiko Igarashi -Project formulation advisor JICA8. Dr. E. S. Abunga -DMoH Kisii 9. Mr. Daniel Sande -DRH MoH 10. Mr. Elijah Kinyangi -JICA SPO 11. Professor Handa Yujiro -JICA 12. Nancy Chelule -MOH-PMO-RVP

Absent with Apology Mr. Kazuhiko Tokuhashi Deputy Resident Representative JICA


Min 1/07/07 Welcome Remarks Welcome and introductory remarks by Head PPHS.

Min 2/07/07 Address by DRR JICA. Apologies from JICA country representative.

� Activities started in the 4th phase � JICA to give a report of mid term evaluation

Terminal evaluation of the project will be done in October 2007.

Min 3/07/07 Results of the Mid Term Evaluation by JICA Professor Handa a Japanese expert, and a member of evaluation team gave summary of the mid term evaluation report to members, which he classified as typical semi internal evaluation. In evaluation, 5 evaluation criteria were used which included relevance, effectiveness, efficiency, impact and sustainability. He looked at the 6 project components where he explained that the sixth component was broken down in smaller units. As much as evaluation was to route out positive issues, the team came up with various recommendations, which included;

� Monitoring of the justified activities � Referral activities to be looked into through proper decision making in referral of

cases� Capacity strengthening of health workers. � Decongestion of district hospitals through transfer of health services to health

centers.

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� Introduction of work empowerment project in health centers by use of 5S1K i.e. Sorting, Setting, Shining, and Standardizing, Sustain and Keep it up, to improve quality of services at the health centers.

� Maintenance of project managers for longer period � Staffing more qualified staff to health centers � Managerial skills to be improved through 5S1K� Advocacy and support supervision by DHMT should be regular especially to health

centers far away from accessible roads.

Lessons Learnt during mid term evaluation. � Utilization of the CBOs, improving status of health centers and working with

district hospitals would improve maternal health services � That the districts work closely with community people � That the community was cooperative to the evaluation team who were able to

collect information from the community.� Signing of the evaluation report done by JICA, and Dr. Kibaru

Min 4/07/07 – PDM (change amendments) Chief Advisor, HANDS explained to members the meaning of SAMOKIKE project, and added that it was a 3-year project that started in March 2005. She explained activities of 1st and 2nd year and emphasized that activities of 2007 were the focus. PDM Amendment She explained that PDM is a tool used for project management, which was revised in Feb 2007.Refer at annex 3.1

� Members looked at the amendments made to the PDM document. This helped in understanding clearly the project targets and achievements.

Dr. Kibaru told the members that it was important to have measurable indicators. JICA was requested to print the new revised registers, which should be disseminatedonce they are available in the two districts, Dr. Kibaru was requested to send a request letter to JICA for printing to be done.

� There is need to address issues revised in the PDM, – including change of indicators to be specific. Time frame for finalization of the document was given a deadline of July 2007, of which confirmation of the PDM changes and minutes of the meeting was to be signed, followed by a written letter to PS for signature, for approval of the PDM document.

Min 5/07/07 Plan of activities for 4th phase Divided activities into 3 categories

1. Capacity building2. Community mobilization3. Information sharing and coordination among MOH/JICA, HANDS, PMOH, MOH and

health centers.

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- Went through the yearly operational schedule-activities to go up to mid March, 2008

- Final evaluation of project will be done in October, 2007 - Final evaluation should be conducted 6½ months before the project

ends to allow any changes to be incorporated. - 3 years after the end of the project, impact assessment will be done

Min 6/07/07 AOB

- Adoption of the mid term evaluation report by JICA, HANDS and MOH (PS)

- Final evaluation to be conducted in early October, 2007 through a joint team

- TOR to be made following PDM change.

Min 7/07/07 Closing Remarks DMOH Kisii said there was improvement in hospital deliveries and referrals in targetedhealth centers. DMOH Kericho said project helped in achieving some of the indicators i.e. increased deliveries in health facilities, he added that project vehicle had an accident and was under repair but referral still continues with another vehicle.

The head-DRH (Dr. Kibaru) said maternal mortality rate cannot be reduced unless there is skilled health care provision and added that supervision will be done in the province soon.

PNO R/Valley � Thanked HANDS for the work they are doing in Kisii/Kericho.� To continue working together to improve morbidity and mortality � Referral system was impressive and should be rolled out to other facilities � Possibilities of extending the project from HC to dispensaries since they are near

communities. The head DPPHS (Dr. Sharif), thanked professor Handa and evaluation team for the mid term evaluation and promised to look at it and address issues coming up especially those under control of the DHMT.

� With no other business meeting ended at 12 pm.

Chairman…………………………………. Date…………………..

Secretary…………………………………. Date………………….

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