A Baseline Assessment in Kenya

Transcription

1 Project for Independent Citizen Monitoring of Goods and Services funded by the Global Fund to Fight HIV/AIDS, TB and Malaria A Baseline Assessment in Kenya Beatrice A. Okundi Consultant Beatrice.okundi@gmail.com / th September

2 TABLE OF CONTENTS TABLE OF CONTENTS... 2 ABBREVIATIONS... 4 EXECUTIVE SUMMARY... 7 I. INTRODUCTION Background Objectives Proposed project concept II. METHODOLOGY, PLAN OF ACTIVITIES AND LIMITATIONS Methodology Plan of activities Limitations of the assessment III. FINDINGS: PRESENTATION AND ANALYSIS Availability of data at district/clinic service point Data on sample PR, SRs and SSRs and the possibilities for electronic citizen monitoring Identification/confirmation of districts to undertake citizen monitoring based on prevalence of GF related information Existence of household survey data IT platforms for citizen monitoring IV. CONCLUSIONS AND RECOMMENDATIONS Feasibility of citizen monitoring of Global Fund provision of goods and services Availability of data at district/clinic service point Data on sample PR, SRs and SSRs and the possibilities for electronic citizen monitoring Identification/confirmation of districts to undertake citizen monitoring based on prevalence of GF related information Existence of household survey data IT platforms for citizen monitoring Proposed project content and recommendations Conclusions ANNEXES Annex A: Detailed discussions on the feasibility of citizen monitoring of Global Fund provisions of goods and services Annex B: Data Collected and analysis

3 Annex C: Monitoring checklists for CSOs Annex D: Sites Visited Annex E: Persons Interviewed Annex F: Consultancy Terms of Reference

4 ABBREVIATIONS ADESO African Development Solutions AFH African Family Health ARV Antiretroviral CACC Constituency AIDS Control Committee CADIF Community Aid Development Fund International CBO Community Based Organization CCC Comprehensive Care Clinics CDC Centre for Diseases Control CDF Constituency Development Fund CEO Chief Executive Officer CHAK Christian Health Association of Kenya CHC Community Health Committee CHW Community Health Workers COBPAR Community-based Program Activity Report CSO Civil Society Organization CU Community Unit DASCO District AIDS and STI Coordination Officer DC District Commissioner DHMT District Health Management Team DoMC Division of Malaria Control DOTS Directly observed therapy short course EACC Ethics and Anti-Corruption Commission FBO Faith based organizations GF Global Fund GLUK Great Lakes University of Kisumu GoK Government of Kenya HFMC Health Facility Management Committee HMIS Health Management Information System HSSF Health Sector Support Fund HSSP Health Sector Support Program 4

5 ICC IRS KANCO KCM KDHS KEMRI KEMSA KeNAAM Interagency Coordinating Committee Indoor residual spraying Kenya AIDS NGOs Consortium Kenya Coordinating Mechanism Kenya Demographic and Health Survey Kenya Medical Research Institute Kenya Medical Supplies Agency Kenya NGOs Alliance Against Malaria KICOSHEP Kibera Community Self Help Program, Kenya KSPA MARPS MDR TB MMS MoH MoPHS MOU NACC NASCOP NCST NEPHAK NGO NLTP OVC PLHIV PMTCT PR PS PTA PTF SANA SIDA Kenya Service Provision Assessment Most at risk populations Multi-Drug Resistant TB Ministry of Medical Services Ministry of Health Ministry of Public Health and Sanitation Memorandum of Understanding National AIDS Control Council National AIDS and STI Control Program National Council for Science and Technology The National Empowerment Network for People Living with HIV/AIDS in Kenya Non Governmental Organization Division of Leprosy, TB and Lung Diseases Program Orphaned and vulnerable children People living with HIV and AIDS Prevention of mother to child transmission Principal Recipient Permanent Secretary Parents Teachers Association Partnership for Transparency Fund Sustainable Aid in Africa International Swedish International Development Agency 5

6 SMS SODNET SR SSR TB TI TOR TOWA USAID VCT XDR TB Short message service Social Development Network Sub Recipient Sub-Sub Recipient Tuberculosis Transparency International Terms of Reference Total war Against Aids United States Agency for International Development Voluntary Counseling and Testing Extra Drug Resistant TB 6

7 EXECUTIVE SUMMARY A decade after its founding, the Global Fund (GF), which was established to address three killer diseases; HIV/AIDS, TB and Malaria, has saved millions of lives directly through its grants. Recent reports of theft, fraud and corruption in the use of GF resources are threatening future support for the GF. A high-level independent review panel has made a number of recommendations on fiduciary controls and oversight mechanisms to improve the accountability structures at the Fund. One of the most obvious places to achieve improved accountability is to address the supply chains that GF recipients use for delivering medicines and other health products. Through improvements in information collection, particularly using mobile telephony, and involving Civil Society Organizations (CSOs) in monitoring the end distribution point of GF programs, it should be possible to provide the GF with information on how effective and transparent its programs are when viewed from the beneficiaries perspective. This in turn should allow the Fund to make changes in the way its country programs operate to improve performance and transparency. The Partnership for Transparency Fund (PTF) has been working in consultation with the Global Fund Secretariat in Geneva and with Aidspan, a Nairobi-based watchdog agency and critical friend of the Global Fund, to identify ways in which grass-roots monitoring of the delivery of goods and services funded by the GF could add to the integrity and effectiveness of these health services. The PTF anticipated that it would be able to support several pilot projects working with local CSOs in Kenya to monitor the delivery of goods and services funded by the GF at the clinic level. This includes both government-run clinics and service distribution points funded by the GF through CSOs, or other types of Sub-recipients (SRs) or Sub-sub recipients (SSRs) of GF funds. To successfully complete the preliminary scoping for the Kenya pilot projects, there arose the need for an analysis of existing and relevant local health data at clinic (service delivery point) level. PTF and AIDSPAN, working with a local partner, ACT, commissioned an assessment to collect the necessary baseline data on GF operations at the grass roots level. It was assumed that the collection of this baseline data and its analysis would give solid recommendations on the way forward. PTF and AIDSPAN selected Nairobi and Nyanza Provinces for the preliminary data collection and analysis as these areas had been studied under previous programs and data was known to be available on health services and user satisfaction. These two provinces also receive a good portion of GF support given the prevalence of the diseases that GF funds target. The assessment has gained a lot of insights into the operations of Global Fund in the country. A major limitation with the assessment is that the assessment team was unable to get authority to visit the service provision points under the docket of the government despite their being major beneficiaries of GF support 7

8 Assessment Findings The assessment yielded the following findings (italics section refers to information being sought in the assessment as contained in the consultant s TOR): Provide available data at district/clinic service point, including health budgets, staffing, etc., on what is being funded by GF, and provide estimates of GF proportion of goods/services that are co-mingled with provisions by other donors and GoK: As the Ministry of Health was unwilling to release the data on the public health facilities, the assessment was not able to know the total provision of drugs and medical supplies at local level, let alone deduce share of GF provisions. Feasibility of summarizing what s available at clinic or service-delivery level - all to determine the indirect attribution of such services to the success (or not) of GF grants: This could not be calculated due to unavailability of information. Key litmus test: does the data available - now or with additional probing - provide a basis for briefing citizens on what they should expect at clinic level. Is this information useful enough to inform their willingness/likelihood to report any variances from what s expected? Again, as the data was not provided, it is not possible to answer this question. Data on a sample of PR, SRs and SSRs to determine what opportunities the data presents, within the potential framework of electronic citizen monitoring; determining whether service delivery provided by GF-funded implementers provides the kinds of services that lend themselves to electronic complaint mechanisms (e.g. SMS): The results of the assessment show that each PR/SR project is individually designed to meet varying objectives and would therefore be difficult to compare with one another and with government facilities in terms of monitoring service and pharmaceutical delivery. Moreover, it is likely that some of these private and faith-based facilities have better internal accountability and ethical behavior than in government facilities. Initial preliminary identification/confirmation of districts to undertake citizen monitoring based on prevalence of GF-related information (considering variants e.g., urban vs. rural, geographic, disease incidence, cultural issues relevant in accessing health, etc): The report concludes that Nyanza and Nairobi would be ideal pilot points for an initial project on social accountability as has also been demonstrated by others in this field. 8

9 Availability of existing household survey data already collected for selected locations in candidate districts. Sources of household survey data as cited are outdated and would not work well for a citizen-monitoring project. A simple SMS tool could provide an effective way to undertake grassroots monitoring. The pharma-tool by TI-Kenya is a good example of such a tool although it is not specific to GF monitoring. Availability of suitable IT platforms either in the proposed districts or elsewhere, capable of being applied in/adapted for the proposed districts: Some IT platforms envisaged under other projects (Total War on Aids TOWA, KEMSA- TI Kenya, Malaria) are underway and could be modified/adapted to monitor GF resources at the local level. TI-Kenya has been able to pilot their pharma-tool and is looking at monitoring the mobile tracking system used by KEMSA. Conclusions and Recommendations In terms of conclusions and recommendations, the following are suggested: From the discussions held with various stakeholders, it is clear that there is significant interest in citizen monitoring in Kenya, yet the duty bearers both in government and some CSOs are not willing to embrace the concept or to give data or information that would allow effective citizen monitoring. A lot of buy-in will be necessary if the project suggested by PTF and partners is expected to meet its objectives. PTF and its CSO partners will need to take into account the multiplicity of players that exist as medical supplies move from the national level down to clinics and other facilities that distribute GF funded resources to citizens. Effective citizen monitoring needs to begin by providing information to the citizens on what is available in terms of resources. How much is GF giving to the countries, which are the targeted areas, and what is the expected impact of the funds that have been provided? It is not clear at this point what process the government is going to adopt with the changes in the Constitution that now recognizes County governments. This has implications on KEMSA and MoH operations. In the case of a PTF project in this direction then there will be need for negotiations and buy in with individual County health directors and the County governor on the direction of a citizen monitoring project. The TI-Kenya platform offers an opportunity for citizen monitoring that looks at procurement of drugs and medical supplies, how these are used at the grassroots level 9

10 and the degree of citizen satisfaction. However this platform examines all health supplies going through KEMSA and does not delineate Global Fund provisions. I. INTRODUCTION 1.1 Background A decade after its founding, the Global Fund (GF) set aside to fight three killer diseases; HIV/AIDS, TB and Malaria, and has saved millions of lives directly through its grants by shifting market dynamics to make antiretroviral medications (ARVs) treatment more affordable to a majority in the developing nations like Kenya. Recent reports of theft, fraud and corruption among its guarantees has threatened the effectiveness of the fund and a number of recommendations have been made by a high-level independent review panel on fiduciary controls and oversight mechanism (HLP) to improve accountability structures at the Fund. The panel s recommendations included a shift in focus from inputs to outcomes, instituting tiers of grant requirements, and creating better accountability structures within the Fund by repurposing committees, empowering middle managers, and adding positions with an explicit focus on risk management. One of the most obvious places to achieve that have been identified is the change in the supply chains its recipients use for delivering medicines and other health products. Through better information collection, particularly using mobile telephony, and enabling a multiplicity of players to participate in those supply chains, efficiency and transparency suggested in this process is the use of a recipient feedback which would allow the Fund to make better use of information, create greater transparency, and have more effective tools to manage performance. Use of the increasingly available mobile phones and broad band networks provides opportunity to improve the transparency, tracking and evaluation of the Fund s programs by collecting data and opening channels of communication between it, its suppliers, the end-users of its products and services, and the intermediaries. In the Transparency International (TI) Integrity Report for 2011, TI acknowledges from the work done by Aidspan that Kenya is on average almost one year behind schedule in implementing and reporting on GF grants with some activities more than three years behind. With this kind of information and the inadequacies that have been reported in the system, there is a need to 10

11 change the accountability structures from top bottom to bottom up, making the citizenry and users of the services directly participate in improvement of the use of Global Fund resources in a timely and efficient way. The Partnership for Transparency Fund (PTF) has been working in consultation with the Global Fund Secretariat in Geneva and with Aidspan, a Nairobi-based watchdog agency and critical friend of the Global Fund, to identify ways in which grass-roots monitoring of the delivery of goods and services funded by the GF could add to the integrity and effectiveness of these health services. It has been agreed that Kenya would be a suitable country to test out the viability and value-added of citizen engagement in monitoring the actual situation on the ground. The project will focus on monitoring delivery of goods and services at the clinic level. This includes both government-run clinics and service distribution points funded by the GF through CSOs, or other types of SRs or SSRs of GF funds. To discuss and ensure the viability of the proposed project, PTF s Judy Edstrom, Aidspan s Angela Kageni and ACT s Faith Kisinga held a series of meetings early in 2012 with stakeholders in Nairobi to evaluate the desirability of such a project. Discussions were conducted with development partners, government officials in the relevant disease areas and potential CSOs that could be part of the desired project. The results of these discussions affirmed the desirability of pursuing a project focused on citizen monitoring at the grass roots level and in the process ruled out some of the previously considered avenues. A new element in the concept would be the proposed inclusion of an emphasis on citizen feedback via electronic communications (e-cis). To successfully complete the preliminary scoping for the project, there arose the need for an analysis of existing, and relevant, local health data at clinic (service delivery point) level. It is assumed that the collection of this baseline data and its analysis would give solid recommendations on the way forward. 1.2 Objectives The main purpose of this consultancy is to carry out the collection of relevant baseline data that will give a clear picture of GF funded commodities and services at service delivery points in the selected regions of Nairobi and Nyanza, and assess the general level of information available to the citizens from GF PRs, SRs and SSRs. Specific objectives include: 1. Give clear information on funded commodities and services at service delivery points 2. Confirm volumes and supplies of GF funded commodities and services in the selected sites 11

12 3. Availability and usability of data at district /clinic service delivery point on health budget, staffing, GF provisions and commodities that are comingled with those of other donors including Government of Kenya (GoK). 4. Data on a sample of PRs, SRs, and SSRs to determine the usability of the data collected 5. Identify preliminary districts to undertake citizen monitoring based on prevalence of GF information 6. Availability of household data in selected districts and access to suitable IT platforms. 1.3 Proposed project concept A concept note developed amongst all the partners is expected to focus on monitoring delivery of goods and services at facility level, including both government-run clinics and service distribution points funded by GF through CSOs or other SR/SSRs of GF. This is expected to be done less by physical or manual tracking than by creating a map of what is available at the clinic in terms of services and provisions, sensitizing citizens to what they should expect, and supplying them with a technological vehicle mostly through SMS to report if they did not receive an expected service or drugs. PTF and partners believe that this form of citizen monitoring can add value without duplicating other forums or creating additional layers of inspection. It is expected that this concept of grassroots monitoring will help the Global Fund retain its streamlined structure while being able to expand its eyes and ears at local level. This will help it to remain agile, responsive and efficient while at the same time tightening its reigns on fiduciary risks and waste of resources through loss, fraud or mismanagement. The original concept proposes the use of a web-based crowd sourcing technology called Huduma developed by the Social Development Network (SODNET) to collect, collate and provide relevant, verifiable information on health. Huduma (meaning service in Swahili) has already collected and inputted for Kenya: (i) basic geographically specific data on health (OpenData sources); (ii) health funding sources, including GF funding by PR and SR/SSR; (iii) household surveys that contain questions about satisfaction with health services; and (iv) a system to collect SMS, direct complaints to the relevant authority and report on action/inaction taken. Information can be categorized to focus on feedback directly related to the health services for diseases supported by GF. Client feedback would be periodically analyzed and reported out at local health accountability forums where citizens and local health officials/clinic staff could meet to ascertain what actions have been taken to address citizen concerns. 12

13 The project is proposed to be launched in up to three districts, possibly within the provinces of Nyanza in the west, Nairobi and Coast Province, and up to health service delivery points in each (this may include the primary care unit of a local hospital and should include if possible government, private and faith-based service providers, to shed light on relative performance). The need to sensitize citizens on expectations and the feedback mechanism (the number to which the text message should be sent) precludes immediately launching the program in a larger number of districts. A second phase could expand the program by district, and to hospitals. This program approach would put the emphasis on efficient/effective implementation of GF-supported services, including but not limited to corruption. Aidspan and others believe that GF is interested in this broader approach, especially in focal areas that highlight vulnerability to risks and wastage, and lack of accountability structures. The current structure of GF distribution through government and non-government PRs, who in turn contract out to SRs and SSRs means that few people seem to know what is happening on the ground. The proposed project would work to address this void. In addition, it promises stronger endorsement by the Kenya Coordinating Mechanism (KCM as the Country Coordinating Mechanism is now referred) as confirmed by a meeting with the KCM Coordinator and the Head of Ministry oof Health (MoH) Disease Control Department. It also builds an initial platform for later citizen involvement in district health planning, envisaged to become more important with the decentralization of services to local government under the new Constitution, to be fortified by the anticipated election of district level CEOs in the next election slated for March II. METHODOLOGY, PLAN OF ACTIVITIES AND LIMITATIONS 2.1 Methodology The study sites were identified as being Nairobi and Nyanza Province. Nairobi and Nyanza were originally identified as areas that had been used in Huduma services and therefore data was already available on health services use and satisfaction. It is further confirmed that the two provinces also receive a good portion of GF support given the disease incidence as supported by GF. The project plan is to start from areas with better off information and reporting that would allow for scale up in weaker areas. The two areas are also known to be way ahead in terms of their reporting on activities on malaria, TB and HIV and their data compares favorably when compared to other regions reporting in the country. Indeed, in discussions with various stakeholders, the two provinces would be ideal start points for any pilot aimed at citizen monitoring given the 13

14 level of awareness of interventions and CSO presence in the two regions. A challenge that stems from the choice of the two provinces if not well handled at project implementation stems from the fact that the populations are believed to have been over-researched and are skeptical to what value another project would add. It is important that during implementation of the pilot, it is clear from the onset what the project hopes to achieve, its life span, parties involved and their level of effort so that all processes are seen to be transparent from the beginning. This ensures buy in by all who will be involved in the project and getting the citizens to also appreciate their role and responsibility in good governance. This process also helps clarify the project goals without raising undue expectations. The assessment did not have a formal guide on how the questioning would be done but there were very clear deliverables on what was expected from the consultancy. Interviews were conducted at the national level with various stakeholders involved in GF 1. This would not be a repetition of what had been done earlier by PTF and partners but to be able to get more information on how a citizen monitoring system would work and the likelihood of an IT platform in the process. Also of importance was to understand how GF works in the country, what commodities and services are procured, what are the reporting or monitoring tools used in this process and also be able to capture that data from the facilities to verify its availability and access to the citizens. The assessment in itself was very exploratory stemming from the unknown to what exists in the country and especially in these two identified regions. Both GF and non GF recipients were interviewed in both Nairobi and Nyanza provinces. In Nyanza, the focus was more on facilities that are recipients of GF funding and had been identified as potential areas to involve the citizens in the monitoring. Also interviewed were potential NGOs who are non recipient of GF support and could be potential partners in the project. 2.2 Plan of activities The assessment being largely exploratory was implemented in a consultative manner between the consultant, ACT, Aidspan and PTF. The following activities were carried out: Developing a clear work plan with the ACT, Aidspan and PTF team Desk reviews of existing information on commodities and services procured through use of GF and existence of client satisfaction surveys Extensive discussions with the assessment team on what needed to be 1 A full list of all those who were interviewed and organizations approached is available as annexes D and E 14

15 prioritized in terms of data collection Seeking authorization to facilitate facility visits from the two directors of health in the Ministry of Public Health and Sanitation (MoPHS) and the Ministry of Medical Services (MMS) Actual information collection from the stakeholders at the national level in Nairobi and from Nyanza province. Service delivery points in the two regions identified and efforts were made to reach all of them Data and information analysis and compilation Draft report writing and submission Final report writing and submission 2.3 Limitations of the assessment The assessment was able to gain a lot of insights into the operations of Global Fund in the country. Discussions with key stakeholders clearly indicate gaps that make GF grants not widely acknowledged as existing in the country and thus it is only those in the know who were able to share information. This fact becomes a limitation because as you think in terms of a citizen monitoring, that knowledge gap then becomes a limitation in identifying what needs to monitored and reported back on. It is also not clear from the onset that other than the PRs, who else can be reached to provide information on GF. A major limitation with the assessment is that the assessment team was unable to get authority to visit the service provision points under the docket of the government yet they are the major beneficiaries of GF support. The two directors of the Ministries of health both declined to give their authority. The director, MoPHS indicated that there was no way that GF or any other interested person would be able to identify any supplies and services as GF only. As a Ministry they are in the process of integrating all services so that the health system can be looked at as one and judged on that basis rather than as pockets of different donor funds. The director for Medical Services initially requested that he is furnished with the full project proposal and later informed the consultant that the assessment needed clearance from the ethical committees like KEMRI or the National Council for Science and Technology (NCST) as a prerequisite to his giving authority, a process which would be lengthy and time consuming in light of the fact that this assessment was not a fully fledged scientific study with protocols. To illustrate the closed way in which the government has viewed this project, discussions were held with the DoMC head as a follow up to initial discussions on the project of which he was supportive. The aim of this second meeting was to get an approval to facilitate getting government authority to undertake the assessment but even he could not break the deadlock, he indicated that a letter should be written to the permanent secretary (PS) MoPHS and highlighting the 15

16 fact that a discussion had been held with him on the importance of the project and that he approved of it. This process was duly followed and a letter was written to the PS who proceeded to mark it to the director MoPHS for his action. Instead of being very forthright as he had done in the past, the director indicated through a letter that for the assessment to take place there was need for ethical clearance from NCST and KEMRI - in essence stopping any further attempts to get direct approval for the assessment from the MoH. Clearly no one wants to take responsibility for approving the assessment. The private sector mainly Coptic Hospital in Nairobi was equally wary of engaging without a letter from the government although in Nyanza, the consultant was able to get service data from non government service providers. The assessment is focused on GF commodities and services however when one looks at the records beyond the procurement point which is KEMSA for most of the GF commodities, nothing indicates the source of funding for supplies received at the facility level. Some of the main government agencies involved in GF were not available for discussions despite and phone appointments. Follow up led to the availability of the NASCOP point person on GF however she was not able to give information without a letter from the government authorizing such access. The malaria contact and TB were not accessible even after many attempts to meet up with them. An interview set up by Aidspan with the contact person at the Division of Malaria Control failed to materialize as they kept asking for a rescheduling of the meeting. The initial scope of this assessment sought not only to inform service provision but also procurement and supply to service delivery points. However the data on procurement and supplies were not availed to the consultant mainly because the concerned person was not available. Any follow up by with the facilities that had given their service data did not yield much information. The central pharmacies within these facilities were not able to avail the required information which was most likely in their custody. It is not clear why even with SRs that were identified there was reluctance to share their data on what they were reporting on or what they procured. Out of the ten sub recipients of both government and CSO PRs that were approached only two were able to share any information on their activities and reporting. There is so much mystery shrouded in the operations of GF. The consultant was able to just get the reporting tool that is used for TB and HIV however malaria does not have an explicit reporting tool as yet. Malaria in the country is prevalent and therefore the drugs are included under the essential drugs package to the public facilities. Its reporting is therefore tandem with reports received on disease incidence which are analyzed and reported monthly to the district level. 16

17 III. FINDINGS: PRESENTATION AND ANALYSIS 3.1 Availability of data at district/clinic service point The MoH were unwilling to release any data on public health facilities. Many attempts earlier pointed out to elicit response at different levels did not bear fruit. Among the CSO sub recipients that were contacted only two were able to share their service statistics and reporting some of which has been analyzed and presented in annex B. Two other service points were also able to share their data which is mainly picked from the reporting tool MOH 711A, a government summary register of HIV, safe motherhood, TB and child welfare clinic service information. This register is expected to be filled by all health service provision points and the data submitted to the district level for compilation and transmission to the national level. The data is submitted on a monthly basis. One of the issues pointed out by KEMSA is that inventory keeping is a major challenge in the public sector. Facilities at lower levels are not able to report in a timely way on their usage and thus re-order. This leads to a lot of delay in responding especially where the supplies are available in the central stores. This fact is also noticed with the facilities that shared their service statistics with some having the information missing while others plainly did not maintain the register at all for a number of months. Data on commodity and supply stocks received that could allow for an analysis and information for a citizen monitoring project was not available during this assessment. With the government door closed, the only other available data would be from non government providers who received GF support. Only one was able to provide their hospital budget in a largely lumped up way. As concerns GF, the facility provided both financial and service data that are very specific to that particular project as indicated in annex B. Given the nature of discussions with varied stakeholders, it is clear that the government is the major procurement agency for GF commodities and supplies most of which go through KEMSA. Beyond KEMSA to service points, one is not able to tell the pot of funding used to procure commodities and supplies as they are all branded GoK. To this extent, it was not possible to determine GF commodities and supplies and the comingling thereof at facility level. 17

18 With the data which was received largely on service statistics, it is easy to deduce the numbers that are reached by the various facilities but even then without any scorecard or base for comparison based on what has been received, it is difficult to evaluate the effectiveness of the services that are received or attribute the numbers specifically to GF support. Given these gaps identified, the assessment was not able to explore the suitability of the data for a citizen monitoring project. 3.2 Data on sample PR, SRs and SSRs and the possibilities for electronic citizen monitoring Several discussions were held with GF stakeholders at the national level. These are people who have been involved in GF either in its management or program managers under the different funding streams from GF. Those who were reached had a lot of information on how GF operates in the country and what a citizen monitoring project should look like. The organizations interviewed included the MoPHS director, Division of Malaria Control (DoMC), National AIDS Control Council (NACC), Kenya Medical Supplies Agency (KEMSA), Kenya NGOs Alliance Against Malaria (KeNAAM), Kibera Community Self Help Program, Kenya (KICOSHEP), Christian Health Association of Kenya (CHAK), The National Empowerment Network for People Living with HIV/AIDS in Kenya (NEPHAK), Kenya AIDS NGOs Consortium (KANCO) and Matata Hospital. NASCOP was contacted by Aidspan directly after attempts by the consultant were not bearing fruit. Details on the discussions are availed in annex A. Since most of the GF supplies are through KEMSA, they are able to reach their delivery points. KEMSA has nine regional distribution centres with Nairobi hosting three warehouses. KEMSA has contracted an independent firm to distribute its supplies to the facilities. KEMSA launched an Enterprise Planning System which is now 2 years old. The system is a logistics management system that sends reports to programs and can analyze data on what is available in stock. The facilities are also able to upload what they have received in their stores and this then helps them update their inventory while also ensuring that data is also available at the facility level. An SMS code has been in place that allows the facilities to monitor stock at KEMSA therefore allowing their orders based on what is available. The system provides dispatch information and also informs of what is in stock. The national HIV and AIDS Monitoring and Evaluation Framework identified COBPAR as one source of data. NACC rolled out this sub-system in July The COBPAR activity form is filled quarterly by implementers with community based interventions; however there are reported challenges with the receiving these reports and currently the government and partners are trying to evaluate 18

19 an IT system that could facilitate easier transmission of the data as captured in the COBPAR forms. 2 copies of the COBPAR form are returned to the Constituency AIDS Control Committee (CACC) Coordinator by the 5th of the month following the quarter. The implementer retains a copy and another copy is sent to the donor of the project. The CACC Coordinator will send one copy to their respective NACC Field/Regional offices by 15 th of the month following the quarter and retain one copy. An inventory form developed by NACC is filled on a one-off basis by the community based implementers. R10 for malaria is yet to develop its approved reporting tools but draft formats have been shared. The reporting for malaria has always been on the patient registers on how many patients were found with malaria and treated, ITN distributions and indoor residual spraying (IRS) schedule where this is done. The MoH 711A is a register that covers all the service statistics related to GF disease areas and safe motherhood. All PRs, SRs and SSRs providing health related services are expected to fill this form as an indication of their service statistics. The service statistics are submitted on a monthly basis and two copies are submitted to the district officer in charge with a copy being left at the facility for their record. One of the copies picked by the in charge officer is then transmitted to Nairobi for documentation purposes and analysis on demand and related supply. Clearly the filling of this vital form that supports the health management information system (HMIS) for the country is not being done with the accuracy and the efficiency that is required. A private facility visited in Nairobi indicated that they recently just filled one under the request of NASCOP but did not keep a copy for their records. Others had some statistics missing while others were just plain neglected with figures not tallying as required. Data from SRs and SSRs, other than what is expected by the government have their own reporting tools which are developed in conjunction with the donors and are responding to donor specific indicators. Given the individual reporting needs by the different PRs, SRs and SSRs, it is difficult to compare with one another and with government facilities in terms of monitoring service and pharmaceutical delivery. The common denominator in all the service delivery points is the MoH 711A register which basically gives a common point of comparison for all health service stakeholders although as earlier noted the forms are not filled to expectation. Regardless of this the form does not indicate the statistics by donor and ends up comingling all service statistics without specifying which statistics can be attributed to which donor. The reality is that the comparison of data from public to private or non government sector cannot render itself to successful comparison across board 19

20 and especially if the purpose is to attribute procurement and service data by donor and in this case GF. 3.3 Identification/confirmation of districts to undertake citizen monitoring based on prevalence of GF related information In terms of the suitability of the choice of Nairobi and Nyanza province as points of focus for the pilots on citizen monitoring and to meet the initial presumption of starting with areas with relatively good information, a number of recommendations are given. NACC felt that very good information would be forthcoming from Nyanza and Nairobi because they are generally more aware about HIV activities than the rest of the population. In Kisumu the suggestion is to work with the Anglican Church who is reported to be good implementers, and Matata Hospital which is privately run in Oyugis in Nyanza. In Nairobi beneficiaries of GF support would be KANCO, NEPHAK, Mbagathi hospital and Dagoretti dispensary. Most of CHAK activities under GF are focused in Nyanza and Western province. In Nyanza, good data is received from Itierio health centre, Kima hospital and Ngiya health centre, and these have been targeted for HIV and TB related activities. In Nairobi, Huruma health centre would be the only facility under CHAK that can be included in any assessment as they also receive GF support. Strong sentiments received on the choice of location are as follows: That Nairobi and Nyanza would be ideal as starting points for any citizen monitoring. However it would be important to identify which regions or parts of these regions receiving the bulk of funding and also can be identified by disease incidence. The areas should also be subject to other funding sources so that bias does not crop in when reporting on GF. This is because if the GF is the only source of funding, then there is bound to be over reporting on successes or failures thus biasing the whole objective of a citizen monitoring system. The members of the communities identified should also be more static to allow measurement over time and to avoid sensationalizing of issues. They should also have a good reporting record and this can be confirmed with the PRs and SRs. The choices given for pilot here go beyond Nyanza and Nairobi to include parts of the Rift Valley Province. The preferred choices include Nakuru and Kericho in Rift Valley, parts of Nyanza in Kisumu towards Bondo, HomaBay/Kendu Bay 20

21 and Ndhiwa areas but not in Kuria. In Nairobi the pilot could focus on Kibera, Langata environs, Kawangware but not Westlands which is very dynamic 3.4 Existence of household survey data Household survey data can be used as a baseline for any citizen monitoring to occur, follow up and evaluation at the end of the project period can determine if the project has had any effect on the delivery of services. Discussions and documents reviewed indicate that there is a client satisfaction survey conducted by the MoH. The annual client satisfaction surveys are used to gauge the performance of the health sector. The interesting fact is that the reports are not readily available even when sought from the planning department of the MoH. A soft copy is also not retained for sharing and neither is the report available or uploaded on the official website of the two Ministries of Health. One copy of the 2009 client satisfaction survey was availed which revealed some information on what is normally collected. At the back of the Kenya Health sector Satisfaction Survey Report is the questionnaires that are used to collect the yearly data; i) Customer exit questionnaire seeks to determine customer satisfaction with services obtained and specifies the facility visited. The questionnaire captures the demographics disaggregated by gender and age, and what service the customer came for. Section 1 covers importance of service attributes Section 2 covers immediate overall experience with different departments Section 3 covers immediate experience specific to places visited on the material day Section 4 covers drugs prescribed and whether they were received and what did the customer think of the service Section 5 covers the client s perceptions on the overall image of the facility and its infrastructure ii) General Public Questionnaire Interviews are conducted on the general public, demographics are collected disaggregated by age and gender Questionnaire covers issues of health care like distance to facility and most preferred facility, opinion about the facility over the past year, and general comments about the public facility The questionnaire goes further to seek the individuals health and that of their family and whether if any they have any suggestions that can improve health in the community iii) Mystery shopper questionnaire This is administered on the facility administrator. Demographics of the shopper are collected. 21

22 The shopper is expected to record details of how they are received and record what payments they have been asked for as hospital charges, registration card, consultation, dispensing medicines, vaccinations, lab and x-ray services, admissions, surgeries and mortuary services. The shopper is expected to record documents they have been requested for, user charges, waiting time and also record observations. iv) Employees questionnaire Measures health facility organization structure, work and work environment, job security, occupational health, freedom from discrimination, communication channels, management practices, organizational culture/ staff morale/ staff perceptions, compensation/remuneration, training and career development and allows the staff to make any suggestions that they may have to improve their work environment. The client satisfaction survey is conducted by the Ministries of Health through an independent body but it does not capture the specifics of particular diseases or in this case GF commodities and services. It gives overall perception on the health facility from the client s point of view, the community, the provider and the mystery shopper s point of view. A useful source with more detail is the Kenya Service Provision Assessment (KSPA) which is carried out every few years with the last one conducted in The assessment has specific information on HIV/AIDS, TB and malaria. The assessment captures information on safe motherhood including HIV care and comprehensive emergency obstetric care by type of facility, ownership and province. A chapter is dedicated to communicable diseases of the HIV, reproductive tract infections, tuberculosis and malaria. The chapter addresses the following key questions: To what extent are STI, HIV, TB and malaria services available? To what extent do facilities offering STI, HIV, TB and malaria services have the capacity to support quality service provision? To what extent is there evidence that health service providers adhere to standards for provision of quality STI and HIV/AIDS services? Do facilities have management practices supportive of quality STI, HIV, TB and malaria services? Do facilities have resources for diagnosing and managing TB? Are clients satisfied with the services provided? The Kenya Demographic and Health Survey (KDHS) also has some information that could be useful in a citizen monitoring baseline data in that the same questions can be used at the end of the project implementation period to evaluate the success of the project in ensuring efficient and effective health service delivery. There are questions that seek to capture ITN use in households, for expectant mothers whether they received anti-malarials in 22

23 pregnancy and much more information on HIV. TB information in the KDHS is just to gauge whether people know what it is and not necessarily on service delivery. The last KDHS 2 was conducted in the year 2008/09 and the findings are published and available on the internet. As much as existing household data is dated with the last efforts more than two years old, for a citizen monitoring project, there needs to be data that is relevant to what will be measured at the end of the project. The questionnaires have to be developed that are specific to the project needs. As noted in the case of TI-Kenya the questionnaire needs to be as simplified as possible and pick on the key indicators that will need to be measured in terms of commodities and supplies procured and service delivery thereof. 3.5 IT platforms for citizen monitoring For effective citizen monitoring that assures of anonymity and a quick way to register a complaint is that where there is use of IT platforms. This assessment sought to find out which platforms exist in the country that have been used or can be built into to enable citizen monitoring. Discussions with the NACC GF point person mentions an IT platform that the government will be implementing with support from CDC and TOWA. It is set to launch in the near future although it is still not clear where pilots will take place. The IT platform (SMS) will use the COBPAR form to allow faster feedback to the national office. KEMSA has launched an Enterprise Planning System which is now 2 years old. The system is a logistics management system that sends reports to programs and can analyze data on what is available in stock. The facilities are also able to upload what they have received in their stores and this then helps them update their inventory while also ensuring that data is also available at the facility. An SMS code has been in place that allows the facilities to monitor stock at KEMSA and therefore they can place their orders on what is actually available. The system provides dispatch information and also informs of what is in stock. A whistle blower site is available on the KEMSA website and this site is accessed by both Ethics and Anti-Corruption Commission (EACC) and the Integrity section of KEMSA. The site has been in operation for the last two years but it is not clear whether the existence of this site is known to the public. On a check on the website- there is actually a very 2 The KDHS 2008/09 report and the KSPA 2010 report are available on ke.org/page/research 23

24 visible whistle blower site indicated as Blow the whistle on corruption here and there is also a public feedback form in place where the public are encouraged to provide feedback. On the question of a citizen monitoring system, KEMSA and other CSOs led by Transparency International-Kenya are already ahead in this kind of monitoring and they have proceeded to launch the program officially and sign a contract with CSOs that allows for procurement and contract monitoring which will cover all drugs and supplies procured by KEMSA. Having to be involved in another parallel system that focuses on only the three disease areas is viewed as a duplication of effort. As it is, the IT platform that has been set up to provide data to the facilities and the one that is to be used by TI-Kenya and partners are derived through CEDILLA IT 3. They utilize the SMS IT platform and this can be further explored to indicate how useful they can be for PTF in establishing citizen monitoring. The district malaria coordinators who are the focal persons at the district level are supposed to know who is doing what in the district but it is reported that their morale has been low and many a times they are not even aware of who is in their own districts of jurisdiction. The reporting has always been on the patient registers on how many patients were found with malaria and treated, ITN distributions and indoor residual spraying (IRS) schedule where this is done. An SMS platform that allows the tracking of malaria drug stocks in various facilities is in place and through this system, the facilities can then report stock outs 4. The data is expected to be loaded on a weekly basis although whether this is actually done is another story. CHAK has in plan to have an IT platform to allow feedback directly from the facilities to the CHAK headquarters who then reports to the various organs of government and the donors. These various platforms show that there have been efforts towards IT in getting information where it needs to be. The efforts noted are for TOWA through COBPAR form as established by NACC, the malaria IT platform as set by the DoMC, the KEMSA planning enterprise and TI-Kenya and partners platform that seeks to monitor procurement and contracting for medical commodities and supplies. The information as available in these platforms is geared towards use by the system for more efficiency for the service providers. This is with the exception of the TI-Kenya platform that seeks to monitor contracting processes 3 CEDILLA IT Limited provides web, media, software and consulting services. They are based in View Park Towers, Ground Floor Suite 9 (Nairobi) and can be found on the web ( IT.com ). It worth a discussion with them as PTF pursues a citizen monitoring system using an IT platform. 4 The link provides the story on a Kenyan daily, The Standard Newspaper page 24 on August 10 th The story indicates SMS reporting of malaria cases in Kenya, an innovation by Novartis but which has been piloted in Tanzania with reported success. 24

25 and brings in place accountability and transparency of the processes by involving CSOs. Nothing is these systems is geared towards the citizens passé whereas they are put up to ensure efficiency in service delivery. IV. CONCLUSIONS AND RECOMMENDATIONS 4.1 Feasibility of citizen monitoring of Global Fund provision of goods and services Availability of data at district/clinic service point It is clear from the findings that none of the commodities procured in terms of drugs and supplies are branded as GF. This is more so for health facility consumables however where GF grants have been used to put up renovations and new infrastructure in facilities, they are branded and clearly indicated as having been constructed through the support of GF. GF has done a poor job at making the duty bearers accountable to the public. It is true and as indicated in the discussions held that GF has made a big impact in this country going by the numbers that are reached because of the funds availability but until the public know that the commodities and supplies are through support of GF, it is easily treated as government support. Because of the inability to identify and categorize anything as GF it then becomes very difficult to establish a citizen monitoring strictly for GF provision of goods and services. All commodities procured are branded GoK thus identified as given by the government. Whether co-mingled with the supplies from other donors, this fact can only be clarified at KEMSA level but not at lower level facilities. USAID has done a good job at branding anything received from the American people and this can be clearly seen in equipment, drugs and supplies. Where renovations or a facility is supported with funding from US agencies, the branding is clear. This is not so for the case of GF; branding guidelines have never been issued, when the proposal development is taking place, it is only discussed at very high levels and is reported to be an academic exercise which may not respond very well to the needs on the ground. Once the proposal is approved and monies disbursed, very few people get to know how much is given and for what purpose, it is normally a very low key affair with only those concerned knowing what is going on. This process has further served to alienate the public from GF processes and therefore accountability remains weak in that sense. 25

26 Even to government officers, where they are receiving allocations specifically for GF related activities, the accounting for the same has in the past been lumped up with other support received from the government for facility management leading to poor accounting and lack of transparency in specifying what exactly the money was used for that relates to a GF supported activity Data on sample PR, SRs and SSRs and the possibilities for electronic citizen monitoring Activities by SRs under GF support can be clearly enumerated as the data that is provided to the PRs clearly indicate financials against activities and a detailed report is also provided. Information is available but sharing that information with a third party then becomes challenging for a number of organizations. This leaves much doubt on whether this information is available for scrutiny. Where financial information is sought, both government and non government become jittery and are not willing to share the information. Out of the 4 SRs that were approached directly to provide information on their budgets only one obliged and shared their information in a lumped up form. Organizations and especially the non government sector feel free to share information on what the expectation of the programme is but are not willing to fully share the results and the process of getting to the results. Clearly the organizations that shared their information showed that they would be willing to share it with any other person if so required. A lot of buy-in at very high levels will be necessary if the project is expected to meet its objectives but with due process in advocacy at the different levels. The new Constitution supports freedom of information, the authorities should then begin to open up and make the data easily accessible. The same hardships have been reported by others attempting to get some sense of accountability but pressure is mounting on the need for information and accountability by duty bearers and success has been achieved by different agencies depending on the approach used. There are tools that have been developed by the PRs for the reporting of GF activities both at facility and community level and reports are submitted regularly to the donor in this sense. The government as the custodian of health information has also been able to develop standards tools that every agency or health facility providing services is expected to report their numbers to NASCOP, NLTP and the DoMC. These tools as they are standardized allow for easy cross checking of service statistics. A good entry point would be communities being aware of what to expect from the facilities and SRs and SSRs receiving GF support and where such services are sought and not provided then that becomes a ground for a complaint that 26

27 would need to be addressed. With adequate information on what is the expectation, then communities can be empowered to start monitoring activities by both government and non government recipients. At the national level, through the ICCs quarterly updates on what is being done at the implementation level on the three different disease areas and achievements of targets can get the duty bearers to begin taking their work more seriously. The ICCs being the interaction point of implementers, policy makers and donors can begin to question effectiveness of some of the services offered and develop better systems to improve accountability. The government system is such that data from facilities are received at the district level but it appears that there is also laxity at that level to verify the data that is coming in if at all received. One of the facilities visited indicated that they had just been through a process of compiling the same data that the consultant was seeking and had since handed it to NASCOP and that this data is available and can be accessed at NASCOP. If this health information was collected and compiled in a regular manner with the duty bearers at facility level knowing that the data will be cross checked then the laxity that exists would be curbed. Clearly laxity is at all levels of authority in terms of data compilation and availability from all service providers further complicating a citizen monitoring project. Given that there is a lot of mystery shrouded in the operations of GF in the country, this to a great extend limits what can be verified or facilities held to account. As has been reported only the PRs seem to know the sub recipients and sub-sub recipients, what they are funded for and what amounts they have received for these activities. Such information is vital for any accountability by the citizenry. As it is, the information blackouts continue to favor those who may not want to be transparent in their activities. SRs and SSRs from the CSOs have their data and there must be something that they are sharing with their donors but this information is not open to public scrutiny. Transparency needs to be ensured from both government and non government stakeholders and it begins with public awareness on what to expect and from whom. With the availability of this information at all levels then more accountability can be realized right from the community levels with the community champions to the community health committees to the health facility management committees to the districts, counties and to the national level; everyone needs to play their role. It is only through such a system that seeks accountability at all levels that citizens begin to see changes in health indicators and health service delivery. KEMSA and CSOs working with them have begun the process of accountability at the very high level with clear deliverables on the MOU that they have signed. The CSOs can be present during procurement and contracting of medical supplies and medicines to ensure that the process is done in a transparent way 27

28 and that due process is followed. This is at very high level and if this can successfully be achieved a major source of what has been contentious will have been dealt with but then, the MOU 5 does not guarantee processes once the commodities and supplies leave the KEMSA warehouses. The CSO led contract monitoring that includes agencies from government have reported a lot of challenges on the road to a citizen monitoring process with some agencies of government not being open to give the nature of data sought or even showing willingness to share information. The health workers were reported to be suspicious and unwilling to share information but the report comes with a suggested simplified tool for collecting the necessary data to allow for a citizen monitoring process to take place; this data will be able to form the baseline for which the success of the process can be measured against. All data received from recipients and non recipients alike can be subject to some level of citizen monitoring when it is availed at the different levels of authority. The health sector has devised a system which if supported and monitored for effective implementation can work to support a citizen monitoring project. The community members are informed on what to expect at their health facility creating room for dialogue between the community members and the community health committee (CHC) members usually with representation from the health facility. The community champions begin to monitor and report to the CHC any of the issues that seem to be a deviation from what has been discussed and agreed. The CHC members who then are part of the HFMC can then pick up the issues at the HFMC level with a clear process of how the feedback can be relayed back to the community. The HFMC has responsibilities and where their selection is in accordance to the norms that can be circulated to build public awareness as has been done with the CDF then they become empowered to start questioning some of the processes at the facility and seeking answers. If the issues are not effectively addressed, taking the complaints to the next level of authority usually the district level. GF in this aspect then begins to get the relevant information to the HFMC on what is received under GF for follow up and monitoring by the citizens. Right now there is a lot of suspicion from the duty bearers from government and non government which will need a lot of discussions, consensus and clear understanding on what the objectives of the project are to begin to get some information that can effectively contribute to citizen monitoring. 5 The report produced on the launch of the contract and procurement monitoring by the CSOs led by TI- Kenya has been attached for your review. It contains information that gives guidance to social accountability and citizen monitoring in the health sector 28

29 4.1.3 Identification/confirmation of districts to undertake citizen monitoring based on prevalence of GF related information The choice of Nairobi and Nyanza Province has been considered suitable for the piloting given the level of awareness, access to various pots of funding and awareness about the existence of the various support available in general. The expected good reporting would help built lessons for scale up of a similar project to other regions. Incidences of disease also seem to support the choice of the two provinces. In terms of counties in Nairobi, Kibera area using facilities such as the Mbagathi referral hospital, Langata Health Centre, Coptic Hospital, Amref CCC in Kibera as link facilities for the citizen monitoring gives room for engagement with different health facility set ups. In Nyanza province preference is given for Homabay County and Kisumu County. The facilities that can be monitored include Matata Hospital, Homabay district hospital, Lumumba health centre, Port Florence hospital, Maseno Mission Hospital and Kisumu District Hospital Existence of household survey data The experience with this exploratory assessment indicates that whereas there are sources of data that can be used for this nature of project, they do not provide the prerequisite information that will be necessary to gauge success or serve as a limitation as to the kind of monitoring that is put in place. KSPA gives more detailed information on satisfaction however they may not meet the needs of the individual sites that are selected for the project. As suggested by TI-Kenya, a simplified data collection tool can be developed with the very important indicators that are expected to be measured, focus group discussions held with the community members to determine the issues around the facility catchment can identified. This can then be discussed with the community in a way of considering a scorecard on various issues that are important to them where GF support is concerned. Key groups to be approached in this aspect would be members of PLHIV groups or support groups for information. Champions can be selected from the affected groups but across board based on age and gender. It is important that the resultant tool or scorecard can be then be used as the baseline, midway through the project to evaluate the project and at end line to determine success of the project in improving information to both the KCM and GF secretariat. This data provided through these systems are then presented to the HFMC where they exist or addressed to the facility by the implementing lead CSO for redress and feedback given to the communities engaged in forums as suggested by the concept paper initially. In set ups where there are the bunges and community dialogue days, the facility staff or HFMC members can be invited to address the community on the progress with their work and such questions 29

30 posed for response and agreed follow up action with the facility. Clear timelines must then be indicated which can then be used as points of follow up. Where such systems are set and media buy-in is assured on community efforts to ensure transparency in the use of GF resources highlighted, action will be remedial. Both electronic and print media are increasingly interested in human stories that show community or individuals efforts to bring about accountability and there will be little costs attached to that kind of publicity. The CSOs selected should also be able to get agencies that can feedback to the different levels of authority to see how far it needs to go for action to be taken. It is important to note that even where challenges are encountered, documentation of these can be used as platforms for future work on citizen monitoring IT platforms for citizen monitoring As had earlier been noted a citizen monitoring system and usually through the SMS service can easily be arranged at the different levels with a back up as to who is receiving the information as the duty bearer and the monitor probably a CSO that is not a GF recipient to reduce subjectivity in addressing the issues that have been raised. Indeed the country is ready for greater accountability. As exemplified by some of the CSOs that have devised networks that they work with, it can be achieved and has been done with noted success and improvement in service delivery. An interesting way of looking at it and engaging the citizens would be to first seek to get information to the public on the services that are supported by GF in the three different disease areas. Who has received funding for what and at facility level, what services can be expected at that facility. This data and information can be shared with the community bunges or in functional community units during community dialogue days as facilitated by the CHC; this is the beginning of empowerment. There is then a need to set up a SMS platform that can be used for a complaint redress mechanism. Working with all the disease areas and CEDILLA IT which is in place and handling most of the IT platform in health determine what kind of information that will be needed for monitoring, in this case I believe availability of drugs and supplies procured through GF support and the services that are expected can be then programmed into the SMS platform in a very simplified way. Community champions that are identified within the different catchment areas can then be capacity build initially on how to work with the SMS platforms and can report on any information that they have received from the community members or through their own observations. The system can also capture stock outs where they are reported as part of the options. 30

31 4.2 Proposed project content and recommendations Looking at the objectives that guided the proposed project and the premises for which the work ought to take place, a few facts need to be noted: Clearly there are no commodities and supplies marked GF whether used in government or non government facilities thus making that recognition a challenge from the start of the project. Given that at facility level all commodities and supplies received from KEMSA are comingled with those of other donors, identifying GF at service provision level including services that are provided at community level poses a challenge The government did not agree to the visit of their facilities to clearly follow up on GF commodities and supplies. Given that they are the largest recipients of GF support, the assessment was curtailed from the beginning. At this exploratory stage, the consultant and all partner efforts to get authority to visit facilities was not forthcoming. In light of a project in this direction, there is no telling to what extent that the government will be receptive to citizen monitoring and even allow the citizen access to data on GF In the case of PRs, SRs and SSRs since the information on who has received what and for what is not readily available, it is difficult to initiate a citizen monitoring system based on GF unless this information is made openly available and citizens begin to become aware of who is receiving what support from GF The concept note is based on provision of information to the KCM and GF secretariat. Currently the functioning of the ICCs which should basically feed what happens at the KCM level is not up to the expectation given that various issues involving GF is not readily available for scrutiny. Discussions held elicit that the ICC has not managed to follow up effectively on the GF processes and deliverables to allow the KCM to undertake their role One fact that has been missed out at the concept stage is the clear avoidance of GF recipients as part of the citizen monitoring CSOs as this is a potential source of bias In light of these observations the project if envisaged to be a reality should begin with getting the information on GF available to allow for a citizen monitoring process to take place. This kind of advocacy can only be achieved at the ICC levels of the three disease areas with a clear illustration of the importance of such a project. It is at the ICC level that government, implementers and development partners get to meet for key decisions to be made and it is at this level that the buy in should first be sought that can facilitate all other processes trickling down to the community level. 31

32 4.3 Conclusions From the discussions held with various stakeholders, it is clear that the time for citizen monitoring is ripe for the country yet the duty bearers both in government and some CSOs are not willing to embrace the concept or to give data or information that would allow this to work out effectively. There is still fear from the duty bearers that exposure of this kind of information that allows them to be open to public scrutiny is something that they are not ready for. However there is hope; increasingly, the country is opening up to the reality as envisaged by the Constitution, judicial processes that have seen the powerful and mighty face public scrutiny and be declared unfit for office, citizens seeking high profile public office being subjected to scrutiny not only by the interviewing panel but by the public at large as such processes have been embraced by the media and relayed to the public. Even as the political processes seem to drag its feet on the integrity bill, the Constitution is supreme in these matters as indicated by chapter six of the Kenya Constitution. Reluctance by duty bearers to follow through and support this process is only an indicator that all has not been w andll there is much that needs to be done so that anyone in a position of authority can begin to take the responsibility that comes with the title. Health is an area that has been neglected for a long time. Money from the exchequer and the development partners are not closely monitored on its utilization. The CSOs have not been adequately empowered to undertake an effective budget tracking and monitor allocations to the sector with the result of a stagnating allocation from the exchequer and poorer health indicators as a result. Cases of double accounting and misallocation of funds have been reported yet no action on the officers are forthcoming, the system in itself has supported corruption and facilitated it to prosper trickling down to the lower levels of health service provision. Commodities and medical supplies sent to facilities sometimes never get to reach where they are expected on time and where they do; the system is not in place to ensure that pilferage by the duty bearers does not happen. A citizen monitoring project will begin to open the eyes of the public as to how much more can be achieved by simply being aware of what they are entitled to and that has been given to them. The government puts in place systems that look very good on paper but their implementation remain weak giving room to corrupt practices at all levels of authority. Unless this is addressed, the health sector will continue to still suffer poor indicators, and not because the resources are not there but they are being put on the wrong hands or diverted to private enterprises. It is not clear at this point what process the government is going to adopt with the changes in the Constitution that now recognizes County governments. The process as it is now has been largely centralized in terms of how KEMSA 32

33 operates, how the MoH operate and supervision is generally top down. The Constitution has now put in place a system that gives specific powers to the County governments and relegated the Central government to provision of policies, standards and guidelines in health and supervision of referral facilities. In the case of a PTF project in this direction then there will be need for negotiations and buy in with individual County health directors and possible the County governors on the direction of a citizen monitoring project. For effective citizen monitoring to be in place it has to begin with information, what is available in terms of resources. How much is GF giving to the country and which are the targeted areas and what is the expected impact of the funds that have been provided. What are the areas of intervention and who is it that has been given this responsibility and in which area. This information should be made available to the community at the lower levels so that they can begin to start questioning the system. Community champions put in the right places can be able to feed the system with what is working where. This then makes the difference between what Huduma did and what is more practical on the ground in that people are identified as opposed to organizations to provide this information. The community champions can then be supported by a system that begins at the local community level to the facility level building up to the county and national level where the issues raised and not addressed can get public attention they deserve and the attention of policy makers at those levels. At the national level, ICCs can then begin to ask questions that are backed up by evidence from the community. At all the levels that have been established, there is representation that ensure the engagement of the civil society and support would then be required to get feedback to the communities where the pilots are being done as the primary stakeholders. Identification of the relevant CSOs should be through a bidding process that looks at capacity within the organization to undertake the role, looks at their financial management and management structures that ensures that the pilots are carried out by organizations that have some record of achieving results and have contacts that should be verified on the ground through some stringent measures set by the selecting team. Ideas of how the monitoring will take place are also important but it should be backed up by requisite staff, monitoring tools and networks that the CSO has been able to develop. Not to pre-empt the final results of the selected CSOs, competency, affiliations, involvement in advocacy work and contributing resources also come into play. As it is often said, advocacy is not a cheap process and seeing results will only happen with the kind of ground work, follow up, reporting and awareness creation that is made. 33

34 ANNEXES Annex A: Detailed discussions on the feasibility of citizen monitoring of Global Fund provisions of goods and services A.1 Global Fund Commodities and services in Kenya Kenya has been a recipient of GF grants to support the three disease areas. Initially all funding was received through the government for procurement and services and in turn the government would contract some CSOs based on their area of strength to support in service provision. After a lot of consultations and advocacy by CSOs, GF grants were opened up to CSOs. Other than the government as a principal recipient, the CSOs now also have a principal recipient. The first of this was Care Kenya who received GF grants Round 7 as a principal recipient. In discussions with Kenya Medical Supplies Agency (KEMSA), GF grants procures all medicines and supplies for the three diseases areas, malaria, TB and HIV. For HIV it includes all the HIV test reagents and laboratory kits to include CD4 machines, and a good proportion of ARVs which are also procured through other means for the country. For HIV, GF supports community related activities that target the youth, expectant women, and most at risk populations (MARPS). TB is totally supported through the GF grants and the support includes procurement of all drug regimens both as first line treatment and second line treatment, the grant supports community based activities related to defaulter tracing, directly observed therapy short course (DOTS), contact tracing and community training on TB. It also supports the supply of TB diagnostics kits, all of which are procured through KEMSA. GF also provided money to facilitate the construction of isolation wards for TB patients, monies which were largely diverted to other supposed needy areas until there was an outcry from CSO TB advocates who were aware about the availability of this funding. This advocacy led to the creation of the isolation ward at the largest referral hospital in the country, Kenyatta National Hospital through use of GF grants. In the case of malaria, all malaria drugs to include the first line Coartem and a limited dosage of second line treatment which includes quinine injections. The long lasting insecticide treated nets (ITNs) are procured through other means and usually through the National AIDS and STI Control Program (NASCOP) but with the use of GF grants. The grants also support community education and environmental activities in support of the eradication and/or control of malaria. 34

35 The distribution for GF funded commodities is through the government systems and the public sector facilities. Non government facilities which include NGO facilities, faith based, and private facilities, access GF commodities and supplies through the district hospitals under the approval of the relevant disease coordinating officers at the district level. In this case the district Aids and STI Coordinating Officer (DASCO) for HIV, and the district TB coordinating officer for TB. Malaria drugs are supplied as part of the essential drugs list to all parts of the country and the ITNs distributed through what the government calls the rapid results initiative where special attention is paid to the distribution of the ITNs for the targeted groups. Community malaria activities are normally coordinated through the support of the district malaria coordinating officer. Distribution by KEMSA is done to all public health facilities directly with hospitals using the pull system 6 and supplies are delivered bi-monthly and lower level facilities using the push system 7 and supplies delivered quarterly. For ARVs, KEMSA monitors the consumption patterns and are able to deliver with a buffer in case of any unexpected demand in supply. Reports are normally submitted to NASCOP who then submits them to KEMSA. ARVs are supplied monthly to facilities based on their demand levels. TB uses the same systems and malarial drugs are supplied together with the essential drugs and quantities to different facilities are determined by the divisions of TB and Malaria respectively; usually based on disease incidence. Discussions with various stakeholders both of who are either recipients of GF government and non government, and non recipients indicate that there is limited knowledge on what GF is all about. Apart from the recipients and key officials working directly under GF, no one knows or understands what GF is all about and the difference that it is making in the country. One of the major complaints received is that unlike other pots of funding that Kenya receives, little publicity is given to GF. Very few people know what has been sent as the final proposal, a process which is viewed to be extremely technical and involves only the elite and those in the academia, no one knows when the signing is done, it is never a public event, and very few have information on the actual amounts received and what it is approved for. Even when the monies are disbursed to sub recipients and sub-sub recipients, no one knows how much they have received and for what purposes. In brief, GF is shrouded in a lot of mystery that makes it very difficult for citizens to identify the support on the ground even when they are beneficiaries. 6 Pull system is one where the health facilities only receive in their stocks what they have ordered from KEMSA 7 Push system is one where the health facilities receive in their stocks what has been predetermined as their requirement usually with the help of the relevant Divisions in the health sector who analyze the facility data. Here there are challenges of shortages and supplies which sometimes may not be utilized at the facility. 35

36 A.2 KEMSA supply chain and data capture at the facility level Since most of the GF supplies are done through KEMSA, they are able to reach their delivery points. KEMSA has nine regional distribution centres with Nairobi hosting three warehouses. KEMSA has contracted an independent firm to distribute its supplies to the facilities. To quote the CEO, KEMSA challenges in meeting demand usually stem from 98 percent funding shortages and only 2 percent can be attributed to procurement procedures ~ KEMSA CEO KEMSA has launched an Enterprise Planning System which is now 2 years old. The system is a logistics management system that sends reports to programs and can analyze data on what is available in stock. The facilities are also able to upload what they have received in their stores and this then helps them update their inventory while also ensuring that data is also available at the facility. An SMS code has been in place that allows the facilities to monitor stock at KEMSA and therefore they can place their orders based on what is available. The system provides dispatch information and also informs of what is in stock. This system was adopted to ensure that the facilities can use the pull rather than push system of reordering but in the words of the KEMSA CEO, Inventory keeping and updating is still a major problem with the public facilities and that is why at lower levels, the push system is used ~ KEMSA CEO. KEMSA at the procurement level is able to indicate what pot of funding will be used to procure what medical supplies and in what quantities. When commodities and supply leave KEMSA premises they are marked as Government of Kenya or GoK and therefore they do not specify who has supplied what. In this aspect then facilities are not able to specify the source of funding. The sub recipients however can be able to indicate what they have procured as these reports are given back to the PRs as part of the reporting on the funding. At the facility inventory, the data captured is mainly supplies that are delivered to the facilities either through the district supplies, when they are received, in what quantities. The data is signed off by the officer receiving. Under this baseline, the consultant was not able to access any of the data at the public facilities to assess what is in their records in terms of procurement but under the mission and private sector, data on when the stocks are received, from what source, what quantities are clearly indicated. The data is captured on computer and the facility can quickly deduce what has been used and what is pending thus informing their reordering and purchases. This information 36

37 provided was largely verbatim as the custodians to the information were not available at the time of the visit and subsequent follow ups did not yield the required information. A.3 Discussions with Global Fund stakeholders and recipients GF supported activities, commodities and supplies Several discussions were held with GF stakeholders at the national level. These are people who have been involved in GF either in its management or program managers under the different funding streams from GF. Those who were reached had a lot of information on how GF operates in the country and what a citizen monitoring project should look like. Kenya has only won two rounds of HIV funding under the Global Fund; Round 7 and 10; 10 being the biggest funding they have received for HIV to date. In paper, NACC is basically supposed to play the coordination role for all HIV/AIDS activities. In GF round 7, other than coordination, they also implemented the mass media campaigns and this became such a big role conflict in that they could not coordinate effectively while at the same time be an implementer. So in Round 10, their role became exclusively to coordinate. In coordination they are allowed to buy vehicles and motor cycles for their field officers. They are also allowed to capacity build their field officers to undertake their role supervise other implementers, identify implementers for funding like the Total war Against Aids (TOWA) funded by World Bank etc, and also capacity build implementers at the community level on how to fill the Community-based Program Activity Report (COBPAR) forms. Global Fund Round 10 for HIV/AIDS is concentrated on 50 high incidence districts of the country and they fall into about 26 Counties which are located along the Kenya Uganda Highway that joins Kisumu, Nairobi and ends up in Mombasa. It specifically targets the high HIV incidence regions of the country. Now GF funded commodities and especially the drugs or even the vehicles in this instance are not branded at all so it would be hard to identify anything as belonging to GF or supported by GF. One of the reasons given why branding by funder is not considered is that it would create a bias in peoples mind that one drug is superior to the other and therefore clients or patients may reject a certain brand believing it to be inferior to the other. KEMSA systems, is able to indicate which drugs and supplies are procured by source of funding. Being the largest consumers of GF support, they procure the drugs and supplies for the different disease areas under GF with the exemption of treated bed nets. For HIV, CD4 reagents, ARVs and cotrimoxazole (Septrin antibiotics) are procured using Global Fund monies. There have been other parallel systems that have also been used to procure HIV drugs and supplies that include procurement by PEPFAR through Kenya Pharma, and Clinton Foundation. GF monies procure all supplies and drugs related to TB that 37

38 includes the lab diagnostics and all drug regimens including for MDR TB. For malaria, GF procures Coartem which is the recommended drug, 2nd line drugs that include injections however bed nets are procured through NASCOP under a different system. The government does not procure condoms as there are many condoms that come into the country through different funding mechanisms. Distribution by KEMSA is done to all public health facilities directly with hospitals using the pull system and supplies are delivered bi-monthly and lower level facilities using the push system and supplies delivered quarterly. For ARVs, KEMSA monitors the consumption patterns and are able to deliver with a buffer in case of any unexpected demand in supply. Reports are normally submitted to NASCOP who then submits them to KEMSA. ARVs are supplied monthly to facilities based on their demand levels. TB uses the same systems and malarial drugs are supplied together with the essential drugs and quantities to different facilities are determined by the divisions of TB and Malaria respectively; usually based on disease incidence. All stocks received are recorded in a book and stock cards kept for all supplies received. However what was not verified was whether the physical records are kept and are up to date in terms of used stock, what is still in stock, the re-order levels and whether there is reconciliation of these data. GF R10 on malaria focuses on work with community units in Nyanza and Western Kenya. The community units are established and through the community health worker, there is expected to be case management of malaria at community level. It is hoped that through this round of funding that in 2013 rapid diagnostic testing for malaria will be availed at the community level, ITNs and training of health workers on malaria and the new policy direction for the country for diagnostics before treatment will be rolled out. KICOSHEP has been funded under GF R10 for malaria and HIV. In HIV, their focus is on most at risk populations (MARPS). They also focus on the people living with HIV and AIDS (PLHIV). The service is focused on adherence to treatment, referrals through the community health workers (CHWs) to facilities that have already been identified. Their areas of operation are Nairobi East and Nairobi west where they work with especially the slum population of City Carton, Fuata Nyayo and Kiambiyo in Nairobi East who are then linked to Bahati, Jerusalem and Makadara Health Centres all of which are managed by the Nairobi City Council. The slum populations of City Carton or Upendo slums are linked to Langata health centre, Mbagathi Hospital and AMREF comprehensive care centre (CCC) in Kibera. KICOSHEP intends to work with 20 PLHIV support groups who will then be empowered to ensure adherence to treatment and prevention of mother to child transmission (PMTCT) for the expectant mothers for identification and follow up to delivery. CHWs identified through the support groups will be empowered 38

39 to enable them conduct the identified deliverables. It is also expected that work will also be done with commercial sex workers who will be reached through their peers who will be taken through capacity building and behavior change/livelihood change. For this activity, the organization is yet to identify peer educators to support their work. Other activities under this funding are HIV testing and counseling, home based care with CHWs who will be taken through refresher courses and orientation on reporting. The CHWs will be motivated through a Ksh. 2000/ allowance approved by government and that has been provided for through GF support. For malaria, the system is to work through community structures and that means through the CHWs. Activities would include environmental activities, adherence to treatment, and distribution of ITNs and referral of cases to the facilities for management. CHW meetings and meetings with the support groups are expected to be done on the monthly basis. CHAK has received GF R2 and 7 for HIV, R4 and 10 for malaria, and R6 and 9 for TB, as a sub-recipient. The support has being going to 18 Faith based organizations (FBO) health facilities under CHAK in designated districts. In HIV they have provided care and treatment, had a CD4 machine bought for one of the FBOs under CHAK and salary support for staff employed. R10 is community focused where they engage in community based activities that would be linked to the CHAK health facilities. Other activities would include counseling and testing and youth activities at community level. In malaria, R4 was about ITN distribution and training of health care workers. The malaria GF monies also allocated activities that allowed for community based distribution of ITNs. Under TB R6 which focused on community interventions and work with 15 CHAK health facilities. The activities included training of health care workers and CHWs on TB defaulter and contact tracing. R9 will be implemented through the government s districts TB coordinators in 20 high incidence districts. KANCO, an SR, received R7, 9 and 10 GF funding. GF R9 for TB involves engaging communities to increase TB case detection among special population like the prison populations. Reporting for TB is normally to the donors and the Division of Leprosy, TB and Lung Diseases Program (NLTP) of the MoH. Matata hospital, a private hospital in Oyugis, Nyanza Province received GF R7 as a sub recipient. The funding was to support HIV counseling and testing, youth outreach activities targeting those in the age group 15 to 35 years, and the establishment of resource centers and supporting their operations. Other than where supplies are procured directly by the sub recipients all other supplies are procured by the Government through KEMSA and NASCOP and equally branded GoK thus from the onset, it would not be easy to identify which supplies are GF as these are all comingled with supplies from other 39

40 agencies including government spending. What stands out however are supplies that are received from US Government agencies as they are clearly branded as having been procured through funding from the American people, this would include both hardware and medical supplies and equipment. Reporting tools and proposed project pilot sites Global Fund Round 10 for HIV/AIDS is concentrated on 50 high incidence districts of the country and they fall into about 26 Counties which are located along the Kenya Uganda Highway that joins Kisumu, Nairobi and ends up in Mombasa. It specifically targets the high HIV incidence regions of the country. In terms of reporting, NACC has a community level reporting tool called COBPAR forms. The national HIV and AIDS Monitoring and Evaluation Framework identified COBPAR as one source of data. NACC rolled out this subsystem in July The COBPAR activity form is filled quarterly by implementers with community based interventions; however there are reported challenges with the receiving these reports and currently the government and partners are trying to evaluate an IT system that could facilitate easier transmission of the data as captured in the COBPAR forms. 2 copies to the COBPAR form are returned to the Constituency AIDS Control Committee (CACC) Coordinator by the 5th of the month following the quarter. The implementer retains a copy and another copy is sent to the donor of the project. The CACC Coordinator will send one copy to their respective NACC Field/Regional offices by 15 th of the month following the quarter and retain one copy. An inventory form developed by NACC is filled on a one-off basis by the community based implementers. R10 for malaria is yet to develop its approved reporting tools but draft formats have been shared. The reporting for malaria has always been on the patient registers on how many patients were found with malaria and treated, ITN distributions and indoor residual spraying (IRS) schedule where this is done. The MoH 711 is a register that covers all the service statistics related to GF disease areas and safe motherhood. The requirement is such that every service provider should be able to fill the details of their services on a monthly basis and submit two copies to the district officer in charge with a copy being left at the facility for their record. One of the copies picked by the in charge officer is then transmitted to Nairobi for documentation purposes and analysis on demand and requisite supply. Clearly the filling of this vital form that supports the health management information system (HMIS) for the country is not being done with the accuracy and the efficiency that is required. A private facility visited in Nairobi indicated that they recently just filled one under the request of NASCOP but did not keep a copy for their records. Others had some statistics missing while others were just plain neglected with figures not tallying as required. 40

41 In terms of the suitability of the choice of Nairobi and Nyanza province as points of focus for the pilots on citizen monitoring, a number of recommendations were given. NACC felt that very good information would be forthcoming from Nyanza and Nairobi because they are generally more aware about HIV activities than the rest of the population. In Kisumu the suggestion was to work with the Anglican Church who is reported to be good implementers, Matata Hospital which is privately run in Oyugis in Nyanza. In Nairobi beneficiaries of GF support would be KANCO, NEPHAK, Mbagathi hospital and Dagoretti dispensary. Most of CHAK activities under GF are focused in Nyanza and Western province. In Nyanza, good data is received from Itierio health centre, Kima hospital and Ngiya health centre, and these have been targeted for HIV and TB related activities. In Nairobi, Huruma health centre would be the only facility under CHAK that can be included in the assessment as they also receive GF support. Strong sentiments received on the choice of location are as follows: That Nairobi and Nyanza would be ideal as starting points for any citizen monitoring. However it would be important to identify which regions or parts of these regions receive the bulk of funding and also can be identified by disease incidence. The areas should also be subject to other funding sources so that bias does not crop in when reporting on GF. This is because if GF is the only source of funding, then there is bound to be over reporting on successes or failures thus biasing the whole objective of a citizen monitoring system. The members of the communities identified should also be more static to allow measurement over time and to avoid sensationalizing issues. They should also have a good reporting record and this can be confirmed with the PRs and SRs. The choices given for pilot here go beyond Nyanza and Nairobi to include parts of the Rift Valley Province. The preferred choices include Nakuru and Kericho in Rift Valley, parts of Nyanza in Kisumu towards Bondo, HomaBay/Kendu Bay and Ndhiwa areas but not in Kuria. In Nairobi the pilot could focus on Kibera, Langata environs, Kawangware but not Westlands which is very dynamic A.4 Discussions with CSOs and stakeholders on citizen monitoring GF recipients response In light of the proposed project, the consultant had a number of discussions with civil society organizations both as recipients of GF grants and those that were not grantees. KEMSA and other CSOs led by Transparency International 41

42 are already ahead in starting a citizen monitoring project of government procured drugs and supplies. Part of the contract also includes the monitoring of contracting for the supplies of medicines and medical supplies by KEMSA. Mr. Otuoma of NEPHAK was of the view that national networks can be the ones to conduct citizen monitoring because their networks have grassroots organizations throughout the country and they can capacity build these organizations at lower level to be able to effectively monitor GF commodities and supplies. These national networks sit at the ICCs of the three disease areas of GF and can be able to raise the complaints received from the grassroots that have not been addressed for redress at the national level. The networks can pick individuals in different parts of the country who can then update the national networks on stock outs and challenges on the ground. Malaria can be monitored through affordable private pharmacies and clinics that receive Coartem and it would be easy to know where there are stock outs. For this monitoring to work out then the private public partnership is important and therefore the involvement of the private sector in allowing the use of their IT systems to support the monitoring and report back. For ITNs which are normally distributed in what the government normally calls the rapid results initiative, this is where they launch massive campaigns to achieve earlier set targets and ITNs have largely been distributed through these mechanisms thus monitoring the extent of the distribution can be done on this basis. In Mr. Otuoma s assertion people need to know where the drugs they are taking are coming from, who are the suppliers and the frequency of the delivery. The networks can recruit literate people who can be able to monitor these commodities and report through the use of SMS platforms which can be initiated for that purpose or alternatively ad hoc calls can be made to the identified individuals so that they can be able to report the situation in their area. On the question of Huduma and whether it had been able to achieve its objectives, he indicated that there had been challenges with their approach because they used civil society as organizations to give information. As no one was really assigned the task, the CSOs ended up giving false alarms on stock outs which did not go down well with the government or those who went out to verify the facts. In his view NEPHAK and KeNAAM can be identified to conduct citizen monitoring with NEPHAK monitoring both for TB and HIV and KeNAAM monitoring for malaria with verifiable champions on the ground who will be trained for the purposes of the project. In Ms. Evelyne Kibuchi of KANCO own estimation, GF is very complex in its application and implementation. The targets set are not realistic. Case detection is given priority over cure rates which should be the determining factor of success. GF is not branded, their monies go through the government and thus to a large extent implementation is through government agencies. Even where now CSOs have been receiving GF grants, they have never received branding guidelines and therefore they do not brand neither do they conduct 42

43 dissemination to the communities to tell them what they have received and what they have achieved. Ms. Kibuchi believes the most important thing to be done if communities are to know about the existence of GF is demystify GF to the communities, develop simplified brochures or fact sheets on GF in the different countries and what it is that they do so that people can begin to understand. There is no link between PRs and the community, GF will only be heard when there is a problem like when funds are misappropriated or when there is a delay in disbursement of the funds or stock outs. There should be disseminations when there is a closeout so that fund recipients are accountable to the people because the current scenario is that this does not happen. The implementer cannot be the monitor; independent CSOs not recipients of GF funds should be identified to conduct the monitoring as there will be no conflict of interest. Her advice was to focus on advocacy or rather policy level CSOs. In her view the monitoring can be achieved by national CSOs like NEPHAK. There should be open forums for disseminating progress and community allowed to ask questions and give feedback. GF should brand for more effective identification of their products and services offered. Their systems of operation should be simplified so that communities can better understand them; the application process should be simplified. In Ms Kibuchi s opinion, the application process for GF looks like an academic affair with only those in the know or having monies to hire a proposal writer can access the funding, the rest of the communities are left out despite the fact that the need has been identified and there is evidence to that effect. In the past GF had given monies to support the putting up of isolation facilities but the government did not do that. This is because knowledge is limited on the ground and instead the money was used for something else which later caught up with the government as increasing cases of XDR TB were reported in the country and there were no isolation clinics to take them. To date there are only three isolation facilities in the country; at Kenyatta National hospital which was put up with GF funding, Moi Referral hospital and Homabay district hospital put up through other funding sources. The first scandal for the country was when Hon. Charity Ngilu was the Minister for Health and she used GF money to host a women s conference. The money used for this conference was supposed to be used to set up VCT centres. The other scandal was when R2 monies were reported as mismanaged. Money that was meant for HIV was used to purchase malaria drugs although later the government replaced the money but they were at pains to explain the withdrawal and later refund of the money to GF auditors. Money to the districts under the GF was in the past handled as normal float to the district and accounted for as such and never as GF monies. These challenges however 43

44 as reported by Mr. Ragi of KANCO who is a board member of GF have now been sorted out. Mr. Ragi asserts that not many people understand GF because of structural issues. The proposal process is only known to a few people and organizations; nobody really knows what is applied for. It is expected that the disease area ICCs should know what is applied for and the budgets. His feeling is that the negotiation and approval process should be made public; communities should know what is being negotiated for and what the approved budget is. The PRs should be publicly known; the SR and SSR selections should be a public affair. The organizations that have received monies should be made public clearly stating the criteria used to identify them, how much money each one of them has received and for what purpose. When the public know, they can begin to ask questions of even the smaller organizations. Mr. Ragi gave the example of the Japanese Government who when giving even the smallest amounts to build a bridge there is so much public fair to raise awareness with cameras taking pictures and reporting in the country s dailies the next day. He questioned why GF cannot also insist on the same for accountability to the public yet their monies are indeed making a difference. The reporting to the public does not need to be extensive but the PRs can identify five key indicators and report back to the public. Progress reporting by districts can be publicized so that the public is aware of the percentage of performance by every district and they can then begin asking questions why their districts are under performing. Once people know who has received what, where and for what purpose, they can then begin following up on why they are under performing. Mr. Ragi feels that the community can be able to effectively monitor GF if structures are put in place to support such a system. The monitoring should take a two prong approach; at the individual level and at the community level. 6 to 7 people identified by the community can form a committee that is the intermediary between the SR and SSR. The committee members can be beneficiaries, representatives of special interest groups, SR representative and SSR representative, and a TOR can be developed for their operations so that they know what is expected from them. The group can meet once a month and facilitated to have these meetings. The SSR can report to the community on their progress, achievements and challenges through this committee and individuals can also report directly to these committees or the chosen representatives to these committees. Where there are complaints, these can then be addressed at the monthly meetings. Meeting key agenda can be points of addressing the wider community through community forums and these form the areas of dialogue between the SSR and the community. In his view, this can be a more effective way of monitoring. 44

45 The way NACC operates, in every constituency they have what they call the CACC Constituency Aids Coordinating Committee which comprises of 18 people representing the government, the public, the persons living with HIV and the private sector. These 18 people meet on a quarterly basis and they are able to agree on which organizations to fund from the TOWA monies. Once the implementers are agreed upon, the list of accepted proposals are displayed publicly in the CACC office and the amounts of money that each of them has been given towards implementation. It is expected that people can walk into the office if they so require this kind of information. During the CACC meetings, all stakeholders are informed of the progress in HIV activities in the Constituency because the CACC coordinator who is a NACC employee has money to facilitate these meetings. The expectation is that from these meetings then the different stakeholders at the Constituency level can then meet up with their constituents to inform them of the progress and any other information on HIV funding and activities. The unfortunate thing is that as these members of CACC are not facilitated to meet their stakeholders, so they do not usually do so and therefore the information is left with the few privileged to be part of CACC. The expectation was always that these members of CACC would form the monitoring team on behalf of their constituents but this never happens. A.5 Non GF recipients interviewed Community Aid Development Fund (CADIF) Stephen Otieno is the project director of Community Aid Development Fund International (CADIF) founded in 2006 and based in Kisumu city. The NGO works in three thematic areas of health, education and capacity building. In health their work is focused on youth in and out of school who they reach through behavior change communication outreaches, reach out to the MARPS and especially men having sex with men, injecting drug users and commercial sex workers and enhance their capacity to especially respond to human rights issues. Other than this, they also capacity built through short small entrepreneurship skills training to enhance alternative livelihoods. The organization also creates awareness on the need to be tested for HIV. In education, they have been able to link HIV to education and are supporting 70 orphans through primary school with fees and stationery. They train teenage mothers and encourage them to re-enter the education system to complete their primary education through offering remedial training part of the day and vocational training for the remaining part of the day. Teachers are recruited by the organization and paid a stipend to support these programs. CADIF also has in place a training centre for access to information and the internet and for their use, they charge a small fee for organizational sustainability. The organization has been able to capacity built 40 CBOs in financial management, communication management and proposal writing. 45

46 CADIF funders include NIKE, Global Footsteps and AMREF under the Maanisha Project. The centre is normally supported by volunteer graduates who as part of their service to the community are able to train and carry out the activities on behalf of the organization. Citizen monitoring has been some the activities that the organization has been able to undertake and this involved monitoring of the Constituency Development Fund (CDF) for Kisumu Town East in a project funded by Swedish International Development Agency (SIDA) for the year 2010 to The CDF funds which are channeled through the Constituency Member of Parliament is normally a very sensitive area to venture and the project was received with a lot of suspicion from the CDF Committee members. The organization had to first talk to councilors individually who are members of the committee to get their buy in before reaching out to the whole group. They took them through understanding the budgets and planning for the budget. They informed the councilors that as part of the committee and to ensure that the community was aware of what they were doing it was important for them to have dialogues with them on their achievements which they readily agreed to. The organization was also able to help them know where they were under performing and in the process helped them work through those areas. They eventually accepted to work with the project and were able to support their activities. The organization took a further step to have discussions with the community bunge 8 who meet informally every other day to discuss ongoing political, economic and social events. Given their peri-urban set up, these groups were largely available. Working with the youth on this project allowed the CDF committee members to be more open and available to respond to the queries raised by the community usually after further information from the organization on areas of contention. The community bunge have a chalk board which they write issues of concern and have meetings with at least one CDF committee member every month. The project recorded very good interactions between the community and the CDF committee. It also allowed better accountability in the use of CDF funds for the Constituency. The organization is currently involved in identifying School Parents Teachers Association (PTA) members who would be trained in tracking school budgets to allow for better accountability by the school administration in the use of the funds available to schools. With such accountability, the PTA members are then able to report back effectively to parents and in the process help create transparent systems in the use of school funds. 8 Bunge is the Kiswahili term for parliament. In every village or peri urban set up, there are places that the community, usually men gather to get the latest updates on what is happening politically. Information from these informal sittings normally filtrate to the community members and is normally taken to be the truth. 46

47 Sustainable Aid in Africa International (SANA) James Koech who is the technical advisor for SANA was able to meet up with the consultant to discuss the organizational activities and the possibilities for a citizen monitoring in the Nyanza Province. SANA is involved in safe water and sanitation projects in Nyanza, Western, Rift Valley and are expanding into Coast Province. They are engaged in community based and school based water and sanitation activities. Some of their activities include: Rehabilitation of water points; Creating new sources of water; Expanding the reach of a water point in towns; Drilling boreholes; Protecting springs; Encouraging and supporting the development of home water catchments; Develop and drench water pans for agriculture and livestock; The normal approach used is that the community identifies the problem and approach SANA to support an intervention. SANA is then able to conduct an assessment and where the need is identified; they source for funding, implement and train the community on maintenance and hygiene. They then monitor the project for two to three years and in the process document progress, successes or challenges. They are also engaged in collaboration and networking and work closely with water boards, primary schools, Ministry of Public Health and Sanitation, fellow NGOs and the community members. Their donors include UNICEF, UN Habitat, CDF, and Municipalities where they work. The organization has been able to network through peer education with colleagues in the sector, share their brochures through district steering committees, their website and is a member of the CSO network in Kisumu. SANA has been taking a lead role in bringing CSOs to create accountability and good governance in the water sector in Kisumu. They were among NGOs that contributed to the citizen s report card which has been documented as a best practice. They are currently in the process of piloting with 10 community based organizations (CBO) who they have capacity built to be able to ask the Municipalities for accountability to their citizens and in the process demand their rights. The community members have formed associations to advocate and demand for service delivery and equity in the distribution of resources. In these associations, they are able to send representatives to meet the Council with their concerns for redress and agree on a realistic timeframe for action. African Family Health (AFH) The African Family Health is an indigenous NGO whose mission is to develop lives of families through capacity building and training of individuals and organizations. The organization has its headquarters in Nairobi and operates in Nairobi, Central, Eastern provinces and Juba in South Sudan. AFH uses 47

48 flexible approaches that can be packaged, mixed and matched into models that can deliver health and development. It has been involved in capacity building of civil society organizations, institutions, governments and individuals around the African continent strengthening their organizational systems, using evidence based approaches while undertaking research, monitoring and evaluation. They are also involved in innovative advocacy and networking with CSOs having trained over 500 CBOs in Nairobi, Eastern and Central provinces of Kenya. On citizen monitoring, AFH believes that the time is right for such a process to be put in place as Eva Muthuuri, the NGO s director believes that people have information but are still not aware on the best way to communicate the information through the systems of government and get effective response that can stimulate actual community engagement in social, health and development activities that are going on around them. Ms. Muthuuri believes the communities are aware of the disadvantages that are among them driven by the ever increasing poverty levels. They realize how poor health and under development affects them personally, their families, the work that they are involved in and the communities they belong to. They work to reduce risk and vulnerability but even their best individual effort cannot achieve much if they are not united under the same goals and objectives and that is where citizen monitoring has a role to play and it begins with empowering the community grassroots organizations to undertake their role as community champions and begin the process; AFH is involved in creating this awareness. Omega Foundation Omega Foundation is an indigenous organization started as a CBO in 1997 in Nyando Division of Nyanza Province. It had a focus on HIV then when there were no ARVs and piloted the first VCT site at Ahero Sub-District Hospital. In 2001, it expanded and registered as an NGO operating in Kisumu, several parts of Nyanza and Rift Valley. Being health focused, it targets orphaned and vulnerable children (OVC) and widows with their interventions. It also reaches out to those who are HIV-positive who are supported through linkages with Port Florence Hospital for counseling and testing, CCC services and ART. They also support nutritional supplements to the HIV-positive in the government run facility in Mageta Island in Siaya district. The organization also runs Kadinda health centre in a rural part of Nyando district where they screen for TB, attend to HIV opportunistic infections and have a static and door to door HIV counseling and testing. They are involved in advocacy to expand access to services including health and education. They train health providers and help them access nutritional supplement for their patients. They empower the PLHIV groups to start income generating activities (IGAs). They are involved in advocacy and intervention to ensure property rights for widows through the local justice system involving the provincial administration. The organization facilitates chiefs, village elders and the victims 48

49 to meet and support the making of such events the norm in a community set up. Where the cases require legal redress they are then able to link the widows to FIDA-Kenya for pro bono services. They are currently involved in capacity building of CBOs to take up the responsibilities on their own. They have 9 affiliate CBOs and NGOs in Nyanza, Western and Rift Valley Province. Their advocacy department is involved in sensitizing the communities to be able to lobby duty bearers to undertake their responsibilities. They help them in identifying issues like school bursaries to the deserving cases. They work with 35 trained paralegal volunteers who help identify issues that need follow up. The technical team is then able to share the information in chief s barazas 9, their website, the churches for the purposes of information and follow up action. They believe there is need to have such activities to get the communities to begin advocating and standing up for their rights. Great Lakes University of Kisumu (GLUK) GLUK has been involved in realizing the Community Strategy of the health sector as advocated by the government. They have set up community units 10 (CUs) in several sites where they monitor implementation and the feasibility of CUs in different set ups. They have assisted to set up CUs in Suba, Rachuonyo, Bondo and Rarieda districts for Nyanza province and Butere district in Western province. GLUK in their monitoring realized that there were no community dialogues taking place and therefore there was no information to the health facility management committee (HFMC). The university trained the members of the community health committee (CHC) who ideally are picked from each CU that is linked to the facility. The university empowered CHCs to have quarterly dialogues with the community members and one of the agendas was usually the budget for the health facility. The HFMC was educated to know their responsibilities in the sites where GLUK is working. Some of these committees now have the capacity to even write proposals for the projects that they need to undertake for their health facilities. The work and evidence of the operations of the HFMC was discussed in the 2012 annual conference of GLUK and the MoH staff at the conference did not take it well. GLUK faced a number of challenges in trying to get the MoH to be accountable and to get the HFMCs to undertake their role. The MoH did not inform the HFMC members that there were terms of reference which indicated the way they should operate and what their responsibilities were. The government is still unwilling to share their budget with the HFMC members 9 An official meeting called by the local provincial administration staff usually a chief who heads a location 10 A community unit as defined in the Community Strategy of the MoH is a unit of about 5000people residing in the same area and who in health terms are supported by 50 CHWs linked to the nearest health facility usually a dispensary or health centre 49

50 thus challenging their efforts in tracking the budgets. The HFMC members had no idea why they were selected to be part of the committee. Most indicated that they had received letters from the MoH informing them that they had been nominated to serve in the HFMC. Those selected are normally too busy to participate in the activities of the facilities or are viewed to be non controversial. In terms of a citizen monitoring project, Mr. Wafula of GLUK indicated that such a project would work very well in a CU setup. He gave the example of Butere district in Western province which has 25 sub-locations and each of them has an established CU. In his view, Butere district would be the perfect model to monitor how an effective CU functions. Usually the CHC members have representation in the HFMC who then are able to address issues identified at the community level. Where the issues are not sufficiently addressed the matter can be taken up to the district health committee level for further action. At this level the matter also comes up before the provincial administration under the leadership of the district commissioner (DC) who is in charge of all administrative matters at the district level. The DC can question why the issues raised by the community have not been dealt with adequately and can give directives. A functioning accountability system needs to have some levels of authority clearly defined for the various levels of committees, there should also be a complaint system and a clear way in which the complaints are handled and dealt with. It should also be very clear what mechanism can be used if the issues are not adequately dealt with at the district level. GLUK has been cooperating in this work with Wemos a Dutch organization and SIMAVI who are working to scale up the community strategy in the country and especially in the western region of the country. A.6 Stakeholders response to citizen monitoring Discussions held with both government and donor agencies indicate that the time for citizen monitoring is ripe. World Bank, DANIDA and the MoH are supporting the Health Sector Support Project (HSSP) where funding is made directly to level 2 and 3 facilities to assist in the procurement of goods, services and infrastructural improvements that may be necessary to keep a facility operating. Dr. Gramana Gandham of World Bank in discussions indicated that the funding for this project came with a push for social accountability which ideally would bring in the citizens to be able to report back on what is happening at the facility level. It was realized that money that was meant for lower level health facilities never reached the health facilities and this greatly crippled the processes and functioning of the lower level facilities 2 and 3. Asked why it was always a challenge to get money to the lower level facilities the districts responded with the fact that it was always difficult to entrust money for which 50

51 you are held accountable to someone else. The district medical officers felt that the facilities did not have the capacity to manage the funds and thereafter account for it therefore they preferred to procure even the smallest of things on behalf of the facilities. This in effect delayed operations at the facility level and frequent stock outs of essentials were noticed. As a first step, there was an official launch of the project and the district health teams trained on how the fund was to operate. Accountants were hired to help support the facilities that did not have the capacity be able to report on the use of funds. Adverts were put in the country s dailies with every tranche of funding that was being disbursed to the facilities. To ease training and implementation, the project was started with level 3 facilities or health centres as they are fewer than level 2 facilities or dispensaries. Each facility would receive funds four times in every financial year. In the first financial year, 610 health facilities countrywide would each receive a total of Kes. 450,000/, with a phased roll-out plan that would begin with health centres, followed by dispensaries and FBO facilities. The funds would be credited directly to the beneficiary's bank account and can be used for medical supplies, rehabilitation and equipment of health facilities The communities are expected to come up with their representatives to the HFMC who together with the facility in charge can be able to determine what the facility priorities are and in what order they will be addressed. There are apparently very clear guidelines 11 on how these committees are set up with stipulated numbers as being between 5 to 8 members. Training has been conducted to the HFMCs and the MoH hired accountants and facility incharges. The paperwork on the use of fund and active implementation began in the two last quarters of The country has been divided into the nine geological zones to pilot the social accountability project. The contract was awarded to an NGO to pilot the social accountability program in the nine identified sites. The expectation is that they will be able to develop a manual that will guide social accountability and document their experiences to help in the scale up. Despite the engagement of government, the process of getting feedback on the process to date is still sluggard and yet to show real results. Discussions on social accountability project of the HSSF Dr. Abel Nyakiongora is heading the social accountability project of HSSF under the Ministry of Public Health and Sanitation. He indicated that the project s idea was to give a voice to the citizens and it is supported by DANIDA and the World Bank. The project is meant to look at accountability in financial management. A draft manual for social accountability was developed by central 11 Health facility management committee guidelines as discussed are expected to be available to guide formation, terms of reference and operations of the HFMC. My best attempt to get these guidelines did not bear fruit. It is not even available on the MoPHS website where HSSF is discussed. The last attempt to develop such guidelines for health facility management boards was done by the Policy Project in

52 level stakeholders and government and is meant to be piloted by the chosen organization that will implement in the nine selected pilot sites. The social accountability structure has 3 levels which are to be monitored; public participation in service delivery, information sharing on drugs received and signed for and a compliments and grievance address mechanism. In service delivery, the public should be involved in planning, monitoring and review. They will measure the level of participation in for example the annual work plan development and review, and identification of priorities. The community will be expected to develop score cards to help monitor what they would like to improve. It is expected that the scorecard will be developed in a negotiated manner with health service providers and the facility users. In information sharing, the public is expected to know what has been received as supplies and in what quantities in the facility and the HMFC should receive and sign. Where drugs are purchased directly, then there should be explanations of why this was done. It is important that information is available to the committee members; information on what is available and how it has been received, adverts on how much funding has been given to the facility and the facility level, basic information to the HFMC on service providers at the facility, outreaches conducted, how they are communicated to the community members, revenue collection, funding and use, payments and explanations for the payments. Information should also be available on the formation of the HFMC and what are their responsibilities. To quote Dr. Nyakiongora, We have solutions for the demand side but information sharing is the missing link to service delivery ~ Head, HSSF Social Accountability In grievance and complaints mechanism, it is expected that the public can raise issues about facilities that serve them through an SMS platform that allows for a quick response mechanism. The challenge that has been there in establishing this grievance and compliments system is that there are advocates who would like to have a national centre which receives all the complaints and distributes to the relevant authorities while Dr. Nyakiongora believes this would be the wrong approach as there are local issues which can be addressed locally without referring everything to the national level which has a tendency to clog the system and create unnecessary delay but it appears that this is what has been agreed on. There is also the issue that the whole arrangement should be externalized and probably managed by CSOs. The other question is who the complaint should be addressed to, is it the in-charge of a facility and what if the complaint is actually against the in-charge. So far there seems to be a lot of questions on how this mechanism will work and it is expected that the pilot being implemented by African Development Solutions (ADESO) formerly Horn Relief would have useful lessons on the way forward. ADESO, the selected NGO to undertake the pilot social accountability has a toll free line that has 52

53 been put in place and the complaints are received currently by them for analysis. The nine sites selected for the pilot are Lunga lunga in Lamu (Lamu County), Medina in Garissa (Garissa County), Mukowe in Kwale (Kwale County), Tom Mboya memorial in Homabay (Homabay County), Mayela in Naivasha (Nakuru County), Makutano in Turkana (Turkana County), Mutithi in Kirinyaga (Kirinyaga County), Riruta Satellite in Nairobi (Nairobi County) and Kalawa in Mbooni (Makueni County). ADESO who were selected through competitive bidding are expected to develop a comprehensive model on social accountability for the health sector. They are expected to have community meetings that will lead to focus group discussions with the community members that will help come up with the score cards. Lessons learned through the process will be expected to influence the quality of health services and thus improve demand. The number of cases reported will be monitored and if all works as planned and where the complaints are addressed, there is expected to be a reduction in the numbers of complaints received. The overall effect is the expectation that there will be more ownership by the people and an empowered community to be in charge of their own health. Dr Nyakiongora s suggestions on a viable IT platform is one that starts at the community level where one is able to identify health champions who can be provided with mobile phones or alternatively airtime where the phones already exist. These will feed to the HFMC directly for action and the complaints copied to the district level where it could be a CSO and the District Health Management Team (DHMT) receiving the complaints. These issues can then be filtered to the County level and further to the national level being the least in the links and only addressing issues that have not been dealt with at the lower levels. Discussions with Transparency International Kenya Forum for Transparency and Accountability in Pharmaceutical Procurement (FoTAPP) Contract Monitoring Kenya Network (CMKN) which is a multistakeholders network comprising government agencies, Civil Society Organizations, Professional Associations, Faith Based Organizations among others that are working on Contract Monitoring in Kenya. The Objective of the Network is to promote transparency and accountability in procurement and administration of contracts so as to improve service delivery and management of resources in key selected sectors. The network is coordinated by Transparency International Kenya (TI-Kenya). In discussions with TI Kenya, it emerged clearly that the two networks that were formed with support from the World Bank Institute are FoTAPP and CMKN. The two groups worked together while reviewing several documents to come up with what is now the pharma tool and a further questionnaire that has information seeking to know whether the citizenry is aware of the KEMSA 53

54 procurement system and whether they would be willing to put money towards getting that information. Now the pharma tool measures procurement to health facilities in terms of medicines and supplies, service delivery and customer satisfaction given that it also asks questions on staff attitudes. The questionnaire is administered on the catchment population of a facility. A pilot for this tool was done in June 2012 in Nairobi areas of Ngara, Umoja and Makadara. Preliminary findings from this pilot indicate that even in Nairobi, only 5.2 percent of the population knew anything about procurement. TI-Kenya notes that the pilot was done in an urban set up where the distances to the facility are very close and they are wary that if a similar study was done in a rural set where the distances are much longer, then varying figures are bound to be realized. To evaluate the KEMSA mobile tracking system, a second questionnaire was administered in a different locality namely Riruta and Lunga Lunga in Nairobi and Tom Mboya in Rusinga Islands in Nyanza province. The KEMSA system is meant to give information to the facilities on stock availability at KEMSA and also dispatch information. TI Kenya and partners therefore are trying to see how this system can be linked up so as to provide information to the citizenry. One of the questions asked was whether the people interviewed were willing to pay for information. This is because the system links up with the SMS platforms available in the country and for sustainability then the citizens need to pay a very small fee to access the information that they need. Other questions sought to know whether the citizens knew what information was available at the facility, if they required the information whether it would be made available and what additional information would they want to have. In testing the system, the respondents were further asked whether they found the system easy to use as set up by CEDILLA (indeed I confirmed that they exist and TI has not had any challenge in their operations). Preliminary findings indicate the people are willing to pay for information on health with the highest percentages seen for Rusinga Island standing at 44 percent. The results of the two pilots will be disseminated next month, October 2012 which actual dates and venue not yet fixed. TI-Kenya is hoping to have more partners share in the importance of social accountability and contribute towards the rolling out of these initiatives. 54

55 Annex B: Data Collected and analysis Matata Hospital Matata hospital became aware of GF grants through an advert that had been placed in the dailies. Through applying, they were able to get GF R7 grants as a sub recipient to Care Kenya who is the PR. The funding has been implemented by Matata hospital with phase 1 implementation ending in June 2011 where they were able to conduct counseling and testing, youth outreaches and established resource centres which are set up at market centres because of the human traffic expected. They were able to work with 21 youth groups whom they facilitated their activities by providing airtime credit for communication, provided stationery and refreshment during their meetings. Each youth group was expected to reach 30 new youth as a measure of their success in achieving their objectives. The youth activities would also include communication on behavior change. They managed during the first phase to establish 10 resource centres and supported them by: Equipping them with computers; Providing books and informational materials related to HIV and AIDS; Supplied newspapers on a daily basis as part of the pull factors to the resource centres; Provided DVDs with health information that the youth could watch as they visit the resource centre; Provided a pool table that could also be an income generating activity to help sustain the resource centre; Provided a television set for each resource centre Provided a modem to allow for internet access Subsidized rent and electricity bills The resource centre coordinator is also paid through the hospital Figure B1 below provides an analysis of the statistics by resource centres established by Matata Hospital in May

56 Source: Matata Hospital GF youth project data The data indicates that there are varied success rates from the different sites. It is clearly emphasized that the revisits in most of the sites would be as a result of the kind of services available in the centre. To measure the effectiveness of the youth centres. The youth could evaluate the value of the resource centre and whether it was meeting their needs giving ground for improvements in the project for the sake of the local youth. However the use of this information at the KCM level then can be in terms of lessons learnt from the implementation and its value in reaching the young people with information and services and thus future focus of youth related interventions for GF. The figure B2 compares the trend again in the youth resource centres for the month of June Here again there are different indications on usage. There is very high attendance for the youth aged 10 to 24 when compared to the older youth but then again the period has no data indicating the level of revisits for all resource centres. This data alone is not enough to make any inferences and may need comparisons overtime to evaluate the impact of such a project implemented with funding from GF to the local community youth. 56

57 Source: Matata Hospital GF youth project data Phase 2 of the Matata hospital GF supported project was basically a continuation of the first phase but more emphasis was laid on the areas that had performed well in meeting the project targets while also supporting them to improve the areas that had been identified as weak. The facility was asked to work with 4 more youth groups to bring their total tally to 25 youth groups. Reporting from the youth groups and resource centers is received on a monthly basis. Quarterly, semi-annual and annual reports are also drawn. The youth coordinator reports that without structured activities by the youth centers, there is normally very low demand and so to motivate new attendees, a motivation allowance of ksh. 250/ is normally given as lunch money to anyone visiting the resource centre for the first time. Reporting is normally to Care Kenya and NASCOP on counseling and testing, condom distribution is normally done in liaison with the public health office. The youth groups are identified through the youth officers at the district level and this helps establish those that are existent on the ground as they are normally expected to register with the local authorities. Through their own resources, Matata hospital has been able to train 105 CHWs who assist in the mobilization for counseling and testing. The youth groups are also able to mobilize the youth through their activities to also undergo counseling and testing for HIV. The youth groups outreach activities are normally conducted in schools, community trading centers with the youth branding themselves with T-shirts that have HIV information. Matata hospital CCC is serving over 3,000 clients. 57

58 Matata hospital has always had outreach activities in the distant villages where the communities have no easy access to the health facilities. The hospital conducts outreaches 3 times a week with each time reaching out to a different location. The community is informed about the outreach through the CHWs and consistently the dates for serving a particular area have remained the same and the community has learned to always wait for them on the scheduled day. Through their efforts, 4 facilities have been put up in the not easily accessed areas. The hospital supervises the resource centers with impromptu visits being conducted to gauge the level of activity and engagement with the local community. The coordinator is also expected to give monthly reports on their activities and access by new clients to the hospital on a monthly basis. Incentives have been approved by the PR to allow for accelerated activities. The low demand or use of the resource centre by the youth is usually as a result of the youth being actively engaged in some income generating activities like the passenger bicycle transport and brick making. By the end of these activities, they are normally too tired to walk to the resource centre for health education talks. The structured activities normally serve as the crowd pullers. Mr. George Osire who is the program coordinator at Matata hospital however notes some challenges in being able to undertake their work even where the GF grants are concerned. He reported late disbursement of funds, infrequent supplies of HIV testing kits from the District headquarters and even at the time of the assessment, there were no test kits and clients were being turned away. The facility had managed to get a few dosages of TB medication which was well below their request while they had never been supplied with coartem yet this is a malaria prone area. The antimalarials are normally bought by the facility and the cost transferred to the patient. In ensuring the operations of their resource centers, Mr. Osire notes that there is low capacity among the local youth to effectively use the resources that are provided, a case in point is the use of the computer or even surfing of the internet for information as the centers are located in rural set ups. 58

59 Figure B3: Matata Hospital GF supported Youth Project financials Source: Matata Hospital GF youth project data Looking at the analysis of the financial implications of the activities supported by GF in figure B3, you will notice that the expenditures more often than not outweighed the approved budget. The question in mind is that is it a question of poor budget estimates not based on fact or under estimating the pull of youth related activities? Although not related to citizen monitoring directly, the data provided may change the way KCM allocates their budgets and targets so that it responds to identified need on the ground and realistic estimates of the costs or alternatively how would the SR justify the expenditures which are way beyond say the 10 percent margin normally allowed? Comparison of service statistics across three different facilities as availed in MoH 711A register Three facilities in Nyanza allowed the consultant access to their service statistics as provided in the MoH 711A register. The three facilities are of different ownership with Lumumba health centre in Kisumu run by the Municipal Council, Matata Hospital in Oyugis run as a private facility and Maseno Mission hospital run as a faith based health facility under CHAK. The figures below give the service statistics by what was retrieved from a three month period from the MOH 711A form. It was noted that the reports as recorded in the forms were not up to date even for the private facility yet this was expected to be a monthly undertaking with supervision from the MoH. As a result of the lack of updated consistent figures that were identified related to the period between April 2011 and June 2011 were picked for Matata while the data for Maseno and Lumumba health centre reflect the same period in The data in MoH 711A allows for comparison across months, periods and performance by each facility. The data may be useful when looked at against 59

60 the performance of other SRs and SSRs. Such data if provided in an orderly way for different counties can bring ground for citizen monitoring to verify why their health facility is not performing well yet the need is on the ground. Such information gives powers to the citizenry to then begin asking the important questions. The only challenge is that such data is held by the MoH fraternity and is not privy to the public. When comparing data for Matata hospital for maternal and child health care in figure B4, it is easy to compare across the months the performance of the facility. Such data provides room for better programming and planning for the facility. Clearly the ANC clients data seems to be rising with every subsequent month but when you compare the proportions counseled and tested for HIV then there is a variance that could have implications on programming and thus messaging to the community. Source: Matata hospital MoH 711A data April to June 2011 Figure B5 shows TB case detection, testing and HIV-TB co-infection of Lumumba health centre in Kisumu over a period of three months; April to June Again such data can be useful for programming and planning. It can also be useful for the government in planning interventions and resourcing for the same. GF provides support for isolation facilities, it is important for such data to be analyzed at district level to provide grounds for the next level of funding and further information to the KCM on priority areas. As far as citizen monitoring is concerned, it is a shame that such facilities as Lumumba can report shortages of TB detection kits when such need is clearly identified. The defaulter rates are also high comparably is that then not a reason for alarm and could that be attributed to the stock outs? This is a question any citizen 60

61 monitoring can be able to raise if built around community dialogue with the health facility. Source: Lumumba Health Centre MoH 711A data April to June 2012 Figure B6 below gives data on the VCT service statistics for Maseno Mission Hospital. Clearly the table provides a good trend in terms of counseling and testing for HIV offered at the facility and surely a reflection of the quality of services that is offered in that area. Source: Maseno Mission Hospital MoH 711A data April to June 2012 Figure B7 gives Maseno Mission hospital enrolment of HIV care by point of entry as provided in the MoH 711A register across a period of three months. 61

62 Source: Maseno Mission Hospital MoH 711A data April to June 2012 Figure B8 shows the patients enrolling for ARVs by WHO stages for Lumumba Health Centre for the period between April and June This has an implication on messaging to the community on the importance of early detection, testing and care. Such figures if discussed with the community can be grounds for improved health service delivery and response to care in the facilities. Source: Lumumba Health Centre MoH 711A data April to June

63 Annex C: Monitoring checklists for CSOs C1: COBPAR Forms 63

64 64

65 C2: Implementer inventory form Due to the size of this document it has been attached a separate document C3: Fotapp Social audit tool Due to the size of this document it has been attached a separate document C4: Community TB referral form 65

66 ANNEX 6 Community client/patient referral form Name of patient/client..patient s mobile number Date of referral TB Reg. No CCC No. Serial No. Sex: Male Female Age Physical address (Community Unit / Village/landmark/) Mobile phone (Patient/treatment supporter) Referred from: Referred to: Reasons for referral: To continue /start anti-tb treatment TB suspect(screening) Default from treatment (TB /ARVs) ARVs Nutritional support Complications Palliative care Psycho-social support HTC Others (specify) Comments Referred by (Name) Designation Signature Date Received by (Name) Designation Signature Date

67 C5: Community TB screening Tool ANNEX 7 Community- based TB Care TB screening tool at community level Name of client Age Sex Physical Address: Community Unit nearest Landmark Telephone number (if available) Date indicate Y/N Yes no 1.Cough for 2 weeks (with or without coughing out blood) 2.History of close contact with confirmed TB or chronic cough 3.Hotness of body or sweating at night even when it is cold 4.Noticeable weight loss 5.Chest pain or breathlessness 6. Night sweats 2 weeks? If yes to question 1 Request the client to produce a spot sample and submit to the nearest TB diagnostic centre and provide feedback to the client the following day. If yes to any other (1 6) refer to health facility for evaluation If No to all (1 6), reassure the client and give TB health education Indicate the Action taken Action taken Yes No Sputum sample taken Client referred Date action taken 67

68 C6: TB Defaulter tracing form 68