A Description of the Private Nurse Midwives Networks (Clusters) in Kenya

Transcription

1 Extended Service Delivery Project Best Practices Series Report #2 A Description of the Private Nurse Midwives Networks (Clusters) in Kenya A Best Practice Model May

2 The Extending Service Delivery (ESD) Project, funded by the United States Agency for International Development (USAID) Bureau for Global Health, is designed to address unmet need for family planning (FP) and increase the use of reproductive health and family planning (RH/FP) services at the community level, especially among underserved populations, in order to improve health and socioeconomic development. To accomplish its mission, ESD strengthens global learning and application of best practices; increases access to community-level RH/FP services; and improves capacity for supporting and sustaining RH/FP services. ESD works closely with USAID missions to devise tailored strategies that meet the RH/FP service delivery needs of specific countries. A five-year Leader with Associates Cooperative Agreement, ESD is managed by Pathfinder International in partnership with IntraHealth International, Management Sciences for Health, and Meridian Group International, Inc. Additional technical assistance is provided by Adventist Development and Relief Agency International, the Georgetown University Institute for Reproductive Health, and Save the Children. Contact information: For further information, please contact: Extending Service Delivery Project 1201 Connecticut Avenue, NW, Suite 700 Washington, D.C Tel Fax esdmail@esdproj.org This publication was made possible through support provided by the Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, under the terms of Award No. GPO-A The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development. 2

3 Acknowledgments The Extending Service Delivery (ESD) Project would like to acknowledge the technical expertise and contributions of all the individuals who were involved in documenting Private Nurse Midwives Networks in Kenya and reviewing and editing this paper. In particular, the ESD Project is grateful for the services of Professor Joseph Karanja, Associate Professor of Obstetrics/Gynecology, University of Nairobi, and Monica Atieno Oguttu, RN/M, PHN, IMH, who conducted the documentation study in Kenya. Pauline Muhuhu, Elsa Berhane and Uchechi Obichere contributed to the preparation of this document. The ESD team of Cate Lane, Jeanette Kesselman and Carla White provided initial document review, and IntraHealth staff members Lindsey Graham and Jacqueline Dowdell supplied design and editorial services. The practices described in this paper are a foundation for establishing services that reach underserved populations in urban and rural communities. The work documented here is a result of the commitment of a few pioneer private nurse midwives in Kenya. The ESD Project dedicates this publication to these critical health providers, whose contributions supported these emerging practices. 3

4 Acronyms and Abbreviations AIDS CAT CME CPR CTU FP GOK HIV KDHS KEPI KNH MCH MGR MOH MVA NCK NNAK PAC PATH PMTCT PRIME PSI RH STI USAID WHO Acquired Immune Deficiency Syndrome Cost Assessment Training Continuous Medical Education Contraceptive Prevalence Rate Contraceptive Technology Update Family Planning Government of Kenya Human Immunodeficiency Virus Kenya Demographic Health Survey Kenya Expanded Program for Immunization Kenyatta National Hospital Maternal and Child Health Merry-Go-Round Ministry of Health Manual Vacuum Aspiration Nursing Council of Kenya National Nurses Association of Kenya Postabortion Care Program for Appropriate Technology for Health Prevention of Mother-to-Child Transmission Reproductive Health Training for Primary Providers Population Services International Reproductive Health Sexually Transmitted Infection United States Agency for International Development World Health Organization 4

5 Table of Contents Acknowledgments...3 Acronyms...4 Executive Summary...6 Introduction and Background...9 Description of the Networks Nyeri Network Nakuru Network 13 The Networks Best Practices A. Networking Structure and Management B. Peer Support Supervision C. Round Fundraising D. Collaboration and Networking Outcomes of the Network System Lessons Learned Challenges Conclusion References 22 Annexes Annex I: List of Informants Annex II: Interview Guide 5

6 Executive Summary At the request of USAID/Kenya, the Extending Service Delivery (ESD) Project documented the Kenya Private Nurse Midwives Networks (commonly known as clusters ) as a promising practice. One of the ESD Project mandates is to identify, document and disseminate Promising and Best Practices in reproductive health and family planning (RH/FP) for application at the community level and for a broader exchange. USAID/Kenya believes the nurse midwives networks represent a promising practice in the delivery of sustainable RH services to underserved communities and merit replication. ESD s operational definitions of Promising and Best Practices take into account definitions used by other projects and organizations such as Advance Africa and the WHO Consortium on Implementing Best Practices, as well as USAID/Washington. ESD s operational definitions are: Best Practice: A specific action or set of actions with proven evidence of success and the ability for replication or adaptation. Evidence of success is demonstrated through qualitative and quantitative information regarding the practice. Promising Practice: A specific action or set of actions that has the potential to become a best practice but requires further evidence of success, or a specific action or set of actions that may include program models, technical guidelines and protocols. Other important key terminologies are defined below. Private Nurse Midwives Networks: These networks are formally organized groups of private clinics and nursing homes operated by nurse midwives. A number of clinics and nursing homes operated by private nurse midwives are grouped together in a given locality for the purposes of facilitating peer support supervision for quality service provision. Networks have a governance system managed by an elected executive committee. Membership to the network is by application. Nursing Homes: Small facilities (10 to 30 beds) that offer outpatient curative and maternal and child health and family planning (MCH/FP) services as well as deliveries and hospitalization for other ailments. Some of the private nurse midwives own these nursing homes. Clinics: Facilities that offer curative and preventive outpatient services. There are no inpatient beds. The PRIME II Project, managed by IntraHealth in partnership with PATH and EngenderHealth and in collaboration with the POLICY Project, developed the capacity of the private nurse midwives documented in this report. Initially, the private nurse midwives were trained in the delivery of comprehensive postabortion care (PAC) services by PRIME II. After the private nurse midwives trained in PAC reported isolation and inadequate or no supervision, PRIME II assisted in the establishment and management of networks of the clinics they operate. The networks were formed to provide much needed peer supervision as well as support to this newly created cadre of PAC service providers. Operation of these networks has helped to ensure service quality in small private clinics and foster their sustainability as evidenced by network efforts to improve the facilities, 6

7 strengthen provider knowledge and skills and expand the types of services offered, and by increased utilization of family planning services and HIV prevention activities. This document presents results of a review of program materials and follow on activities as well as interviews with stakeholders from the Ministry of Health s Division of Reproductive Health and the PRIME II project implementing partners (IntraHealth, EngenderHealth, provincial health supervisors, the National Nurses Association of Kenya, the Nursing Council of Kenya and a sample of private nurse midwives in the networks). Site visits were made to two networks comprising 47 clinics in Nyeri and Rift Valley provinces to validate improvements from networking inputs. Where possible, data at the facilities were reviewed for pre- and post-network formation comparisons. It was found that these networks of health professionals contributed to an increase in the use of family planning services and have improved access to essential reproductive health services for women, including those seeking care for management of complications of abortion. Client records also indicate a decrease in the total number of clients needing postabortion care services. This suggests a positive impact of advocacy and educational campaigns and family planning services aimed at reducing unwanted pregnancies. The network system has been responsive to the needs of the population and private nurse midwives groups in a number of ways. First, members commit and utilize shared resources for the common good, and innovations have increased the clinics funds base. Second, continuing education has improved skills and service delivery to networks in different localities. The use of a variety of practices and approaches described below enabled the private nurse midwives to address their goals. Merry-Go-Round, an income generation and resource mobilization activity in which members contribute to a common kit at specified intervals. The group contribution is then distributed to members in turns until all members have had a share. Peer support supervision, in which the members consult one another in the management of complicated or challenging cases. The nurse midwives evaluate one another s facilities using PAC set standards and provide feedback and recommendations for action and followup on the implementation of recommendations. In some networks, non-compliance is penalized. Continuing education for members through formal training programs organized and outsourced from the MOH and NGOs by the network system. Establishment of a fees system that combines sliding scale and payment in-kind renders their services affordable. These practices demonstrate key evidence of success and replicability and as such are considered promising practices in this publication. In the geographical area studied, two networks started in with 27 nurse midwives operating 27 clinics. At the time of the study in 2006, there were four networks comprising 47 clinics an increase of 74%. The nurse midwives have demonstrated the capacity to build and 7

8 sustain momentum for facility and service quality improvements within each network through this growth in network membership. The ability to mobilize financial resources other than fees from services and the fact that nurse midwives own these facilities has contributed to the sustainability of the clinics over time. In addition, there is increased demand for reproductive health services as indicated by new and continuing family planning clients in 2005 and In the Nakuru network in June 2005, fewer than 50 women initiated use of contraceptive methods while 150 continued their use of contraception. In May 2006, 350 new clients were served while 450 clients continued their use of contraception. These statistics are not broken down by methods. The networks have been effective in providing support to members as well as improving access to quality FP and PAC services, and expanding the range of RH/FP services offered within the networks. In addition to MCH services, which were the main services offered before the network formation, the clinics now offer FP, PAC services, general counseling and education on HIV/AIDS and referrals for PMTCT. From June 2005-May 2006, 300 women were counseled and referred for PMTCT services from these clinics to PMTCT centers in their localities. Despite these successes, the networks face challenges that include: inadequate coverage of facilities on a 24-hour basis due to shortage of staff, fear of misinterpretation of PAC services as abortion, and the burden of costs for patients unable to pay for the service. The networks would also benefit from external support for monitoring, validation of quality and information on new technology such as they received from PRIME II, which ended in September This paper describes the networks and presents the rationale for their establishment, the approaches used in their formation, the strategies used by the members for improvement of the clinics capacity (knowledge and skills of service providers, facility improvements and flexible fee payment structure) and the results, lessons learned and challenges of their experience. The conclusions provide guidelines on creating working networks. 8

9 Introduction Background: The Evolution of Private Nurse Midwives Networks During the 1990s in Kenya, nurse midwives, a new group of private-sector service providers, were licensed to operate private clinics close to communities. Licensure to operate a private clinic requires at least ten years of service in a government or large private health care system to ensure supervision of professional experience and competencies in an effort to safeguard the communities from malpractice arising from lack of experience. The private nurse midwives operate private clinics, nursing and maternity homes primarily in densely populated peri-urban areas, rural trading centers and towns. The networks described in this report emerged out of the need for a sustainable supervision system and a continuing education program for the private nurse midwives. Supervision for nurse midwives is provided through the Ministry of Health as the custodian of health care in the country. Specifically, the District Public Health Nurse in the government health care system is the official supervisor of this group in their locality. However, due to the overwhelming responsibilities of the Public Health Nurse and the immense geographical area to cover, the private nurse midwives experienced inadequate technical support. Furthermore, services by private nurse midwives were fairly new, and a supervision structure to accommodate the needs of this group was not developed. The private nurse midwives therefore sought technical advice from their peers when in need. In 1997, nurse midwives licensed by the Nursing Council of Kenya (NCK) to operate private clinics, nursing and maternity homes requested assistance from the PRIME Project to include postabortion care (PAC) in the range of services they offer. In partnership with the Nurses Association of Kenya (NNAK) and with support and approval from the NCK and the MOH, the PRIME Project launched the pilot project Expanding Opportunities for Comprehensive PAC at the Community Level through the Private Nurse/Midwives in Nairobi, Central and Rift Valley provinces in Kenya. The goal of the project was to improve access to quality PAC services by decentralizing this service to facilities closest to larger populations and private facilities operated by nurse midwives. Comprehensive postabortion care includes the following service elements. Emergency treatment of abortion complications using Manual Vacuum Aspiration (MVA) Postabortion family planning counseling and services Linkage with other reproductive health services Community involvement in postabortion care Referrals for other services. This new job performance expectation of the private nurse midwives required technical support to consolidate PAC skills learned, update the nurse midwives skills in family planning and monitor adherence to the standards of care. Ultimately, this support was to ensure client safety, professional credibility as a new service provider and community acceptance of this new cadre of service providers. Following the work of the PRIME Project, the PRIME II Project worked to bridge the 9

10 supervision gap that existed by supporting the development of a peer support system building on the consultation practices that existed among the providers. The results of the PRIME II Private Nurse Midwives PAC pilot phase were encouraging. 1 The Nursing Council of Kenya approved training of and PAC service delivery by nurse midwives in private practice. There was extensive community education on family planning and the dangers of unsafe abortion in the communities served by the private nurse midwives clinics. Despite indicating that they did not have additional space in their clinics, 59 percent of the pilot group (including the Nakuru and Nyeri networks) created special MVA rooms that provided privacy, clean operation areas and restrooms for women after the operation. The space was created by either partitioning or reorganizing the clinic. Challenges encountered included: Limited professional/colleague and community support for private nurse midwives in the provision of PAC services, at the time viewed as synonymous with abortion. Inadequate technical supervision of trained PAC providers by District Public Health Nurses. Very poor record keeping practices in general for all services offered, except for general attendance register. Inadequate attention and oversight of infection prevention practices such as disinfection and high disinfection. Insufficient or outdated family planning service delivery skills, especially IUD insertion skills. Inability to provide 24-hour PAC service coverage in clinics (with only one service provider trained in this service skill). Limited number of staff and inadequate equipment and supplies to provide consistently high-quality services. Inability to charge fee for service when the clinic is located among the poor. This threatened the sustainability of the clinic. The network system evolved to respond to these challenges. Building on existing ad hoc peer consultation practices among the private nurse midwives, the PRIME II Project provided technical support to private midwives in Central and Rift Valley provinces to formalize the consultation and support relationships. Teams from Nyeri and Kiambu districts in Central Province and Nakuru and Kajiado districts formed networks, and concepts and approaches to peer supervision were introduced to the group during training. The networks were assisted to develop strategic plans for the establishment and management of the networks. The action plans developed by the networks included strategies to overcome a number of challenges listed above. In the action plans the private nurse midwives targeted colleagues in the public sector and community leaders to: 1 Intrah. Expanding opportunities for postabortion care at the community level through private nurse midwives in Kenya. PRIME Technical Report 21. Chapel Hill, NC: Intrah,

11 Create support for the group in the delivery of PAC services at the community level. Improve facilities including space and equipment to create a safe environment for PAC service delivery. Provide technical support and peer reviews of performance in the delivery of family planning services and adherence to PAC service delivery standards for quality monitoring and improvements (each clinic had been provided with the performance standards). Practices used by the private nurse midwives networks have emerged as promising practices that contribute to ensuring service quality and sustainability of small private clinics at the community level, as evidenced by facility improvements, increased provider knowledge and skills, expanded types of services offered and increased utilization of family planning (see graph on page 19) and HIV infection prevention activities. The following sections describe two major networks visited by an ESD team in June 2006 and the package of networking practices that work well for the improvement of services and facility sustainability. Description of the Networks This paper describes two private nurse midwives networks consisting of 47 clinics, nursing and maternity homes and their networking practices, which enhance facility sustainability, service quality and service expansion. There are several different regional and local regulatory bodies for private nurse midwives. These levels include: The Nursing Council of Kenya, a professional regulatory body that licenses nurses and midwives as private practitioners. The Kenya Medical Board, which licenses private clinics. The National Nurses Association, the professional and welfare association for nurses where individuals are members. Private Nurse Midwives have a chapter within the association. The private nurse midwives therefore have dual membership. Members of the East, Central and Southern African College of Nursing (ECSACON), a regional nursing body that also includes members of the Association. ECSACON is the designated regional advisory body to the Conference of Ministers of Health in the Eastern, Central and Southern African Health Community. The private nurse midwives networks that are a peer association and subject of this paper. The diagram on page 12 depicts the professional and operational linkages. 1

12 KENYA MEDICAL BOARD PROFESSIONAL ASSOCIATIONS I N D I V I D U A L N E T W O R K S P N M C H A P T E R N N A K E C S A C O N Nursing Council of Kenya MEMBERSHIPS Nyeri Network The Nyeri network of 12 clinics was formed in 2001 by members who were trained in PAC service delivery. The size of the network, which operates in an area with a population of 661,156 (322,521 males and 338,635 females), has remained the same since inception, admitting only nurse midwives who are trained in comprehensive PAC services. The network focuses on an advocacy and educational campaign aimed at reducing maternal mortality through reduced incidence of abortion and life threatening complications related to abortion. In addition to general MCH/FP services, the network also offers PMTCT services. Since the formation of the network, the members have received contraceptive technology updates and training in PMTCT. Capacity building of the networks has continued through various agencies and projects such as ACQUIRE and the Ministry of Health. Approaches cited by members that facilitated meeting their goals include discussions with women s groups and churches and education outreach to clients and youth groups on a variety of topics such as prevention of STI, family planning, dangers of abortion and services available. The services offered, like those shown in the picture at left (taken at the entrance of the Marine Maternity Clinic), are posted within the health facilities to educate the communities on what is available. Services offered at the Marine Maternity Clinic. Photograph by Monica Oguttu (authorized by the facility proprietor). 2

13 Peer support supervision in this network includes: A system to ensure that each clinic has a PAC trained nurse midwife on call should the owner be away from the clinic. This reduces emergency intervention delays experienced when the woman has to be transferred to the public-sector referral hospital. Support to one another in improving the quality of care in facilities. Merry-Go-Round member contributions, a form of resource generation. Network financial management, where the network invests in group bank loans and members contributions and provides collateral for a member s loan and monitors repayment. Through this networking support, the facilities have been reorganized, extended and renovated to create additional space and privacy, and improvements have been made to furniture, equipment and supply of running water. Nakuru Network The Nakuru network of 15 clinics formed in 2002 by 12 members trained in PAC service delivery, is the first network formed and as a result is further along in the development, innovation and scale-up of the networking practice. This network, known as the mother network, provides technical assistance to two sub-networks Molo with 15 clinics and Gilgil with five clinics to improve facilities. The diagram on page 14 depicts the relationship of the three Nakuru networks. In order to have membership to the main network, a facility must meet specified criteria. The main network supports facilities in the two sub-networks to reach the set criteria. When the facility meets the set criteria, it will be admitted to the main network. 3

14 Nakuru Main Network of 15 Members Technical Assistance Quality Monitoring Molo Network of 15 members Cont. Education Financial Support Gilgil Network of 5 members The three networks Nakuru, Molo and Gilgil in Rift Valley are managed by Nakuru. The three networks serve a population of 1,187,039, of which 588,336 are women in both urban and agricultural settings. The need for multiple networks that are linked arose because traveling in this area is difficult and clinics are scattered over an expansive geographical area. Like the Nyeri network, the Nakuru network provides support through monthly meetings and telephone consultations. In particular, the networks: Conduct peer reviews and exchange visits for information sharing and problem solving on site, assess facilities and quality of care and identify needs to be addressed by the network or in collaboration with other agencies. Perform telephone consultations and provide guidance to members in the management of difficult cases. Further financial support through member contributions to facilitate clinic improvements for quality service provision. 4

15 Promote continuing education through organized training activities by the MOH or other projects and maintain a central network library in one clinic. The collection in this library includes different training programs and publications from technical assistance agencies. Encourage investment for future business plans, such as establishing a referral facility owned by the nurse midwives. You have somebody to consult when you are not sure, or you have an extra hand when you need one. Network member Duncan Maingi, Que Bee Clinic The Networks Promising Practices A. Networking Structure and Management To date the networks are well organized and registered by the Ministry of Social Services as a community based organization. Ensuring good governance, the networks are managed by an elected executive team of Chairperson, Secretary and Treasurer. The members meet monthly to share experiences, discuss service issues and problems, and map out actions to address problems and needs. The minutes of the meetings are maintained and distributed to members. The networks organize seminars and update sessions on reproductive health and other health issues within their networks and participate in the annual conference organized by the private nurse midwives chapter of the National Nurses Association of Kenya. These continuing education sessions contribute to the annual Continuing Education Units required by the Nursing Council of Kenya for maintaining a practice license. Described below are practices that are attributed to sustainability of services and success in improvement and expansion of services to underserved populations. B. Peer Support Supervision and Facilitation (Also Known as Intervision) The following major activities form the backbone of peer supervision. Admission to networks by application. The networks set parameters for inclusion; for example, a network may require that a clinic have one nurse midwife trained in PAC service delivery. This is the case for networks in which PAC, including family planning services and advocacy for reduction of unwanted pregnancies, is the primary objective of the network s existence. Other networks admit any clinic where the nurse midwife is licensed to operate the clinic. The application process is followed by an initial peer site visit to the clinics by members of the networks initiated by the PRIME II Project. These members assess the status of the prospective candidates clinic, the quality of care and their needs. A 5

16 plan is jointly developed with the applicant to address the shortcomings identified and to provide the assistance needed. Attendance of monthly meetings that serve both business and continuing education agendas. In a 2003 study of the networks, 79 out of 106 respondents attended meetings. 1 Fundraising through a Merry-Go-Round strategy. This process (described in Round Fundraising below) allows members to improve drug stocks, purchase requirements for infection prevention and reorganize clinics to meet set PAC performance standards. To this end, the networks have mobilized resources to help members purchase autoclaves as well as medications for their facilities. Exchange visits to other nurses clinics in an effort to offer peer supervision, exchange of experience and technical assistance in gaps identified during such visits. This activity was most commonly cited as the one most valued by members. One year after the initial networks were formed, 97% of providers in four networks were visited at least once by their peers; 85% of the visits included discussions on family planning and 68% on HIV/AIDS counseling and prevention. 2 Telephone consultations in the management of difficult cases. The most commonly cited consultations in the 2003 study were management of severe bleeding and retained products of conception. Ninety-four percent of respondents sought assistance from their peers and 90% of the problems were resolved. Continuing education through organized training activities and access to central network library. The training activities are organized by networks for members either free-of-charge or at-cost. Examples of group organized training at cost include Norplant insertion training by the Reproductive Health Services Institution. In other cases, members attend MOH and other NGO training activities organized in their localities. This includes PMTCT training. This continuing education is linked to the Nursing Council Continuing Education documentation system for license retention. C. Round Fundraising During the PAC project evaluation, private nurse midwives cited as one challenge the inability of most clients to pay for services rendered, and midwives could not turn away clients without money. The group trained in PAC was also trained in cost analysis to assist with the justification of the fees charged for all services provided. The networks members set their fees based on the condition of the client but capped charges at 2,000 shillings ($30). Normally the poor are charged less. Some clients pay after full recovery, and payment may be made with other goods in lieu of cash. The fees collected through service by itself have not been adequate for maintenance of highquality services in these communities. To address this shortcoming, the networks initiated an income generating and resource mobilization initiative called a Merry-Go-Round (MGR) to raise funds for the purchase of facility supplies and equipment. The MGR is a traditional Kenyan method of resource mobilization where a group of people with common interests and goals come together to assist one another in regular 1 PRIME II Project. Exploring peer support networks for provision of high-quality postpartum care by private nurse midwives. Technical Report # 49. Chapel Hill, NC: Intrah, PRIME II Project. Final project evaluation report. Chapel Hill, NC: Intrah,

17 fundraising and savings activities. The group makes regular contributions, usually monthly, and the total monthly collection is given to one member in rotation until all have received their dues and the cycle continues, hence the term Merry-Go-Round. This approach has been used by the networks to improve their facilities through renovations and expansions, and to purchase additional and essential equipment like autoclaves for the improvement of infection prevention. Equipment purchased through MGR. Photograph by Monica Oguttu. Authorized by the clinic proprietor for publication, July The income generated through networks MGR practice is subsidized by a portion of the membership fee. The networks also invest their funds for group purposes. For example, the Nakuru networks have raised more than $6,000. The funds are invested as shares of KenGen, an electrical power supplier. The aim is to purchase a piece of land to build a community nursing home for joint admissions of their clients. D. Collaboration and Networking outside the Private Nurse Midwives Networks Strategic collaboration and networking with government and nongovernmental agencies and the community at large has resulted in general improvement of the facility as well as capacity building for service providers. Results include: Improved support from Ministry of Health staff members who occasionally visit the facilities to offer solicited and unsolicited technical assistance and training. This is a marked improvement from the days when clinic operators functioned independently. Ongoing updates/refresher courses on surgical contraception conducted by a local NGO at a cost, on PMTCT and immunization by MOH and USAID collaborating agencies such as ACQUIRE, and gender based violence training by local NGOs. This has helped networks improve the range of services offered by members. All facilities have a wide range of integrated services, including FP and HIV/AIDS, making it possible to provide clients with a breadth of services. The role of the public-sector health provider has also become clearer 7

18 through this collaboration. The MOH team provides oversight in some areas, especially where training is conducted by the MOH. Identification and agreements with other agencies and individuals on clinic backup within the network catchments area for referrals and other necessary support. Provision of water supply to the Nyeri network through its collaboration with the Ministry of Water. The network has running water at all the facilities to improve infection prevention standards. This is a group negotiated achievement. As a result of lobbying, networks are now receiving contraceptives and vaccines from the Ministry of Health at no cost. They only charge the client for the consultation; they do not sell vaccines or contraceptives. The networks used the case of stagnated CPR (39%) between 1998 and 2003 as their rationale for seeking the MOH commodities to improve access by complementing the MOH s efforts to raise the CPR in the next DHS. Previously, private midwives were expected to pay 2,000 Kshs. before collecting the commodities. The unique approach of the network for continuing medical education (CME) is being adopted by training providers at other organizations as a sustainable way to support supervision. Outcomes of the Network System Two major outcomes of these networks practices stand out. Expanded range and quality of services: Quality performance by the network members has attracted increased clientele. The network members reported an increase in family planning clients; however, the increase could have been higher if the contraceptives were available and accessible at all facilities on a continual basis. The networks reported erratic contraceptive supplies nationwide, Family planning Clients 600 Number served New Reattendance 0 June July August Sep Oct Nov Dec Jan Feb March April May June May

19 compromising their efforts to advocate for clients right to choices. The table above reflects data collected from four selected facilities. The steady rise in both new and re-attendance is attributed to providers use of postabortion care as an entry point for timely FP service provision to cut the vicious cycle of unsafe abortions, which private nurse midwives attribute to increased caseloads. Over 300 women have been referred from the network to the government health facilities for PMTCT services. The increase in clientele has also added to clinic income. Service sustainability: Several elements of the network practices undertaken by nurse midwives make the services sustainable. These providers own the facilities they work in. They are committed to the services they offer and proud of what has made them work, as evidenced during interviews. Improved quality of care has increased clientele, improved the ability to take care of supplies and equipment and helped establish rapport with other stakeholders and community members. These results were cited as positive elements affecting the long-term sustainability of the network. Focusing on collective responsibility and quality assurance in addition to a creative sustainability plan for the entire network, such as MGR and other investments, have made the networks more solid and created a family-centered environment. Potential exists for development of these networks into centers of excellence. Financially, the nursing homes reported better results than the small clinics, which may be understandable given that the range of clientele, services offered and the size of facilities are different. The small clinics have reported an increase in family planning uptake and a reduction in women seeking PAC services. Lessons Learned The private nurse midwives networking system is working well toward: Promoting a reduction in professional isolation, which private nurse midwives experienced prior to formation of the networks. Supporting the creation of a workforce group able to negotiate with government and nongovernmental agencies for the improvement of services offered in communities. Ensuring continuing education of nurse midwives. Building and sustaining collaboration and new networks with public-sector facilities, health and non-health sectors as well as local and international NGOs. Improving and expanding services offered to underserved populations. Developing the sustainability of the services as a result of group financial support to improve the facilities and thus attract clients and reduce the likelihood of clinics shutting down. The following appear to be ingredients for success in small, privately-owned clinic networking. Commitment and dedication to make networks function. At the time the networks were formed, most clinics had only one trained nurse midwife working with assistants, and at times required hiring another nurse to cover the clinic in the owner s absence. Attendance 9

20 at monthly meetings, financial contributions and peer visits are demonstrations of commitment and dedication. Accountability for group bank loans and group management of the repayment of the loan by one member builds credibility for the group with the banking system. Good governance is critical. Networks demonstrated good governance through democratically elected leadership and accountability for funds collected, including custody and disbursement of funds. Innovation is useful for building profitable and productive networks. The use of the MGR system for the generation of funds addressed both short-term and medium-term financial needs. Wisely made investments provide longer-term financial stability for clinics. Challenges The advances that networks have made over a five-year period are slow but sure. A number of challenges persist. They are as follows: Since most facilities have only one provider trained in PAC, coverage of facilities in the absence of the PAC trained providers is still an issue. Some members who have been on the waiting list for PAC training feel that they are being shortchanged and call for a speedy mechanism for reaching them. Private nurse midwives networks would benefit from an institutional linkage and the types of external support they received from PRIME II for monitoring and technical updates. However, no mechanism is currently in place to provide this. There are still many sections of the population that do not differentiate abortion from postabortion care. The private nurse midwives are afraid of being perceived as providing abortions and being charged with a criminal act. This fear may affect record keeping and could be addressed by continued education of the public, including law officers. Private midwives will not turn away poor clients who are unable to pay for services. This has longer-term implications, especially since the clinics operate in poor communities. Kenya is piloting a community insurance system, and when it is adopted as a general practice, this challenge may be addressed. Some members attend monthly meetings irregularly. There may be a need to analyze and address the issues around non-attendance. Conclusion The private nurse midwives networks demonstrate substantial social and technical interaction among the members. This interaction has in turn resulted in improved access to quality FP and PAC services, expansion of the range of services offered within the networks as compared to initial MCH and management of minor curative ailments and increased RH service utilization. To develop viable networks, the following ingredients seem imperative: 0

21 Membership by choice Business approach to the development and management of networks Good governance Adherence to membership standards Recognition by government agencies responsible for technical services, community organization and administration Linkages and ongoing interaction with other service providers of crucial community services Innovations to maximize access and utilization of community resources. The Kenya Private Nurse Midwives networks are a resource for others to emulate but also need to continue expanding to cover all clinics owned by private nurse midwives. In addition, there is need to continue monitoring the networks performance and collect additional service data as evidence of best practices for service improvements for the underserved populations. 1

22 References 1. USAID Final Evaluation of Kenya PAC, Expanding Opportunities for Postabortion Care at the Community Level through Private 3. Nurse-Midwives in Kenya (July 1999), PRIME I Technical Report # Expanding Opportunities for Postabortion Care at the Community Level through Private Nurse-Midwives in Kenya Final Report (September 2000), PRIME II Technical Report # Kenya Postabortion Care Special Study: A Focus on Other Reproductive Health Services from the Perspective of Kenyan Private Nurse-Midwives (October 2003), PRIME II Technical Report # World Health Organization (WHO) Unsafe abortion: Global and regional estimates of incidence of unsafe abortion and associated mortality in th edition. Geneva, WHO. From 7. Lema, V.M & Kabereri-Macharia J. (1992). A review of abortion in Kenya. The Center for the Study of Adolescence. Nairobi. 8. Rogo K, Bohmer L, Ombaka C. Community Level Dynamics of Unsafe Abortion in Western Kenya and Opportunities for prevention: Summery of findings and recommendations from pre-intervention research. Pacific Institute for Women's Health. Los Angeles Postabortion Care Consortium Community Task Force Essential Elements of Postabortion Care: An Expanded and Updated Model. PAC in Action, No. 2. Special Supplement 10. Ministry of Health (MOH). Reproductive Health/Family Planning Policy Guidelines and Standards for Service providers. Divisions of Primary Health care. Nairobi. June Monica and Monica Ong ech, Oguttu, Machoki, Khisa,Orero PAC services at KNH-Journal of Obs/GYN of Eastern and Central Africa 13. The Penal Code 2

23 Annexes Annex I: Key Informants Name Title Organization/Contact 1. Dr Solomon Orero Senior Reproductive Health Technical Advisor ESD Essential Service delivery (ESD) 2. Dr Peter Gichangi Regional Director IntraHealth International 3. Alix Grubel Kenya Country Director IntraHealth International 4. Margaret Waithaka M&E Manager IntraHealth International 5. Christine Ayuyo Personal Assistance IntraHealth International 6. Dr Marsden Solomon Deputy Manager Division of Reproductive Health 7. Dr Isaac Achwal Medical Associate Engender Health 8. Evelyn Mutio National Secretary National Nurses Association 9. Elizabeth Oywer Registrar Kenya Nursing Council 10. Nester Theuri Deputy Director Family Planning Private Sector 11. Dr Jane Othigo Coast Provincial RH & Ministry of Health Training Supervisor 12. Maina Moragu PAC provider Nyeri Gichera Clinic - Nyeri Network 13. Josephine Gikunju PAC provider Nyeri Mariine Maternity - Nyeri Network 14. Rachel Kiuna PAC provider Nakuru KIMSAW Med. Clinic network 15. Dancun Maigi PAC provider Nakuru network Que BEE Health Care 16. Rose Otieno PAC provider Nakuru Racecourse Clinic network 17. Benjamin Mutai PAC provider Molo network Mutai Clinic Box 752 Molo 3

24 Annex II: Interview Guide QUESTIONS RESPONSE A. FOR THE NETWORKS About the network 1. How many are you in this network? ( # of Providers and clinics) 2. When was the network formed and Why? 3. How was it formed? 4. What is the mission? 5. What is the goal? 6. What is the geographical coverage? 7. Have other health workers (other than nurse midwives joined the networks? 8. Briefly describe the kind of activities the network is involved in? 9. What are the results of these activities? 10. How often do you meet? 11. Do you have any guiding rules and regulations for members? 12. List Major accomplishments of your 4

25 Network 13. What have been the effects of network formation on: a) Service improvements b) Service utilization c) Service sustainability d) Individual clinic performance Training 1. Was the Idea of training N/M in post abortion care good? a. If yes or no explain why? 2. How did the PAC training help you? 3. What other training have you received since the PAC training? 4. Who offered the training? 5. How paid for the training? 6. How has the additional training after PAC helped in your job? 7. Briefly explain how the trend has been since the training in terms of services provision, clientele and the clinic income? 8. If this project was to scale up what would 5

26 be your suggestions? 9. Do you think more N/Ms should be trained? Sustainability 1. What are the charges for the services offered? How are these charges decided? 2. Are the charges adequate to meet your time and the clinic supplies/drugs? 3. If not, what sustains the operations of the clinic? Linkages 1. Who are your other partners? (explore type of partnership) 2. How collaborates with this network? (explore type of collaboration) 3. What kind of linkages do you have with the Ministry of health (specify departments of MOH in the response) 4. What kind of back up do you have especially for complications? Challenges 1 What challenges have you met in a) Offering post abortion care since you 6

27 were trained? b) Other services (Specify) c) How did you tackle them? 1. What challenges have the networks encountered? 2. How have these challenges been managed? 3. What have been the benefits of being in networks? 4. If you were to start all over again, what would you do differently? Data 1. How many clients have you served in the last three months? a. MVA ---- b. PAFP c. FP Is there any particular case you mangled that you cannot forget? (Explain) 7