FURTHER ANALYSIS OF THE COST ESTIMATE STRATEGY FIELD TEST IN KENYA MARGARET MAKUMI TAKEMI FELLOW 2003/2004 HARVARD SCHOOL OF PUBLIC HEALTH JUNE, 2004
TABLE OF CONTENTS Acknowledgment-------------------------------------------------------------------------------------v List of Abbreviations--------------------------------------------------------------------------------vi Executive Summary--------------------------------------------------------------------------------vii Chapter 1----------------------------------------------------------------------------------------------1 Introduction-------------------------------------------------------------------------------------------1 Background-------------------------------------------------------------------------------------------1 Cost Estimate Strategy (CE) -----------------------------------------------------------------------1 The CES Field Test in Kenya----------------------------------------------------------------------2 Setting up the CES in Kenya-----------------------------------------------------------------------3 a) Selection of important RH conditions and services------------------------------------3 b) Determination of local prices--------------------------------------------------------------4 Rational for further analysis of the CES field test Data----------------------------------------4 The Research Questions-----------------------------------------------------------------------------5 Chapter 2----------------------------------------------------------------------------------------------7 Methodology------------------------------------------------------------------------------------------7 Study Sites and Sources of Data and Methods---------------------------------------------------7 Data Collection and Analysis-----------------------------------------------------------------------8 Chapter 3----------------------------------------------------------------------------------------------9 Part 1---------------------------------------------------------------------------------------------------9 Availability of RH basic commodities and equipments at sample facilities---------------------------------------------------------------------------------------9 a) Availability of Key Commodities from the Districts Perspective------------------------10 i) Amoxicillin-----------------------------------------------------------------------------10 ii) Normal Saline--------------------------------------------------------------------------11 iii) Non Sterile Gloves and Sterile Gloves---------------------------------------------12 b) Equipment----------------------------------------------------------------------------------------13 i) Basic Equipment for MCH Clinics--------------------------------------------------------13 ii) Basic equipment for Labor, Delivery and Postnatal Care-----------------------------14 iii) Equipment Required for Caesarian Section Services---------------------------------15 Practice Patterns-------------------------------------------------------------------------------------16 Health Care Provider Reported Practices--------------------------------------------------------16 i) Provision of Iron Sulphate to ANC Mothers--------------------------------------17 ii) Use of Ergometrine in Normal Delivery-------------------------------------------18 iii) Use of Amoxicillin in the Management of Puerperal Sepsis--------------------18 Mothers Interviews--------------------------------------------------------------------------------19 Estimated Cost for Treating RH Conditions and Equipments--------------------------------20 Part 11------------------------------------------------------------------------------------------------21 Nature of Service Packages------------------------------------------------------------------------21 Usefulness of the Costing Model-----------------------------------------------------------------21 Location of Services Provided--------------------------------------------------------------------22 Reported Treatment Patterns----------------------------------------------------------------------22 Chapter 4---------------------------------------------------------------------------------------------23 Conclusions and Recommendations--------------------------------------------------------------23 i
Reference--------------------------------------------------------------------------------------------24 Annex 1----------------------------------------------------------------------------------------------26 Selected RH Conditions and Services Annex 2----------------------------------------------------------------------------------------------27 Tables on Availability of RH Commodities at Sampled Health Facilities Annex 3----------------------------------------------------------------------------------------------34 Tables on Availability of RH Equipment at Sampled Health Facilities Annex 4----------------------------------------------------------------------------------------------41 Tables on Health Care Workers Self Reporting Practice Patterns Annex 5-------------------------------------------------------------------------------58 Survey Forms ii
TABLES AND FIGURES Figure 1 Availability of Amoxicillin---------------------------------------------------------11 Figure 2 Availability of Normal Saline at All Facilities-----------------------------------12 Table 1 Availability of Non Sterile Gloves and Sterile Gloves----------------------------------------------------------------------------------13 Figure 3 Availability of Suction Machine at all Facilities---------------------------------15 Figure 4 Availability of Lagenback Retractors in all Facilities-------------------------------------------------------------------------------16 Table 2 Health Care Workers recommending use of Iron Sulphate to ANC Mothers-----------------------------------------------------17 Table 3 Use of Ergometrine by all health care workers in Normal Delivery------------------------------------------------------------------18 Table 4 Use of Amoxicillin by all Health Care Workers for Management of Puerperal Sepsis--------------------------------------------------19 Table 5 ANC mothers Given Iron Sulphate------------------------------------------------19 Table 6 Postnatal Mothers Who Bought Non Sterile Gloves----------------------------------------------------------------------------------20 Table 2.1 Facilities where RH Commodities were Available------------------------------------------------------------------------------28 Table 2.2 Availability of Selected Key Commodities at Sample Facilities in the Sampled Districts-------------------------------------------------30 Table 3.1 Availability of Essential Basic MCH Clinic Equipments---------------------------------------------------------------------------35 Table 3.2 Availability of Essential Labor, Delivery and postnatal Care equipment----------------------------------------------------------------------37 Table 3.3 Availability of Essential Equipment for Caesarian Section--------------------------------------------------------------------------------40 Table 4.1 Drugs Recommended to Mothers for Routine ANC-----------------------------------------------------------------------------------42 Table 4.2 Laboratory Tests Recommended to ANC Mothers--------------------------------------------------------------------------------43 Table 4.3 Drugs Used by Health Care Workers for Management of Pre-Eclampsia---------------------------------------------------------------------44 Table 4.4 Drugs Used by Health Care Workers for the Management of Dysfunctional Labor----------------------------------------------45 Table 4.5 Drugs Used by Health Care Workers for Management of Normal Delivery-------------------------------------------------------------------47 Table 4.6 Drugs Used by Health Care Workers for Management of Hemorrhage-----------------------------------------------------------------------48 Table 4.7 Drugs Used by Health Care Workers for Caesarian Section---------------------------------------------------------------------------------49 Table 4.8 Drugs Used by Health Care Workers for Management of Puerperal Sepsis------------------------------------------------------------------50 iii
Table 4.9 Drugs Used by Health Care Workers for Management of UTI---------------------------------------------------------------------------------52 Table 4.10 Drugs Used by Health Care Workers for Management of GUD--------------------------------------------------------------------------------53 Table 4.11 Drugs Used by Health Care Workers for Management of Gonorrhea---------------------------------------------------------55 Table 4.12 Drugs Used by Health Care Workers for Management of Acute PID--------------------------------------------------------------------------56 iv
ACKNOWLEDGEMENT My sincere gratitude goes to the Takemi Program which provided the funds that made it possible for me to conduct the further analysis of the Cost Estimate Strategy (CES) Field Test in Kenya. To meet and establish new contacts with the international community at Harvard School of Public Health from whom I have learnt a great deal of new information. The knowledge that I gained from auditing the classes that I was able to attend will go along way in improving my performance. I acknowledge the contributions of the faculty in the Department of International Health at Harvard School of Public Health. My appreciation goes to Marc Mitchell who was always ready to give technical advice. To Michael R.Reich the Takemi Program Director, whose talks on issues pertaining to politics has made me change my attitude towards politics. To Catherine Haskell the Program Coordinator and Nadie Trotman the Staff Assistant for their support that made it easy for me to complete my work. To my fellow colleagues, the Takemi Fellows, who were great source of inspiration. Special Thanks go to Dennis Ross-Degnan Associate Professor of Harvard Medical School and Director of Research, Harvard Pilgrim Health Care Drug Policy Research Group for his technical advice and great interest in the study. Dennis I shall forever be indebted to you. v
LIST OF ABBREVIATIONS AIDS ANC ASTGs BCG CEOC CES CO DHMT DHMTs EPI GP KEMSA HIS HIV IMCI MEDS MCH MOH MW NHSSP NMW OB/GYN RH RPM SIDA STGs TB USAID VAT Acquired Immune Deficiency Syndrome Antenatal Care Adjusted Standard Treatment Guidelines Bacilli Calmette Guerin Comprehensive Essential Obstetric Care Cost Estimate Strategy Clinical Officer District Management Team District Health Management Teams Expanded Program on Immunization General Practitioner Kenya Medical Supplies Agency Health Information System Human Immunodeficiency Virus Integrated Management of Childhood Illnesses Mission for Essential Drugs and Supplies Maternal Child Health Ministry of Health Midwife National Health Sector Strategic Plan Nurse Midwife Obstetrician Gynecologist Reproductive Health Rational Pharmaceutical Management Swedish International Development Agency Standard Treatment Guidelines Tuberculosis United States Agency for International Development Value Added Tax vi
EXECUTIVE SUMMARY At the 1994 Cairo International Conference on Population and Development, recommendations called for action to reduce maternal morbidity and mortality among other things. Governments and donor agencies responded to the call by supplying the reproductive health commodities that are necessary for improving women s reproductive health (RH) care services. This assistance was however being provided without the benefit of information necessary for determining the cost and quantities of commodities required for improving the provision of the RH care services to women. There was therefore a need for a systematic approach to asses supply requirements to provide adequate RH services. In response to the need, the Rational Pharmaceutical Management (RPM) and MotherCare both funded by the USAID developed the Cost Estimate Strategy (CES) tools. The Cost Estimate Strategy tools were designed to identify ways to improve the availability and use of reproductive health drugs, medical supplies and equipment at the various levels of health care. They also provide a framework for using cost information for policy making and planning based on the cost of commodities and equipment and the standard treatment guidelines of a particular country. The tools were field tested in Kenya between September 1997 and June 1998 in four provinces namely: Nairobi, Central, Nyanza and Western. Except for Nairobi, four districts: Nyeri and Nyandarua in Central, Nyamira in Nyanza and Bungoma in Western were selected for the field test. The primary objective of the field test was to asses the feasibility of the CES approach and the extent it proved to be feasible, to determine ways of improving it as a management tool. Twenty two reproductive health conditions covering ANC, delivery services, maternal and neonatal complications and; selected reproductive tract infections were selected for the exercise. Data was collected from the central level, private pharmacies, government, mission and private facilities at all levels of care within the four districts and Nairobi province. Analysis of data obtained from the field test was conducted from the national level perspective. The tools were proven useful for generating data and information at the national level for decision making and planning interventions. At the national level dissemination workshop for the CES field test report held in 1999, participants drawn from the national, provincial and the district levels recommended among other things that i) reproductive health commodity needs be quantified using tools such as CES, especially at the provincial and district levels and; ii) the CES tools be reviewed to allow district level officials establish the commodities needs for all health vii
care services at the district level. These recommendations called for a study to conduct further analysis of the CES field test data from the districts perspective and review of the existing CES model. The study identified the following research questions: Can the CES tools and approach also generate practical data and information for decision making, planning interventions and monitoring progress at the district level in regard to reproductive health? With modification, would CES tool generate data and information for decision making and planning interventions at the district level for all the high priority health packages as stipulated in the National Health Sector Strategic Plan (1999-2000)? Findings from the study have shown that the CES tools can generate practical data and information for decision making and planning interventions at the district level in regard to reproductive health. Primarily however, for the CES tools and approach to be applicable at the district level for all the health services, the services and drugs, supplies and equipment should be easily separated from rest of the system. Application of the current computer based costing model of the CES at the district level is limited due to the inadequate computer technology. Weak demographic data, epidemiological data, inventory of drugs, supplies and equipments and local cost estimates of the individual items further compounds the use of the CES model at the district level. A simplified costing model for use at the district level would be more appropriate. The findings have also shown that the current CES model does not take into account staffing, training, operating costs and the commodity needs for the community based health care services. To estimate the cost of providing health services of a particular package, there is need to include these variables in the CES model. None the less, at the district level where the CES model is applicable, it can be a good tool for quantifying commodity needs and estimating cost. In addition, some of its components can be developed further into monitoring tools for the District Health Management Teams (DHMTs) to monitor the rational use of drugs and availability of essential commodities and equipment. However, strengthening the DHMTs capacity would be required. viii
CHAPTER 1 INTRODUCTION Background Factors contributing to poor quality of health care services in Kenya are multifaceted and can include inequitable distribution or lack of access to health services, insufficient resources, poor performance of the health system, inappropriate health seeking behavior etc. To address issues that relate to poor quality of health care services in general, the Ministry of Health, Kenya has instituted a Health Sector Reform process whose goal is to promote and provide quality, curative, preventive, promotive and rehabilitative services to all Kenyans. The Ministry has developed a 5 years National Health Sector Strategic Plan (NHSSP-1999-2004) that articulates the areas to be focused on. Based on available data on the burden of disease, cost-effectiveness of the interventions and the health outcomes in relation to health expenditure, 6 high priority health packages have been identified namely: Malaria prevention and treatment package Reproductive Health (RH) package HIV/AIDS/TB prevention and management package Integrated Management of Childhood Illnesses (IMCI) package Expanded Program on Immunization (EPI) Control and prevention of major environmental health related communicable diseases such as Cholera, Typhoid, and Dysentery as well as food safety. In the context of the Health Sector Reform process, it is envisaged that the aforementioned goal will be achieved through decentralization, which entails delegation of power and transfer of authority for planning, management, resource allocation and decision making from central level to the periphery. It is however recognized that for the decentralization to be effective, there is a need for among other things generation of data and information at the district level that the district health managers can use for decision making, planning interventions and monitoring progress. Cost Estimate Strategy (CES) At the 1994 International Conference on Population and Development held in Cairo, recommendations called for actions to reduce maternal morbidity and mortality. Governments and development partners pledged to support those actions by among other things supplying commodities that will ensure provisions of quality RH care services. However, this assistance was being provided without the benefit of information necessary - 1 -
for determining the cost and quantities of commodities needed for effective implementation of RH programs. In response to the need for a systemic approach to asses supply requirements to provide adequate RH services, the Cost Estimate Strategy (CES), a set of tools was designed by the Rational Pharmaceutical Management and Mother Care both funded by the USAID. The CES is designed to identify ways to improve the availability and use of reproductive health drugs, medical supplies and equipments at different levels in the health care system. In addition, it provides the framework for using cost information for policy making as well as for planning, based on the cost of commodities and the standard guidelines of treatment for the specific country being considered. The CES consists of three components: the normative cost estimate, based on international standard treatment guidelines and prices; the country-specific cost estimate, based on local epidemiologic and service utilization data, and commodity prices; the actual cost estimate, as a result of a survey of observed service provider and consumer behavior and; of the performance of public and private drug management and supply systems and; a policy decision making workshop, a framework for using the survey findings and outputs from the previous stages for the development of a prioritized, phased work plan for improving the management of RH drugs and supplies. The CES Field Test in Kenya The CES tools were field tested in Kenya between September 1997 and June 1998 with technical and financial assistance from Rational Pharmaceutical Management Project of the USAID. The field test was conducted in four (4) provinces namely Nairobi, Central, Nyanza and Western. Except for Nairobi, four (4) districts were randomly selected from a list of sixteen (16) from districts in the other three (3) provinces. The primary objective of the field test was to asses the feasibility of the CES approach and the extent it proved to be feasible, to determine ways of improving it as a management tool. The field test consisted of 6 study components namely: Estimating local costs of treating selected RH conditions Estimating local costs of medical equipment items needed to deliver the essential RH services Examining Variations in costs of RH commodities when purchased locally by health facilities or in private pharmacies Examining availability of key drugs, medical supplies and equipment items in government, mission and private health facilities and in private pharmacies. Surveying reported RH treatment practices among government, mission and private medical personnel and among private pharmacy personnel. - 2 -
Assessing actual RH treatment practices for key RH conditions by reviewing medical records at health facilities, treatment cards retained by pregnant or newly delivered mothers or in simulated visits to private pharmacies. A set of six forms were used for data collection. They included the following: Health Facility Survey Form; Patient Contact Form; Health Care Provider Form; Mothers Interview Form; Maternal History Form and; Pharmacy Survey Form. See attachments in Annex 5 Data was collected from the central level, private pharmacies, government, mission and private facilities at all levels of care within the 4 districts and Nairobi province. Data was analyzed using Epi info Version 6.03, SAS or Quattro-Pro. The analysis was from a national level perspective. Setting up the CES in Kenya The setting up of CES field test involved among other things selection of the RH conditions and services to be studied. Treatment requirements (drugs, supplies and equipments) for each selected case were also determined thus yielding the Adjusted Standard Treatment Guidelines. In addition, local and international prices for drugs, medical supplies and equipments required for the treatment of the selected RH conditions were determined. The prices formed the bases for comparisons with MEDS prices. The process followed is as described below. a. Selection of important RH conditions and services A total of 22 important RH conditions and services covering ANC, delivery services, maternal and neonatal complications and selected reproductive tract infections were selected for the field test (see Annex 1). The requirements per case for the treatment of the selected RH conditions and services were estimated using the treatments as outlined in the Ministry of Health s Clinical Guidelines (1994) referred to as the Kenya Standard Treatment Guidelines (STGs) in this study. In order to do this, the existing STGs were validated and /or updated where necessary by an expert advisory team comprising of senior local nurses and obstetrician/gynecologists. For each of the selected RH conditions and services, the team reached a consensus on the adequacy of the treatment regimen described, including dosage and duration of the drugs of choice, and estimated the type and number of medical supply items needed to implement the treatment ( medical supplies and equipments were not outlined in the STGs). Through this process, an adjusted STGs (ASTGs) were developed for the field test. - 3 -
It is important to note that the study team rather than take the RH package as described in Kenya; they selected RH conditions that were important from the national level perspective. At the district level, each District Health Management Team (DHMT) would have to select conditions that are important from their district s perspective. b. Determination of local prices (National level) A local procurement price for drug and supply requirements as per the Kenyan ASTGs, needed to be determined for each item (generally equivalent to a wholesale price plus fixed administrative markup). Since the Kenyan MOH procures its drugs and supplies for health facilities in drug kits at a single tendered price for all items included, it was impossible to identify the individual unit prices paid for each item contained in the kits. However most of the drugs and supplies in the ASTGs are also supplied by MEDS which operates a large centralized, low-cost procurement system to service mission facilities. In this regard therefore, the MEDS list prices formed the basis of the procurement price estimates. Data for drugs, expendables and equipment in the ASTGs was also requested from Pharmaciens Sans Frontiers and added to the database. In addition to the above, the price list for reproductive health expendables and equipments was requested from ten private suppliers. Seven of the ten suppliers contacted completed the unit cost forms by providing wholesale cost that included transport to Nairobi. Where VAT tax (16%) applied to an item, it was added. The median unit cost from all the suppliers was taken as the unit cost for drugs, expendables and equipment. The unit cost for drugs and equipment determined through the described process was from a national level perspective. This is due to the current procurement system that is central. This unit cost will therefore not be applicable at the district level. However, since some procurement goes on at the districts albeit within a certain ceiling, data on costs can be collected that can be used for comparing costs between districts and other levels. Rationale for the further Analysis of the Cost Estimate Strategy field test data From the analysis, the CES tools were proven useful for generating data and information on the RH commodity needs to improve RH services at the National level. In this regard, the CES approach has been found to be a useful management tool. The CES field test report was disseminated at a national level workshop in Kenya in 1999 and at a Regional workshop for Eastern, Central and southern African Countries held in Mombasa, Kenya in 2000. During the two workshops, CES approach was found to be a useful management tool and one of the recommendations made was that the report be disseminated as widely as possible to facilitate its implementation. In addition, the National level workshop also recommended among other things that; - 4 -
Reproductive health commodity needs be quantified using tools such as CES, especially at the provincial and district levels in Kenya Provincial and district officials be given clear responsibility, authority, and necessary technical support to monitor the availability of essential reproductive health commodities and act on observed needs at the facilities Materials to be developed to support training at the district level on selection and quantification of drugs and other commodities at the provincial and district levels. The guidelines be reviewed to allow district level officials establish the commodities needs for all health care services at the district level. Recommendations made at the national level workshop if implemented would contribute to the process of health sector reforms agenda. However, the analysis of the data so far conducted has only generated data and information that is useful for decision making and planning interventions at the national level. To implement the above recommendation therefore, there is a need to prove that the CES tools can also generate data and information for decision making and planning interventions at the district level. This then calls for further analysis of the CES field test data from the district perspective. The Ministry of Health Kenya is committed to the Health Sector Reforms whose Key strategy is the decentralization process. In the context of decentralization the Ministry s policy is to ensure that the district level health mangers are equipped with knowledge and health management skills that will enable them take up their increased management roles. The CES approach among others provides an opportunity to the Ministry of Health to build the management capabilities of the health mangers at the district level, the foci of decentralization. The National Health Sector Strategic Plan has identified six high priority health packages to be focused on. Data and information generated from the analysis so far conducted of the CES field test provides for reproductive health only. To make the National Health Sector Strategic Plan operational through the decentralization process among other things, data and information for all the six identified high priority health packages need to be generated for decision making and planning interventions. This then calls for CES tools to be reviewed to allow district level officials establish all the commodities needs at that level. The Research Questions Based on the recommendations made during the National level dissemination workshop, the question that arises is: Are the CES tools and approach applicable at the district level? To respond to the above question, further analysis of the CES field data will focus on two specific questions. The two questions are: - 5 -
Can the CES tools also generate practical data and information for decision making and planning intervention at the district level in regard to reproductive health? With modification, could the CES tools be used for generating practical data and information for decision making and planning intervention at the district level for all the six high priority health packages? Key issues include i) are services & drugs/supplies/equipment easily separated from the rest of the system ii) could some key components/indicators be developed to link theoretical treatment approach to real world services. This will contribute to the efforts of the MOH in strengthening management skills of the district level managers to carry forward the decentralization process. - 6 -
CHAPTER 2 METHODOLOGY In Can the CES tools also generate practical data and information for decision making and planning interventions at the district level in regard to Reproductive Health the existing data files of the Kenya CES field test data will be used. In With modification, could the CES tools be used for generating practical data and information for decision making and planning intervention at the district level for all the six high priority health packages the existing CES model will be used. Study Sites and Sources of Data and Methods The Kenya CES field test carried out between September 1997 and June 1998 was conducted in four provinces namely Nairobi, Central, Nyanza and Western. The provinces were intentionally selected by the MOH to represent a range of conditions in the non-arid portions of rural, Kenya. Except for Nairobi, four districts were randomly selected from the other provinces. The districts included Nyeri and Nyandarua in Central, Nyamira in Nyanza and Bungoma in Western. Within the districts, facilities were selected through a stratified random sampling method. Private pharmacies were randomly selected from those that were in the same geographical area as the hospitals included in the sample. Data was collected from the central level and from a total of 15 hospitals, 3 maternity homes, 29 health centers, 9 dispensaries and 98 private pharmacies (24 pharmacies with stock surveys and pharmacist interviews and 74 pharmacies with simulated purchase survey). The facilities included were operated by government, mission and private sectors. A total of 124 mothers for ANC were interviewed. In the Pharmacy survey, simulating clients were attended to by 57 registered pharmacists and 17 non-pharmacist pharmacy staff. Face to face interviews at the 24 pharmacies was conducted with 24 pharmacists and 15 non-pharmacist staff. Data collected included information that pertains to the facility (management, infrastructure and equipment check list and drug and supply check list); self reported information by the health care providers on their practices that was cross checked with actual practice pattern that were recorded in the medical records; information regarding ANC services and labor/delivery collected from mothers and; information about reported practices for ANC services at pharmacies which was cross checked by a simulated purchase survey. - 7 -
Methods of data collection included: Review of published documents and reports; Special reports from computerized MOH Health Information System (HIS); A mini survey of drug, medical supply and equipment supplies; A stock survey and medical records review at government, mission and private health facilities; A stock survey and simulated purchase survey at private pharmacies and ; Interviews with local key informants, health personal, staff at private pharmacies, women attending antenatal care (ANC) and newly delivered mothers. Data collection and Analysis After research questions were identified, existing field test data files and the CES model were used. Literature and document review was also conducted. Consultations were held with members of the CES Kenya team, RPM/MotherCare Team and faculty members at Harvard School of Public Health, Department of Population and International Health. This study did not conduct further analysis of the field test data obtained from private pharmacies through face to face interviews and simulation surveys. This is because the proposed health reforms in Kenya do not include the functions of the private pharmacies. Excel software was used for data analysis. Information gathered was compared and presented in tabular and graphic forms. - 8 -
CHAPTER 3 PART I CAN THE CES TOOLS ALSO GENERATE PRACTICAL DATA AND INFORMATION FOR DECISION MAKING PLANNING INTERVENTIONS AND MONITORING PROGRESS AT THE DISTRICT LEVEL IN REGARD TO REPRODUCTIVE HEALTH? Findings of further data analysis of the CES field test from the district perspective are discussed below in the following four categories: Availability of RH basic commodities and equipment at sample facilities; Practice patterns; Mothers interviews and; Estimated costs for treating RH conditions and equipment. AVAILABILITY OF RH BASIC COMMODITIES AND EQUIPMENT AT SAMPLE FACILITIES The study looked at the availability of selected drugs and medical supplies present at the sampled facilities at the time of the survey regardless of quantity. Health facilities at the same level of care (hospitals, health centers, maternity and dispensaries) are required by policy to offer the same type of health care services including those that pertain to reproductive health. A general overview of the availability of RH commodities at the various levels of care in the sampled districts is presented in Table 2.1 in the Annex 2. The data presented is not disaggregated by districts but summarized by the level of care and by the type of management (government, mission and private). The commodities are grouped into three categories: Drugs and medical supplies that should be available at all level of care; Drugs and medical supplies that should be available at facilities performing normal deliveries (health centers and above) and; Drugs and medical supplies that should be available at facilities offering obstetric surgery (hospitals). Although the number of samples is not comparable, government facilities generally tended to have more stock out items at the time of the survey than did mission and private facilities. 56% of commodities analyzed, were present in government hospitals as compared to 87% and 74% in mission and private hospitals respectively. Availability of drugs and supplies was generally lower at the government and mission health centers and dispensaries than in the hospitals by the same management. Compared to 74% of private health centers, only 53% and 67% of government and mission health - 9 -
centers had stock of the analyzed commodities respectively. The proportion of maternity homes (all private) and dispensaries (government and mission) that had stock of analyzed commodities were 6 and 27% respectively. a) Availability of Key Commodities from the Districts Perspective Availability of drugs and medical supplies at the facility level is one of the factors that contribute to the provision of quality health care services. Lack of key drugs and medical supplies implies that the facility has inadequate capacity to provide health care services that are appropriate for its level. The study looked at the availability of some key commodities at the time of the survey in the sampled facilities. The data is disaggregated by sample districts and by the different types of management to provide for comparison of commodity availability between the districts and by the different types of management (see Table 2.2 in Annex 2). Availability of analyzed key commodities was generally lower at government facilities than at mission and private facilities. This pattern was observed from the level of the hospitals to the lowest level of care, the dispensaries. 48% of government facilities had key commodities at the time of the survey compared to 73% and 64% of mission and private facilities respectively. Government health centers and dispensaries were noted as the facilities with the lowest availability of all the key commodities. This depicts poor provision of health care services that may lead to under utilization of the facilities. This could be one of the factors contributing to over congestion at government hospitals a phenomenon that has already been observed in many government hospitals in Kenya, including the tertiary levels of health care. There were some key drugs and medical supplies whose low availability is of a major concern considering that they are required for core management of RH conditions some of which, are life threatening. For example: i) Amoxicillin A basic drug that is necessary at all levels of care for management of infections including life threatening conditions such as puerperal sepsis was out of stock in many facilities particularly those managed by government. Figure 1 below is a presentation of Amoxicillin availability in all facilities. Availability in government facilities was highest in Nairobi at 5 followed by Nyandarua at 43 %, Nyeri at 29% and Bungoma and Nyamira at 22% and 14% respectively. Availability at the mission facilities was in all the districts. In private facilities, availability was in all the districts but Nyandarua where availability was 67%. - 10 -
Figure 1 Availability of Amoxicillin Percentages 12 8 6 4 2 Government Mission Private BUNGOMA NAIROBI NYAMIRA NYANDARUA NYERI Districts Many government health centers and dispensaries had no stocks of Amoxicillin compared to availability in mission and private lower level facilities Nyamira District Hospital, a government hospital and a referral hospital within the district was also found lacking stock of Amoxicillin. All other hospitals had stocks of Amoxicillin ii) Normal Saline An essential commodity for all levels of care above the dispensary level for the management of some RH conditions for example obstructed labor, hemorrhage and acute pelvic inflammatory disease was out of stock in all hospitals by all types of management in Nyandarua, in the private hospital in Nairobi and in the government hospitals in Nyeri and Bungoma. Many government health centers in all districts reported a stock out of normal saline. Figure 2 below is a presentation of normal saline availability at all facilities. In government facilities, availability was highest in Nairobi at 43% followed by Bungoma at 29%, Nyamira and Nyandarua at 2 each and Nyeri at 17%. Availability was at in mission facilities in Bungoma, Nairobi and Nyeri and at 5 and in Nyamira and Nyandarua respectively. In private facilities, it was at in Bungoma, Nyamira and Nyeri and at 67% and in Nyandarua and Nairobi respectively. - 11 -
Figure 2 Availability of Normal Saline at all Facilities Percentages 12 8 6 4 2 Government Mission Private BUNGOMA NAIROBI NYAMIRA NYANDARUA NYERI Districts Availability at government health centers in all the districts was very low. Mean percent of availability was 2. The same was also observed for I.V set an essential commodity for setting up I.V fluids (normal saline, dextrose 5% and blood transfusion) where the mean percent of availability was 21%. This finding implies that women presenting at most of these facilities with emergencies have to be referred to higher levels of care thus causing delay and putting the mother and/or baby at risk. iii) Non Sterile Gloves and Sterile Gloves. Health care workers use gloves as a barrier to prevent transmission of microorganisms between the patients and themselves. While sterile gloves are used for aseptic procedures, non sterile gloves are used for handling potentially infectious materials such as blood, feces, wound secretions, mucus membrane lesions, skin lesions and when the health care worker has non intact skin on hands The table below is a presentation of the availability of both types of gloves at the sample districts by the different types of management. It is shown that in both the government and private facilities in all the districts, availability of sterile gloves was higher than the availability of non sterile gloves. In some districts there were facilities managed by mission or private that had no stocks of non sterile gloves. - 12 -
Table 1: Availability of Non Sterile and Sterile Gloves District Government Facilities Mission Facilities Private Facilities Non Non Non Sterile Sterile Sterile Sterile Sterile Sterile Bungoma 11% 86% 5 Nairobi 25% 43% 5 Nyamira 71% 8 5 Nyandarua 43% 8 67% Nyeri 71% 83% 75% 75% Availability of gloves at the facility level is of great importance. In this error of HIV/AIDS and considering that over 5 of our hospital beds are occupied by HIV/AIDS positive patients, health care workers need gloves as one of the requirements for observing infection prevention practices. In a situation where there is a stock out of non sterile gloves but a stock of sterile gloves, there is likelihood that the sterile gloves may be used inappropriately thus depleting the stock. (b) Equipment Availability of equipment at the facility level is yet another factor that contributes to the facility s capability to provide quality health care services appropriate for its level. Lack of individual items or full sets of equipment impacts negatively the provision of quality health care services. To study equipment necessary for providing the selected 22 RH services, the equipment was divided into three packages namely: Basic equipment for maternal and child health (MCH) clinic, Basic equipment for labor, delivery and postnatal care Basic equipment for obstetric surgical procedures Equipment was counted as present if it was in a functional state. The number of individual items that are absolutely essential for providing minimally acceptable level of care was derived from the ASTGs. i) Basic Equipment for MCH Clinic ANC mothers are seen at the MCH clinics where they are screened to identify potentially high risk conditions and are prepared for the birth process and emergencies. The study obtained information on the availability of Basic MCH equipment sets at the sample facilities. Since many of the sets were incomplete, four items considered absolutely essential to maintain the minimum level of MCH services were selected for availability comparison at the various levels of care by the different types of management in the sample districts. The four items are adult scale, adult stethoscope, fetal stethoscope and sphygmomanometer. - 13 -
Availability of the four items considered absolutely essential to maintain the minimum level of MCH services was generally high at all levels of care by the different types of management in the sample districts. Availability at the mission facilities was 98% followed by private facilities at 9 and government facilities at 89% (see Table 3.1 in Annex 3). It is however important to note that the private hospital in Nairobi had no stock of any of the four items. A few government health centers also lacked stocks of the four items. In country where 94% of mothers attend ANC at least once during pregnancy, the high availability of the four essential items is a good indication that minimum level of ANC services is being provided at the MCH clinics. Whether the mothers are satisfied with the services needs to be determined. ii) Basic Equipment for Labor, Delivery and Postnatal Care Availability of basic equipment sets for labor, delivery and postnatal care services indicates the facility s readiness to provide the services. There was also incompleteness of the sets and therefore, seven items that were considered absolutely essential to provide the minimum level of services in labor, delivery and postnatal care were identified for review of their availability. These items were: suction machine, adult stethoscope, fetal stethoscope, sphygmomanometer, artery forceps 8, mackintosh sheet and cord scissors, 10cm. Availability of the items analyzed was lower in government facilities than in either the mission or private facilities. The total mean percent of government facilities that had the analyzed items was 44% compared to 78% and 93% mission and private facilities respectively. Availability was noted to be high at the hospital level by all types of management in the sample districts. However, availability was notably low at the government health centers at 33% compared to and 71% at the private and mission health centers respectively (see Table 3.2 in the Annex 3). Unavailability of some of the essential equipment items at the various levels of care is of concern. Figure 4 below for example is an illustration of the availability of the suction machines, a life saving piece of equipment required at all facilities conducting deliveries.. - 14 -
Figure 3 Availability of Suction Machine at all Facilities Percentages 12 8 6 4 2 Government Mission Private BUNGOMA NAIROBI NYAMIRA NYANDARUA NYERI Districts In government facilities, availability was highest in Nyeri at 5 followed by Bungoma and Nairobi at 43% and Nyamira and Nyandarua at 4. There was no suction machine in the mission and private facilities visited in Bungoma district and in the mission facilities visited in Nyamira district. While most of the hospitals by all types of management had a suction machine, it was not available in Nyandarua District Hospital, managed by the government and in the mission and private hospitals in Bungoma district Availability was also low at the government health centers with a mean percent of 34%. The mean percent availability at the mission health centers was 5 while at the private health centers and the maternity homes it was. Implicitly, lack of the item implies inadequate capacity for the facilities to provide health care services that are appropriate for their level. Subsequently, this may contribute to low use of services and loss of confidence with the affected facilities. iii) Equipment Required for Caesarian Section Services One of the essential obstetric emergencies considered a component of comprehensive essential obstetric care (CEOC) is caesarian section. At the time of the survey as previously noted with the availability of other equipment sets, most sets for caesarian section were also incomplete. Eight items that were considered absolutely essential were therefore identified for review of their availability. The items were: blade handle, any artery forceps, any sponge forceps, any tissue forceps, lagenback retractor, any mayo scissors, needle holder and abdominal sheet or green towel. Since caesarian sections are not performed at the lower level facilities, only hospitals were considered for caesarian section services. - 15 -
Availability of the items analyzed was generally high at all the hospitals by the three types of management. The total mean percent of availability was 89%, 97% and 92% in all the hospitals managed by government; mission and private sectors respectively (see Table 3.3 in Annex 3) Although there was a high level availability of most of the items at the hospitals by all types of management in the sample districts, it is important to not that six out of the fifteen hospitals did not have all the essential equipment items for caesarian section. For example, the lagenback retractor was the least available compared to the other items. Figure 5 below illustrates its availability at all the hospitals by the different types of management. It was not available at the mission and one of the government hospitals in Nairobi and; at the Nyamira and Nyandarua District Hospitals both managed by the government. Figure 4 Availability of Lagenback Retractor in all the Hospitals Percentages 12 8 6 4 2 Government Mission Private BUNGOMA NAIROBI NYAMIRA NYANDARUA NYERI Districts Lack of some of the essential equipment items indicates inadequate capacity of a facility to offer caesarian section. Implications of this is that hospitals that are referral institutions within the districts for cases requiring caesarian section are either having to refer the mothers to higher levels of care or providing substandard services. Again this can contribute to loss of confidence in the facility care by users and potential users, resulting in the low use of the facility for the service. PRACTICE PATTERNS Health care provider reported practices The field test study attempted to assess the treatment practices of the health care providers at the facilities visited versus the recommendations as stipulated in the Kenya Standard Treatment Guidelines (STGs). Eleven reproductive health conditions namely: ANC, Pre-Eclampsia, Dysfunctional labor, Normal Delivery, Hemorrhage, Caesarian - 16 -