REPORT OF CHAK ANNUAL HEALTH CONFERENCE 2011 Theme: Scaling up quality maternal & child health services in Kenya; the role of Church health system DATES: APRIL 12-14, 2011 JUMUIA CONFERENCE CENTRE, LIMURU 0
Programme focus Day one: Secretariat programme reports CHAK HMIS Software Day two: Scaling up quality maternal and child health services Launch of New CHAK Strategic Plan 2011-2016 CHAK Times 10th Anniversary Celebration Day three: AGM An Exhibition will be held throughout the AHC/AGM Conference objectives To reflect on the status of maternal and child health services (MDG 4&5) in Kenya and the contribution of the Church health system To discuss challenges facing delivery of maternal and child health services in Kenya and opportunities for scaling up To review the role of policy and guidelines in the delivery of quality reproductive health, family planning and child health services To discuss essential health systems strengthening for quality maternal and child health services To discuss financing options for maternal and child health services in Church health facilities To share lessons on the success of the primary health care approach in promoting access to maternal and child health services by CHAK member health facilities To share new developments in Family Planning technology and policy To Launch the New CHAK Strategic Plan 2011 2016 and celebrations to mark the 10-year anniversary of the CHAK Times Newsletter 1
Why the theme on maternal and child health? 1) Health indicators in Kenya Health indicator 2003 DHS result 2008/9 DHS result Infant Mortality Rate /1000 77 52 Under Five Mortality Rate/1000 115 74 Newborn Mortality Rate/1000 33 31 Delivery in a Health Facility 40% 43% FP Contraceptive Prevalence Rate 39% 46% Unmet FP need 24% 25% Maternal Mortality Ratio/100,000 414 410 2) Sub-Saharan Africa with 10 per cent of the global population contributes 51 per cent of global maternal deaths. (2005 Data) Total global deaths = 536,000 (Source: UNICEF global database 2009) 2
3) In sub-saharan Africa, unmet need exceeds current use of contraception. Family planning challenges The Kenya National Reproductive Health Policy of 2007 summarizes Family Planning challenges as the impact of HIV&AIDS pandemic; general shift of focus for international assistance from population to HIV&AIDS; disparities in health resource allocation; and lack of interventions targeting the resources to the poor and the hard to reach populations. The result of inadequate funding has been a weak health system, inefficient integration and poor quality of service delivery, contributing to negative trend in Reproductive Health related indicators as revealed by Demographic & Health Survey (DHS) General challenges facing MCH/FP services Inadequate funding there has been major decline of funding to MCH and RH/FP services from the mid 90 s Lack of funding to subsidize MCH, FP/RH services and support outreach activities Lack of security for contraceptive commodities leading to irregular supply to the service delivery points Lack of sustained demand creation for family planning services, ANC services and hospital deliveries Inadequate MCH/FP training for service providers 3
Shortage of health workers and frequent migration of skilled workers Lack of integration of family planning with HIV&AIDS and other health services Millennium Development Goals The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the world's main development challenges adopted by UN Millennium Summit in September 2000. They are as follows: 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce infant mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development Millennium Development Goals 4, 5 and 6 focus on women s and children s health. Most countries are lagging behind in achievement of these MDGs. The United Nations Children s Programme released a global strategy to address the situation in August 2010 when stock taking was done and the realization that many countries were lagging behind in achievement of the MDGs hit home. A number of strategies were recommended and a call to action made. Faith communities are considered very critical players in achievement of MDGs. The World Council of Churches (WCC) is mobilizing faith communities to wake up to the contribution that they can make. Global Strategy for Women's and Children's Health released on August 6, 2010, by the UN Secretary General Target: - Saving 16 million lives by 2015 Every year around 8 million children die globally of preventable causes. More than 350,000 women die from preventable complications related to pregnancy. Achieving MDG 4 (a two-thirds reduction in under-five mortality) and MDG 5 (a three-quarters reduction in maternal mortality and universal access to reproductive health) - would mean saving the lives of 4 million children and 250,000 women in 2015 alone. Key areas where action is urgently needed Enhancing financing Strengthening policy Improving service delivery Recommended Strategy Support to country-led health plans to involve increased, predictable, and sustainable investment. Integrated delivery of health services and life saving interventions so women and children can access prevention, treatment and care when and where they need it. Stronger health systems with sufficient skilled health workers. Innovative approaches to financing, product development and efficient delivery of health services. Improved monitoring and evaluation to ensure the accountability of all actors for results. Call to Action by the UN Everyone has a critical role to play in improving the health of the world s women and children. Importance of the Global Strategy on Women s & Children s Health The Global Strategy is an important step toward better health for the world s women and children. But it must be rapidly translated into concrete action and measurable results, and all parties must make concrete commitments to enhance financing, strengthen policy and improve service delivery. 4
Reproductive health policy priorities for Kenya 1. Safe motherhood 2. Maternal and neonatal health 3. Family planning 4. Adolescent and youth sexual and reproductive health 5. Gender issues including sexual and reproductive rights Strategies to increase utilization of MCH/FP services Advocacy and mobilization for MCH/FP at community, national, regional and international levels Increased funding towards MCH/FP from national budgets and Development Partners to subsidize costs and fund community based activities Programmes for community mobilization to create sustained demand for MCH/FP Guarantee contraceptives/anc and immunizations commodity security through adequate and consistent supplies and efficient logistics Improve access to pre-service and in-service Child Health, RH/FP training Support community-based education and MCH/FP services through outreach services and community health workers Promote public-private-partnerships for a multi-sectoral approach to MCH/Reproductive Health/FP services Promote increased involvement of men in MCH/FP mobilization Ensure that adolescents and youth have access to adequate and appropriate reproductive health information and services The dream That MCH/Family Planning education and services will become easily accessible through a community based health care system That MCH/FP services will become readily available at subsidized cost in both static and outreach clinics to expand access and utilization That FP, ANC health facility delivery and PNC will become a right for every woman and family That we shall reclaim the gains of the 80s and 90s in MCH/FP mobilization and services Thus improve MDG 4 & 5 indicators Questions and discussions Is there focus on the male population as stakeholders in improving the health of women and children? The strategy has a male involvement component. 5
Key note address from Assistant Minister in the Ministry of Public Health and Sanitation, Dr James Gesame Assistant Minister Dr James Gesame addresses the CHAK Annual Health Conference. Sitting to his left is Dr Migiro, Head, Child Health Division, while on the right is CHAK chairman Bishop Sande. Maternal and child health is particularly important because the health of any nation is determined by the health of its women and children. The NHSSP II-KEPH shows how much importance Kenya places on the subject of maternal child health. On the global front, four MDGs focus on maternal health. Despite the good policies, Kenya is performing poorly in the area of maternal child health. The 2008/09 demographics confirmed this challenge. The number of women delivering in health facilities is quite low while child mortality rate is high. Contraceptive prevalence rate is low while maternal mortality rate remains high. The coastal and lake regions have higher indicators than other areas. In Homa Bay, for example, there were 1,000 deaths of mothers per 100,000 live births, probably due to endemic malaria. While the national average stands at 410, this is quite high and should be brought down. The maternal mortality rate in Nyeri is less than 50. We must reverse the trends in MDGs 4 and 5. The ministry has taken the lead in resource mobilization, among other key areas and welcomes participation of other stakeholders. The priority areas are: Maternal and neonatal health Safe motherhood 6
Family planning Adolescent and youth sexual and reproductive health Gender issues All of the Ministry s annual plans have indicators in the maternal health area. The FBOs need to participate in AOP development as they are key partners in health service delivery. The Government provides less than 50 per cent of health services while the remainder is provided by other partners, key among them FBOs. The FBOs have a strategic advantage in the implementation of the community strategy as they have grassroots structures and know communities better. In addition, the church enjoys the trust of the community. The ministry is aware of the challenges faced by FBOs in financing health care. Human Resources for Health is another major challenge affecting the entire sector. Human resources have not been adequately trained and do not want to work in the rural areas. A key indication of the human resources for health challenge that the country faces is that some constituencies could not get 20 nurses in the recent recruitment, which also caused migration of health workers from church health facilities. The Government provides vaccines, TB drugs, HIV test kits, ARVs, ACT for malaria management, family planning methods and dispensary kits for level two health facilities. The Government has also seconded a few health workers to FBO facilities but acknowledge that there is still much to be done. In the new constitution, health is a right, meaning that the Government may be sued if drugs and commodities are lacking. In an effort to address financial challenges, the Health Sector Service Fund (HSSF) was launched in October 2010. It will be rolled out in FBO health facilities by the beginning of July 2011. Assessment of FBO secretariats and lower level facilities is on-going to provide information on capacity needs, among other things. CHAK has developed a new strategic plan aligned to the NHSSP and which has prioritized health systems strengthening, health service delivery, HRH, research, advocacy and communication, among other areas. Congratulations to CHAK on this step forward as we all seek innovative ways to address the challenges we face. The Assistant Minister then launched the New CHAK Strategic Plan 2011-2016 and declared the AHC/AGM officially opened. Dr Gesame officially launches the New CHAK Strategic Plan 2011-2016 assisted by CHAK General Secretary Dr Samuel Mwenda. 7
Questions and comments The Assistant Minister was requested to help in pushing Treasury to sign the MOU between Government and FBHS. The MOU has been signed by FBHS (CHAK, SUPKEM and KEC), the Ministry of Medical Services and the Ministry of Public Health and Sanitation and has been awaiting a signature from Treasury. Secondment of health workers: Can the Government have a policy of seconding health workers who have migrated from FBOs back to their work stations? It is the mandate of the Government to provide health care and a key part of this is health workers. The Government wants to second health workers but is also facing challenges such as health care financing and shortage of health workers. Currently, there are 37,000 nurses in the Government and private sector, yet about 76,000 are needed as per WHO standards. However, the Government will continue to support FBOs with human resources for health. 8
Community based approaches in scaling up access to maternal and child health services: Strategies and lessons from Maua Methodist Hospital Introduction Maua Methodist Hospital is a conference institution of the Methodist Church in Kenya and was started in 1928. Located 310km from Nairobi on Eastern Slopes of Mt Kenya, the 275-bed capacity hospital provides a wide range of diagnostic, curative, preventive and rehabilitation services. The Hospital serves a catchment population of 700,000 people and runs a nursing college offering Diploma in Registered Community Health Nursing and Internship training for Doctors, RCOs and BSN nurses. The hospital s total staffing establishment is 350. Sister Janet Munene from Maua Methodist Hospital making the presentation. Maua Methodist Hospital MCH/FP objectives To provide child health services to the under five year aged children through immunization, growth monitoring, curative services, growth monitoring and effective referral system To provide access to information to the community on safe motherhood and child survival including nutrition education To prevent the high number of unnecessary deaths of mothers in pregnancy and child birth- and long term complications afterwards To provide access to information and services to both men and women to help them make informed choices for family planning, reduce risk of pregnancies, child birth and reproductive cancers. To encourage males to adopt and practice family planning methods and use Condoms where appropriate To develop linkages with other health care providers in promotion of women s health through strengthening referral systems. To prevent and reduce maternal mortality and morbidity related to pregnancy, delivery and postpartum To provide access to information for the community on safe motherhood and child survival. To provide focused antenatal care services to the expectant mothers 9
To provide PMCT services to antenatal mothers and new born babies Strategies Training community health workers to increase access to health services for the community as well as serving as a link between the health facility and the community Provision of accessible, sustainable and affordable MCH services both at static clinic and operational outreach clinics in the hospital catchment area Publicity for available services through churches and open day forums by involving private practitioners, political leaders, and other influential people in the community. Encouraging the community to enroll with the NHIF to make delivery services by skilled health workers accessible and affordable Ensuring adequate supply of contraceptives and quality FP services Supplying birthing kits to all pregnant women in remote clinics and dispensaries Community health education to enhance positive behavior change on retrogressive cultural practices with regard to maternal and child health Integration of primary health care services both in static and outreach services Staff development through CPDs, updates and in-service training for staff providing MCH services Continually monitoring and evaluating MCH/FP services to identify existing gaps for improvement FANC services including Malaria prevention in pregnancy Provision of ITNs in MCH/FP clinic to children under five and pregnant mothers Strategies to scale up services Waiting time is kept as short as possible. Children who only require immunization go direct to the nurse to allow care takers to go home quickly The hospital has identified a space for immunization of well children, separating them from their sick counterparts who are examined through IMCI. Services are given at low cost. Health education is provided on MCH/FP services to waiting groups and individual mothers. No eligible child or pregnant mother leaves the clinic without getting services. No mother is scolded or made to feel foolish when they come to the clinic. CHWs assist to weigh the children in the clinics, refer and give them information. Pregnant mothers are able to sit down at each clinic station and waiting time is kept at a minimum. Use of CORPS to identify pregnant women or sick children and refer them to the health facility or other provider networks in the community Distribution of the appropriate IEC materials on safe motherhood and health education to the community Holding a quarterly evaluation meeting with MCH/FP CORPS/CHWs and filling health happenings reports in the villages Provision of PMTCT services to all ANC mothers and referral to Compressive Care Clinic for further management Provision of cervical cancer screening services in the Hospital MCH clinic and referring cases to a gynaecologist Weight and BP are taken for all pregnant mothers before review by the nurse. Packets of iron and folic acid tablets are handed out by the nurse. Charges are kept as low as possible so that the poor can easily afford the services 10
Strategies to improve the health of pregnant mothers Regular urine testing for all ANC mothers on booking and at 36 weeks with additional monitoring where indicated ANC card is especially designed to help CHWs detect at-risk clients and refer them to the hospital IPT for Malaria prevention is given in the clinic ITNs are distributed in community outreach clinics PMCT to mothers attending the ante-natal clinic Palliative care referral for ART and care for the mother and family Challenges Clients perceive the services to be expensive against the expectation that services in mission facilities should be free. Inadequate human resource as a result of massive staff turnover Inadequate funds to run some of the services due to low costing Poor infrastructure and road network leading to wear and tear of vehicles and high cost of maintenance and inability to replace vehicles Inadequate supply of immunization and FP commodities increases missed opportunities Lack of service sustainability due to poverty prevailing within the catchment area High Illiteracy levels prevailing in the community Social cultural beliefs and practices e.g. FGM Political interference Difficulties in reaching some of the areas without 4WD vehicles and high cost of fuel Lack of partners to subsidize the services Lessons learnt Early Detection of cancer of the cervix (Via/vili) pap smear for prompt intervention or early referral Through community health education, malnutrition has drastically reduced except in times of drought. Improved public relations with the community is important for service delivery. Motivated community health workers are key to improved service delivery. There is reduced mortality and morbidity of mothers and under five children as a result of integration of MCH/FP services. Health services can be improved through frequent surveys. Maua s primary health care work over the years has significantly reduced the burden of disease in the catchment area. The hospital had a dedicated measles ward which was always full but this has since been closed. There is reduced social stigma in relation to HIV/AIDS. Increased immunization coverage has led to better control of some diseases. Registration of community members with NHIF has increased the number of hospital deliveries. There has been improved family planning uptake and reduced method failure. Due to health education, cases of malnutrition have drastically reduced. It is important to engage the community in dialogue through meetings and barazas to set specific terms of reference for health committee members at the very beginning of a community outreach. There should be a process of replacing non-performing community health workers. Patience is required to build capacity and achieve fully operational health committees. 11
Scaling up MCH/FP services is always a joint venture with the community who take up increasing responsibility for setting up and sustainability of outreach services. Questions and discussions Does the hospital have a pediatrician in addition to the gynecologist? There is a pediatrician who runs a clinic in the MCH. What is the cost of NHIF to the mother and is it in any way linked to the OBA? The NHIF covers a family for very many conditions while the OBA targets only deliveries. Is Maua a high risk Malaria zone? Maua is a high risk zone with Malaria being the leading cause of admission in the hospital. The hospital receives less vaccines than it requires and is looking at modalities of getting the commodities directly from KEMSA. The hospital is partnering with a friend in the US to get birthing kits. These are taken to very remote areas as a way of improving care as mothers take a long time to get to a hospital for delivery. Service charges: Mothers are charged Ksh80 while children pay Ksh40. Service statistics: The hospital is currently doing about 300 deliveries per month. The immunization target which is set at district level is 90 per cent and the hospital has been able to surpass this figure. Maua has also been able to meet the targets for IMCI, Malaria and TB. Political interference: Maua lost a dispensary due to political interference. How is the hospital tackling the FGM menace? Maua is working in partnership with the church to address this issue. Mary Gitari, the hospital s nursing officer is part of the team that fights FGM. Mothers are sensitized on the dangers of the practice as they are the chief advocates for FGM in most cases. In addition, about five days are set aside every year to talk to children about FGM. Improving male participation: Mothers are asked to bring their husbands to the clinic. The men are fast tracked through the service queue to encourage them to come to the clinic. Motivation of community health workers: Although CHWs have been providing free services, there is a need to rethink this strategy and come up with modalities for compensating them. However, the impact of their work also serves as a motivator. 12
Integrating maternal and child health services in community development: Lessons from Tenwek Hospital Community Health and Development Presented By Jonathan Bii, Director, Tenwek Hospital Community Health and Development Tenwek Community Health and Development was started in 1983 as an outreach arm of the hospital in response to the many patients visiting the hospital due to preventable diseases. Such cases were estimated at approximately 80 per cent of the total patients visiting the hospital. The moto is Bir Mat Ko Loo! (Prevention is better than cure). Tenwek Hospital Community Health and Development is a holistic ministry that focuses on bringing God s hope to individuals, families, and communities. Mission: To serve Christ by facilitating change through primary health care and appropriate development within needy communities. This is carried out in a variety of outreach projects. Outreach ministries Maternal Child Health (ANC, immunization, growth monitoring and health education, FP and PMTCT) HIV/AIDS prevention and care - counseling and testing become an entry point for care and treatment. Lessons on prevention are also given during mobile clinics and men as partners meetings. Hygiene and sanitation - lessons given in mobile clinics enhance safe infant feeding, health of the mother and the entire family. Child to Child (CtC) approach to PHC in primary schools reinforces lessons taught in clinics as children replicate lessons learnt in their homes. Safe and Accessible Water- Water tanks, spring protection and promotion of bio-sand filters. This intervention reduces water borne and diarrheal diseases especially in infants and young children. Food security - Improved nutrition leading to improved health and livelihoods Church mobilization for wholistic ministry - Church social ministries following the model of Jesus Christ enhance all the above. People Owned Process(POP) facilitates communities to start own development initiatives Maternal Child Health Monthly immunization and antenatal care/ FP clinics Growth monitoring Malaria prevention education through Community Health Workers Community based distribution of essential drugs through Community Resource Persons (CRPs). PMTCT follow up and referrals HIV/AIDS Prevention and care Counseling and testing becomes an entry point for care and treatment. Lessons on prevention are given during monthly mobile clinics. Men as partners meetings 13
Health teachings - hygiene and sanitation Lessons given in mobile clinics enhance safe infant feeding, health of the mother and the entire family. Child to Child (CtC) approach to PHC in primary schools reinforces the same in homes. Safe and accessible water This includes construction of water tanks, protection of natural springs and promotion of bio-sand filters. This intervention reduces water borne and diarrhea diseases especially in infants and young children. Mr Jonathan Bii addresses the Annual Health Conference. Food security The department believes that improved nutrition leads to improved health. It partners with target communities in the establishment of food banks for maize, beans, pumpkins and keeping of dairy goats for milk, among other ventures. Challenge and equip the Church for wholistic ministry Church social ministries following the model of Jesus Christ enhance the wholistic human approach. People Owned Process (POP) The department facilitates communities to start their own development initiatives and enhances health seeking behavior. The gender daily calendar allows both men and women to note the activities they undertake daily and has encouraged men to participate in family activities. The department also strives to take MCH services closer to mothers and children. This approach employs the following strategies: Communities identify themselves for partnership 14
Participatory learning, action and reflection are emphasized. Networking and collaboration for best practices and building synergy Lobbying and advocacy Challenges Funding Conflicting approaches Poor roads Occasional shortage of clinical supplies Questions and discussions Resource mobilization: All projects are cost-shared with benefitting communities. Communities contribute 30 per cent in cash, labour, among other resources. Communities also own the capacity building processes and are encouraged on the rights based approach to development so they can mobilize resources from Government and other potential partners. The basket approach allows communities to identify sources of resources. How are families that receive the water filters identified? Communities apply and pay Ksh300 as cost sharing. The beneficiaries are selected according to laid-down criteria. Construction of the filters is done in the communities. The communities must form self help groups to fix toilets, drying lines, trash cans and ensure clean compounds. Child to Child (CtC) approach: Every year, the department partners with 15 schools who apply for the programme. Sanitation: Community health programmes mostly focus on villages as opposed to urban areas. There is need to focus more on urban areas. The POP approach is being scaled up in many communities. Among the challenges is that some organizations provide handouts to the communities as opposed to teaching them to manage projects that benefit them. 15
Financing maternal and child health services; Opportunities and challenges Presented by Dr Samuel Mwenda General Secretary, CHAK Financing is one of the essential inputs in health service delivery. Finances are needed to procure and pay for other health systems necessary for health service delivery. Health workers may be considered the most important resource due to their role in quality service delivery and management of other resources to achieve effectiveness, efficiency and desired health goals. However HRH recruitment, development, motivation and rewards all require financing. Health services are expensive to deliver. When one considers; the capital cost of investment, operational costs, regulatory compliance costs, infection prevention procedures, safe waste disposal and sanitation. The diverse range of health service delivery institutions calls for varied investments and sustainable financing strategies. Diagnostic and curative services involve a lot of inputs that include; consultation, investigation, radiology, procedures and drugs. Inadequate health care financing is a common and persistent challenge among CHAK member health facilities and in developing countries in general. There cannot be any adequate single source of financing. Challenges faced in achieving annual goals by both MOH and FBO health facilities CHALLENGES FACED IN ACHIEVING ANNUAL GOALS 16 Financial Resource shortage Human Resource shortage Staff turnover Community interference Government/management disagreements defaulters
Income sources for health financing The main financing mechanisms in Kenya include; i. Tax financing ii. Pooled funding through risk pooling initiatives such as NHIF, private insurances and community based health financing iii. Employer supported health schemes iv. Fee for service/user fees/cost sharing In a study of the faith based health services providers which was conducted in 2007, the main sources of financing health care were; patient fees/user fees 71 per cent, donors 13 per cent, NHIF 9 per cent, others 7 per cent. Government support is provided in-kind and was not costed in this study. Income sources; MOH-FBHS situational analysis study 2007 NHIF 9% Others GOK 0% 7% Donors 14% User Fees 70% GOK Donors User Fees NHIF Others Mrs Nancy Ng ang a from AIC Cure Kijabe Hospital raises a point during the event. 17
Partnership and collaboration with MOH Types of Collaboration CHAK Facilities 30% 25% 20% 15% 10% 5% 0% D ru gs E q p ui m en in ar h ts g H an m u re u so e rc N o l co la b at or io n R l ra er f e s in in a Tr gs a Tr po ns rt V ci ac ne s Who pays for health? According to the National Health Expenditure Household Survey results of 2005/06, the total health expenditures was estimated at Ksh69 billion and was financed by; households 36.7 per cent, Government tax revenues 30 per cent, donors 29.4 per cent and private companies 3.4 per cent. 18
Government in-kind support comes in the form of: Commodities such as vaccines, FP methods, PMCT commodities, ITNs Seconded health workers Training materials and IEC materials Clinical guidelines and policies M&E system including ANC and child welfare cards and service registers Communities contribute in various ways including: Fee for service as an out of pocket payment Human resource contribution through community volunteers CHWs and Community health committees Community fundraising for hospital bills Partners to FBOs in health care financing include but are not limited to: Communities Government departments Education institutions Donors Churches and church organizations NGOs Academic institutions in the form of research and new knowledge Private sector Other service providers Several categories of insurance schemes exist: The NHIF maternity package offers great opportunities for mothers and their families. The CHAK network has raised several issues on NHIF compensation which are being addressed. OBA for Reproductive Health which is being supported by GTZ and UNICEF Private insurances Community-based health care financing schemes Fundraising innovations CHAK member hospitals are engaging various innovative strategies towards increasing sustainable financing for healthcare: Costing of services: according to the findings of a costing study that was conducted by CHAK in 2005, cost recovery is often a challenge due to lack of comprehensive costing of service inputs. CHAK has recognized the need to identify and reasonably cost the various inputs that go into health service delivery. The cost should inform the pricing strategy for all services. The pricing should however recognize the subsidies from external funding sources whether in cash or in kind. External subsidies are intended to benefit the patients or users and not the health institutions. In CHAK hospitals the cost elements that are frequently missed include donated services (seconded staff), indirect costs and the cost of depreciation of medical equipment and buildings. 19 Computerization of revenue collection and management systems: experiences from CHAK hospitals has provided evidence that changing from manual revenue management to computerized system significantly enhances transparency and efficiency by providing itemized
patient bills and receipts. CHAK is now advocating that all member health facilities should move towards installation and use of computerized revenue management system. CHAK has supported this strategic move by developing an open source Hospital Management Software which can be used at all levels of health care facilities. The software is able to do patient billing, receipting, debtors management and inventory/stock control. It also has an accounting system which enables timely generation of accounting reports. CHAK Hospital Management Software was launched on 12th November 2010 following successful six months pilot at Maseno Hospital and Soweto Kayole Dispensary. Diversification of services: CHAK hospitals are working on diversification of services through introduction of specialized services and training programmes in order to gain a competitive edge over competitors. Some examples include; a. Tenwek Hospital has introduced Heart Surgery services, the first to be offered in rural areas of Kenya. The hospital has also introduced High Dependency Unit, Orthopaedic Surgery, specialized Endoscopy services, cleft lip corrective surgery, Eye Surgery and Medical Training including residency programmes in Family Medicine and Surgery. Plans for installation of a CT Scan machine are underway b. PCEA Kikuyu Hospital has introduced a Renal Dialysis Unit. It already has a well established specialized Eye Care services, Orthopeadic Surgery and Dental services. PCEA Chogoria Hospital is working on the installation of a CT Scan to become a regional referral hospital for this diagnostic service as well as support surgery services at the hospital c. AIC Kijabe hospital has developed highly specialized surgical services for children and adults. With the opening of nine well equipped major Theatres in October this year, the hospital has become the busiest surgical facility among the Church Hospitals in Kenya conducting an average of 10,000 major surgeries each year. The specializations include paediatric neurosurgery and ortheopaedic surgery. It has also established a surgical residency programme and anaesthetist training programme. The hospital has a well equipped intensive care unit (ICU). 20 Marketing of services: CHAK hospitals have recognized the need to publicise the variety of health services available. With the increasing competition from alternative providers, CHAK hospitals have recognized the need to identify their service niche and use it as an entry point for publicity and marketing. Kijabe hospital is leading as a best practice in establishing a marketing department whose core business is to package and disseminate information on the broad range of services available. The hospital has established a niche in highly specialized surgical services which is drawing patients from all over Kenya and neighbouring Somalia. The Private ward with additional comfort and amenities attracts patients who are able to pay higher fees for services provided. The marketing department is actively engaging media, communities, leaders and also uses a revamped hospital website for marketing. Maua, St Lukes and Lugulu Hospitals are engaging strategies of
community outreach, community mobilization, Hospital Open Days, Free Medical Camps and Anniversary celebrations for hospital services publicity and marketing Partnership with the National Hospital Insurance Fund (NHIF): NHIF is the largest social health insurance in Kenya with over 10 million beneficiaries. NHIF provides comprehensive in-patient cover in various Church Hospitals in Kenya. Revenues from NHIF have been recording a steady upward trend and this has come to be regarded as a key health financing mechanism for CHAK Hospitals which ranges between 10 40% of the inpatient revenue. NHIF has continued to innovate in it s services and systems to enhance efficiencies in beneficiaries identification and claims processing. NHIF is compulsory for all Kenyans in formal employment and voluntary for the informal sector. In the rural areas where most of the population is in the informal sector there are few members with NHIF cover. CHAK hospitals have recognized the need to enter into partnership with NHIF for mobilizing informal sector recruitment. A best practice is found in Maua Methodist Hospital, which has offered NHIF an office at the Hospital entrance. The hospital has invested in an NHIF community mobilization team and programme. The community team has a vehicle, power generator, a photocopying machine and a digital camera. The team collaborates with NHIF and the Provincial Administration to conduct community education and mobilization campaigns for NHIF membership. The Hospital Staff SACCO Bank also assists community members with Accounts at the SACCO Bank to join NHIF. This initiative has enabled the hospital to change the trend in debt accumulation and significantly increase revenues from NHIF from 15% - 40% of the in-patient fees. MMH - %NHIF TO GROSS FEES 50 40 30 20 10 0 2005 2006 2007 2008 2009 (JAN &FEB) Analysis of revenue from NHIF as a percentage of the total in-patient revenue at Maua Hospital Maua has inspired other CHAK hospitals to prioritize NHIF membership mobilization as a strategy of empowering communities to access inpatient services. Plans by NHIF to roll out out-patient insurance cover services will further expand opportunities for revenue generation from this national social health 21
insurance system. Similar partnerships are being engaged for community based health financing initiatives even though these are to a much smaller extent. Out-sourcing of non-core functions: there is growing realization that Hospitals can successfully outsource the burden of several non-core services. This enhances efficiency and reduces management time consumed in planning and monitoring these services. These include; security services, banking services and equipment maintenance services. Other services that can be considered include cleaning and catering services. Income Generating Activities: CHAK hospitals are engaging various approaches towards additional revenue generation to compliment user fees. From previous experiences, income generating activities in non-core business areas proved challenging, time consuming and did not result to significant investment returns. An example was Chogoria hospital IGA in Restaurant, Petrol Station and Farming all of which were outsourced due to persistent non-profitability and burden on hospital management time. There are however some exciting income generating initiatives within the core business of health services provision or investments towards lowering the cost of providing services a. Innovative income generating activities examples of successful initiative include: i. Private or Amenity Wards where the package of in-patient services includes higher privacy and comfort. The patients able to pay for these services also pay differentiated higher rates for all the other services including Laboratory, Theatre, Radiology, Drugs and procedures ii. Fast track outpatient clinics these are provided at a much higher consultation fees for clients who can afford and who are unwilling to queue for routine services. These also include direct Doctors consultation. Lighthouse for Christ Eye Care Centre runs a Private (Appointment Clinic) by Opthalmologists with credit card payment facilities and additional comfort where the consultation fees is five times higher than the general clinic. Funds generated from this clinic are used to subsidize patients from the general clinic who cannot afford to pay the Ksh 200 fee charged. iii. Satellite clinics Church hospitals were supporting opening of satellite clinics driven by the mission to take essential primary health care services to the communities most under-served. These however create a much bigger challenge of financing. For income generation, Church Hospitals are now moving into establishment of branded satellite clinics in urban areas where there are potential clients with ability to pay. Kikuyu and Kijabe hospitals have already started satellite clinics. Lighthouse for Christ Eye Care Centre has established several Optical Shops in various towns within the Coastal region. This is a strategy that has been used by well established private hospitals in the city of Nairobi. 22
iv. Diagnostic and Pharmaceutical services hospitals are also establishing Laboratory and Radiological diagnostic services as income generating services which attract referrals from other health facilities and private clinics. Well equipped Laboratories and Radiology units offer specialized diagnostic services that attract well paying clientele. The challenge remains how to balance the pricing strategy that does not exclude the poor needy patients v. Funeral Homes Hospitals with well developed and equipped Mortuary services are developing comprehensive funeral homes services. These include Body cold storage or embalming, Chapel for prayers, body preparation for burial and a hearse transport service. Funeral Homes are run as independent service which should attract demand from outside the hospital vi. Endowment funds:- Hospitals are establishing Endowment Funds in which capital is raised from donors and other sources, which is then invested and the interest generated is used to finance designated services. Examples include Chogoria Hospital endowment fund for community outreach services, Maua Hospital endowment fund for Doctors training sponsorship. There are also innovative designated funding initiatives such as hospital bed cost per day and per year which is marketed for donor support, needy patients support fund to assist very poor patients. b. Investments to subsidize cost of health services: - these investments in medical equipment and hospital plants target to reduce the cost of providing medical services. Some innovative examples include; i. Hydro-electric power generation plant at Tenwek Hospital which has provided the hospital with reliable electricity supply for over 20 years. This project saves the hospital an average electricity bill of Ksh 1.2 million per month Hydro-electric power generation plant for Tenwek Hospital on the Amara River waterfall. This generates enough electricity for the whole hospital lighting and electric equipment and the staff housing 23
ii. Oxygen Generation Plant these have been installed to produce, purify, compress and store oxygen from the atmospheric air. This is then stored and distributed through oxygen piping to the various user outlets in the emergency rooms, theatres, OPD and wards. Though the cost of initial investment is expensive, it pays off over time by removing the cost of Oxygen cylinders deposit, oxygen purchase and transport and enhances efficiency and convenience. The cost on the system is electricity and routine maintenance. Maua, Kijabe, Chogoria, Litein and Tenwek have installed this system. Tenwek has an additional facility of filling Oxygen Cylinders for backup storage. iii. Intravenous fluids production plants MEDS supported the establishment of IV Fluids production units in several CHAK Hospitals. These support production of the commonly used IV fluids at a rate that meets the fluctuating hospital needs. The challenges of stocks management, procurement and transport logistics are minimized iv. Biogas production project this is a new emerging area of potential hospitals investment to address the challenges of rising cost and non availability of firewood fuel for cooking services for patients and Nursing students. There are already positive lessons on this in Kenya and two CHAK Hospitals are working on biogas harvesting projects from waste disposal 24 Partnerships with Donors and NGOs project funding to support capacity building and health systems strengthening for new or ongoing services mobilizes additional funding to provide subsidized services to the users. Good examples are found in HIV prevention, care and treatment, Malaria and TB programmes. Funding is either obtained directly from Donors or through international NGOs. PEPFAR has provided a lot of resources in support of HIV treatment programmes through AIDSRelief project and other partnerships. There is need for CHAK health network to build technical skills in project proposal development and project management in order to effectively pursue available funding opportunities Public-private-partnerships: CHAK promotes public-private-partnerships as a strategy for mobilizing financial, material and technical resources to support health service delivery. We partner with Government for enabling policy environment, patient management guidelines for various conditions, regulatory compliance requirements, IEC materials, disease preventive and curative commodities such as vaccines, ARVs, TB drugs, HIV test kits, Anti-malarial drugs, Dispensary Drug Kits and reproductive health commodities. Hospitals are also partnering with the private corporations for funding through the corporate social responsibility programmes. A good example is the Standard Chartered Marathon which raises funds that supports payment for cataract surgeries at the Specialized Eye Care Hospitals. Another form of partnership is with Medical Equipment Companies which offer medical equipment of lease arrangement. Examples include BD Facs Count HIV testing machines, Abbots Chemistry Analyzers, Oxygen Concentrators and a most recent modern high capacity Chemistry Analyser provided by Philips Company to
Tenwek Hospital. The lease arrangement provides for the hospitals to buy the reagents over a period of time during which the Medical Equipment is placed at the hospital and maintained by the company. Commercial Banks are also willing to offer credit facilities to hospitals for capital investment and operational financing needs through short-term credit facilities. A new Chemistry Analyzer at Tenwek hospital acquired from Philips Company through a lease arrangement has added 14 new blood tests at the hospital and enhanced efficiency and volumes of samples that are processed daily Pre-payment delivery packages where patients pay a certain amount of money before delivery to access services. We can appeal to donors for funding of delivery beds or delivery of babies We can also fundraise for equipment and supplies which are very essential for maternal child health. Emerging and promising options Health Sector Services Funds (HSSF) AOP financing at District level. Devolved funds e.g. CDF: These are set to increase with creation of county governments Fundraising proposals Integration of Donor funded programmes like APHIAPlus USAID programme; DFID, UNICEF, GTZ/GIZ, DANIDA 25
Kenya Strategy for scaling up quality maternal and neonatal health services Presented by Mary Gathitu-Division of Reproductive Health Reproductive Health programming in Kenya Reproductive Health Programmes in Kenya aim at improving maternal health, reduce maternal, neonatal and child mortality, the spread of HIV/AIDS and promote women s empowerment and gender equality. This contributes to achieving the Millennium Development Goals. The National Reproductive Health Policy focuses on enhancing the reproductive health status of all Kenyans in alignment with the National Heath Sector Strategic Plan II (NHSSP II). The NHSSP II represents a paradigm and policy shift that emphasizes on preventive rather than curative services. It focuses on service delivery to the general public and promotion of healthy lifestyles for individuals and communities. Essential components of Reproductive Health Maternal and Neonatal Health Family planning/stis/hiv Adolescent/youth sexual and reproductive health Gender Rights Reproductive Tract Cancers Reproductive Health for Elderly persons IEC/BCC Monitoring and Evaluation RH Training Infertility Current status Total Fertility Rate: 4.6 CPR- any method: 46% Unmet need for FP: 26% Population growth rate: 2.8% per yr Total population (2009): 38.6 million Proportion of under 15yrs: 45% Maternal mortality ratio: 488/100 000 Neonatal mortality rate: 31/1 000 HIV prevalence among pregnant women: 9.7% Coverage for interventions Proportion attending at least 1 ANC visit: 92% Proportion attending 4 ANC visits: 47% Delivery by skilled birth attendant: 44% Delivery in a heath facility: 43% Proportion receiving PNC within 48hrs: 42% Skilled birth attendant/1000 population: 1.2 /1000 (requirement to attain MDG 5 is 4/1 000) 26
Key challenges Inadequate skilled care throughout the continuum of pregnancy, delivery, post-partum and post-natal periods Inadequate coverage of EOC interventions Low FP CPR and high unmet need Health system Challenges Low community involvement in maternal health High impact interventions for accelerating the attainment of MDG 5 Early in 2010, Maternal and Neonatal Health stakeholders in Kenya defined high impact interventions as follows: Demand creation for early initiation of ANC Increased coverage of basic and emergency obstetric and newborn care Skilled care along the continuum of pregnancy, childbirth and the postpartum period Family Planning (increased CPR) Essential newborn care Ms Gathitu makes her presentation at the conference. The Kenya MNH road map This is the strategy document for accelerating the reduction of maternal and neonatal morbidity and mortality in Kenya. It was adapted from the AU road map and has been adopted by MNH stakeholders. Vision Efficient and high quality MNH services that are accessible, equitable, acceptable and affordable for all Kenyans Goal To accelerate the reduction of maternal and newborn morbidity and mortality towards the achievement of the Millennium Development Goals (MDGs) 27
Specific objectives Specific Objective 1: To strengthen data management and utilisation for improved MNH Specific Objective 2: To increase the availability, accessibility, acceptability and utilisation of skilled attendance during pregnancy, childbirth and the post partum period at all levels of the health care delivery system Specific Objective 3: To strengthen the capacity of individuals, families, communities, and social networks to improve maternal and newborn health MNH road map strategies 1. Strengthen Monitoring and Evaluation system for Maternal and Newborn Health 2. Strengthen focused operations research in Maternal and Newborn Health 3. Strengthen National, provincial, and district MN health planning and management 4. Improving availability of, access to, and utilisation of quality Maternal and Newborn Health Care including adolescents, youth, people with disabilities and other vulnerable groups 5. Reduce unmet need through expanding access to good quality family planning options for sexually active men, women adolescents and people with disabilities. 6. Strengthening the referral system 7. Advocating for increased commitment and resources for MNH and FP services 8. Fostering partnerships 9. Strengthening community based Maternal and Newborn Care approaches Roles and responsibilities MOMS and MOPHS Ensure the creation of an enabling environment for the implementation of MNH programs Ensure that health facilities have adequate capacity in terms of staffing, equipment and supplies to adequately provide quality services Allocate necessary resources using existing national initiatives for the implementation of MNH programs. Establish mechanisms for supervision and ensure regular monitoring and evaluation of progress made Health facilities As far as possible, provide timely, efficient, and quality health care to all women and newborns presenting to the hospital Ensure that standards of care are effected and maintained Consistently document processes and keep registers so that data is available for decision making Establish facility based maternal and perinatal death review committees NGOs, CBOs, FBOs and Private sector These organisations will be encouraged to expand coverage and improve access to MNH services. They will advocate for and promote the rights of women and children and the need to address their problems in addition to mobilising and allocating resources for MNH programmes. They would also implement community based strategies to promote healthy behaviour during pregnancy, childbirth and the postpartum period. Other sectors These include education, agriculture, police, water, transport, roads, trade, communication/ media, gender, social services, parliament, councillors, chiefs, etc. All have to play their part to ensure that women and children access services that are necessary to reduce death and disability. 28
Communities, households and individuals Communities will participate through the health facility committees, village health committees as well as community health extension workers in resource mobilisation, planning, monitoring and evaluation of MNH services. Households and individuals will be encouraged to participate and contribute towards improvement of MNH. Role of training institutions The Ministry Of Education needs to ensure that the girl child has the basic education as this positively impacts health seeking behaviour. The approved university based medical and nursing schools, Kenya medical training colleges, and private and mission medical training hospitals will be expected to regularly update and incorporate evidence based MNH practice into their curriculum. AIC Kijabe Hospital CEO Mrs Muchendu speaks during the meeting. 29
The Role of FBOs in scaling up quality child health services in Kenya Presented by Dr Migiro, Head, Child Health Division Child health indicators (KDHS 2008) Infant Mortality Rate: 52/1,000 live births Under-five Mortality Rate: 74/1,000 live births Neonatal Mortality Rate: 31/1000 68 per cent of children aged 12-23 months are fully immunized Overall underweight stands at 22 per cent Stunting has increased from 33 per cent in 2003 to 35 per cent in 2008/9 Trends in Under five and infant mortality 1990-2015 140 120 100 NOT ON TARGET Acceleration Required 80 60 40 20 0 IMR 1990 30 1998 2003 U5MR 2006 KIHBS 2008/9 2015 MDG GOAL
Causes of under-five mortality in Kenya Distribution of causes of deaths among under fives in kenya, 2000-2003 3% 5% 0 Neonatal causes 24% HIV/AIDS Diarrhoeal diseases 20% measles malaria 15% 14% pneumonia injuries 3% 16% 0thers Main Causes of <5 mortality (WHO Country Fact Sheet, 2006) Neonatal causes- 24 per cent (contributes up to 60 per cent in some provinces) Pneumonia 20 per cent especially where malaria prevalence is low Diarrhoea -16 per cent Malaria-14 per cent (intense control efforts have borne fruit) Malnutrition is the underlying factor in up to 55 per cent of <5 deaths Causes of death in newborns Infections - 36 per cent (sepsis, neonatal tetanus, diarrhoeal disease) Prematurity 28 per cent Asphyxia 23 per cent Coverage of neonatal interventions along the continuum of care in Africa 100 C o v e ra g e % 80 31 69 65 60 42 40 30 20 0 16 A N C (a n y ) S k ille d a tte n d a n t P o stn a ta l c a re Ex c lu siv e b re a stfe e d in g (< 6 m o s) EP I (D P T 3 + )
Scaling up high impact interventions as articulated in the Child Survival and development Strategy 2008-2015 would help address these negative trends. Child Survival and Development Strategy 2008-2015 Objectives To provide a framework that all partners will support to scale up and accelerate child survival and development in Kenya To advocate for increased political will and financial commitment for child survival and development in Kenya High impact interventions Maternal Health (2010, 2011) Early initiation of ANC Individualized birth plan Emergency preparedness Use of Partograph Maternal nutrition Family planning Maternal and Perinatal Death review and Verbal Autopsy Newborn Early and exclusive breastfeeding Temperature management Identification of danger signs and early referrals Hand washing with soap and water Skilled attendance at delivery Universal coverage with a few interventions can prevent over six million deaths every year Prevention Intervention Deaths prevented as proportion Of all child deaths Treatment Intervention Deaths prevented as proportion of all child deaths Breastfeeding 13% Oral rehydration 15% Insecticide-treated materials 7% Antibiotics for pneumonia 6% Complimentary feeding 6% Antimalarials 5% Zinc 5% Zinc 4% Hib vaccine 4% Antibiotics for dysentery 3% Water, sanitation, hygiene 3% Vitamin A 2% 32
Global evidence-based cost effective interventions T a b l e 2 a : C o st E ffe c ti v e P r e v e n ti v e I n te r v e n ti o n s: L a n c e t 2 0 0 3 B r e a s t f e e d in g IT M C o m p le m e n t a r y f e e d in g Z in c C le a n d e liv e r y H ib V a c c in e A n t e n a t a l s t e r o id s S e rie s 1 W a t e r S a n it a t io n H y g ie n e N e w b o r n T e m p e r a tu r e M a n a g e m e n t T e t a n u s T o x o id N e v ir a p in e a n d r e p la c e m e n t f e e d in g A n t ib io t ic s f o r p r e m a t u r e r u p t u r e o f m e m b r a n e s A n t im a la r ia l f o r IP T in p r e g n a n c y 0% Integrated Management of Childhood Illness (IMCI) IMCI Health System Health Worker Skills IMCI: Healthy Child Families and Communities 33 5% 10% 15%