afya ziwani county organizational capacity …

Afya Ziwani

COUNTY ORGANIZATIONAL

CAPACITY ASSESSMENT REPORT

Kisumu County

17th to 21st September 2018

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This county Organizational Capacity Assessment (OCA) was conducted by the Afya Ziwani project in close

collaboration with the Kisumu County Government. Afya Ziwani is a United States Agency for

International Development (USAID) project that is funded by the Presidents Emergency Plan for AIDS

Relief (PEPFAR) and implemented by a PATH-led consortium of Kenyan Non-governmental Organizations

(NGOs) and American small businesses.

Disclaimer

The views expressed in this report do not necessarily reflect the views of USAID or the United States

Government (USG).

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Table of Contents

Abbreviations ................................................................................................................................................ ii

1. County OCA Overview .......................................................................................................................... 1

1.1 Introduction .................................................................................................................................. 1

1.2 OCA Purpose ................................................................................................................................. 1

1.3 OCA Approach .............................................................................................................................. 2

1.4 OCA process description ............................................................................................................... 3

2. County OCA Key Findings and Critical Gaps ........................................................................................ 5

2.1 OCA Summary of Scores .............................................................................................................. 5

2.2 Domain 1: Governance and Leadership ....................................................................................... 6

2.3 Domain 2: HIV Service Delivery ................................................................................................... 7

2.4 Domain 3: Human Resources for Health (HRH) ........................................................................... 8

2.5 Domain 4: Access to HIV Essential Medicines & Other Commodities ........................................ 9

2.6 Domain 5: Health Information ................................................................................................... 10

2.7 Domain 6: Health Financing ....................................................................................................... 11

2.8 Domain 7: Community Health ................................................................................................... 12

2.9 Domain 8: Research and Development ..................................................................................... 13

3. Emerging Capacity Gaps and Proposed Interventions .......................................................................... 13

4. Lessons Learned ................................................................................................................................. 14

5. Recommendations ............................................................................................................................. 15

6. Appendices ......................................................................................................................................... 15

Appendix 1: OCA Scores – Kisumu County and Subcounties .................................................................. 15

Appendix 2: Capacity Development Plans – Kisumu County and Subcounties ...................................... 16

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Abbreviations AIDS Acquired immune deficiency syndrome CHEW Community health extension worker CHMT CHV

County Health Management Team Community Health Volunteer

CU Community units DHIS District health information system DQA Data quality assurance EMMS Essential medicines and medical supplies FTE Full time equivalent HFMC Health facility management committee HIV Human immunodeficiency virus HMB Health management board HRH Human resources for health HSDSA C1 HIV Service Delivery Support Activity Cluster 1 HTS HIV testing services ICT Information, communication and technologies IHRIS Integrated Human Resources Information System IT Information technology KHQIF Kenya HIV/AIDS Quality Improvement Framework KHSSP Kenya Health Sector Strategic and Investment Plan LMIS Logistics management information system M&E Monitoring and evaluation MOH Ministry of Health NACOP National AIDS Control Programme OCA Organizational Capacity Assessment OJT On-the-job training PBB Performance based budgeting PFMA Public Finance Management Act QIT Quality improvement team SCHMT Sub-county Health Management Team SCM Supply chain management SOP Standard operating procedure TOR Terms of reference TWG Technical working group WIT Work improvement team

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1. County OCA Overview

1.1 Introduction

This report presents the results of the OCA conducted for Kisumu County and its project supported subcounties

of Kisumu East, Kisumu West and Kisumu Central. It includes a detailed analysis of key findings as well as the

Capacity Development Plans (CDP) recommended by the county officials to address the gaps identified through

the OCA.

The county has seven sub counties: Kisumu East, Kisumu West, Kisumu Central, Nyando, Seme, Nyakach and

Muhoroni, with a total of 35 wards. The county has an estimated population of 1,107,755 comprising of

545,670 males (49%) and 562,085 females (51%). HIV prevalence in Kisumu is at 16.3%, which is 3.4 times

higher than the national prevalence.1 The prevalence among women in the county is higher (17.4%) than that

of men (15%), indicating that women are more vulnerable to HIV infection than men in the county. Kisumu

County contributed to 7.7% of the total number of people living with HIV in Kenya as of 2018 and is ranked the

fourth highest nationally. In 2018, the county contributed to 13.7% of the total new HIV infections in Kenya

among children and adults respectively.2

1.2 OCA Purpose

Western Kenya has the highest HIV prevalence in Kenya. Afya Ziwani aims to support the counties of Kisumu,

Homabay, Migori, Nyamira and Kisii in western Kenya to achieve the global 90-90-90 goal for HIV/AIDS service

delivery. Strengthening county health systems to better plan and budget for HIV service delivery, improve the

availability of appropriately skilled human resources, strengthen the distribution of quality commodities,

enhance the effective use of data for decision-making, and operationalize national quality assurance and

improvement mechanisms is essential if the counties are to achieve the 90-90-90 goal by 2020. To improve the

sustainability of HIV/AIDS service delivery in the five counties, Afya Ziwani provides support to county and

subcounty governments to strengthen health systems. The purpose of the Afya Ziwani conducted county

organizational capacity assessment (OCA) process is to implement a structured approach to establish a baseline

for health systems performance, develop specific and agreed upon systems strengthening interventions, and

conduct measurement of systems strengthening over time.

1 National AIDS and STI Control Programme, Kenya HIV Estimates, 2015 2 National AIDS and STI Control Programme, Kenya HIV County Profiles, 2016

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1.3 OCA Approach

The OCA approach used by Afya Ziwani is to facilitate counties to conduct a self-assessment framed around the

USAID developed county OCA tool. The process enabled Afya Ziwani and county staff to systematically evaluate

essential county health system elements in a structured manner. The OCA tool outlines eight key capacity

domains of health systems: 1) governance and legislative framework, 2) service delivery; 3) human resources

for health, 4) health infrastructure, 5) health products and technologies, 6) health information, 7) health

financing, and 8) research and development. Each domain is further divided into standard elements that

encompass critical issues identified as essential for capacity to be sufficient.

During the OCA, participants assessed the capacity of the health system in their respective counties and

subcounties by reviewing the standard elements under each domain, discussing existing practice and evidence,

and gaining consensus on the appropriate score for each assessed standard and domain. In order to reduce

subjectivity in scoring, each standard element under each domain has 5 clearly measurable categories, scored

from 0 - 4, where 0 is no capacity and 4 is high capacity. Appropriate evidence and verification was provided by

the participants to support each score, and the issues underlying the scoring were identified and documented.

These scores were then aggregated as an overall score, which measures the capacity of the health system.

Scores for individual domains and overall capacity are presented in a dashboard using traffic lights as per the

OCA Likert scale in table 1 below.

Table 1: OCA Likert scale

0% - 39% Health System has limited capacity requiring significant support

40% - 69% Health System has some capacity but there are areas requiring additional support

70% - 100% The health system is managed well and has the capacity to deliver its mandate

During discussions, capacity issues were summarized along with any needed technical assistance, which formed

the foundation of the county CDP. A local consultant and project technical advisors guided county participants

through the OCA process and ensured thorough documentation of the scores, issues and the action plans.

The outcome of this process was a quantitative and qualitative baseline and a detailed action plan to guide

capacity development and technical assistance over the next year to strengthen health systems. The OCA is

designed to be repeated annually to assess county organizational capacity progress over time and guide

ongoing systems strengthening technical assistance.

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1.4 OCA process description

Afya Ziwani conducted the participatory county OCA process for Kisumu County and 3 subcounties, namely

Kisumu East, Kisumu West and Kisumu Central, between September 17th – 21st 2018 at the Cold Springs Hotel

in Homa Bay. A total of 28 participants were engaged in the process. Seven of the participants were Kisumu

County Health Management Team (CHMT) representatives and 14 Subcounty Health Management Team

(SCHMT) representatives. Nine representatives from Afya Ziwani facilitated and coordinated the OCA process.

Table 1 provides the names and titles of the participants.

Table 2: Participants List

Name Title Work Station

County Representatives

Boaz Ndong CAOT Kisumu CHMT

Jared Otieno SCASCO Kisumu CHMT

Dr Otieno Kennedy SMO Kisumu CHMT

Elijah Oyolla CCHSFP Kisumu CHMT

Festus Ondola D/CHRIO Kisumu CHMT

Sub-County Representatives

Charles Olwenge SCHAO Kisumu West Subcounty

Paul Ogutu SCCO/SCD&C Kisumu West Subcounty

John Seda SCCOFP Kisumu West Subcounty

Rinnie Juma SCHRIO Kisumu West Subcounty

Esther Onyango SCTLC Kisumu West Subcounty

Wilson Achola SCHAD Kisumu East Subcounty

Elizabeth Ayieko SCASCO Kisumu East Subcounty

Fredrick Oluoch SCMCC Kisumu East Subcounty

Dr. Irene Olweny SCP Kisumu East Subcounty

Peter Kenyagah SCHAD Kisumu Central Subcounty

Jane Nyambane SCACC Kisumu Central Subcounty

Larry Mwallo SCHRIO Kisumu Central Subcounty

Alfred Oginga SCMOH Kisumu Central Subcounty

Omwoha James Ongai SCASCO Kisumu Central Subcounty

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Afya Ziwani Representatives

Cenan Ojunga TC Kisumu Afya Ziwani Office

Dennis Kimanzi TA HRH Kisumu Afya Ziwani Office

Dr.Linet Nyapada HSS Advisor Kisumu Afya Ziwani Office

Stephen Washington Research Assistant Kisumu Afya Ziwani Office

Sylvertone Clare Research Assistant Kisumu Afya Ziwani Office

Vincent Kisukwa Research Assistant Kisumu Afya Ziwani Office

Lilian Oronje Research Assistant Kisumu Afya Ziwani Office

Mercy Apiyo Research Assistant Kisumu Afya Ziwani Office

Catherine Nderi OCA Advisor Nairobi

In order to promote sharing of best practices and learning between counties, the Kisumu OCA was conducted

alongside the OCA for Migori County. Though the two counties and their respective sub-counties were

organized in separate groups during the OCA, they were brought together during presentation and validation

of OCA results and CDP. This enabled the counties to learn from each other and also share best practices on

actions they could take to address gaps identified through the OCA.

Members of the CHMT and subcounty representatives made themselves available throughout the 5-day

workshop. On the first day, Monday, 17th Sept 2018, the group were taken through a brief overview of Afya

Ziwani and the OCA process and how it links to HSS. Plenary discussions on the OCA and CDP tools were held

on the same day, where participants gave suggestions on which standard elements were applicable to the

county and subcounties along with suggestions for minor adjustments to the tool. On day 2 and 3, the

participants were organized into teams according to their county and subcounties and then conducted the OCA

self-assessment exercise. Team members provided crucial information regarding the strengths and weaknesses

of the health systems in their respective county and subcounty and provided scores for each of the domains.

On the 4th day, participants developed CDPs for their specific county and sub-county to address capacity needs

identified through the OCA. Review, validation and presentation of scores and CDPs were done by the

participants on the 5th day, Friday 21st Sept 2018. The OCA results for Kisumu County and the 3 subcounties are

presented in section 2 of this report. Completed score matrices and notes on the evidence to support the

scores are attached in Appendix 1, and the completed CDP is attached in Appendix 2.

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2. County OCA Key Findings and Critical Gaps

2.1 OCA Summary of Scores

This section analyses the findings and gaps identified from the OCA conducted by Kisumu County and its

subcounties of , Kisumu East, Kisumu West and Kisumu Central. Table 2 below presents a summary of the OCA

scores for all the 8 domains.

Table 3: Summary of OCA Results

Figure 1 below shows the overall capacity of the health system in the county and subcounties for all eight key

capacity domains. The overall OCA results were as follows: Kisumu County (61%), Kisumu East (64%), Kisumu

West (63%), and Kisumu Central (60%). It is of interest to note the close scores as the difference between the

highest and lowest score was only 4%.

Figure 1: Overall

Capacity (all domains)

Summary of OCA Results

Governance and

Leadership

HIV Service Delivery

Human Resources for Health

Access to HIV Essential Medicines & Other Health Commoditie

Health Information

Health Financing

Community Health

Research and Development

Score as percentage

Kisumu County812101514155161%Maximum score possible1616202016201212Performance score50%75%50%75%88%75%42%8%

Kisumu East Sub-County14127816179264%Performance score88%75%35%40%100%85%75%17%

Kisumu West Sub-County813141014168063%Performance score50%81%70%50%88%80%67%0%

Kisumu Central Sub-County121291216126060%Performance score75%75%45%60%100%60%50%0%

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63

64

61

5859606162636465

Kisumu Central Sub-County

Kisumu West Sub-County

Kisumu East Sub-County

Kisumu County

County/ Sub-County

Overall Capacity

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The section below gives an analysis of the findings around each domain with a focus on the achievements and

challenges highlighted.

2.2 Domain 1: Governance and Leadership

Results on governance varied across the county. At both county level and Kisumu West, there was a common

score of 50%, while in Kisumu Central, the SCHMT scored this domain at 75%, and a notably high score in East

at 88%, as illustrated in Figure 2.

Figure 2: Governance and

Leadership

The OCA established that the relevant guidelines, laws and policies on HIV are available and have been

distributed to most facilities. The subcounties have adopted the guidelines and are adhering to them, On-the-

Job Training (OJT) and mentorship on HIV services are being carried out in most facilities, but further

strengthening is required. The county HIV and AIDS Strategic Plan is in place; however, most subcounties lack

awareness of the plan as it has not been disseminated to their level. One of the challenges faced by most of the

HIV based programs is partners’ lack alignment to the strategic plan, as they typically come in with donor-

aligned plans and areas of support.

The OCA also revealed that the county has performance management mechanisms and structures in place.

Performance contracting at the subcounty level is weak as the SCHMTs lack funds to undertake this to the

facility level. The SCHMT leadership has, however, adopted set targets for performance contracting from the

county. In Kisumu West, for instance, the SCHMT reported having a health sector coordination committee and

an HIV Technical Working Group (TWG) in place, but Kisumu East did not seem to have the TWG. The hospital

boards are in place across the county, but training and gazettement of these boards have yet to take place.

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Coordination of partners remains a key action point so that it is clear which partner is supporting which area to

avoid duplication of activities. The county proposed the need to engage HIV supporting partners to align work

plans with the county HIV strategic plan.

2.3 Domain 2: HIV Service Delivery

The scores on HIV Service Delivery were quite high, with a common score of 75% at county level, and for

Kisumu East and Central. The leading score was in Kisumu West, which scored 81%, showing that this domain is

well supported and has the capacity to deliver as expected.

Figure 3: HIV Service

Delivery

The county reported that the number of identified people living with HIV is at 76%. In Kisumu East, for

example, viral suppression stood at 86%, with 100% linkage rate of the identified HIV positive persons. Facilities

in all the subcounties use the test and treat approach for HIV services. Challenges include poor patient

adherence to treatment, high staff turnover, and inadequate integration of staff into HIV programs. The

referral system, according to the county, exists in a physical form e.g. the movements of specimens and

patients from one facility to another. There has not been any draft developed on the referral strategy, and

intercounty referral/cross border linkages are ineffective and need to be established and operationalized. More

support needs to be channeled towards improving the referral system at all levels. In regard to facility-based

Quality Improvement Teams (QITs), some have been established while in others are inexistent. In Kisumu East

and Central, the teams have been constituted in 50% of the facilities, while Kisumu West has a QIT focal person

in charge of QIT. This component needs to be strengthened through trainings and facilitation QIT meetings. The

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Terms of Reference (TOR) for the teams also need to be developed. Underutilization of suggestion boxes and

the display of service charters needs to be strengthened through awareness creation to the public.

2.4 Domain 3: Human Resources for Health (HRH)

This domain had varied scores, with the highest being Kisumu West at 70%, and the lowest Kisumu East at 35%,

as illustrated in the figure below.

Figure 4: Human Resources for Health (HRH)

A few milestones have been achieved amidst several challenges. The county reported that the HRH norms,

standards and guidelines are available and accessible. The Integrated Human Resources Information System

(iHRIS) is only available at the county level, but information is not always updated as required due to challenges

around Information, Communication and Technologies (ICT) infrastructure and internet connectivity. The

subcounties have no access to the iHRIS system and information on HRH, so they store their HRH information

manually. A refresher training on iHRIS would be helpful to specific departmental HR staff, at both county and

subcounty level. The incentive and motivation policy for attraction and retention of staff has not been

developed; hence, there are major staffing gaps in the facilities due to the high staff turnover that is being

experienced. The county sees the need to develop a reward mechanism to aid in attracting and retaining staff,

which will require additional support.

The CHMT would also require support in developing strategies that promote access to equal opportunities and

career growth for the county staff. It was noted that the schemes of service being used have been adopted

from the national government and are therefore not specific to the county. The subcounties also reported that

they lack the schemes of service and job descriptions that clearly stipulate their roles and responsibilities. At

the county level, there were reports that the county does not have a training database for HIV activities, which

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is a gap that the county plans to address it by lobbying for support from partners. In regard to performance

contracting, there is general performance contracting and appraisals in the county, complemented by regular

client satisfaction surveys. These, however, are not specific to HIV, For example, performance contracting for

2017/2018 was done and even cascaded to the subcounties, and there are plans to conduct this again in

2018/2019 after the county has set its HRH targets. Lastly, the county requires support in order to develop an

HRH management and development plan, in addition to an HRH policy.

2.5 Domain 4: Access to HIV Essential Medicines & Other Commodities

This domain was marked with varied scores across the county as shown in figure 5. Kisumu County scored 75%,

Kisumu East 40%, Kisumu West 50% and Kisumu Central 60%.

Figure 5: Access

to HIV Essential

Medicines &

Other

Commodities

A formal commodity management unit does not seem to exist at all levels. There were, however, reports of a

commodity TWG but the TOR is yet to be developed and disseminated. The Logistics Management Information

System (LMIS) is in place at the county level and is responsible for procuring commodities amidst challenges of

long procurement cycles and technicalities. The subcounties submit their orders using drawing rights provided

by the county. The subcounties are able to estimate their commodity needs of the HIV essential medicines on a

monthly basis but lack the capacity to fully procure these commodities. Partners supporting Reproductive

Health (RH) and Malaria have conducted OJT of staff involved in supply chain management and forecasting for

Kisumu Central. As for Data Quality Assessments (DQAs), these are done based on the program and support

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from partners. In Kisumu East, for example, Malaria and RH DQA is done on a quarterly basis, but there is no

DQA for HIV services. Storage and warehousing is marked with challenges due to the condition and space of

the available stores. Kisumu East and West reported that there is no assigned warehouse for commodity

storage and they are therefore forced to use makeshift structures to act as stores. Kisumu Central also

reported that the current store is not conducive for storage of HIV essential medicines and other health

commodities. These, according to the teams, can be addressed through continuous advocacy for support in

setting up proper warehouses and logistical support in the distribution of commodities. The DQAs also require

strengthening through resources to support the meetings.

2.6 Domain 5: Health Information

From the results in Figure 6 below, this domain seems to be performing extremely well with two common

scores at 100% and another two at 88%. The scores were as follows: Kisumu County 988%0, Kisumu East

(100%), Kisumu West (88%), Kisumu Central (100%).

Figure 6: Health

Information

The assessment found out that the Health Information System (HIS) policies, strategies and guidelines are all

available at both the county and subcounty level. Data review meetings at both levels take place as required,

but more support is needed to strengthen these meetings. The main challenge is in the availability of reporting

tools, which are, at most times, inadequate. Whenever new tools are introduced e.g. MOH 731, staff are also

not sensitized and this has effects on the use of the tool due to low user understanding. Training on the

national District Health Information System (DHIS2) database has been done for most in-charges, but data is

not always updated due to challenges around ICT infrastructure and internet connectivity.

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In Kisumu East, the SCHMT reported that regular supervision is done at the facility level, which creates a good

platform for mentorship and OJT. The CHMT also revealed that facilities have not been able to attain 100%

reporting rates on timeliness and completeness of data. If support can be channeled towards HIS

infrastructure, such as desktops and modems, the reporting rates could improve greatly. When it comes to

DQAs, these are conducted irregularly and sometimes do not conform to the DQA protocols. The teams

established that there is a need to give support for routine DQAs that are targeted rather than integrated, to

allow a more comprehensive assessment. Kisumu West identified orientation of health facilities and subcounty

teams on data analysis and interpretation as one of the ways to enable the leadership to better use data to

inform decisions. The CHMT is already analyzing and disseminating data every quarter to key members of the

CHMT, SCHMT and health facilities. It would be of importance to the county if key personnel are trained on

advanced data analysis to further their skills and capacity.

2.7 Domain 6: Health Financing

Figure 7 shows that Kisumu County scored 75%, Kisumu East 85%, Kisumu West 80% and Kisumu Central 60%.

Figure 7: Health

Financing

Discussion points revolved around annual work planning and budgeting, resource mobilization, and financing

for HIV services. The OCA found that the Annual Work Plans (AWP) and budgets are prepared on an annual

basis as per the government planning cycle. The health budget is about 30% of the county budget, but there

are challenges in implementing and disbursing the funds. The subcounties confirmed their participation in the

planning process, and that the AWPs are developed at the facility level and then consolidated at the subcounty

and shared with the county to feed into the final county AWP. The budget is used to mobilize alternative

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sources of funds from partners, but major deficits in funding are experienced at the county. This has had

effects on the operations at both county and subcounty level. A good example is the inconsistencies

experienced in conducting support supervisions and low support for implementation of HIV activities among

other programs. The HRH required to support HIV activities is marked with shortcomings, as there is no budget

set aside to support this.

The CHMT reported that the county has a functional resource mobilization unit with a focal person in charge,

and an MOU has already been developed to ensure public private partnerships. Funds received are utilized

across all programs and the absorption is above 90%. There were various challenges reported by the

subcounties, including the channeling of funds to the facilities, which is done directly without passing through

the subcounty. This impacts accountability and coordination, as the facilities are expected to report to the

SCHMTs. Advocacy leading to changes in this situation would positively impact on SCHMT oversight and

accountability. Among other action points is the continuous lobbying for adherence and implementation of the

AWPs as per the plans.

2.8 Domain 7: Community Health

Figure 8 illustrates that Kisumu County scored 42%, Kisumu East 75%, Kisumu West 67%, and Kisumu Central

50%.

Figure 8: Community

Health

The national community strategy is available to the county and has already been adopted to support the

county community health component. The county is utilizing Community Health Workers (CHVs)/peer

educators to act as a link between the facilities and the community. At least 50% of the CHVs have been

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trained on HIV service delivery and are reporting on HIV activities. Kisumu East reported that only 30% of the

CHVs have been trained, showing a gap in their training. It was recommended that partners support the

training of the remaining CHVs. The training areas have mainly been on home-based HIV care, and HIV/TB

services. In regard to the Community Units (CUs), these have been established by the county/subcounties as

per the national Community Health Strategy guidelines and are functional. An estimated 83% of the population

is covered by CUs across the county. The CUs are supervised by the QITs on a quarterly basis. Challenge around

CUs include inadequate budget to support establishment of new ones, and to run operations (e.g. printing

tools and facilitating supervisions) for the existing ones. The county is still in need of 47 more CUs in order to

cover the entire population. It was also discussed that sensitization of health workers on the national

Community Health Strategy is still pending and this can only be done if a partner supports the activity.

2.9 Domain 8: Research and Development

The Research and Development domain had the following scores as illustrated in figure 9: Kisumu County 8%,

Kisumu East 17%, Kisumu West 0%, and Kisumu Central 0%.

Figure 9:

Research and

Development

3. Emerging Capacity Gaps and Proposed Interventions

Table 4 below shows the key emerging gaps identified through the OCA and the CDPs proposed by the CHMT

and SCHMTs to address these gaps.

Table 4: Emerging Capacity Gaps and Proposed interventions HSS Pillar Emerging Capacity Gaps Proposed Capacity Development

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Interventions

Governance and Leadership Lack of performance management contracts and targets.

Fast track the signing of the performance contracts and cascading of the targets to the subcounties.

HIV Service Delivery Planned supportive supervision schedule is lacking and QITs are unavailable at the subcounties

Document a support supervision plan and disseminate to the SCHMTs as appropriate Cascade and mentor the QITs to the subcounties

Human Resources for Health Rewards and incentive mechanisms have not been developed

Come up with rewards, incentives and improvement strategies, including CME

Access to HIV Essential Medicines and Other Health Commodities

Low skill amongst relevant staff on commodity management e.g. commodity requisition and pharmacovigilance

Support relevant staff on refresher trainings on commodity management

Health Information Gaps on data analysis and low infrastructure to support HIS activities

Training on advanced data analysis (e.g. IGIS), support county and subcounty Health Records information Officers (HRIOs) with laptops and internet connectivity for data analysis

Health Financing

Inadequate budget allocation and implementation to support county activities including HIV-related activities Limited capacity in planning and budgeting processes

Continued collaboration between the county government and the HIV implementing partners to support the budgetary needs Training and mentorship on planning and budgeting

Community Health

Gaps in the adequacy of the relevant reporting tools and overall technical skills for CHVs

Support the training of CHVs on various components and provide budget to support printing of their reporting tools


County coordination framework for Health Research and Development has not been established and functionalized

Build the capacity of the CHMT/SCHMTs on research and development and constitute /operationalize the research teams

4. Lessons Learned

• In order to promote sharing of best practices and learning between counties, the OCA was conducted

by two counties at the same time. Though the two counties were organized in separate groups during

the OCA, bringing them together during presentation and validation of OCA results and CDP enabled

the counties to learn from each other and also share best practices.

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• Engagement with county senior health leadership at the beginning of the OCA process to discuss the

technical approach, OCA tool, and process was very important as it enhanced commitment towards the

process. It will also be important to engage with senior leadership during the dissemination of the OCA

results and CDP so as to enhance ownership of the results and actions needed to address the gaps.

• Conducting the OCA at the County and Sub-County Level and bringing the county and sub-county

officials together to discuss HSS issues was beneficial in that it raised awareness on current HSS

activities at the both county and sub-county levels. Involvement of the sub-county officers in the OCA

process was also very important as they are directly in charge of service delivery at the sub-county level

• Sourcing, collection, and evaluating appropriate evidence during OCA is essential as it supports the

verification of the scores and findings and limits response bias.

5. Recommendations

• Feedback mechanisms between the county and the sub-county appear inadequate and need to be

enhanced to enable efficient delivery of services. In some cases, the subcounties do not know what is

happening at the county level and vis-versa. e.g. some key officers at the subcounty level are not

involved in the planning and budgeting process.

• It would be beneficial to harmonize the functions and roles of the county and sub-county officers with

the set rules in the County Governments Act, and also to look at the implementation of the Act.

• The Public Finance Management Act sets the rules for how the government at national and county

levels can raise and spend money. Therefore, understanding the Act and implementing it will ensure a

smoother planning and budgeting process at the county and subcounty level.

• Health Systems Strengthening should be mainstreamed at the county, subcounty and facility levels

to ensure more efficient and effective health service delivery.

6. Appendices

Appendix 1: OCA Scores – Kisumu County and Subcounties

Final OCA Kisumu County & SC-Afya Zi

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Appendix 2: Capacity Development Plans – Kisumu County and Subcounties

Final CDP Kisumu County & SC -Afya Z

afya ziwani county organizational capacity …

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