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MaternalandNewborn

CommunityHealthProject

AICKijabeHospital

ANNUALREPORTDECEMBER2016

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AcknowledgementsWewishtothanktheboardandtheseniormanagementteamofAICKijabeHospitalfortheircontinuoussupporttotheMNCHteaminthepastyearsinourmissiontosupportthevulnerablecommunitiestoimprovetheirmaternalandnewbornhealthindicators.WealsothankStricthingRoer,Netherlands;HilfefurBruder,Germany;andEquippingAfrica,USAfortheirfinancialsupportthathasmadeouractivitiesasuccess.WesincerelythanktheNavigators,thesendingagencyofourcurrentprojectdirectorDr.MaryAdamandSIM,thesendingagencyofDr.MaureenMcAlhaney.WewishtothankthecommunityleadersandgovernmentauthoritiesfromtheMinistryofHealth,includingDr.SalimHussein,HeadoftheNationalCommunityHealthServicesUnitaswellasallthoseatCountyandsubCountyHealthManagementTeamsforcontinuedcollaborationandtheirsupport.WegratefullyacknowledgetheCommunityHealthVolunteerswhoworktirelesslytoreachtheircommunitieswiththisproject.Lastly,wethanktheMNCHPstafffortheireffortinreachingthecommunitywithaccuratehealthinformationandwiththeloveofJesusChristdespitethechallengestheyfacewhileonduty.

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MNCHPTeamProjectDirectorDr.MaryAdam(from1.1.2011)MD,MA,PhD,FAAPDeputyDirectorDr.PeterMeissner(from1.1.2011)ProjectOfficerDr.MaureenMcAlhaneyOD,MS,MDProjectOfficerSimonMbuguaBA,KRCHNProjectOfficerJoramNdunguKRCHNProjectOfficerCarolyneWaithera,MPH,BA,MCOCommunityHealthInternJacobChegeBSCAssistantProjectOfficerThomasRennerBA,MAAssistantProjectOfficerDorothyRennerBSListofAbbreviationsAIC-AfricanInlandChurchANC-AntenatalCareCBO-CommunityBasedOrganizationCHC-CommunityHealthCommitteeCHU-CommunityHealthUnitCHV-CommunityHealthVolunteerCHEW-CommunityHealthExtensionWorkerMNCHP-MaternalNewbornCommunityHealthProjectMOH–MinistryofHealthNGO-NonGovernmentOrganizationPHO-PublicHealthOfficerTBA-TraditionalBirthAttendant

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ExecutiveSummary

2016wasayearofgreatopportunityfortheMaternalNewbornCommunityHealthProject.Itmarked the start of several new developments in addition to continuation of our coreworkstrengtheningcommunityhealthunitstobuildhealthiercommunities.

Highlightsinclude:

• Aweeklongin-servicecourseforCHEWsfromGarissaCounty.Itwasafirsttimetohaveafullclassfromthisneedyarea,knownforpoormaternalandnewbornoutcomes.

• ThedevelopmentofaSALTworkshop(Strengthen,Appreciate,Learn,andTransform)aninnovativeapproachtoqualityimprovementatLevel1inKenya’shealthsystem.Resultsareshowingcommunityhealthvolunteerscandrivepositivehealthchangeusingtheirownresourcesandtheirownideas.

• 157CHVshavebeenintroducedtothematernalnewborncurriculumbytheteamthisyearalone,bringingthetotaltrainedtoover34communityhealthunitsandover800volunteers.

• We are addressing health system utilization questions in Naivasha sub County withresearchaddressingthedecisionsmothersandfamiliesmakeonwheretodeliverandhowtheyunderstandqualitycare.

• We continue to bring health and hope to communities by training community healthvolunteersattachedtogovernmentfacilities,buildingupCHEWs,demonstratewaystoimprovequalitydatacollectionandbuildKijabeHospital’spublicprivatepartnershipwithCountygovernments.

WecountitaprivilegebeextendthereachofKijabeHospital’smissionandvisionofhealthcaretoGod’sglory,beyondthewallsandintothecommunity.

MaryB.Adam,MD,MA,PhD,Director,MaternalNewbornCommunityHealthProject

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Introduction

TheAICKijabeMaternal&NewbornCommunityHealthProject(MNCHP)hasinthepasteightyearsworked todecreaseneonatal andmaternalmorbidityandmortalitybypartneringwithMinistryofHealthbothatthenational,countyandsubcountylevelstoempowerhealthcareprofessionals working at Tier 1 & 2 ( dispensaries and health centers) through training andtechnical support forCommunityHealthExtensionWorkers (CHEWs)and CommunityHealthvolunteers(CHVs)toshareaccuratematernalandnewbornhealthmessages,caseidentificationatthehouseholdleveltherebydrivingdemandforhealthcarebyenhancingtimelycommunityreferralstothehealthcarefacilities.

The project provides one-week training to government employed health workers who arecurrently working as Community Health Extension Workers (CHEWs). These CHEWS areresponsibleforsupervisionoftheCHUs.MostCHEWshaveabackgroundofnursing,publichealthofficers (PHOs)andsocial sciences.Thesupervisory role for theCHUs isaposition thatoftenrequiresthemtosplittheirtimebetweenfacilitybaseddutiesandthecommunity.MostofthemlackskillsrequiredtoworkwithadultsoflowliteracywhichisneededtoworkeffectivelyatTier1&2.TheyalsolacktrainingandexperienceincommunityhealthreportingtoolsandthereforetheyareunabletosupporttheCHVsinconductinghouseholdmappingandregistrationwhichbuildsthelocaldatabaseofcommunityhealthindicatorsthatprovidesanimportantopportunityfortherealhouseholdhealthissuestobeidentifiedandprioritized.Theprojectworkswithdiversecommunitiesthatincludesagrarian,pastoralistsandsemiurbanacross 14 counties in Kenya with more concentration and support to Kijabe hospital nearneighbors; Nakuru, Nyandarua and Kiambu Counties. The project team works with thecommunity members to developed culturally appropriate adaptations of evidenced basedinterventionsinaddressingmaternalandchildhealthissues.

The project has also partnered with County governments in developing CHUs, conductinghouseholdmappingandregistrationaswellasstrengtheningtheexistingCHUswithMaternalandNewborn healthmodule training.We have also supported CHUs in coming up incominggeneratingactivities(IGAs)toensuresustainabilityoftheunits.

Wehaveworkedwiththesubcountyhealthmanagementteamsandthevolunteerstoaddresscomplexcommunityhealthchallengesthroughanongoingresearchagenda.TheprojectdirectorDr.MaryAdamisamemberoftheNationalDivisionofCommunityHealthInteragencyCoordinatingCouncilandontheTechnicalWorkgroupforOperationalResearch.

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Inall theplacesweworkwe seek the loveofChrist, a love thatgivesbirth tohope throughknowingJesusChrist.

Theobjectivesoftheprojectare:

1. TopartnerwithMOHat countyand subcounty levels in developingnewCommunityHealthUnits(CHUs),strengtheningtheexistingCHUs, in-servicetraining,andtechnicalsupport forCHEWsworkingatTier1&2.

2. To improve health promotion and disease prevention with a focus onMaternal andNewbornmoduleusingagovernmentcertifiedcurriculumwhichincludestheimportanceofANC,developinganindividualbirthplan,dangersignsinpregnancy,howtocareforanewborn, danger signs in a newborn, importance of exclusive breast feeding,immunizations, danger signs in a postnatalmother and the role ofmen in improvingmaternalandchildhealth.

3. TrainandsupportCHVstocollectandutilizeaccuratehouseholdleveldatabyconductinghousehold mapping and registration using government certified tool (MOH 513) todevelopcommunityhealthinformationsystems.

4. Todevelopcommunitybasedparticipatoryprocessesatlevel1throughoperationalresearchtobuildcapacityinprimaryhealthcaresystemsandsupportthecommunitiestoidentifyandutilizetheirstrengthstodrivelocalsolutions.

5. Todevelopquality improvementprocessesandtoolsstartingatLevel1andthatworkacrossthecontinuumofcare(spanningthecommunity,facilityhealthcare,andmid-levelmanagement)strengtheningthehealthcaresysteminKenya.

6. Spiritualgrowththatdemonstratesitsrealitybybringinghealthandhopetopeople.

PROJECTACHIEVEMENTS

1. CHEWstraining

TwelveCHEWsfromGarissaCountyweretrainedinJuly2016.Thisbringsacumulativetotalof183CHEWswhohavegonethroughourtrainingcentersinceSeptember2012.Over80%of(83%)CHEWtraineeshavesuccessfullyimplementedtheiractionplansandscoredthepassinggradeasperSeptember2016.The12CHEWsfromGarissaareintheprocessofimplementingtheiractionplansandhalfofthemhavealreadyreceivedafollowupvisitfromtheMNCHPteam.TheCHEW training program has been a success and the county governments have beenmakingrequeststohavemoreoftheirCHEWstrained.DuringoneofthesupportfollowupvisitstoaCHEWwhoisafulltimePHO,hesaid,“WhenIwasgiventheroletobetheinchargeofthisunit,Iwasnottrainedorbriefedonmyexpectationsinthisaddedrole.Iwasalsonotfacilitatedwith

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requiredresourcestobeabletomoveintothevillagestosupportandsupervisetheCHVsmakingmyworkverydifficult.ThetrainingatKijabehashelpedmetounderstandmyrolesasaCHEW,to support the CHVs, and to learn that it is possible for us to do our dutieswith the limitedresourceswehave.AlsoaftervisitingthemodelCHUsforKijabe,IwasabletoevaluatetheworkthatisbeendonebyourpartnersinourCHUsandIrealizedtheywerenothelpingusmuch.NowIknowhowtodirectthem”.

GroupphotoforGarissaCHEWsaftercompletingthe1weektrainingatKijabeHospital

Dr.EvelynMbuguafromKijabeHospitalissuingcertificatestoGarissaCHEWgraduates

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2. DevelopingnewCommunityHealthUnits

Theprojecthasfundeddevelopmentof2CHUsin2016in2counties.SelectionoftheseunitswerebasedonbeingnearneighborsofKijabeHospitalnamely;RaithaCHUinKinangopSubCounty and Kamburu CHU in Lari Sub County. The CHUs are in Nyandarua and Kiambucounties respectively. This brings a total of 8 CHUs with a total of 211 CHVs who haveundergonea10daystrainingandamongthem158CHVsreceivingagovernmentcertifiedcertificateandabadgesincetheinceptionoftheproject.

CommunityHealthUnitsdevelopedwithfundingfromMNCHPKijabe

NameofCHU

County/SubCounty Yeartrained

No.ofCHVstrained

SupportgivenbyMNCHP

Kinale Kiambu/Lari 2013 20 Meals,transportforMOH,MNCHP&CHVsfor10days,stationaries,certificatesandbadges.

Mbauini Kiambu/Lari 2014 25 Meals,transportforMOH,MNCHP&CHVsfor10days,stationaries,certificatesandbadges.

Naivasha Nakuru/Naivasha 2014 28 Meals,transportforMOH,MNCHP&CHVsfor10daysandstationaries.

MaiMahiu Nakuru/Naivasha 2014 25 Meals,transportforMOH,MNCHP&CHVsfor10daysandstationaries.

Rwanyambo Nyandarua/Kinangop 2015 28 Meals,transportforMOH,MNCHP&CHVsfor10days,stationaries,certificatesandbadges.

Kijabe Kiambu/Lari 2015 25 Meals,transportforMOH,MNCHP&CHVsfor10days,stationaries,certificatesandbadges.

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Raitha Nyandarua/Kinangop 2016 30 Meals,transportforMOH,MNCHP&CHVsfor10days,stationaries,certificatesandbadges.

Kamburu Kiambu/Lari 2016 30 Meals,transportforMOH,MNCHP&CHVsfor10days,stationaries,certificatesandbadges.

3. EmpoweringexistingCHUswithMaternal&Newborntraining

In2016,6CHUswith157CHVswerestartedonmaternalnewborntraining,whichisstillongoing.Thisbringstoacumulativetotalof34CHUswith834CHVsfromthecountiesneighboringKijabeHospital(Kiambu,NyandaruaandNakuru)since2012.TheMNCHtrainersutilizethegovernmentcurriculumthatincludestheimportanceofANC,developinganindividualbirthplan,dangersignsinpregnancy,howtocareforanewborn,dangersignsinanewborn,roleofmeninmaternalandnewbornhealth, importanceofexclusivebreast feedingand immunizations,dangersigns inapostnatalmotherandhowtoconductahomevisit.

PhotoofanongoingmaternalandnewborntraininginNamuchaCHU,NaivashaSubCounty

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TheCHVsworkvoluntarilywithoutanyremunerationorbenefits.Theyareexpectedtomeetonceamonthastheybringintheirmonthlyreportsfromhouseholdvisits.Duringthistime,thevolunteersalsogettogetherfortheirincomegeneratingactivity.ThetrainersutilizethesedayswhentheCHVsaremeetingforotheractivitiestotrainthem.Thisreducestheburdenofhavingthe volunteers spend extra days for training. The module requires meeting on 7 days andspendingabout2hoursintraining,takingabout7monthstocompletethemodule.Theprojectprovidesmaterials,transportforCHVs,MNCHPstaff,andCHEWs,andasnackduringthetraining.AnursewhoisinchargeatalocaldispensaryisalsoaCHEW.WithencouragementandcoachingfromtheMNCHstaff, she successfully ledamaternalnewborn trainingwith theCHVsatherdispensary.ThisincludedatourofthefacilityfortheCHVssothattheycouldunderstandhowthingsworkatthedispensary.Shereportedthatthevolunteershavehelpedinimprovingtherelationship between the community and the health facilitywhichwas tense before. “Whenpeoplesaynegativethingsaboutourfacility,theCHVsclarifytothemthetruth.Forexample,theCHVssawtheworkloadhereandtheyappreciatedthatwearestrained,sowhenthecommunitymembers complain of long waiting hours, they now tell them that wemultitask to register,diagnoseanddispensedrugs.Itisabigreliefformesincecomplaintshavereduced.Alsoreferralsfromthecommunityhavegraduallyincreased”,theCHEWsaid.

4. MOH513Householdmappingandregistration

In2016,3CHUswerefundedbyMNCHPKijabeHospitaltoconductMOH513householdmappingandregistrationandcommunityfeedbackactivitiesnamelyMaiMahiu,RaithaandKamburuinNaivasha,KinangopandLariSubCountiesrespectively.Thisbringstoatotalof7CHUsthathasbeenfundedforMOH513activitybytheproject.Thehouseholdregistrationsaimathelpingthevolunteers map their villages, divide the households each will be visiting and also get thecommunity baseline health indicators. This will guide the volunteers to understand theircommunityhealthchallenges,prioritizethem,andguidethemoncommunityactionanddialogueday activities. This is where they engage the community to get solutions for their healthchallenges. During the household visits, they also give health education on prevailing healthproblemsandmakeappropriatereferrals.

TheCHVsareoftenadultsoflowliteracyrequiringalotofclosesupervisionastheyfilltheMOH513toolthatisinEnglish.SupervisorsfromMNCHPandMOHaccompaniesthemforatleastthefirst3householdsandobserveastheyaskquestionsandfillinthebooks,areavailablephysicallyandonthephonetoanswerquestionsastheyarisefromCHVsduringhomevisits,crosscheckanddebriefdailytocorrectmistakes.

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Duringthehouseholdvisits,manyCHVsappreciatedthediseaseanddisabilityburdenintheirowncommunity.Onevolunteersaid“Iamsurprisedthatwehavealotofchildrenwithdisabilitiesinourcommunity,IliveherebutIdidn’tknowmanypeoplearesuffering.”“PeoplehavetoldmealotabouttheirhealthproblemsandonewomanshowedmeascaryskinconditionthatIhadnever seen”, another volunteer said. “Visiting many homes with sick people has made meappreciategoodhealthasapreciousgiftthatIhadtakenforgranted,myperceptionaboutlifehaschangedforgood.Iwillencourageeveryonetobegoingformedicalcheckupsevenwhentheyfeelokaytodetectdiseasesearlybeforetheygetchronic”,anothervolunteerreported.

5. Communityfeedbackactivities

AftertallyingallthehouseholddatacollectedduringtheMOH513activity,theinformationissharedwith the community and a discussion is generated to get the root cause of the poorindicators.Everyindicatorisdiscussedwithdifferentcommunityandhealthsystemstakeholderstakingstagetoleadinaddressingindicatorsthataffecttheirareasofoperationwhilesupportingthecommunitymemberstoappreciatetheirrolesingettingsolutionstotheirchallenges.

Duringoneofthefeedbackactivityaddressingpoorimmunizationindicators,anelderlywomansaid,“Nothingeverhappenedtomychildrenwhowerenotimmunized.Whenwewerebringingupourchildrenduringthosedays,immunizationswerenotthereandtheygrewwell.”“Whenyoucallforsuchmeetingwherehealtheducationtakesplace,theyoungwomendon’twanttoattend.Whenwegobacktoadvisethem,theycallusoldfashionwithnothingtoofferotherthanbullythemaround.Itisverydifficultwiththeyoungmothers”,anotherelderlywomansaid.Onemansaid,“Doctor,youknowtheseissuesofimmunizationareforwomen,sowhentheydon’tfollowthescheduleasadvised,usmencanneverknow.I’mverysurprisedwiththatreport.”

“Thehealthworkersshoutatuswhenwemissclinicsasscheduled.Becauseof fear,motherschoosenottogoatall.”Ayoungmotherreported“whentheyinjectourchildren,theyarealwaysinahurryandtheydon’texplainwhytheyinjectthem.Sometimesmorethanoneinjectioninonevisit.Thisraisessuspicionandwefear”,saidayoungwoman.

Bytheendofthediscussion,thefacilitatorshaveaddressedalltheissuesthathavearisen,givenhealtheducationespeciallyonthedangersofnottakingchildrenforimmunizations,men’sroleandinvolvementonissuesofMCHandreassuringthecommunityofgovernmentstakeholder’seffortinmakingservicesbetter.

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CommunityfeedbackbarazainprogressatRaithavillage,KinangopSubCounty

6. Healthsystemstrengthening

a) Ongoingoperationresearch

MNCHP has an ongoing research agenda aimed at addressing important questions in healthservices delivery. We have presented our findings on the effectiveness of evidenced basedadaption’swedelivertocommunityhealthworkersatbothnationalandinternationalforumse.g.inApril2016,wepresentedourfindingsoneffectsofashorttrainingcourseandprofessionalbackgroundonthejobperformanceofthecommunityhealthextensionworkersinKenyaatthe7th Annual Global Health Consortium of Universities for Global Health in San Francisco, USAamongotherpresentations.

We are currently partnering with Naivasha Sub County in a research titled “UnderstandingdeliverydecisionsofNaivashasubcountymothers.”Thisqualitativeresearchwillhelp informNaivashaSubCountyaboutwhythereferralhospitalisoverloadedwithdeliveringmothersandwhysomanyfamilieschoosenottodeliveryattheircloserlocalfacility.

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b) SALT(Strengthen-Appreciate-Learn-Transform)

Intheyear2016,theprojecthasworkedtodevelopcapacityinprimaryhealthcaresystemsusingSALTapproachworkshopinWangucommunityhealthunit,NaivashaSubCounty.Theapproachinvolves the community identifying their strength (resources) todrive local solutions to theirchallenges.Thelocalvolunteersdevelopactionplansthroughacommunityparticipatoryprocessbasedonthecommunity’sprioritizedchallengesaddressingpoornutrition,poorsanitationandimprovingmotherandchildhealththroughhouseholdvisits.ThisisaninnovativeapproachtodoingqualityimprovementatLevel1withCommunityHealthVolunteers.Thecommunitywentthroughaprocessofinnovationandincaseswheretheyfailedthefirsttime,theyiterateduntilthebestprocessinaddressingthechallengewasfound.Theaimistoutilizethesuccessofthisapproachtoduplicatetheapproachinaddressingfutureproblemsatthecommunityandhealthmanagementteamsinalllevelsofthehealthcaresystem.

CHVsdiscussingonhowtohandletheirSALTactionplanimplementationchallenges

Onegroupwasaddressingpoorcommunitynutritionasaresultofoverrelianceononeseasoncropsandprioritizingoncashcrops.Thegroupdecidedtostartkitchengardenswithshortseasoncropsat theirownhomeswhich they coulduseasdemonstration sites forother communitymembers to learn. They also decided to increase community awareness on proper nutritionthrough health education. Unfortunately, they were not successful with the kitchen garden

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initiativeduetolackofrainandnoreliablesourceofwaterforthecommunity;theylackpipedwater,noriversorshallowwells.Duringoneofthemeetingstheyhadtoiteratetheirplanofactionorchoosesomethingdifferenttoimplement.“Whenweselectedthisactionplan,wewereconvincedthatthereisagreatneedinourcommunity,sochangingitwillnotsolvethatproblemwhichneedstobeaddressed.Ithinkweshouldlookforwaystosolveourchallengesratherthangivingup”,onewomansaid.

“Ivisitedarelativelivinginasemi-aridareaandIlearnedthatwecanrecycledomesticdirtyandsoapywaterfromwashingclothesandutensilsforourgardens.Whattheydoiscollectusedwaterinatankandaddwoodashandaftersomedaysitissafetouseinthegarden.Iwishwecanadoptandtrythisout”,anotherwomansaid.

Afteraheateddiscussion,thegroupagreedtotryalltheyhadlearnedfromeachotherandfromthefacilitators.

7. Incubatingnewideas:MamaTips

MamaTipsisawaytosendvoiceandtextmessagestohelpteachpregnantwomenaboutthegrowing baby in their womb. MamaTips is also a group of bright young Kenyan socialentrepreneurs,FaniceNyatigo,LaureneAmoit,GloriaNyanja,andJacobChege.TheMNCHteamisprovidingtechnicalexpertisetotheseyoungKenyansbecauseofourshareddreams.Inworkingtogether with theMamaTips teamwe have had additional assistance frommembers of thenutritiondepartmentandtheFamilyClinicofKijabeHospitalindevelopingthepropercontextformessages.TheMamaTipsteamare learningaboutdevelopingthe idea,findingfunds,andexploringhowtobringthiswonderfuldreamintoreality.