norms & standards guide

7/30/2019 Norms & Standards Guide

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Norms and

standardS

For Health Service Delivery

Ministry of HealthJune 2006

Republic of Kenya

Reversing the trends

The Second

NATIONAL HEALTH SECTORStrategic Plan of Kenya


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THIS PUBLICATION is one of a series that the Ministry of Health will produce to support theachievement of the goals of the second National Health Sector Strategic Plan for 20052010(NHSSP I I ). Aiming to reverse the declining trends in key health sector indicators, NHSSP I Ihas five broad policy objectives. These are: Increase equitable access to health services. Improve the quali ty and responsiveness of services in the sector. Improve the efficiency and effectiveness of service delivery. Enhance the regulatory capacity of MOH. Foster partnerships in improving health and delivering services. Improve the financing of the health sector.

Any part of this document may be freely reviewed, quoted, reproduced or translated in full or inpart, provided the source is acknowledged. I t may not be sold or used in conjunction withcommercial purposes or for profit.

Norms and Standards for Health Service Delivery

Published by: Ministry of HealthHealth Sector Reform SecretariatAfya HousePO Box 3469 - City Square

Nairobi 00200, KenyaEmail: [email protected]


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Contents

List of Tables and Figures iiiL ist of Abbreviations ivMessage from the Director of Medical

Services v

1. Background 11.1 Challenges to Developing and

Implementing Norms and Standards 11.2 J ustification for Norms and Standards 21.3 The Health System Structure Needed

to Deliver the Essential Package 21.3.1 Guiding principles in thedefinition of services at differentlevels of care 31.3.2 Definitions of service deliveryunits for each level of care 41.3.3 Summary of needed units 6

2. Human Resources for Health Norms and

Standards 82.1 Methodology for Deriving HRH

Norms and Standards 82.2 Proposed Standards for HRH by

Level of Care 82.3 Proposed Norms for HRH by Level

of Care 102.3.1 Overall norms for key staff 102.3.2 Rationalization of staffing 10

3. Infrastructure Norms and Standards 133.1 Methodology for Deriving

Infrastructure Norms and Standards 13

3.2 Proposed Standards forInfrastructure by Level of Care 14

3.3 Proposed Norms for Infrastructureby Level of Care 14

4. Supervision and Monitoring forAdherence to Norms and Standards 174.1 Guidelines and Interventions for

Achieving HRH Norms and Standards17

4.2 Guidelines and Interventions forAchieving Infrastructure Norms and

Standards 184.2.1 Define catchment areas 19

4.2.2 Identify critical problems forthe different catchment areas 204.2.3 Determine solutions for therespective catchment areas 204.2.4 Prioritize solutions for thecatchment areas 20

4.3 Focus for the Coming Three Years 22

AnnexesA: Service Standards in Line with KEPH 24B: Standard Activities for Different Cadres 30C: Sample Calculation Tables 33

List of Tables and Figures

Tab les

1.1: Service delivery units needed andavailable, by level of care 7

2.1: Staff required to deliver KEPHservices, by level and category 9

2.2: Norms for key service delivery cadres,by level of care 11

3.1: Minimum infrastructure for deliveryof KEPH, by level of care 14

4.1 Average poulations served by varioushealth facilities 18

4.2: Prioritization of solutions for thecritical problem areas: Interpretationof the selection criteria for scoringcatchment areas 21

4.3: Scoring of the selection criteria foreach catchment area 21

4.4: Activity outline for implementation ofnorms and standards for the sector 23

B1: Derivation of available working time 30B2: Standard activities for different staff

cadres 31

F i gu r es

1.1: Health sector pyramid 34.1: Example of national summary of

staff workload at national level 184.2 Definition of catchment areas for

the level of care being reviewed 194.3: The facility analysis 204.4: Summary table for calculating the

total scores for each catchment area 22


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List of Abbreviations

LST L ab TechnologistLTN Lab TechnicianMCH Mother/child healthMDGs Millennium Development GoalsMDRTB Multi-drug resistant tuberculosisMO Medical Officer

MOH Ministry of HealthMSP Medical SpecialistMVA Manual vacuum aspirationNCD Non-communicable diseaseNHSSP I I Second National Health Sector

Strategic Plan, 20052010NVP NevirapineOPD Outpatient departmentOPV Oral polio vaccineORT Oral rehydration therapyP PharmacistPEP Post-exposure prophylaxisPHMT Provincial Health Management

TeamPH T PhysiotherapistPMOH Provincial Medical Officer of

HealthPMTCT Prevention of mother to child

transmission (of HIV)PWD Person with disabilityPSP Pharmacy SpecialistPT Pharmaceutical TechnologistRCN Registered Comprehensive NurseRRI Rapid Results I nitiativeSida Swedish International

Development Cooperation AgencySP SpecialistSTI Sexually transmitted infectionSWAp Sector-wide approachTB TuberculosisUSS Ultra sound scanVCT Voluntary counselling and testingWHO World Health OrganizationWISN Workload indicator for staffing

need

AAFB Atypical acid fast bacilliAIDS Acquired immune deficiency

syndromeAOP 2 NHSSP I I Second Annual

Operational Plan, 2006/07ANC Antenatal care

ART Anti-retroviral therapyBCG Tuberculosis vaccineCDF Constituency development fundCHEW Community Health Extension

WorkerCO Clinical OfficerCOC Combined oral contraceptiveCORP Community-Owned Resource

PersonCSF Cerebro-spinal fluidDCL Data ClerkDFID Department for International

Development

DHMT District Health Management TeamDMOH District Medical Officer of HealthDMPA Depot medroxyprogesterone

acetateDOTS Directly observed treatment

short courseDPT Diphtheria, pertussis and tetanus

vaccineEC Emergency contraceptionENT Ear, nose and throatEPI Expanded Programme of

Immunization

FP Family planningHIV Human immuno-deficiency virusHRH Human resources for healthICT Information and communication

technologyIMCI Integrated management of

childhood illnessesIUCD Intrauterine contraceptive deviceKEPH Kenya Essential Package for

Health


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Message from the Director of

Medical Services

The Ministry of Health has elaboratedits second National Health SectorStrategic Plan (NHSSP I I , 20052010),

which outlines the strategic objectives thesector is focusing on in the medium term toenable it to achieve the expectations outlined

in the Kenya Health Policy Framework, theEconomic Recovery Strategy and the health-related targets of the Mil lenniumDevelopment Goals (MDGs).

NHSSP I I has also proposed therationalization of service delivery, from level1, where community-based services are to beprovided, to level 6, which provides services atthe national level.

Significant effort has been made toredefine the service delivery strategicobjectives outlined in the Kenya EssentialPackage for Health (KEPH). This package

elaborates the expected services the sector willdeliver to Kenyans, by li fe-cycle cohort andservice delivery level, during the period ofNHSSP II .

However, the sector has to-date beenoperating in an environment where thereare differences in activities offered at similarlevels of the system, with wide variations inthe type and quali ty of service. Investments,particularly in infrastructure and humanresources, have not been appropriatelycoordinated, with the result that these inputsare not rationalized or equitably distributedacross the country.

The mix of inputs has not beenappropriately coordinated at the differentlevels, so that in many areas, some inputs areavailable but not used, as others that areneeded are lacking. For example, healthworkers are posted to facili ties withinadequate equipment or commodities. This isall in an environment where increasinginvestments are being made in the sector,through Government, local resources (such as

constituency development funds) and fundingpartners.

The sector has therefore developed thisbooklet, Norm s and Standards for H ealthSer vice Del i ver y, to help provide a rationalframework to guide our investment in healthsector inputs across the country, and toensure equity in availability of investments

needed for the delivery of service to theKenyan population.The norms and standards were developed

through a technical consultative process overan eight-month period. They are apresentation of the expected inputs that areneeded to ensure the efficient and effectivedelivery of defined health services at thedifferent levels of the health system.

Norms and standards refer to them i n i m um andap p r op r i a t emix ofhuman resources and infrastructure that is

required to serve the expected populations atthe different levels of the system with thedefined health services. They define:

The health system structure needed todeliver the defined health services to thepopulation in an efficient, equitable andsustainable manner.

The expected service standards for different

activities to be delivered at the differentlevels of the health system to ensurecomprehensive health service delivery.

The minimum human resources and

infrastructure needed to ensure that thedifferent levels of the system are able tooffer the expected service standards.

The process and expectations for

supervision and monitoring for adherenceto the norms and standards.

The Ministry of Health acknowledges theconcerted effort of the Rapid Results Initiative

(RRI) Working Group on Service Delivery,


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other individuals and numerous institutionsat different levels of the health system thathave worked tirelessly to develop these normsand standards. Acknowledgements also go tothe members of the J oint Sector-WideApproach (SWAp) Steering Committee for

their dedication to this process.The Ministry of Health would like to

specifically acknowledge the World HealthOrganization (WHO), together with theDepartment for International Development(DFID) and the Swedish InternationalDevelopment Cooperation Agency (Sida) for

technical and financial assistance to plan,organize and coordinate the technicaldevelopment of this process.

D r . J am es N yi k a l

Director of Medical ServicesMINISTRY OF HEALTH

J une 2006


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Kenyas health sector has, through thesecond National Health SectorStrategic Plan (NHSSP I I ), defined its

strategic direction for the period 20052010, inthe context of the Kenya Health PolicyFramework. NHSSP I I outlines the results to

be delivered over the period of the strategicplan, and the process to achieve this. Thestrategic focus is defined in a paradigm shift,with the emphasis on ensuring a healthypopulation, as opposed to managing illness.Additionally, a sector-wide approach isintroduced to guide the coordination ofactivities amongst sector partners to maximizeinputs from all.

To achieve the strategic focus, the plandefined a common service delivery package,the Kenya Essential Package for Health(KEPH). KE PH is a unique combination of

integrated activities that wil l be provided toall the citizens of the country to enable theachievement of the health results. To make itwork, however, there must be an appropriatemix of inputs human resources,infrastructure and commodities.

This booklet sets out the norms andstandards that are established to guide theefficient, effective and sustainable delivery ofthis package of services. Service deliverys t a n d a r d s relate to the expectations of eachlevel of care with regard to service delivery

and the human resources needed to meetthese expectations. Service delivery n o rm s define the quantities of these resource inputsneeded to efficiently, effectively andsustainably offer the service delivery package.

1.1 Challenges to Developing andImplementing Norms andStandards

Kenyas health care services have beendelivered through dispensaries and health

centres, complemented by hospital servicesprovided at the district, provincial and

national levels. A lack of guidance on thenorms and standards for these different levelshas resulted in vastly different capacities

across the system facil ities are of differentsizes and the services offered at the respectivelevels of the system vary widely.

Additionally, investments have not beenappropriately coordinated, with the result thatservice inputs are not rationalized or equitablydistributed across the country. Locallymobilized financing, such as through theconstituency development funds (CDFs), hasfurther contributed to uncoordinatedinvestment in health service inputs. The mixof inputs at the different levels has not beencoordinated. Thus some inputs are available

but not used in some facil ities, while othersare needed but lacking.

1. Background

Norms and s tandards

are a statement of the inputs that are

necessary to ensure efficient and

effective delivery of health services to the

population in Kenya. They define:

The health system structure needed to

deliver the defined health services in

an efficient, equitable and sustainable

manner.

The expected service standards for

different activities to be delivered at

the different levels of the health

system to ensure comprehensive

health service delivery.

The minimum human resources and

infrastructure needed to ensure thatthe different levels of the system are

able to offer the expected service

standards.

The process and expectations of

supervision and monitoring for

adherence to the norms and standards.


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These service delivery norms andstandards intend to redress this imbalance.They define the expected inputs required toefficiently and effectively deliver the KEPH atthe different levels of the health system. Theyrefer to the minimum appropriate mix of

human resources, infrastructure andcommodities required to serve the expectedpopulations at the different levels of thesystem.

1.2 J ustification for Normsand Standards

The paradigm shift in the services to bedelivered, from managing health conditions toimproving health, is associated withdifferences in services being delivered.Additionally, the health sector is workingtowards maximum efficiency and equity inservice delivery through a rights-basedapproach aimed at ensuring that all clientshave an equal access to defined results fromthe health sector. This requires adjustinghealth service inputs to ensure capabil ity toprovide the defined services.

Additionally, as the Ministry of Health isnow focusing on building partnerships withother health sector actors, a rational approachis needed in the:

Definition of service delivery standards toachieve at each level of the service deliverysystem.

Quantities of the mix of inputs necessary todeliver the expected services.

Provision of guidance on how to worktowards this mix of inputs for the differentlevels of service delivery.

This booklet provides that guidance. I tpresents: Descriptions of the rationalization of

services by level of service delivery, fordifferent populations.

Descriptions and roles of each servicedelivery level of care, in relation to thepopulation being served.

This document definesm i n i m um resources for each level, recognizing that in

many facilities these may not be the samebecause of the lack of an implementable basicpackage and defined service deliverycatchment areas. It is this lack that hasresulted in differences in packages of servicesbeing provided, even by facil ities supposedly of

the same category, and wide variations incatchment populations. As such, facil ities mayhave service delivery inputs above the definednorms and standards, as a result of highworkloads. For equitable service delivery, thedocument also defines solutions the differentlevels of the sector should undertake to ensureappropriate distribution of these inputs.

1.3 The Health SystemStructure Needed to

Deliver the EssentialPackage

For efficient and effective service delivery,each defined level of the system is expected toprovide KEPH services for a definedpopulation. The size of the population isdetermined by population numbers that areappropriate for the delivery of the definedservices, taking into consideration otheraccess-limiting factors such as naturalbarriers to services. The defined services to be

focused on are elaborated in the KEPHmatrix.

NHSSP I I specified six levels of the healthcare system. Each level has both servicedelivery and management functions to ensureefficient and effective delivery of healthservices. The health systems organizationalstructure is elaborated in F igure 1.1.

At levels 13 of the system, service

delivery and management functions arecombined at the health facilities. Servicedelivery staff also carry out management

functions related to planning, monitoring andsupervision activities.

More extensive management functionsare provided at levels 46. Overallcoordination roles are introduced at theselevels, which calls for more dedicatedstructures. These are the: Office of the District Medical Officer of

Health (DMOH), at level 4 (district level),to coordinate activities in addition toplanning, monitoring and supervisionroles at district level.

Office of the Provincial Medical Officer ofHealth (PMOH), at level 5 (provinciallevel), to coordinate activities in addition

NHSSP II specified six levels of the health

care system. Each level has both service

delivery and management functions to

ensure efficient and effective delivery ofhealth services.


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to planning, monitoring and supervisionroles at provincial level.

Ministry of Health headquarters, at level6 (national level), to coordinate activitiesin addition to planning, monitoring andsupervision roles at national level, andthe development and enforcement ofguidelines, standards and norms fordifferent activities at the different levelsof the system.

1.3.1 G u i d i n g P r i n ci p l es i n t h e

De f i n i t i o n o f Ser v i c es a t

Di f fer en t L evel s o f Car eBasic principles guiding the definition oflevels of care include: Un i t s of ser v i c e del i v er y : The focus is

on the function, rather than the physicalstructure, for example, a level 3 function,as opposed to a level 3 facility. This isbecause the function may also be providedby a higher level facil ity.

Equ i t y i n ac c ess an d u t i l i za t i o n : Allinhabitants of the country and itsrespective districts have equal right notonly to access health services, but also touse them equally for equal need.Important determinants are geographical,

demographic (age and gender), socio-cultural and economic factors.

Rel evan ce an d accep ta b i l i t y : Healthcare must take account of the demand forcare and respond to the real and priori tyneeds of the population. Health careneeds to be rooted in the cultural andsocial reali ty of the communities and toinclude user satisfaction in the healthcare delivery equation.

Con t i n u i t y o f ca r e: A person who seeksassistance for a health problem (whetherto cure or to prevent illness when at risk)is taken care of from the start of theil lness or the risk episode unti l itsresolution. This means that a functionalreferral and counter-referral systemshould exist to make sure that services

are availed to the sick person or person atrisk. Continuity also includes the activefollow-up of certain patients/persons atrisk in order to protect the patient/personand/or the community at large.

I n t eg r a t i o n o f ca r e: Every contact withindividuals, households and communitiesis used to ensure that a comprehensive setof defined services is made available. Thisis different from using every opportunityto do everything.

A comp r ehensi v e /ho l i s t i c ap p r oach :

The health problems of individuals are

Figure 1.1: Health sector pyramid

5,000

10,000

25,000

100,000

1,000,000

Households / Communities / Villages

Level 2Level 2 Level 2 Level 2

Level 3 Level 3 Level 3

Level 4 Facility

Level 5

(Regional Referrals)

Level 6

NATIONAL REFERRAL

HOSPITALS

Provinc ial Level

(PMOH & provin ce partners)(estimated population 4,000,000)

National Level

(MOH, nat ional partners)

Distr ict Level

(DMOH & distr ic t partners)(estimated population 320,000)

DistrictHealth

System

Populat ion

served


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taken care of while considering all the

dimensions of the persons and theirenvironment (this means the householdand the community and their social,cultural, economic and geographiccharacteristics). In order to do so, the

health providers in direct contact with thecommunity have to know thepopulation. They wil l maintain apermanent interaction and dialogue withindividuals, households and thecommunity at large.

The i n v ol v emen t o f i n d i v i d ua l s,

househo ld s an d comm un i t i e s:

Involvement is expressed in people takingup responsibil ity for their own health; itprovides them with a sense of ownership

of all they undertake relating to theirhealth. Such involvement includesindividual participation in healthactivities, as well as collectiveparticipation through management ofhealth facilities. The establishment of afunctioning health committee (a unitmanagement committee), constituted ofinterested and informed communitymembers, is an example of how thiscollective involvement can take shape.

1 .3 .2 Def in i t i ons o f Ser v i ce Del i ver y

Un i t s f or Ea ch L evel of Ca r e

For each level of service, the specific activitiesand populations served are defined on thebasis of the need for equity and efficiency incarrying out the activities.

L evel 1

Level 1 is the community level, which is thefoundation of service delivery. Activities hereare focused on ensuring that individuals,households and communities carry out appro-priate healthy behaviours, and recognize signs

and symptoms of conditions that need to bemanaged at other levels of the system. Eachlevel 1 unit is to take care of 5,000 persons.

L evel 2

Level 2 is the interface between thecommunity and the physical health system. I tis expected to organize and coordinatestructured, permanent dialogue andinteraction with the community and itsstructures by ensuring provision of:a) Curative activities:

Case management of suspected malariacases, acute respiratory infections, fevers,

diarrhoea, simple skin conditions andother simple common illnesses

Case management of chronic illnesses(tuberculosis, AIDS)

Dressing of wounds, simple stitching Case management of simple conditions in

schoolchildren by the health teacherwith first aid kit

Limited (emergency) normal deliveryservices (clients found in stage 2)

b) Rehabilitative activities: Identification of cases needing application

of assistive devices and rehabilitativetherapies through curative and preventivehealth activities and visits to villages

Proper information on referral for thosewho need referral

c) Preventive activities: Antenatal care (screening for risk factors,

administration of iron and folic acid,chemo prophylaxis [intermittentpresumptive treatment] against malaria)

Immunization, administration of vitamin A Under-five growth development follow-up Family planning

d) Promotive activities: These involve socialmobilization through health education forbehaviour change. Activities may range from

group heal th edu cati onduring integratedsessions of preventive and promotiveactivities, to succin ct ind iv id ual healtheducationas appropriate during the curativeactivities. Such activities will focus on: Safe water and sanitation Child nutrition Prevention of blindness, deafness and

injuries Counselling Bednets Mobilization, for preventive health

activities, Expanded Programme ofImmunization (EPI), antenatal care,growth and development follow-up ofunder-fives, voluntary counselling andtesting (which is primarily theresponsibil ity of the Health Centre 3 incollaboration with the Health Centre 2),etc.

e) Health census of the population in thecatchment area

f) Record-keeping and reporting onactivities:


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Keeping and utilizing family files and atickler system for operational charts

Follow up of registration of births anddeaths to guide planning and follow up ofservices

Information on the activities carried out Information on the management of

resources

g) Micro-planning to ensure that allcommunities in the catchment area arereceiving the integrated services

Considering the roles and activitypackage of level 2, a population basis of up to10,000 inhabitants is specified in rural areasand about 15,000 or more in urban areas. TheKenya Services Provision Assessment survey,2004, estimates these services are available to7,989 persons on average in the country.

L evel 3

Level 3 provides the services detailed abovefor the 10,000 persons in its immediatecatchment area (its level 2 function). Level 3also provides the following additional supportservices for level 2 facilities:a) Health activities: Additional outpatient care, largely limited

to minor surgery on outpatient basis Limited emergency inpatient services

(emergency inpatients, awaiting referral,12-hour observation, etc.,)

Limited oral health services Individual health education Maternity for normal deliveries Specific laboratory tests (routine lab,

including malaria; smear test for TB; HIVtesting)

b) Recognizing the need for and facil itatingreferral of clients to and from appropriatelevels

c) Providing logistical support to the level 2

facilities in the catchment area (e.g., EPI coldchain with the fridge and vaccines that are

kept there to cover the immunization needs ofthe catchment area)

d) Coordinating information flow fromfacilities in catchment area

The catchment area for the level 2 servicedelivery functions remains as above. For theadditional functions, however, the catchmentarea is larger, at 30,000 persons (up to 40,000in urban areas), allowing for an average ofthree normal deliveries per day to beconducted at each unit, assuming all clientswere to come to deliver at the units. TheKenya Services Provision Assessment survey,2004, estimates these services are available to19,898 persons on average in the country.

L evel 4

Level 4 facilities focus on appropriate curativecare and constitute the principal referral levelfor all KEPH interventions. Their functionsare again provision of level 2 and level 3services for 10,000 and 30,000 persons,respectively. I n addition to these, level 4 alsoprovides the following services:a) Clinical supportive supervision to lowerlevel facilitiesb) Health activities: Referral level outpatient care Inpatient services

Emergency obstetric care Oral health services Surgery on inpatient basis Client health education More specialized laboratory tests Radiology services

c) Recognizing the need for and facil itatingreferral of clients to and from appropriatelevels, to include Proper case management of referral cases

through the provision of the four mainclinical specialties (internal medicine,

general surgery, gynae-obstetrics,paediatr ics) by general practitionersbacked by appropriate technical devices)

Proper counter-referral

d) Providing logistical support to the lowerfacilities in the catchment area

e) Coordinating information flow fromfacilities in the catchment area

For effective provision of these additionalservices, a population of 100,000 persons in

rural areas and up to 200,000 in urban areaswil l be the defined catchment area for the

Community involvement is expressed in

people taking up responsibility for their own

health; it provides them with a sense of

ownership of all they undertake relating to

their health. To facilitate this process, the

health providers in direct contact with thecommunity have to know the population.


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level 4 services. The Kenya Services ProvisionAssessment survey, 2004, estimates theseservices are available to 100,539 persons onaverage in the country.

The management related activities thatsupport level 4 are coordinated through the

office of the District Medical Officer of Health.These activities relate to additionalcoordination and management roles for thefacil ities in the district in question. Districtlevel partner activities are also coordinatedthrough this office, in line with i tsstewardship role for district health systemmanagement. Each DMOHs office wil l bemanaging on average four level 4 facilities.

L evel 5

This level introduces a broader spectrum of

specialized referral curative services. It aimsto ensure that a wide scope of potential healthneeds of the communities is addressed at apoint where they have access. In addition,level 5 also includes training facil ities forcadres of health workers who function at theprimary care level (nursing staff and clinicalofficers). They also serve as internshipcentres for all staff, up to Medical Officers.

The expected population served by eachlevel 5 facility is 1,000,000 persons. However,population is not the only determinant of theexpected services for this level, as with the

previous levels. Available workload,particularly for the specialized services isanother. This is because it is necessary toavail specialized services on the basis of thedefined need, and not just the expecteddemand.

Management related activities thatsupport level 5 are coordinated through theoffice of the Provincial Medical Officer ofHealth. These activities relate to additionalcoordination and management roles for thedistricts in the province. Provincial level

partner activities are also coordinatedthrough this office, in line with i ts

stewardship role for provincial health systemmanagement. Each PMOHs office will bemanaging on average 12 districts. Thisimplies that each province will have a numberof level 5 service delivery units.

L evel 6This level completes the spectrum ofspecialized referral curative services. I tcontains all the remaining specialized servicesthat are most efficiently provided at a nationallevel. I t includes training facil ities for cadresof specialized health workers that function atthe secondary and tertiary care, up to degreeand postgraduate levels. Level 6 centres alsoserve as internship centres for all other staffnot served at the level 5 facilities.

Level 6 aims to complete the scope of

expected services to cater for the potentialhealth needs of the communities. The level 6facilities wil l be defined on the basis of need,as expressed by prevailing workload regardingspecialized services. This is because of theneed to avail such services according todefined needs, and not just the expecteddemand.

The management related activities thatsupport level 6 are coordinated through theMinistry of Health headquarters. Theseactivities relate to additional coordination andmanagement roles for the provinces, with

specific district support in the form ofbackstopping the provincial teams inidentified weak districts for a respectiveintervention. National level partner activitiesare also coordinated through the Ministry ofHealth, in line with its stewardship role foroverall health system management.

In addition to super specialized care andtraining, level 6 serves as a centre forresearch, with clinical research coordinatedthrough the health facilities and operationsresearch through the management level.

1 .3 .3 Su mm ar y o f Needed Un i t s

The sector therefore requires a total of 6,400level 1 service delivery units, 3,200 level 2service delivery units, 1,067 level 3 servicedelivery units, 320 level 4 service deliveryunits and 32 level 5 service delivery units. Interms of the average number of availablefacil ities, additional investment in facil itieswil l be minimal in the sector, as overall thereappear to be adequate numbers. The situationis different across the different provinces,

however, as illustrated in Table 1.1.

The management related activities that

support level 6, which are coordinated

through the Ministry of Health

headquarters, relate to additional

coordination and management roles for the

provinces, with specific district support in

the form of backstopping the provincial

teams in identified weak districts for a

respective intervention.


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I t should be noted that: The levels of care and service packages

have been redefined for efficient andeffective service delivery. These normsrelate to the delivery of the sectorsdefined package of services, delivered

through these defined levels of care. Forexample, the level 4 norms do notnecessarily relate to a district hospital, ashas been conventionally known, butrather to a level 4 facility serving 100,000persons (this may or may not be a districthospital). The different levels of thesystem stil l have to review and gradetheir respective facilities as per thenorms.

Additionally, the norms refer to them i n i m um expectations not theo p t i m a l .Optimal norms would be derived on the

basis of actual workload at the facility, asdefined in Section 4.

Finally, as each proceeding level of careoffers the services of those levels below it,staff of lower levels should automatically

be included at the level being defined tooffer that service. For example, a level 4facility has level 3 functions (such asoffering normal delivery) for a defined30,000 persons, level 2 functions (OPDoutpatients for first contact) for a defined10,000 persons and level 1 functions(health promotion on the community) fora defined 5,000 persons. These are inaddition to its level 4 functions for itsdefined 100,000 persons. All thesedifferent functions wil l need to berationalized at the health facil ity toenable it to concentrate on its corefunction (as defined by its level).

Table 1.1: Service delivery units needed and available, by level of care

Province Population Service delivery units

Level 1 Level 2 Level 3 Level 4 Level 5

Central 3,909,728 Required service delivery units 782 391 130 39 4

Existing health facilities - 372 89 65

Gaps in service delivery units - 19 41 -26 4

Coast 2,801,356 Required service delivery units 560 280 93 28 3Existing health facilities - 334 42 64

Gaps in service delivery units - -54 51 -36 3

Eastern 5,103,110 Required service delivery units 1,021 510 170 51 5

Existing health facilities - 692 80 65 Gaps in service delivery units - -182 90 -14 5

Nairobi 2,563,297 Required service delivery units 513 256 85 26 3Existing health facilities - 381 54 58


North

Eastern 1,187,767 Required service delivery units 238 119 40 12 1Existing health facilities - 68 12 8

Gaps in service delivery units - 51 28 4 1

Nyanza 4,804,078 Required service delivery units 961 480 160 48 5

Existing health facilities - 333 117 98 Gaps in service delivery units - 147 43 -50 5

Rift Valley 7,902,033 Required service delivery units 1,580 790 263 79 8Existing health facilities - 1,006 161 100


Western 3,853,936 Required service delivery units 771 385 128 39 4

Existing health facilities - 196 94 68 Gaps in service delivery units - 189 34 -29 4

NationalTotal 32,125,305 Required service delivery units 6,425 3,213 1,071 321 32

Existing health facilities - 3,382 649 526 20



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2. Human Resources for Health

Norms and Standards

Human resource norms are rationallydefined for different levels of thesystem in order to ensure an

adequate and appropriate work force for theworkload, and vice versa. What is thereforepresented is:

Standard human resources needed for eachlevel of care. Expected standards with regard to service

delivery that need to be kept for the differentstaff cadres at each level of care.

Quantities of each staff cadre needed todeliver the defined package of services,packaged as the norms.

2.1 Methodology for DerivingHRH Norms andStandards

The norms of human resources for health arederived using a two-step approach:1. To quali fy the expected types of staff

cadres needed at each level2. To quantify the numbers of the different

identified staff cadres needed at everylevel.

The qualification of staff required at eachlevel is based on the services that need to beprovided. The services are detailed in the

KEPH matrix derived during the develop-ment of NHSSP I I . The necessary staff cadresdetermined by this process are detailed below.

The next step, the quantification of thenumbers needed, is based on two differentmethods: Determining the expected workload based

on the activities to be performed, and Rules of thumb

The workload is a function of the expectedactivities to be carried out at each level and

the time it takes to carry out the activities.This provides the total time needed for each

activity of service delivery, within a givenperiod (one year). This is then correlated withthe available time the respective staff cadrehas to carry out the activities over the sameperiod, so as to determine the total numbersof staff needed for the activity. Expectedactivities are based on expected services to bedelivered, while time taken for each activity is

based on World Health Organization (WHO)standards. This methodology is largely usedto determine staff needs for primary caretechnical personnel.

Definition of norms for some staff is basedon rules of thumb. This is largely used forprimary care support staff and hospitaltechnical personnel.

2.2 Proposed Standards forHRH by Level of Care

On the basis of the defined activities to becarried out at each level of care, then, therequired staff cadres are as elaborated inTable 2.1.

In keeping with the rationalization ofKEPH service delivery, the higher the level ofcare (level 1 towards level 6), the higher thespecialization of the staff cadres. As such,more general staff cadres are found at levels 1and 2, with specialization increasing at otherlevels.

For each of these levels, expected service

standards are defined in l ine with expectedKEPH services. Service standards for staffcadres at the different levels are detailed in

The qualification of staff required at each

level is based on the services that need to

be provided, which are detailed in the

KEPH matrix derived during the develop-

ment of NHSSP II. A formal process is used

to determine the numbers of staff requiredat different levels to deliver the services.


15/42


Table 2.1: Staff required to deliver KEPH services, by level and category

Note: The staff standards at each level refer to those needed for the core function of that level. The facili ty willtherefore need the defined staff, plus those of the lower facilities to provide the function of those lower facilities.

For example, the lab technicians are only reflected in level 3, as they offer a level 3 function. They are also needed

at the level 4 facilities to offer this level 3 function. Where staff appear in higher levels of the system (such asRCNs), the implication is that they have additional functions at that level, over and above what they are doing atthe lower level.

Key staff by level of care

Service delivery staff

Community-Owned Resource

Person (CORP)

Registered ComprehensiveNursesCommunity Health Extension

Worker

Nursing staff

Clinical officersLab technicians

Pharmaceutical technologistsCommunity oral health officers

Abov e staff, plus:

Medical Officers

Clinical officers (general andspecialized)

Nursing staffLab technologist

RadiographerPharmacist

Dental technologistDentist

Abov e staff, plus:

Medical specialists (physician,

obstetrics/gynae, surgeon,paediatrician)

Rehabilitative specialists (physio-therapist, occupational therapist,

orthopaedic technologist, social

workers)Nursing staff (intensive care)

Abov e staff, plus:

Medical super specialists withineach discipline

Support staff

General attendantsWatchman

Abov e staff, plus:

Statistical clerksClerk/ cashier

Cooks

Abov e staff, plus:

Drivers

Health AdministratorOfficer

Store attendant

Abov e staff, plus:

Accountant

Medical Engineer

Above staff

Key management support staff

District Medical Officer of HealthDistrict Public Health Officer

District Public Health NurseDistrict Health Administrative Officer

District Health Information Officer

Provincial Medical Officer of HealthProvincial Public Health Officer

Provincial Public Health NurseProvincial Health Administrative Officer

Provincial Health Information Officer

Health promotion support

Environmental health supportDisaster management support

Disease outbreak management supportNon-communicable diseases support

Clinical services supportNursing programme support

Pharmaceutical programme supportMental health programme support

Oral health programme supportRehabilitative therapy support

Malaria programme supportTuberculosis programme support

Child health supportHIV/AIDS programme support

Nutrition programme supportReproductive health programme support

Laboratory services supportDiagnostics radiology support

Health administration supportHealth services management support

Level

of care

1

2

3

4

5

6


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Annex A. Establishing service standardsensures that: There are specified staff cadres at each

level to deliver each component of theKEPH, and

The identification of areas for

strengthening staff ski lls is clear, on thebasis of matching available skills withservice standards to il lustrate gaps.

2.3 Proposed Norms for HRHby Level of Care

Following the definition of the staff cadresbased on expected services, the next step is toquantify the numbers needed to further refinethe norms. Staffing needs are defined as therelationship between annual workload andthe standard workload for the staff cadre atthe defined level of care.

The standard workload for each staffcategory at each level of the system refers tothe volume of work involved in deliveringhealth services that can be accomplishedduring the course of one year by a competentand motivated health worker working toacceptable professional standards. Thestandard workload is a function of theavailable time for work and the time it takesto carry out the respective activities.

Available time for work takes into account thetime the health workers are legitimately notavailable to offer services. This may be due toleave absence, public holidays, off the jobtraining or sickness. On the other hand,activity time for each staff category is definedon the basis of standards for carrying outtheir tasks that have been determined inextensive assessments in similar countries.

Calculations for the standard workloadare summarized in Annex B for each staffcadre at each level of the system, il lustrating

how each staff cadre is quantified at eachlevel of care.Each level of the system can therefore

determine its staff availability according tothe expected norms. Note that the norms arebased on provision of services for a givenpopulation. Not all facil ities wil l be servingthe expected populations; more often,population catchment areas for respectivefacilities are much larger than the definednorms. We therefore define the process forstaff deployment/redistr ibution to guidemovement towards more equitable

distribution of human resources.

For nursing staff, for example, theworkload parameters defined above yieldedan estimate of one RCN for each 5,000population (two at each level 2 facility). Thiswas modified for higher levels to ensure that: A nurse is available for each ten inpatient

beds At least two nurses are available per

operating theatre table, and Three nurses are needed every 24 hours

(eight-hour shifts) A nurse is not responsible for more than

1,000 inpatients annually (ten inpatientsfor every three nurses, each covering aneight-hour shift)

Norms for the key human resources ateach level are presented in the following

sections.

2.3.1 O ver a l l No rm s f or K ey St a f f

The minimum numbers and types of servicedelivery staff needed at each level arepresented in Table 2.2.

2.3.2 R a t i on a l i za t i on of S t a f f i n g

Regarding levels 4 and 5, rationalization ofstaff at these levels is leading to the definednorms. The MOH policy prior to the definitionof KEPH was to work towards having

specialized services at each district hospital(one of the level 4 hospitals). This policy is notchanged. However, as the focus and aimrelate to services, as opposed to the actualcadres: Medical Officers will run the specialized

clinics at level 4 for the four generalspecialities.

Medical specialists wil l be concentrated atthe level 5 facilities, to ensure theyprovide:} Specialized care at this level} Outreach to the level 4 facilities in the

catchment area of the level 5 facility,with at least 1 outreach per month ineach level 4 facility. These wil lprovide specialist care for cold cases orin clinics, and offer on-the-job trainingfor the Medical Officers to improvetheir skills.

Nursing staff will provide the backbone offirst contact services at the outpatients, inline with the level 2 function of services.

Clinical officers wil l provide the firstreferral level for outpatients, managing the

clients as referred by the nurses. This willlargely be at the outpatients.


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Medical officers will provide the firstreferral level for inpatients and secondreferral level for outpatients, managingclients referred by clinical officers (whetherfrom same or other facility). Outpatientreferral management will be through the

specialized clinics at level 4 facil ities. Specialists wil l provide second level referral

for inpatients and third level referral foroutpatients. Outpatient referralmanagement wil l be at specialized clinics atlevel 5 and outreaches to the same clinics atlevel 4 facil ities.

Finally, level 6 provides a variety ofnationally determined services. Somefacil ities, like Kenyatta National Hospital,offer a wide range of such services, whileothers are more specialized, such as theNational Mental Hospital. The staffing is

determined by the expected services theparticular level 6 is providing, guided by thedefined rules of thumb for the staffing.

Continued

5,000

10,000

30,000

100,000

Level 1

Level 2

Level 3

Level 3

function

Level 4(core)

function

General attendants

Watchman

Statistical clerksClerk/cashier

General attendantsCook

Watchmen


General attendants

DriversCooksWatchmen

Store attendantHealth Administrative

Officer

Table 2.2: Norms for key service delivery cadres, by level of care

Level Population Level of Minimum human resourcesfunction Service delivery staff No. Support staff No.

1

2

3

4

CORPs

Nursing staff (RCNs)

Community Health Extension Worker

Clinical officersOutpatient support

Management supportNursing staff

OutpatientsDelivery/inpatients

MCH activitiesDressing room

Overall coordinationCommunity oral health officer

Laboratory technicianPharmaceutical technologist

Clinical officers (outpatient filtering)

Nursing staffGeneral outpatients

Delivery/MCH activitiesLaboratory technician

Pharmaceutical technologist

Medical OfficersOutpatients

Inpatients

ManagementDentistPharmacist

Clinical officersSpecialized clinics

AnaesthesiologistNursing staff

In chargeSpecialized outpatient clinics

WardsTheatre

NurseryRadiographer

Dental technologist

Laboratory technologists

50

2

2

21

114

34

42

11

11

2

82

62

2

62

3

111

54

260

18

3010

31

1

1

2

1

21

21

2

2

1

1024

31

1


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Table 2.2, continued

Level Population Level of Minimum human resources

function Service delivery staff No. Support staff No.

5 1,000,000 Level 3function

Level 4

function

Level 5(core)

function

Clinical officers (outpatient filtering)Nursing staff

General outpatientsDelivery/MCH activities

Laboratory techniciansPharmaceutical technologist

Medical Officers

OutpatientsWards

MaternityManagement

DentistsPharmacists

Specialized clinical officersAnaesthesiologists

Paediatric clinical officerPsychiatrist clinical officer

Dermatology clinical officerENT clinical officer

Ophthalmology clinical officerNursing staff

ManagementSpecialized outpatient clinics

WardsTheatre

NurseryRadiographers

Dental technologistsLaboratory technologists

Medical specialists

PhysiciansObstetricians/Gynaecologists

PaediatriciansSurgeons

PsychiatristsOphthalmologists

ENT specialistDermatologist

AnaesthetistsPathologist

RadiologistOrthopaedic surgeon

Rehabilitative therapistsPhysiotherapist

Occupational therapistOrthopaedic technologist

Social workerMedical officers (intensive care unit)

Nursing staff (intensive care unit)Clinical pharmacist

422

1012

44

15

48

21

22

124

12

11

3178

410

12040

43

43

24

34

33

12

11

31

11

41

11

11

121


General attendantsDrivers

CooksWatchmen

Health AdministrativeOfficer

AccountantsStore attendants

Medical Engineer

2

220

24

32

22

1


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3. Infrastructure Norms and

Standards

For efficient uti li zation of humanresources, appropriate infrastructureis required to ensure they have the

necessary tools to employ their skills.Infrastructure refers to four differentcomponents of these tools:

Buildings: Medical and non-medical Equipment: Medical and hospitalequipment

Information and communicationtechnologies (ICTs): Radio calls (two-wayradios), telephones, networks

Transport services of various types

These four components of the healthinfrastructure must be integrated into aharmonious whole, together with otherrequired inputs (especially human resources),to avoid mismatches in their development and

ensure that health services are deliveredefficiently, equitably and effectively in asustainable manner.

The sector appreciates the fact that, atpresent, there is a variety of infrastructure atthe different levels of care. Therefore, as withthe human resources, the standards definedare meant as a guide to them i n i m um infrastructure needs at the defined levels.They correlate with the defined scope ofservices and expected populations to accessthese services, as specified in the KEPH. The

MOH prioritization of investment wil l bebased on availing these minimuminfrastructure standards.

However, as many facilities wereestablished prior to setting of the presentpopulation-based levels of service delivery,optimal levels of infrastructure are alsodefined. This relates to the desiredinfrastructure a particular level may aspire toif it is operating in a less resource-constrainedenvironment. Minimum standards refer to theleast infrastructure needed to define a level offacil ity, while the optimal standards definethe desirable infrastructure. Priori tization ofinvestment by the sector will be based on the

minimum standards up to a point whereinfrastructure investment ensures adequateaccess to minimum health services. Facilitiesthat have, or communities that seek,infrastructure over and above the minimumstandards will be advised that suchinvestments wil l be considered secondary tothe need for availing the minimum standardsto the whole country.

3.1 Methodology for DerivingInfrastructure Norms andStandards

The services and human resources at thedifferent levels largely determine the requiredinfrastructure, equipment and ICT. Thehealth infrastructure is designed to supportthe implementation of the Kenya EssentialPackage for Health. We can now define themethodology of ensuring that appropriateinfrastructure is available at the differentlevels.

Similarly, equipment is defined byinfrastructure together with human resourcesand services. The standard list of equipmentneeded for the different levels of the system isto be detailed by the sector during the secondAnnual Operational P lan (AOP 2 2006/07)for NHSSP I I . This wil l serve as a guide forbudgeting and planning at the different levelsof care.

The four components of the health

infrastructure buildings, equipment,

ICTs and transport must be integrated

harmoniously, together with other required

inputs (especially human resources), to

ensure efficient, equitable, effective and

sustainable delivery of health care

services.


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3.2 Proposed Standards forInfrastructure by Level ofCare

Section 1 defined the expected standards with

regard to service delivery, by level of care. I tis expected that a level 2 facil ity will beavailable for each 10,000 population, a level 3for each 30,000, a level 4 for each 100,000 anda level 5 for each 1,000,000, or as defined bythe workload for the level 5 function.

The level 1 facil ity wil l have no physicalinfrastructure. However, it will haveequipment and commodities to support thecommunity-owned resource persons (CORPs)and community health extension workers(CHEWs) in their activities.

The level 2 service provision unit will beon a minimum plot size of 1 acre and willconsist of: A medical services provision unit A pit latrine Staff housing Communication equipment

The level 3 service provision unit requires aminimum of 2 acres and will consist of: A medical services provision unit with

maternity and inpatient facil ities A pit latrine

Staff housing Supplies services unit Communication equipment

The level 4 service provision unit requiresa minimum of 5 acres and wil l consist of:

Outpatient service provision unit Mother-child health (MCH)/Family

planning (FP) service provision unit Inpatient service provision unit Radiology unit Administration unit A pit latrine Staff housing Supplies services unit Communication equipment Transport facilities

3.3 Proposed Norms forInfrastructure by Level ofCare

Standard physical infrastructure for each ofthese levels is il lustrated in Table 3.1. Notethat the distr ict health office complementsservice delivery by having equipment for com-munication with facilities and one supportambulance to complement the level 4facil ities support to referral services in the

district.

Continued

Level Population Minimum physical infrastructure

1 5,000 No physical infrastructure

2 10,000 Medical services provision unit of 6 rooms: 1 waiting room1 consultation, with an OPD shed

1 treatment room1 community services room

1 MCH/FP services room1 store

Labour bed and low-cost delivery bed

Staff houses for 2Pit latrine (2 stance)Simple incinerator

Simple transport (1 bicycle primarily for outreach, and motorcycle for supplies collection)Locally defined referral transport (bicycle ambulance, etc.) to facility from community

Communication equipmentWater storage for roof catchment

Fence and gateComposite pit

Minimum acreage, 1 acre

3 30,000 Medical services provision unit with: 3 consultation rooms

1 treatment room1 minor theatre at outpatients

1 records room2 rooms with total of 11 inpatient beds

Table 3.1: Minimum infrastructure for delivery of KEPH, by level of care


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2 stores; 1 for drugs, 1 general1 laboratory room

1 labour ward for two, and delivery room

1 community services roomStaff housing for 24 stance pit latrine

1 simple Incinerator1 placenta pit

1 motorcycleCommunication equipment

Water storage for roof catchmentFence and gate

Composite pitMinimum acreage, 2 acres

Supply services unit with: KitchenLaundry

4 100,000 OPD block with: 1 waiting room4 consultation rooms

1 registration room1 injection room

1 plaster room1 minor theatre

1 dental unit room1 ENT services room

1 laboratory room

MCH/FP unit with: 1 immunization services room

1 FP coordination room1 antenatal coordination room

1 maternity ward for 3 deliveries1 nursery room with 3 cots

Inpatient services with: 50 beds for male inpatients50 beds for female and children inpatients

2 operating theatre beds

Administration unit with: 1 pharmacy/drug dispensing room

1 cash office2 stores

2 administration offices1 room for health records

1 community services room1 mortuary

Staff quarters for 4 persons on duty

Radiology unit with: 1 x-ray room1 USS room

Ablution block4 stance pit latrine

Source of running waterWater reservoir

1 placenta pit1 generator house

1 incinerator1 motorcycle

Communication equipment2 vehicles 1 ambulance

1 support vehicle



Continued


22/42




Fence and gate

Composite pitWater storage for roof catchment

Minimum acreage 5 acres

5 1,000,000 OPD block with: 1 waiting room6 consultation rooms

1 registration room2 injection rooms

1 plaster room1 minor theatre

1 dental unit room1 ENT services room

1 laboratory room

MCH/FP unit with: 1 immunization services room

1 FP coordination room1 antenatal coordination room

1 maternity ward for 6 deliveries1 high dependency unit with 6 cots

Inpatient services with: 200 beds for male inpatients200 beds for female and children inpatients

4 operating theatre beds (1 gynae emergencies,1 cold case, 1 general emergencies, 1 ophthalmic)

1 Intensive care unit with 4 beds

Administration unit with: 1 pharmacy

1 drug dispensing room1 cash office

4 stores2 administration offices

1 room for health records1 community services room

1 mortuaryStaff quarters for 8 persons on duty

Radiology unit with: 1 x-ray room1 USS room

Ablution block10 stance pit latrine

Source of running waterWater reservoir

1 placenta pit1 generator house

1 incinerator1 motor cycle

Communication equipment

2 vehicles 1 ambulance1 support vehicle


Fence and gateComposite pit

Water storage for roof catchmentMinimum acreage 10 acres

Medical engineering unit


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4. Supervision and Monitoring for

Adherence to Norms and Standards

Just as standards are required for thephysical resources, so are theynecessary for the supervisory and

monitoring mechanisms that intend to keepthe resources in place. This section providesguidelines for ensuring that the norms and

standards for both human resources andinfrastructure are maintained.

4.1 Guidelines andInterventions forAchieving HRH Normsand Standards

The guidance towards prioritization of staffmovement is aimed at ensuring a moreequitable distribution of workload across the

health workers in the system. Guidance onplanning for where new staff should be postedand how staff can be redeployed is definedhere on the basis of a rational methodology.This is based on prioritizing situations wherethe comparative work pressure is highest.

A workload indicator ratio (WISN workload indicator for staff need)) defines theworkload on the staff. This ratio is based onthe relationship between the actual and theexpected staff numbers per populationserved.1 A WISN of 1.0 indicates staffing is

per norms. I f, for example, facility A has 7nurses against an expected 10, its WISN ratiois 0.7; or 70% staffed (30% understaffed).Facility B, with 85 nurses against an expected100, has a WISN ratio of 0.85 (85% staffed;15% understaffed). As such, facil ity A receiveshigher priori tization compared with facil ity B,as its understaffing situation is greater(workload of missing staff is spread over

fewer staff in facil ity A than B, meaning theyare under much greater work pressure).

The same logic applies for redistributionof staff away from facilities with staff over theestablishment. As an example, facility C has15 nurses, against an expected norm of 10,implying its WISN ratio is 1.5 (50%overstaffed). On the other hand, facility D has

120 nurses against an expected norm of 100,implying a WISN ratio of 1.2 (20%overstaffed). The extra staff at facility C givea higher degree of overstaffing (50%) and soredeployment will start there.

This method helps to identify staffinginequities between facilities, even if there isan overall staff shortage, and guides specificactions that should be taken to remedy this. I tprovides clarity on: How the workload pressure at each

measured unit (facility/district) can becompared with others;

Where staff shortages or workloadpressures are concentrated for thedifferent staff categories; and therefore

Where new staff in each category shouldbest be posted or where transfers wouldimprove the overall situation.

This analysis should be carried out on aregular basis for the national and districtlevels. The national level defines movementsbetween districts on the basis of themethodology described above. This could then

be summarized in a table like the one shownin Figure 4.1. Redistribution/deployment is

1 The actual population served is used because atpresent most facilities are serving populations that

do not necessarily coincide with the expected

population levels. As such, it limits the situationswhere staff are removed from high volumefacilities.

Supervisory and monitoring mechanisms

are an essential part of norms and

standards because their purpose is to keep

the phyisical resources in place. The

prioritization of staff movement, for

example, is aimed at ensuring a more

equitable distribution of workload across the

health workers in the system.


24/42


However, because of differences betweendistricts and regions, some areas haveinadequate infrastructure, and thereforeinvestment is called for. I dentification andpriori tization of this investment is done atdefined levels of service delivery: distr ict level

for investments at levels 14; provincial levelfor investments at district level; and nationallevel for investments at provincial level.Information to guide each is based onsummaries derived from the lower level.National level is based on information fromprovinces and provincial level on informationfrom districts. The resource envelope at eachlevel is applied to the highest priori tizedinvestments.

Development of health infrastructureshould be such as to ensure that it is firstlocated in those areas that are under-served.

Furthermore, any upgrading of infrastructureshould be aimed at achieving the respectivefacilitys prescribed level of service inaccordance with the definitions in Section1.3.2. The following are exceptions: Where a level 3, 4, 5 or 6 facility is

located, a new one of a lower level for therespective catchment population need notbe established. Such units wil l also servethe functions of the appropriate lowerlevel facility for the respective catchmentpopulation. For example, if a level 5

facility exists, it also provides for the level4 functions for i ts immediate 100,000250,000 persons, level 3 functions for itsimmediate 25,00040,000 population, andlevel 2 functions for its immediate 10,00015,000 population.

In areas where access to the appropriatehealth centre level is grossly impairedbecause of terrain, water bodies, etc.,another health unit of the same level mayneed to be provided to serve the affectedarea. For example, an island with 5,000

persons may be provided with a level 3facil ity meant for 25,00040,000 persons.

based on moving staff from districts withhighest WI SN ratios to those with lowestratios.

At the district level, a similar summary isproduced for all the facilities at each level ofcare. Staff redistr ibution/deployment is based

on the analysis, prioritized according tochanges made through the process at thenational level. The dummy table used is thesame as above, with facilities instead ofdistr icts as the categorization used.

4.2 Guidelines andInterventions forAchieving InfrastructureNorms and Standards

A review of Kenya Service ProvisionAssessment Survey (2004) data on availablefacilities, including non-government ones,shows that on average, if the publicprivatepartnership is appropriately util ized, limitedadditional facilities are required, as thoseavailable should by and large be able toprovide the services for the different levels ofcare. Table 4.1 il lustrates the averagepopulations served by available healthfacilities.

Table 4.1: Average populations served by

various health facilities

Level of care Median population in

catchment area

Hospital 100,539

Health centre 19,898

Maternity 7,989

Clinic 10,973

Dispensary 7,937

Stand alone VCT 150,400

Source: Adapted fromKenya Servi ce Pr ovision

Assessment Su r vey, 2004. Maternal & Child Health,Family Planning and STI s volume, p. 30.

Figure 4.1: Example of national summary of staff workload at national level

Staff category

District Category 1 Category 2 Category 3 (etc.)

Actual Staff WISN Actual Staff WISN Actual Staff WISN

staff reqd. ratio staff reqd. ratio staff reqd. ratio(A) (B) (A/B) (A) (B) (A/B) (A) (B) (A/B)

__________________________________________________________________________________

__________________________________________________________________________________


25/42


Standard basic infrastructure require-ments and designs (for new constructions) atthe respective levels have been developed andare available on request from the Ministry ofHealth Infrastructure Department. Theprocess of selecting areas for new

infrastructure is done in a series of steps:1. Define the catchment areas.2. Identify the critical problems for the

different catchment areas.3. Determine solutions for the respective

catchment areas.4. Pr ioritize solutions for the catchment

areas.

4.2.1 Def i n e Ca t c hmen t A r ea s

This is part of the overall planning andservice organization process for the respective

level of care. The aim is to facilitatecategorization of service delivery fromadministrative areas to catchment areas. Thecatchment areas define units of populationthat require a defined level of services. Fromthe service delivery norms, we see the definedpopulations for each service delivery level.

Each level of service delivery is assessedindependently. The exercise involves reviewof the approximate administrative level interms of defining how many catchment areasit has, for the respective level of care. Forexample: sub location for level 2 facilities;location for level 3 facil ities; and division forlevel 4 facil ities. The district health team,following the defined guidelines, determinesthese catchment areas for the different levels.This analysis needs to take into account thecriteria to demarcate such areas, such as

population base and natural barriers anddensity. To the extent feasible, facilities of thesame level should be in separate catchmentareas.

A catchment area may therefore becategorized as:

Similar to its correspondingadministrative level.

Smaller than its correspondingadministrative level (each administrativelevel made up of more than one catchmentarea).

Larger than its corresponding admini-strative level (each administrative levelmaking up part of a catchment area).

Note that it may be necessary to mergevil lages from different administrative levels

into one catchment area.Where the population of anadministrative level is greater than one andone-half times that stated above, such anadministrative level qualifies for a secondfacility of the same level. For example, adistr ict with 500,000 persons having anexisting district hospital qualifies for a secondlevel 4 facility (to be established as perminimum standards, and not as anotherdistrict hospital).

I f two neighbouring administrative levelseach have populations under one and one-half

times that stated above, but their combinedpopulations are over this, a new facility maybe justifiable to serve populations across thisadministrative level.

The dummy table in Figure 4.2summarizes this review of catchment areas.

Figure 4.2 Definition of catchment areas for the level of care being reviewed

Name of Complete administrative Villages included of incomplete Total popula Administra-

catch- level included* administrative levels tion of catch- tive levelsment ment area involved in

area Names Population Name of sub loca- Population catchmentof admini- tions (names from each area

strative level of villages for sub loca-each sub location) tion

(1) (2) (3) (4) = (2) + (4)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

* Villages for level 2; sub locations for level 3 and locations for level 4.Following this, the respective catchment areas that require services are defined for the different

levels of care. What is left is to define their situation and plan how to address it.


26/42


revitalization of a facility or the establishmentof a new facil ity:

The critical problem areas identified

under the activity approach (situationcategory 2 or 3) will require revitalizationof one sort or another as the solution in

order for the health unit to become fullyfunctional.

The critical problem areas identified

under the facility approach (situationcategories 46) wil l require theestablishment of a new health unit.

4.2.4 P r i or i t i ze Sol u t i o n s f or t h e

Ca t c hmen t A r ea s

In order to prioritize over a time period whichhealth units wil l be taken on first, we need aseries of selection cri teria. Table 4.2 presentsa tentative list of five criteria on which theselection should be based. For each cri terion,there are three factors to be taken intoaccount:a) The specific description of the criterion.b) As not every criterion may be of similar

importance, each criterion is given aweight between 0 and 1 with incrementsof 0.25.

c) A score (for example, from 1 to 3: 1 beingthe least favourable and 3 the mostfavourable condition) is further used to

appraise each criterion for eachcatchment area. For example, for thecriterion distance, understood as accessto health care by the population of thearea of responsibil ity, a score of 3 meansfarther away from any health unit. Forthe criterion total population, a score of1 means lower total population and ascore of 3 the highest total population.

For the health units to be revitalized, onemore criterion is proposed: the relative

importance of the resources required forrevitalization. Multiplying factors 2 and 3then produces the calculation of the score foreach criterion (Table 4.3).

Once all criteria one catchment areas arescored, a total score can be made by adding upthe calculation results for each criterion andfilling in the bottom row of the table. See thedummy table in F igure 4.4 for the scoring ofeach individual catchment area.

The information to be calculated can besummarized into two tables like the dummytable, one for the catchment area with

revitalizations of health units and one for thecatchment areas with new establishments.

4.2.2 I d en t i f y C r i t i c a l P r ob l ems f or

th e D i f f er en t Ca tchm en t A r eas

This is done for each level of service deliveryto determine the respective infrastructureneeds. This is defined using two approachesbased on the presence or the absence of ahealth facility for each correspondingadministrative level. These approaches are: The activity approach, which means

that there is a health facil ity but it may ormay not be ful ly functional. It means thatsome of them require minimuminfrastructure that is not available.

The facility approach, which means thatsome of the defined catchment areas arenot covered with a level 2 health centre.

We have summarized these approaches in

Figure 4.3, which presents six distinctsituations.

Figure 4.3: The facility analysis

Infrastructure available

Yes Partly No

Facility Present 1 2 3

Absent 4 5 6

Situation 1 implies that there is a facil itywith adequate infrastructure as per thenorms.

Situation 2 implies that there is a facil ity,but with inadequate infrastructure as perthe norms.

Situation 3 implies that there is a facil ity,but with no infrastructure. These areusually facil ities that exist, but are hardlyused.

Situation 4 is not feasible, as there cannotbe a lack of a facility if there is adequateinfrastructure.

Situation 5 implies that there is nofacil ity, but there is some infrastructure

available, for example through donations. Situation 6 implies there is no facil ity and

no infrastructure

Using the same table as in F igure 4.3,each catchment area is reviewed and itssituation category is defined as 16,depending on the review.

4.2.3 Det er m i n e Sol u t i o n s f or t h e

Respec t i ve Ca t chm en t A r eas

There are two types of solutions according to

the approaches used for the identi fication ofthe critical problem areas: either the


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Description of criterion Weight Score interpretation (1 to 3)

Distance (~ access tohealth care by pop of the

catchment area)

1 1 = nearer to health unit (other facility of similar or higher level inneighbouring catchment area)

3 = further from a health unit (no nearby other facility of similaror higher level)

Access to catchmentarea by DHMT (Weightedby distance, and terrain)

0.25 3 = nearer to DHMT1 = further from DHMT

Population of catchmentarea

0.5 1 = lower population than the defined norm3 = higher population than the defined norm

Population readiness 1 3 = populations that have expressed willingness to supportestablishment of a facility (CDF funds or other source ofadditional funding available)1 = No expressed willingness to support establishment of a

facility (will most likely be sole responsibility of the sector)

Strength of existingcommunity structures

0.25 3 = stronger community structures and involvement1 = weak community structures and involvement

Solution required(revitalization orestablishment of afacility)

1 Health unit to be revitalized:3 = if catchment area is of situation 2 (some equipmentavailable)1 = if catchment area is of situation 3 (no equipment available)Health unit to be established:3 = if catchment area is of situation 5 (there is some availableequipment for facility)1 = if catchment area is of situation 6 (no available equipment)

For units to be revitalizedonly

Input required torevitalize

0.75 1 = If substantial input required3 = if minimal input is required

Table 4.2: Prioritization of solutions for the critical problem areas: Interpretation of the

selection criteria for scoring catchment areas

Description of criterion Weight Score interpretation (1 to 3)

Table 4.3: Scoring of the selection criteria for each catchment area

Name of CATCHMENT AREA: _______________________________

SOLUTION: (Revitalization/Establishment) ____________________

Description of criterion Weight Score Calculation for

each criterion

(2) (3) = (2) x (3)

1.Distance (~ access to health care by pop of

the catchment area) 1

2.Access to catchment area by DHMT (weighted

by distance and terrain) 0.25

3.Population of catchment area 0.5

4.Population readiness 1

5.Strength of existing community structures 0.25

6.Solution required (revitalization or

establishment of a facility) 1

For health units to be revitalized only

7.Input required to revitalize 0.75TOTAL SCORE


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Once the scoring exercise is completed foreach catchment area, the information isrecorded in a summary table whilesubdividing the health units by solution(revitalization or establishment) and rankingthem according to their total scores.

Note that the scoring of some of thesecriteria may change over time, for examplereadiness of the population in the catchmentarea to collaborate in the revital ization/establishment of a level 2 health centre.Th erefore, the rank in g of th e healt h uni ts

should be reviewed annual ly d ur in g the

oper ati onal pl ann i ng exer ci ses. Even duringthe year, however, some communities may forwhatever reason become active and plan tostart the revitalization/establishment of ahealth unit. This should only be allowed aftersufficient interaction with the community andthe agreement to a contract on the roles andresponsibilities of the community (as is theroutine practice for each revitalization orestablishment of a health unit).

(See Annex C for versions of the dummytables in F igures 4.2 and 4.4 that are suitable

for phtocopying.)

4.3 Focus for the ComingThree Years

The sector will focus on: Disseminating these norms and standards

to all levels of the sector. Developing training modules for

provincial and district levels on theapplication of these norms and standardsto rationalize their service deliverysystems.

Supporting the provincial and district

levels on guiding their respective distr ictsand health facili ties in the use of thesemodules and guidelines.

Providing specific support to districts asmay be determined.

Reviewing strategies to adopt norms andstandards at different levels.

Monitoring adherence to norms andstandards.

Activities and timelines to achieve theseobjectives are illustrated in Table 4.4.

Figure 4.4: Summary table for calculating the total scores for each catchment area

Name of catchment Calculation for each criterion Total Rank

area 1 2 3 4 5 6 7 score

______________________________________________________________________________________

______________________________________________________________________________________

_______________________________________________________________________________________

________________________________________________________________________________________

_______________________________________________________________________________________

________________________________________________________________________________________

_______________________________________________________________________________________

Note: Prepare one table for revitalizations, one table for new establishments.


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Table 4.4: Activity outline for implementation of norms and standards for the sector

Objective Activity Responsible unit Time frame

Year 1 Year 2 Year 31 2 3 4 1 2 3 4 1 2 3 4

Dissemina- Development of dissemi-ting these nation package Level 6 X

norms and Definition of dissemina-standards tion process Level 6 X

to all levels Dissemination process Level 4, 5, 6 Xof the sector Monitoring and review of

dissemination process Level 5, 6 X

Developing Development of training

training modules Level 6 X Xmodules Incorporation of module in

planning guidelines Level 6 XTypesetting and printing

of modules Level 6 X

Supporting theprovincial, anddistrict levels on Training of provincial level Level 5, 6 X

guiding their Training of district level Level 5, 6 X Xrespective Technical support to train-

districts and ing process Level 5, 6 X Xhealth facilities in Review of training impact Level 5, 6 X X

use of thesemodules and

guidelines

Providing specific Identification of specific

support to dis- districts nee

norms & standards guide

Documents