primary facilities assessment level report 2014 _2

MINISTRY OF HEALTHSTATE OF HEALTH SERVICE DELIVERY

SEPTEMBER 2014

Health Sector Monitoring & Evaluation Unit

An Assessment Report for Primary Level Facilities

ii An Assessment Report for Primary Level Facilities

State of Health Service Delivery

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FOREWORD

The constitution of Kenya 2010 guarantees Kenyans the Right to health. In addition, the constitution further guarantees the right to the highest attainable standards of health, including reproductive health. In the current devolved system of Government, it is imperative that the two levels of Government work together to guard this constitutional right. One of the ways of moving towards this aspiration is through monitoring and evaluation of service delivery. This not only helps in redirecting resources but also helps identifying areas that may require improvement in an effort to offer quality services to Kenyans. Innovative initiatives such as the free maternity services and the free services at the Primary care facilities among others have been implemented in the health sector. Concerted efforts therefore are required by all the players in health to sustain these innovations in order to improve health indicators and attain health goals. In addition, progress made in delivery of quality health services in the last decade need to be sustained.

The primary objective of the monitoring exercise was to track the delivery of health services in the facilities for purposes of providing information to policy makers both at National and county Government, the implementers in the facilities and the community at large. Such information would in return help in decision making towards improving delivery of health services to Kenyans. In addition, the information is useful in identifying the investment that is required to improve the service delivery. Since 2008, enhanced supportive supervision had been carried out on regular basis in facilities especially in the hospitals. However this was the first such exercise to be carried out in the primary care facilities. Hence the monitoring exercise was important in ensuring these facilities that may not have benefited as much earlier on, are not left out. The expected outcomes are improved efficiency in service delivery and improved quality of care while improved health status of Kenyans is the ultimate goal.

Hence the National and the County Government carried out a joint exercise in the month of July 2014. This report highlights key achievements in various aspects of service delivery, strengths, challenges identified during the exercise as well as recommendations for purposes of improvement. It shall form the basis for future such exercises in order to track progress. I wish to encourage Continuous monitoring and evaluation of health services delivery by both counties and National for better health outcomes.

DR NICHOLAS MURAGURI

DIRECTOR OF MEDICAL SERVICES

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ACKNOWLEDGEMENT

The successful completion of the monitoring exercise in the health facilities in Kenya was made possible by both individual and collective efforts of various players in the health sector for the period of 2013/14 Financial Year.

Special thanks and appreciation go to the Health Cabinet Secretary James W. Macharia, Permanent Secretary Khadijah Kassachoon for their able leadership, guidance and support during the exercise of monitoring of service delivery in facilities within the country. We are also indebted to Dr. Nicholas Muraguri, the Director of Medical Services for his overall coordination of the exercise as well as offering technical guidance during the exercise.

We acknowledge the commitment of the monitoring teams for working tirelessly and for their commitment. These team members included, Dr David Kiima, Dr John Odondi, Mrs Zipporah Wanderah, Mr Joseph Baraza, Dr Osore, Dr Kibias, M/s Rose Kuria, John Kabanya, Dr Phillip Mbithi, Dr Izaq Odongo, Manasseh Mbocha, Ann Kibet, Dr Thiongo, Dr Jackline Kisia, Sr Agnes Khati, Eunice Ambani, Dr Antony Miano, Milka Kuloba, Mary Wachira, Dr Riara Nthuraku, Dr Pacificah Onyancha, Nafatri Murage, Dr Pauline Duya, Dr Shikely, Dr Gachari, Sammy Muia, Dr Amin, Dr MaryAnn Ndonga, Dr Nancy Njeru, Dr John Kihama, Betty Samburu, Dr Elizabeth Onyiego, Dr Brenda Makhoha, Dr Simon Mueke, Susan Otieno, Mr Mutiso and Dr Lusi Ojwang. In addition we recognize the staff in the health facilities for their assistance.

Many thanks also go to the Health Sector Monitoring and Evaluation unit Staff for their coordination of the activity and the subsequent production of this report. These include Dr Maina Isabella, Dr Hellen Kiarie, Mr Pepela Wanjala, Tom Mirasi, Beatrice Muraguri as well as the interns in the unit namely Joseph Mwangi and Michael Onyango. Finally we are indebted to World Health Organization (WHO) for their support of the entire exercise both financially and technically.

DR ISABELLA MAINA

HEAD; HEALTH SECTOR MONITORING AND EVALUATION UNIT

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TABLE OF CONTENTSFOREWORD .................................................................................................................................................... iiiACKNOWLEDGEMENT ..................................................................................................................................... vLIST OF FIGURES ............................................................................................................................................. ixLIST OF TABLES ............................................................................................................................................... xiLIST OF ACRONYMS ..................................................................................................................................... xiiiEXECUTIVE SUMMARY ................................................................................................................................... xvCHAPTER 1: INTRODUCTION .................................................................................................................. 11.1 Background ............................................................................................................................................. 11.2 Objectives and scope of the reforms assessment exercise ..................................................................... 1CHAPTER 2: METHODOLOGY ................................................................................................................. 32.1 Assessment Framework ........................................................................................................................... 32.2 Process .................................................................................................................................................... 32.3 Sample Size .............................................................................................................................................. 32.4 Data Processing and Analysis .................................................................................................................. 3CHAPTER 3: PRIMARY LEVEL FACILITIES PERFORMANCE ......................................................................... 53.2 Compliance with Service Delivery Charter .............................................................................................. 63.2 Timely delivery of health services .......................................................................................................... 63.3. Quality Clinical care (OPD) ...................................................................................................................... 63.4 Improved Nutrition care .......................................................................................................................... 73.5 Outreach services .................................................................................................................................... 83.6 Community Involvement and Participation ............................................................................................. 83.7 Emergency Preparedness and Timely Response in Facility ..................................................................... 93.8 Diagnostic and Blood Services ................................................................................................................. 93.9 Commodity supply Management .......................................................................................................... 103.10 Child Health ....................................................................................................................................... 113.11 Maternal Health ................................................................................................................................. 133.12 Disability Mainstreaming .................................................................................................................... 163.13 Gender Mainstreaming ....................................................................................................................... 163.14 Quality of Mental Health .................................................................................................................... 173.15 Improved Facilities Environment ........................................................................................................ 173.16 Adherence to safety guidelines ........................................................................................................... 193.17 Automation ......................................................................................................................................... 203.18 Efficient Records and Information System ........................................................................................... 203.19 Human Resources Management ......................................................................................................... 203.20 Facility assets ....................................................................................................................................... 213.21 Efficient Healthcare Financing ............................................................................................................ 223.22 Facility Planning, Leadership and Management ................................................................................ 223.23 Innovations .......................................................................................................................................... 23CHAPTER 4: RECOMMENDATIONS AND CONCLUSION .......................................................................... 254.1 Recommendations ................................................................................................................................. 254.2 Conclusion ............................................................................................................................................. 26

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LIST OF FIGURESFIGURE 1: IMPLEMENTATION OF SERVICE DELIVERY CHARTER 6

FIGURE 2: QUALITY OF CLINICAL RECORDS (OPD) 7

FIGURE 3: NUTRITION SERVICES 8

FIGURE 4: OUTREACH SERVICES 8

FIGURE 5: COMMUNITY SERVICES 9

FIGURE 6: EMERGENCY PREPAREDNESS AND RESPONSE 9

FIGURE 7: AVAILABLE LABORATORY SERVICES 10

FIGURE 8: COMMODITY SUPPLY MANAGEMENT 10

FIGURE 9: NEWBORN CARE 12

FIGURE 10: AVAILABLE VACCINES AND SUPPLEMENTS 12

FIGURE 11: HOURS SKILLED BIRTH ATTENDANTS’ AVAILABLE 14

FIGURE 12: FAMILY PLANNING 15

FIGURE 13: DISABILITY MAINSTREAMING 16

FIGURE 14: GENDER MAINSTREAMING 17

FIGURE 15: FACILITY POWER SOURCE 19

FIGURE 16: BARRIER NURSING 19

FIGURE 17: PERFORMANCE APPRAISAL SYSTEMS 20

FIGURE 18: FACILITY ASSETS 21

FIGURE 19: HEALTH CARE FINANCING 22

FIGURE 20: PLANNING, MANAGEMENT & GOVERNANCE 22

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LIST OF TABLES TABLE 1: STAFFING IN PRIMARY FACILITIES .....................................................................................................5

TABLE 2: HEALTHCARE FINANCING- PRIMARY FACILITIES ......................................................................................5

TABLE 3: SERVICE DELIVERY DATA (OPD) .........................................................................................................7

TABLE 4: NEONATAL RESUSCITATION ..............................................................................................................11

TABLE 5: IMMUNIZATION SERVICE DELIVERY DATA ........................................................................................13

TABLE 6: GROWTH MONITORING ...................................................................................................................13

TABLE 7: MONITORING OF LABOUR ...............................................................................................................14

TABLE 8: ANC SERVICES ..................................................................................................................................14

TABLE 9: ANC SERVICE DELIVERY DATA ...........................................................................................................15

TABLE 10: AVAILABLE GUIDELINES, POSTERS AND JOB AIDS ..........................................................................15

TABLE 11: REPORTED DELIVERIES ...................................................................................................................16

TABLE 12: SGBV SERVICE DELIVERY DATA .......................................................................................................17

TABLE 13: MENTAL REFERRAL CASES SERVICE DELIVERY DATA ......................................................................17

TABLE 14: IMPROVED FACILITY ENVIRONMENT .............................................................................................18

TABLE 15: FIRE SAFETY....................................................................................................................................19

TABLE 16: EFFICIENT RECORD SYSTEMS .........................................................................................................20

TABLE 17: KEY STAFF CLINICAL OFFICERS AND NURSES ..................................................................................21

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LIST OF ACRONYMS

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal Care

ARVs Anti-Retroviral

BCG Bacille Calmette-Guerin

CME Continuous Medical Education

DOT Directly Observed Therapy

GOK Government of Kenya

HIV Human Immunodeficiency Virus

IPT Intermittent Preventive Therapy

ITN Insecticide Treated (Mosquito) Nets

MDGs Millennium Development Goals

OPD Outpatient Department

PMTCT Prevention of Mother To Child Transmission

SOPs Standard Operation Procedures

SP Sulphadoxine Pyrimethamine

TB Tuberculosis

TT Tetanus Toxoid

VIA/VILLI Visual Inspection in Acetic Acid/Visual Inspection with Lugose Iodin

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EXECUTIVE SUMMARY

The Health Sector Reforms supervision exercise was undertaken in June 2014 based on the ministry’s norms and standards for selected indicators across selected hospitals, health centres and dispensaries in the Country. The exercise was carried out in collaboration with the County government to establish the progress of health services under the devolved government and with a view to continually improve service delivery. This report therefore gives a detailed analysis of the performance in primary health facilities.

KEY RESULTS Compliance with Service delivery charters – The level of implementation of the service delivery charters in primary level facilities is at 33.3% with an average 14.4% having departmental charters and characterized by lack the key components. For example, only 9.1% had a contact person and address and only 10.6% had the charter in two languages.

Timely Delivery of Health Services (Waiting time) – A majority 87.9% of primary level facilities had not conducted a survey in the previous six months to inform waiting time. Without this, it would be difficult to inform average waiting times in the service charters.

Quality Clinical care – On average, health centres scored 8.2% while dispensaries scored 4.3% as per the evaluation tool. For example, full patient history, was satisfactory in only 7.5% and 3.8% of health centres and dispensaries respectively. There were no records signed, dated and timed by clinicians in all sampled health centres and dispensaries. A similar scenario was observed for the treatment sheet in dispensaries while only 5% of the treatment sheets were clear and signed in health centres.

Improved Nutritional care – From the facilities assessed, 80% of primary level facilities conducted nutritional assessment with 70% of them offering basic nutritional interventions such as counseling and diet therapy and 60.6% further offering support with supplemental feeds. Availability of guidelines to standardize care and ensure quality was in place for 56% of the facilities.

Outreach services - Of the outreach services assessed, over half of the facilities offered these services with defaulter tracing scoring highest at 80.3%. This is mainly carried out to trace patients defaulting on appointments for critical services such as immunization, TB patients and those on antiretroviral therapy so as to improve adherence and reduce drug resistance among the population. However, mental health outreach services were lowest at 19.7%.

Community Involvement and Participation - Community involvement and participation through campaigns, dialogue days, action days and community mobilization meetings is in over 60% of the primary facilities assessed. However, the number of community units linked was only in 33.3% of the facilities.

Emergence preparedness – On average emergency trays in all OPD consultations rooms, injection rooms and maternity were completely available in only 26.8% of sampled facilities. The availability of fully equipped crush box was only in 4.5% of the sampled facilities. In addition only 3.0% of primary facilities had a written emergency plan and only 7.6% had a functional emergency response team in place.

Diagnostic services – The major diagnostic tests such as malaria, blood glucose, urinalysis and stool examination are widely available varying between 65% to 92% in both health centres and dispensaries for the individual tests. However, the full haemogram test was only available in 10.0% and 7.7% of the health centres and dispensaries respectively. It was also noted that, despite an 85.0% availability of blood glucose test in health centers, the same was only available in 23% of dispensaries.

Commodities and supplies – Less than 50% of the facilities had all the tracer commodities in stock with 47.5% and 26.9% availability of the 16 tracer drugs in health centres and dispensaries respectively. Similarly, 50% of health centres had all the 16 tracer non-pharmaceuticals in stock while only 19.2% of health centres

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were fully stocked indicating a major challenge for dispensaries since tracer commodities must be available in all facilities at all times for efficient delivery of quality services. Regarding expiries, there was a 15.0% and 11.5% of expired drugs in health centres and dispensaries respectively which was way higher than the recommended level of 5%.

Child health – Majority of the primary level facilities do not have sufficient equipment for newborn resuscitation and only 33.3% of the sampled facilities had. However, vaccines are widely available in over 90% of facilities. In addition, a 100% of the health centres sampled had a cold chain infrastructure and 95.8% of dispensaries. Defaulter tracing for children under immunization within the first year of life was in place in over 85% of facilities. However, documentation on growth monitoring for babies was poor with all individual indicators below 20%. New born care was worst in dispensaries which scored 3.8% in only two indicators while health centres scored below 25% for all indicators.

Maternal health – Analysis showed that 82.5% of health centres have a skilled birth attendant at all times (24 hours, 7 days a week) at the facility, but only 34.6% of dispensaries have. Monitoring of labour was poor at an average of 24.8%. Over 80% of the primary facilities have supplements available. ANC services are generally available in over 60% of the facilities with lowest service being post abortive care available in only 36.4% of primary facilities. Cervical cancer screening was available in 54.5% of facilities and at least 66.7% provided clinical breast examination. Guidelines, posters and job aids were generally available in over 68% of facilities and family planning methods are widely available in the facilities assessed. A further analysis shows that the health centers deliver an average 143 mothers per year while dispensaries deliver on average 16 mothers per year.

Disability mainstreaming – The overall implementation of this indicator in our primary level facilities is at 25%.

Gender mainstreaming – At least 40.9% of primary facilities are offering SGBV services though only 9.1% have a designated officer for the same with facilities referring between 0 and 25 cases of SGBV in a year (Av. Of 3 per facility)

Quality of Mental health services – The availability of mental health services in the primary level facilities is low at 16.7%.

Improved facilities Environment - Primary facilities scored above 50% on facility the majority of compound indicators except availability of all-weather pavements which was poorest at 21.2%. Waste disposal individual indicators scores were below 50% (Av. 41.5%) with availability of a set of 3 color coded bins in wards and clinical scoring poorest at 30.3%. Water and hygiene scored highly at 61.7% with the poorest score being on availability of running water in sinks and toilets for staff and patients at 48.5%.

Adherence to safety guidelines - Demonstration of the presence of barrier nursing in the facility was on average 23.1% with barrier nursing notice available in only 1.5% of facilities. In addition, availability of firefighting equipment and signage was poor scoring below 17%. From the 66 primary facilities assessed, only two (2) had an institutional policy guideline on fire outbreak.

Automation - Only 6.1% of the facilities had an integrated information system while 37.9% utilized the DHIS for reporting.

Efficient Records and Information System - Facilities forward monthly service delivery reports to the county/sub-county on a timely basis and it was evident that information/data sharing in monthly meetings took place.

Human Resource Management - Fifty six (56.1%) of sampled facilities are using the performance appraisal system while 42.4% have continuous development education at least once a month for the staff.

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Only 5% of the facilities had all staff trained. Further analysis indicate availability of an average of 2 clinical officers and 7 nurses in health centres and one clinical officer and 3 nurses in dispensaries with an average 4 nurses in health centres being partner sponsored.

Facility Assets - Primary level facilities scored poorly on indicators for facility assets with only 10% of the sampled facilities having title deeds, 7.6% and 10.6% having an annual preventive maintenance plan and list of idle assets respectively with at least 62.1% having an inventory of facility assets for the current financial year.

Efficient Healthcare Financing – On average, HC scored 54.7% and dispensaries 32.0% under healthcare financing. The poorest performing indicator was on monthly bank reconciliation updates with only 40% and 19.2% for both HC and dispensaries respectively. In addition, only 26.9% and 23.1% of dispensaries had reimbursements for HSSF and free maternity services respectively.

Facility Planning, Management and Governance – Over 60% of health centres have annual work plans & staff duty roasters in place and are displaying the facility statistics as required, while this was low in dispensaries. Availability of quarterly facility management committee meetings, monthly facility management team meetings and monthly infection prevention committee meetings was poor in both health centres and dispensaries with all individual indicators scoring below 8%.

Innovations - The assessment established that only 30.4% of the primary facilities had at least 2 innovations.

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CHAPTER 1: INTRODUCTION

1.1 Background

The policy framework 2012-2030 and strategic plan 2013-2017 spearheads the Ministry’s agenda on reforms, investments, and governance of the health system in line with Vision 2030 and the Constitution of Kenya. The goal of health sector reforms is to promote and improve the health status of all Kenyans through the deliberate restructuring of the health sector to make all health services more effective, accessible and affordable. This has been a success and there have been tremendous growth with implementation of reforms in the Kenyan hospitals despite a number of challenges.

The main challenges include dwindling resources for health against the numerous health priorities, increasing burden of diseases, and inadequate institutional and organizational capacity to effectively respond to the existing and emerging health challenges.

Following the promulgation of the new constitution 2010 and its implementation in 2013, a new devolved structure of governance was put in place that impacted on service delivery for the health sector. Major expectations in the sector revolved around a more responsive health service, closer and widely available to the masses than before. However, the reorganization and re-structuring of both the national and the devolved county structures have been met by various setbacks and are still unsolidified. Nevertheless, the roles of the national and county governments which are distinct and interdependent continue to be exercised at the two levels of government. It is under this prevailing situation that the reforms exercise was undertaken in both hospitals and primary level facilities to gauge the performance of the health sector one year after the devolved structure of governance were put in place.

Reforms have in the past focused on hospitals, being the biggest institutions of service delivery and where greatest impact was expected. This saw health centres and dispensaries, which are the majority of the health service delivery points left out in reform supervision. The 2014 annual supervision exercise sought to initiate reform supervision in primary facilities. The Ministry has 66 primary care facilities ( health centres and dispensaries) and 155 hospitals.

The primary level facilities which provide the first contact for the community and the health care systems. They are widely distributed and are structured to provide basic healthcare to the immediate population that focuses mainly on promotive and preventive services. Nevertheless, varying levels of essential services are also offered and which have increased over time. This makes it important to institutionalize the reform exercise in all facilities.

1.2 Objectives and scope of the reforms assessment exercise

The specific objectives include:

• Document gains made one year after devolution of health services

• Identify performance gaps and challenges

• Give recommendations for improvement

• Build capacity of county/facility teams in carrying out assessments

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CHAPTER 2: METHODOLOGY

2.1 Assessment Framework

The National government exercises its constitutional mandate of ensuring standards and regulation of health services to deliver the highest quality of health services to the population as required in the constitution. This way, the National government and county level health systems are linked by relating standards and norms to service delivery.

2.2 Process

The integrated assessment tools for assessment of hospitals were reviewed and in addition, this was customized for Primary facilities that were being assessed for the first times. The tool’s scope of assessment was to cover all areas within a health facility. Specifically, the tool addressed up to twenty seven (27) and twenty two (22) result areas for hospitals and primary facilities respectively. Both the national government and the county levels contributed in developing the tools as well as carrying out the exercise.

The tools were pretested before use in the field. A facility service data capturing tool was sent in advance to allow facilities to input data.

The assessment process involved walking through the various hospital departments while observing and filling the assessment tool. At the end of the assessment, the team had a meeting with hospital managers to discuss key concerns arising from the activity.

2.3 Sample Size

Sixty six Primary Health Facilities were assessed, 26 Dispensaries and 40 Health Centers across the different counties.

2.4 Data Processing and Analysis

Data was entered using Research Electronic Data Capture (REDCap), an-online data management software. The software allowed for robust methods of data cleaning and quality checks to assure quality of data. Analysis was done using Stata 13 and the reports generated.

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CHAPTER 3: PRIMARY LEVEL FACILITIES PERFORMANCE

This Chapter gives the primary facility performance as evaluated against the following indicators for the financial year 2013/2014; facility service charters, quality healthcare including diagnostic services, outreach and community services, child and maternal health, commodities and supplies, gender, disability, mental health, nutrition, emergency preparedness, environment and safety, leadership and efficiency in financial management.

3.1 Human Resource

Average staffing in Health Centers was 1.3 for clinical officers and 5.5 for nurses against recommended norms of 6 and 36 respectively. Dispensaries had an average of 1 for clinical officers and 1.6 for nurses, against recommended norms of 2 and 8 respectively. Some facilities reported having no clinical officer while some did not have any nurse while some had up to 27 nurses.

Table 1 Staffing in Primary facilities

Primary facilities staffing

Cadre Dispensaries Health Centers Overall Min Max

Clinical officers 1 1.3 1.2 0 5

Nurses 1.6 5.5 3.5 0 27

In Primary facilities, about a half had done monthly expenditure returns for HSSF and involved facility committee and /or staff in budgeting. On the other hand, only 34.8% had evidence of receipts of monthly reimbursements for free maternity services, a third had done bank reconciliations while 48.5 % had evidence of receipt of quarterly reimbursements for free primary health services (table 2).

Table 2. Healthcare Financing- Primary facilities

Primary Facilities performance No. %

Presence of an updated cash analysis summary 27 40.9

Facility committee and staff involved in budgeting 38 57.6

Bank reconciliation upto date 21 31.8

Evidence of monthly expenditure returns for HSSF- cash analysis 39 59.1

Evidence of receipt of reimbursements for free primary health services 32 48.5

Evidence of receipts of Monthly reimbursements for Free Maternity Services 23 34.8



3.2 Compliance with Service Delivery Charter

In line with services available, all facilities are required to develop and strategically display (at the entrance) a Service Delivery Charter with four columns that provides: - common services offered, obligations of the customer, charges if any and time which the customer should wait to receive the service. The charter should indicate mechanisms to seek redress if the client is not satisfied with the services by having a contact person and telephone in the charter, as well as the contacts for commission of administrative Justice and be available in at least two languages. In addition, each of these departments must also have individual charters. Suggestion boxes are important for receiving complaints and suggestions from clients served and each facility should have a minimum of 2 functional suggestion boxes that must be opened regularly (at least biweekly) and discussed by the hospital management with reports generated on actions taken.

Figure 1: implementation of service delivery charter

figure 1 above showed that only 33.3% of primary level facilities have implemented service delivery charters with an average 14.4% having departmental charters. Specifically, only 9.1% of the service charters had a contact person and address and only 10.6% had the charter in two languages. Suggestion boxes were available in 28.0% of the facilities with only 15% having a report from suggestion boxes and actions taken.

The main challenge is to sensitize primary level facilities on the guidelines for developing and implementing the service delivery charters with emphasis on key components of a service charter.

3.2 Timely delivery of health services

Patients queue for health services and in some cases; the long durations taken to receive a service may be un-acceptable with majority of client complaints gearing towards waiting times. Waiting times are a good measure of efficiency in service delivery and health facilities are striving to minimize the time taken for a patient to be served. In line with this, all facilities are required to undertake a baseline survey every 6 months to establish their waiting time and comply with the minimum norms without compromising quality. None of the primary facilities sampled had conducted a survey on waiting time in the previous six months.

3.3. Quality Clinical care (OPD)Evaluation of clinical care was done by assessing 3 Out Patients’ Department patients’ files for quality of clinical notes, observation of patient assessment processes in the OPD department and completeness of patient’s records. Specifically, records were evaluated for completeness of patient history, vital signs (blood pressure, pulse rate, temperature, weight, and height), patient examination, clear diagnosis made with a

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clear name, sign and date for the clinician seeing the patient.

Figure 2: Quality of clinical records (opd)

Figure 2 indicates that quality of care in primary level facilities is poor with all assessed indicators individually scored below 15% each with an average 8.2% for health centres and 4.3% for dispensaries. Regarding full patient history, this was satisfactory in only 7.5% and 3.8% of health centres and dispensaries respectively. There were no records signed, dated and timed by clinicians in all health centres and dispensaries sampled. A similar scenario was observed for the treatment sheet in dispensaries where no treatment sheets were signed while only 5% were clear and signed in health centres.

Table 3: Service delivery data (opd)

Service delivery Data

VariableALL Dispensaries Health Centers

Mean Min Max Mean Min Max Mean Min MaxOPD - female 7670 231 26286 4974 257 13978 9255 231 26286OPD - male 7468 188 83080 3960 188 14877 9531 192 83080OPD -Total 14664 445 47692 9749 445 28865 17275 995 47692Clients Counseled and tested for HIV 1778 18 9190 1014 18 5408 2231 48 9190

Clients on HAART 1034 0 17695 185 0 1383 1405 0 17695+ve malaria tests 912 0 12163 389 0 1477 1198 0 12163No. of malaria cases 6208 0 208983 1336 0 8679 9400 0 208983

Table 3 above indicate that on average, dispensaries serve between 445 to 28,865 clients in OPD in a year (Ave. 9,749) while Health Centres serve between 995 to 47,692 OPD clients with an average of 17,275. On average, dispensaries have between 185 and 1383 clients on HAART and health centres have between 1405 and 17,695 clients cumulatively.

3.4 Improved Nutrition care

The requirement to integrate nutrition care in patient treatment and management has gained significance with emergence of conditions such as HIV AIDs. Poor nutritionals status including lack of nutrition management during treatment can lead to poor clinical outcomes calling for a holistic patient management in our health facilities.



FIGURE 3: NUTRITION SERVICES

In figure 3, it was commendable to find that a majority 80% of sampled primary level facilities conducted nutritional assessment with the basic minimum on weight and height. This followed nutritional interventions such as counseling and diet therapy in over 70% of the facilities while at least 60.6% of the facilities had supplemental feeds available. In addition, more than half of the sampled facilities, 56% had nutrition

guidelines in place.

The average performance for nutrition services is 67.4%, however, it is important to continue addressing the concern of availability of guidelines to ensure that quality and standard services are offered. The aspect of nutrition commodity availability can also be improved.

3.5 Outreach servicesPrimary level facilities provide an important link between the healthcare facilities and the community/society and offer primary care health services to the population at their day to day settings such as homes and schools. Some of the indicators assessed included carrying out home visits, school health, and community outreach services such as immunizations, mobile clinics, medical camps as well as defaulter tracing mechanisms for critical areas like TB, ARVS, and Immunization.

Figure 4: Outreach Services

Figure 4 shows that over half of the primary facilities are offering outreach services to the community with defaulter tracing at 80.3%. The mental services outreach services were poorest at 19.7% perhaps due to lack of sufficient capacity at the facility.

3.6 Community Involvement and ParticipationPrimary level facilities have played a key role in implementation of the community strategy by offering health information on promotive and preventive health as well as to sensitize and create demand for these services.

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This can be done through community dialogue days, community action days, community mobilization meetings and campaigns whose availability was assessed at the facility.

Figure 5: Community services

Figure 5 above shows that over 60% of primary facilities are actively involving communities and sensitizing them on health services through campaigns, dialogue days, action days and community mobilization meetings. However, the number of community units linked was only in 33.3% of the facilities.

3.7 Emergency Preparedness and Timely Response in FacilityLessons learnt from recent disasters show that most facilities are ill prepared to handle major disasters. In this regard, facilities were assessed on minimum norms for which an acceptable level of emergency preparedness can be assured.

Figure 6: Emergency preparedness and response

Figure 6 above shows that on average emergency trays in all OPD consultations rooms, injection rooms and maternity were completely available in on 26.8% of sampled facilities. The availability of fully equipped crush box was only in 4.5% of the sampled facilities. A least 65.2% of the sampled primary facilities had access to a standby ambulance. In addition only 3.0% of primary facilities had a written emergency plan and only 7.6% had a functional emergency response team in place.

3.8 Diagnostic and Blood ServicesThe availability of quality, timely and accurate forensic and laboratory services is fundamental to provision of quality health services by helping achieve correct diagnosis of health problems and eventual proper management. The evaluation focused on laboratory tests available, availability of standard operating



procedures (SOPs), and presence of supervision from the regional supervisors.

Figure 7: Available laboratory services

table 7 above shows that major diagnostic tests such as malaria, blood glucose, urinalysis and stool examination are widely available varying between 65% to 92% in both health centers and dispensaries for the individual tests. However, two tests were noted with major concern; the full haemogram test that was available in only 10.0% and 7.7% of the health centers and dispensaries respectively. Secondly, despite an 85.0% availability of blood glucose test in health centers, the same was only available in 23% of dispensaries. A further 33.3% of primary facilities provided other tests such as……

3.9 Commodity supply Management

The primary level facilities are managing an increasing number and scope of medicines among other health commodities as health services are brought closer to the communities. The main focus for commodity supply management was on six key indicators which included the availability of the commodities using the tracer pharmaceuticals and tracer non-pharmaceuticals list; the documentation of the process from receipt to use as per the guidelines by evaluation the updating of bin cards and delivery notes and presence of quarterly supervision from the region. The percentage of expiries was also evaluated which is a good indicator of the commodity management process and to avoid wastage.

Figure 8: Commodity supply management

Figure 8 shows that the percentage of health centres with all 16 tracer drugs in stock at the time of visit was 47.5% and 26.9% for dispensaries indicating lack of commodity supplies at below 50%. Similarly, 50% of health centres had all the 16 tracer non-pharmaceuticals in stock while only 19.2% of health centres were fully stocked. Tracer commodities must be available in all facilities at all times for efficient delivery of quality services and this was not the case.

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All facilities must strive to minimize expiry of medicines to an acceptable level of < 5% of the total volume. There was a 15.0% and 11.5% of expired drugs in health centres and dispensaries which is 3 and 2 times higher than the acceptable levels respectively. In addition, on average 71.2% of the facilities had updated bin cards and delivery notes while supervision from the regional pharmacist was available in 57.6% of the facilities.

3.10 Child Health

Most facilities based child mortality occurs within the first 24 to 48 hours of admission with children below 5 years of age being most affected in which newborns contribute the largest proportion in this age group.

The millennium development goals number 4, 5 and 6 which aim at reducing child and maternal mortality in addition to combating Malaria and HIV/AIDS epidemic have contributed significantly to the health of mothers and the children through improvement in services delivery at facility level among other strategies such as community sensitization and mobilization. The assessment was guided by minimum norms within the MDG strategies and focused on the following areas; new born services (new born resuscitation equipment, supplies and guidelines); new born care (the processes of clinical care, feeding, immunization at birth, weight monitoring and including referrals where required). The availability of vaccines and supplements were also evaluated.

3.10.1 New born resuscitation

Table 4 below shows the percentage of primary facilities with suitable surface for new born resuscitation is 42.4% and only 16.7% have a warmer for use during resuscitation. Forty three (43.9%) had a working valve mask, 39.4% had functional clean suction equipment for new born resuscitation while only 19.7% had oxygen, flow meter and mask/catheter for use in new born resuscitation. The overall new born resuscitation indicator is at 33.3%. An increasing number of primary facilities are offering maternal delivery services under the free maternity program and this assessment is indicative of an urgent need to improve the infrastructure at these facilities.

TABLE 4: NEONATAL RESUSCITATION

Neonatal resuscitation % of facilities

A firm suitable surface for newborn resuscitation 42.4

Warmer for use during resuscitation 16.7

Working bag valve mask for newborn resuscitation 43.9Working and clean suction equipment for newborn resuscitation 39.4Gloves and towels present for drying resuscitation 37.9

Oxygen, flow meter and mask /catheter for use in newborn resuscitation 19.7



3.10.2 New born care

Figure 9: Newborn Care

Figure 9 indicates that quality of new born care in primary level facilities is worst in dispensaries where all indicators scored zero except for two (immunization at birth and weight monitoring charts) that scored 3.8%. Health centres scored poorly too with highest score at 25%.

3.10.3 Immunization

The immunization of children within the first year of life against immunizable diseases is essential and the primary level facilities play a critical role to ensure that every child in the community is immunized. This calls for a sustainable supply of key vaccines and the cold chain infrastructure as well as supplements. The defaulter tracing mechanisms for children immunization is also important to increase adherence and complete coverage.

Figure 10: Available vaccines and supplements

Figure 10 shows a wide and commendable availability of vaccines within the primary level facilities with an average 94.2% and 91.7% availability in health centres and dispensaries respectively.

A 100% of the health centres sampled had a cold chain infrastructure while the percentage of dispensaries with a cold chain infrastructure was 95.8%. Defaulter tracing for children under immunization within the first year of life was in place in 86.1% of the health centres and 85.7% of the dispensaries sampled.

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Table 5: Immunization service delivery data


VariableALL Dispensaries Health Centers

Mean Min Max Mean Min Max Mean Min Max

Children fully Immunized (<1year) 556 1 13227 203 1 720 747 15 13227

Facility based Neonatal deaths 0 0 2 0 0 0 0 0 2

3.10.4 Growth monitoring

Table 6 below shows that the level of growth monitoring for babies in primary facilities assessed was poor with all individual indicators below 20%. Specifically, vital signs were completely recorded in 13.6% of the facilities while the feeding monitoring charts were complete in only 4.5% of the assessed facilities. The weight monitoring was at 19.7%, immunization at birth monitoring in 16.7% while presence of baby cots and incubators for referral services were in 9.1% and 6.1% of facilities respectively.

Table 6: Growth monitoring

Growth monitoringDescription FacilitiesVital signs recorded 13.6%Feeding monitoring chart with minimum 8 entries in 24hrs 4.5%

Weight monitoring 19.7%Immunization at birth monitoring 16.7%Presence of a baby cot 9.1%Incubator for referral services 6.1%

3.11 Maternal Health Maternal mortality rates in Kenya have remained high at 488 per 100,000 live births due to various challenges including smaller proportions of skilled health personnel that largely affect the primary facilities. The assessment evaluated compliance to minimum norms by focusing on the following indicators; clinical process of monitoring labour, hours of availability of skilled birth attendants in the facility, antenatal care services (ANC) for both services offered and investigations available, availability of standard guidelines and family planning.



3.11.1 Monitoring of labour

Table 7: Monitoring of labour

Variable Description FacilitiesMothers condition documented by nurse 30.3%Fetal condition 24.2%

Progress of labour (cervical dilatation and descent of fetal head) 21.2%

Maternal conditions(vital signs) 22.7%Table 7 above shows that the monitoring of labour is taking place in primary facilities to some extent with 30.3% of facilities recording the mother’s condition, 24.2% of facilities documented the foetal condition while progress of labour was documented in 21.2% of the assessed facilities. The average score for monitoring of labour was 24.8%.

3.11.2 General Maternity availability of skilled birth attendants

Figure 11: Hours skilled birth attendants’ available

Figure 11 show that 82.5% of health centres had a skilled birth attendant at all times (24 hours, 7 days a week) at the facility, while only 34.6% of dispensaries had a skilled birth attendant at all times. In other cases, the availability of skilled birth attendants varied greatly.

3.11.3 ANC services

Table 8: Anc services

Services/ investigations

offered at ANCPercent

ANC Services Drugs/supplement

offered at ANC Percent Reproductive

Health Services Percent

Provision of ITN 63.6 SP for IPT using DOT (where applicable) 50.0 Post abortive care 36.4

Hb test 60.6 Ferrous Sulphate 89.4 Breast cancer clinical exam 66.7

Urinalysis 72.7 TT Injection 90.9 Cervical cancer screening 54.5

Grouping & Rhesus 72.7 Folic acid 89.4 Pap smear 4.5PMTCT services 80.3 Multivitamins 48.5 VIA/VILLI 97.4

Table 8 shows that majority of the primary facilities (over 80%) have supplements available with SP for IPT being available in 50% of facilities mainly those in endemic areas with an exception of multivitamins that

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were only available in 48.5% of the facilities. A further analysis showed that ANC services are generally available (>60% of facilities) with lowest service being post abortive care available in only 36.4% of primary facilities and cervical cancer screening in 54.5%. For cervical cancer screening, Visual Inspection with Acetic Acid and Visual Inspection with Lugose Iodine (VIA/VILLI) method was the most utilized at 97.4% and pap smear method being the least utilized at 4.5%. At least 66.7% provided clinical breast examination.

Table 9: Anc service delivery data


VariableALL Dispensaries Health Centres


Number of women with at least one ANC visit 570 0 2586 314 6 1573 709 0 2586

No. that completed 4 visits 163 1 620 101 1 620 196 13 617

New FP clients 425 0 2081 400 0 947 439 9 2081

3.11.4 Availability of guidelines, posters and job aids

Table 10: Available guidelines, posters and job aids

Guidelines availability FacilitiesPMTCT guidelines 78.8Infant and young child Feeding guidelines 71.2Syndromic Management chart 71.2Early Infant Diagnosis Algorithm 68.2ARV Prophylaxis and treatment algorithm/ARV dosing algorithm 68.2Breast feeding chart 68.2Information, Education and communication materials 74.2

Table 10 above indicates that guidelines, posters and job aids were generally available in over 68% of assessed primary care facilities.

3.11.5 Family planning

Figure 12: Family planning

Figure 12 above shows family planning methods are widely available in the facilities assessed however; the male condoms were lowest at 60.6%.



3.11.6 Reported Deliveries

Table 11: Reported deliveries

Dispensary Health Centre Overall primary level

Variable Type Mean Mean MeanTotal Deliveries 15.8 143.0 66.8Total live births 16.0 140.2 68.0Fresh still birth rate 5.0 1.7 1.9

Table 11 above shows that the health centers deliver an average 143 mothers per year while dispensaries deliver on average 16 mothers per year per facility.

3.12 Disability Mainstreaming

Disability mainstreaming entail actively identifying and removing any structural, organizational, physical, and attitudinal barriers which exist for persons with disabilities within our facilities. It therefore involves putting mechanisms in place to ensure all disabled persons seeking services are minded. Some of the evaluated indicators include; functional disability assessment teams, designated car parks, disability friendly toilets, friendly walkways and delivery bed (appropriately adjustable in labour ward). In addition, there should be at least 1 wheelchair in OPD for use by PWDs.

Figure 13: Disability mainstreaming

figure 13 above shows that the overall implementation of disability mainstreaming in primary level facilities is on average at 25% and only 19.7% of the primary level facilities availability had a disability delivery bed.

3.13 Gender Mainstreaming

Disability mainstreaming entail actively identifying and removing any structural, organizational, physical, and attitudinal barriers which exist for persons with disabilities within our facilities

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Figure 14: Gender mainstreaming

figure 14 show that at least 40.9% of primary facilities are offering SGBV services though only 9.1% have a designated officer for the services. Guidelines on SGBV were available in 18.2% of the assessed facilities.

Table 12 below shows that on average, primary facilities are referring between 3 and 25 cases of SGBV annually with an average of 3 cases per facility

Table 12: SGBV service delivery data




Number of referred SGBV cases 3.3 0 25 1.7 0 6 4.3 0 25

3.14 Quality of Mental Health

Facilities were assessed on the provision of basic mental services (counseling, substance abuse and dependence treatment. Only 16.7% of the sampled primary facilities offered some level of mental health services (n=64).

Table 13: Mental referral cases service delivery data




Number of referred mental health cases 4 0 24 3 0 10 4 0 24

Table 13 indicate that the 16.7% of facilities offering mental health services see on average between 0 to 24 clients in a year with an average of 4 per facility.



3.15 Improved Facilities Environment

A beautiful, well maintained and clean health facility environment free from contamination can help reduce stress and fatigue in both patients and healthcare workers. The ministry therefore has developed minimum standards on facilities landscaping, hygiene, safety and waste management which facilities have to adhere.

Table 14: Improved Facility Environment

a) Facility Compound % FacilitiesPresence of a fence 78.8Well-manicured Lawns and flower beds 48.5At least 10% of the acreage with trees 54.5Facility generally clean 72.7All weather Pavements 21.2

b) Waste Disposal % FacilitiesA functional incinerator or access to a functional incinerator 42.4Well protected Compost pit 43.9Well protected placenta pit 54.5Well protected ash pit 36.4A set of 3 color coded bins in all wards and clinical departments 30.3

c) Water and Hygiene % FacilitiesReliable running water in the facility 59.1Running water available in sinks/toilets for staff and patients 48.5Clean functional Water closet toilets for patients & staff 51.5Clean functional pit latrine toilets with handwashing facilities 72.7Clean functional pit latrine toilets with handwashing facilities 60.6Clean functional bathrooms for patients 69.7Alcohol based hand-rubs for staff in clinical areas 65.2Soap available for staff/client handwashing 66.7

Table 14 above shows that primary facilities scored above average on hospital compound indicators with at least 78.8% having a fence but scoring poorest on availability of all-weather pavements which was available in only 21.2%.

Regarding waste disposal, all facilities scored below 50% with an average of 41.5%. Availability of a set of 3 color coded bins in wards and clinical areas was poorest at 30.3%.

Water and hygiene scored highly on individual indicators with an average 61.7% indicating that facilities

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are clean and well maintained. However, the poorest score was on availability of running water in sinks and toilets for staff and patients at 48.5%.

d) Power source

Figure 15: Facility Power Source

Figure 3.15 above shows that 74.2% of the facilities have electricity supply with at least 6.1% of the facilities having generators. Other sources of power include wind in 3.0% and solar in 25.8% of the facilities.

3.16 Adherence to safety guidelines

The facilities were evaluated on adherence to safety which included a demonstration of the presence of barrier nursing in the facility and mechanisms put in place to ensure fire safety.

3.16.1 Barrier nursing

Figure 16: Barrier nursing

Figure 3.8 shows that other than availability of gloves, the implementation of barrier nursing was low at an average 23.1% in the sampled facilities. Though isolation rooms were available in 25.8% of the facilities, the barrier nursing notice was only available in 1.5%.

3.16.2 Fire safetyTABLE 15: FIRE SAFETY



Table 15 indicate that on average, departmental indicators on fire exits signage and fire-fighting equipment was poor

scoring below 20%. Specifically, 24.2% of assessed facilities had at least a fire-fighting equipment in the facility and only 17.7% of the sampled facilities had at least a form of signage for fire exits.

From the 66 primary facilities assessed, only two (2) had an institutional policy guideline on fire outbreak.

3.17 Automation

This involves an integrated electronic system with necessary functions for capturing and reporting clinical, supply and financial information among others in the facility. Facilities were assessed on having functional modules for the key departments in the facility including a billing/financial module, OPD, registration, pharmacy, laboratory and inpatient (where applicable). Only 6.1% of the facilities had an integrated information system while 37.9% utilized the DHIS for reporting.

3.18 Efficient Records and Information System

Data is critical for informed and sustainable planning, decision making, long term forecasting and budgeting in facilities. There is therefore need to strengthen collation of data, capacity building and presentation of data that can contribute towards informed decisions by the FMT, facilities boards/ committees and the staff.

Table 16: Efficient record systems

Efficient Records systems Mean Std. Dev.

Monthly service delivery reports to sub-county/county 11.1 2.1

Evidence of on data/information sharing in Monthly meetings of the facility 8.0 4.6

Table 16 shows that facilities forward monthly service delivery reports to the county/sub-county on a timely basis (mean of 11.1 reports in 11 months; Std. Dev. of 2). In addition, it was evident that there is information/data sharing in monthly meetings with a mean evidence in 8 meetings in a year.

3.19 Human Resources Management

There is need to equip medical staff with modern skills and techniques to enable them provide quality and efficient medical services to Kenyans. Facilities are required to enhance human resource management by ensuring use of performance appraisal systems, establishing functional reward and Sanction system and competence development through CMEs.

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3.19.1 Performance appraisals

Figure 17: Performance appraisal systems

in figure 17, 56.1% of sampled facilities are using the performance appraisal system while only 18.2% have evidence of sanctions and rewards. A further 42.4% of the sampled facilities have continuous development education at least once a month for the staff. The proportion of trained staff was 26.9% in dispensaries and 52.5% in health centres while only 5% of the facilities had all staff trained.

3.19.2 Staffing in primary facilities

Table 17: Key staff clinical officers and nurses

VariableLevel 2- Health Centres Level 1-DispensariesMean Min Max Mean Min Max

Clinical officer - GOK supported 1.6 0 5 1.2 0 2Clinical officer -Partner supported 0.9 0 5 0.9 0 1Total Clinical officers 1.3 0 5 1.0 0 2Nurses- GOK supported 6.9 1 27 3.2 1 13Nurses Partner supported 4.1 0 8 0 0 0Total Nurses 5.5 0 27 1.6 0 13

Table 17 above shows an average of 2 clinical officers and 7 nurses in health centres and one clinical officer and 3 nurses in dispensaries with an average 4 nurses in health centres being partner sponsored.

3.20 Facility assetsAn annually updated inventory should be maintained to ensure accountability for all facility assets including buildings, vehicles and equipment together with their respective preventive maintenance plan and job cards. Similarly idle and disposable assets should be identified and disposed according to government regulations. The facility land title deed is an important document as it has been found that facilities lacking land ownership have challenges in laying down major development plans.



Figure 18: Facility assets

figure 18 indicate that 62.1% of the facilities sampled had an inventory of facility assets for the current financial year. However, the primary level facilities scored poorly on other indicators for facility assets with only 10% of the sampled facilities having title deeds, 7.6% and 10.6% having an annual preventive maintenance plan and list of idle assets respectively.

3.21 Efficient Healthcare Financing Facilities are required to utilize public funds in adherence to the Government financial regulations with high level of accountability and transparency which in turn contribute towards an efficient healthcare financing system.

FIGURE 19: HEALTH CARE FINANCING

Figure 19 shows dispensaries are below 50% on implementation of all health care financing indicators with health centres performing better. The poorest performing indicator was on monthly bank reconciliation updates with only 40% and 19.2% for both HC and dispensaries respectively. In addition, only 26.9% and 23.1% of dispensaries had reimbursements for HSSF and Free maternity services respectively. On average, HC scored 54.7% and dispensaries 32.0% under healthcare financing.

3.22 Facility Planning, Leadership and Management Good planning, management and governance are critical in facilities reforms and this is evidenced in governance systems and processes put in place as well as adherence to the same. Specifically, facilities were assessed for availability of work plans, staff duty roasters, quarterly and monthly management meetings as well as strategic display of facility statistics.

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Figure 20: Planning, Management & Governance

Figure 3.20 above indicate that over 60% of health centres have annual work plans, staff duty roasters in place and are displaying the facility statistics as required, while this was low in dispensaries. However, availability of quarterly facility management committee meetings, monthly facility management team meetings and monthly infection prevention committee meetings was poor in both health centres and dispensaries with all individual indicators scoring below 8%.

3.23 Innovations

Innovations create a means to improve quality as well as increase cost-effectiveness and value addition in service delivery. Potential innovations considered included energy (solar, wind, bio-gas), water supply (roof water catchment, borehole), oxygen supply (oxygen concentrators), income generation, waste disposal, among others. The new innovations were considered for implementation within specified period of two years.

The supervision found that only 30.4% of the primary facilities had at least 2 innovations (n=34)

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CHAPTER 4: RECOMMENDATIONS AND CONCLUSION

4.1 Recommendations

Most areas scored poorly for primary level facilities and the key highlighted areas recommended for improvement include: • Clinical care: There is an urgent need to address quality of clinical care in all areas; OPD, maternity and

new born care through capacity building. These should be coupled with appropriate documentation. • Financial Management: Financial stewardship is very crucial to ensure accountability for public funds

and stipulated guidelines should be strictly followed. This should be coupled with strengthening stewardship and governance in the same line.

• Embrace services that ensure human rights are respected as per the constitutional requirements. Gender and disability mainstreaming services ensure these groups are not discriminated. The low uptake of the services in the primary level facilities needs to be fast tracked.

• Human resource; This can be done through hiring to alleviate shortage and management of the existing staff to offer motivation, a function the County government will require to prioritize under the devolved structure especially for nurses and clinical officers in primary level facilities.

• Invest in supportive supervision for lower level facilities The Counties will require investing in and budgeting for regular supervision of lower level facilities to

uphold quality of services.• Institutionalize the reform agenda for all facilities in the county. This can be done through investing

in and budgeting for the reform exercise that can then be carried out together with the national government of separately.

• Support generation, use and flow of health information from lower level facilities. While most primary level facilities don’t have electronic records, health record officers are also lacking. CHRO be supported to oversee records management coupled with hiring more where required.

• Commodity management supervision role: To avoid under and overstocks coupled with increasing expiries of the scarce health commodities, lower level facilities require pharmaceutical technologists/personnel to support the few clinical staff available. This will also require supportive supervision from the regional pharmacists.



4.2 ConclusionThe primary facilities have undergone reforms supervision for the first time giving a baseline to inform subsequent exercises. Some of the indicators were new to the facility teams and this provided a good opportunity to learn while the supervision teams offered on-the job training and mentoring on the reforms indicators and targets. It is expected that Counties will customize and utilize the tools to improve on the services.

Some recommendations require immediate action such as quality of clinical care and financial management. Clinical records suffered greatly perhaps due to poor documentation which can be instituted immediately while the aspect of capacity gap cannot be ruled out and will require follow-up through identification of need. Financial management procedures need to be instituted immediately.

Some recommendations may impact cost implications, both huge and small. Other recommendations may be worked on in the short term and others will require longer duration of time thus it is upon the respective counties to identify priority areas and develop work plans for resolving the raised concerns. It would be prudent to ensure budget allocations are provided for where necessary to address the reform agenda.

The major areas of strengths to build on for primary facilities include availability of vaccines and supplements, defaulter tracing for immunization and outreach services. It is hoped that this strong areas will continue to be upheld and sustained as primary level facilities take on an increasing scope of services in the restrained health system.

primary facilities assessment level report 2014 _2

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