Report of the CHAK Annual Health Conference and AnnualGeneral Meeting (AHC/AGM) 2013

April 23-25

Jumuia Conference and Country Home, Limuru

Conference Theme:Kenya Health Policy 2012-2030; Roadmap to the attainment ofVision 2030 goals in health through a devolved health system

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Table of Contents

Conference Programme................................................................................................................................3

About CHAK...................................................................................................................................................4

Opening remarks........................................................................................................................................... 6

The CHAK Annual Health Conference and Annual General Meeting 2013...................................................7

Devolution of health services between national and county governments: Role of FBO facilities..............9

Overview of the Kenya Health Policy..........................................................................................................16

The Health Sector Service Fund (HSSF).......................................................................................................19

Transforming social health insurance in Kenya ..........................................................................................21

The Kenya Model for Health Quality ..........................................................................................................22

Good Dispensing Practice – Rational Use of Medicines .............................................................................28

MEDS: Ensuring Access to reliable, quality and affordable essential medicines and other medicalcommodities in a devolved health sector...................................................................................................31

Psycho-spiritual approach in management of HIV .....................................................................................39

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Conference Programme

Day one: Reports of secretariat programmes1

Day two:

Devolution of the health sector to county governments Kenya Health Policy Framework 2012-2030 Draft Health Sector Strategic Plan 2012-2016 Health care financing partnership opportunities – NHIF and HSSF Kenya Quality Model for Health (KQMH) Discussion: Re-positioning Church Health Services in a devolved health system Access to quality essential medicines and their rational use

Day 3: AGM

An exhibition will run throughout the period of the AHC/AGM.

1 Reports of CHAK Secretariat programmes and projects are available in the CHAK Annual Report 2012.

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About CHAK

CHAK is a national network of Protestant Churches’ Health facilities & programs from all over Kenya startedin 1930’s as a Hospitals’ Committee of NCCK.

Its name was changed to Protestant Churches Medical Association (PCMA) in 1946 with the sole mandate ofreceiving and distributing government grants to Protestant churches’ health facilities.

The organization acquired the name CHAK in 1982 and expanded its mandate to that of facilitating thechurches’ role in health. Government grants gradually declined and completely stopped in 1996.

CHAK’s foundation

Revelation 22:1-2 “…the River of the water of Life…flowing from the throne of God …down the middle of thegreat street of the city. On each side of the River stood the tree of life bearing twelve crops of fruit, yieldingits fruit every month. And the leaves of the tree are for the healing of the nations”

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VisionAll member health units providing efficient and high quality health care that is accessible, equitable,affordable and sustainable, as a witness to the healing ministry of Christ

MissionTo facilitate member health units in their provision of quality healthcare services through advocacy, healthsystems strengthening, networking and innovative health programmes

GoalPromoting access to quality health care

Our purposeThe purpose of CHAK is to facilitate member health facilities to deliver accessible, comprehensive, qualityhealth services to Kenyans in accordance with Christian values and professional ethics guided by the nationalhealth sector policies.

Strategic directions /Core functions1. Health services delivery2. HIV&AIDS programmes3. Health systems strengthening including Medical Equipment Programme4. Governance and accountability5. Research, advocacy and communication6. Health care financing and sustainability7. Human Resources for Health (HRH)8. Grants management

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Opening remarksBishop Michael Sande – CHAK Chairman

In his opening remarks, Bishop Sande noted that the Bible had many examples of devolution. For instance,when Moses met his father-in-law, Jethro, there was segregation of duties.

In sharing responsibilities, it is important that only leaders with integrity are elected. Such leaders need to begood stewards of resources and distribute them equitably. They have to be capable and hate dishonest gain.

The CHAK chairman noted that member health units would be working in the counties and would need todeal with attendant challenges, including corruption.

Adding that Kenya would be holding its jubilee independence celebrations in 2013, he reminded theparticipants that poverty, disease and ignorance were identified as the country’s key enemies in 1963. InKenya’s jubilee year, the country was looking afresh at these three enemies. Kenya had also declared war ondisease in its development blue-print, Vision 2030, a course to which CHAK member health units remaincentral.

The CHAK Annual Health Conference and Annual General Meeting 2013 would seek to clarify how CHAKhealth facilities fitted into the devolved government system whose implementation would begin during theyear to ensure that the Church facilities continued to deliver on their mandate.

At the end, we shall thank God for a system that is biblical, i.e. people centred and equitable. By learningfrom each other at the CHAK 2013 AHC & AGM, we shall have used our time justifiably.

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The CHAK Annual Health Conference and Annual General Meeting 2013Dr Samuel Mwenda – General Secretary, CHAK

Conference objectives• To present and disseminate the Kenya Health Policy 2012 – 2030• To provide an overview of the draft National Health Sector Strategic plan 2012 – 2016• To discuss strategic positioning of Church Health Services in a devolved County Health System• To discuss priority health systems strengthening for the sustainability of Church Health Services• To present the new Kenya Quality Model for Health (KQMH) and discuss strategies for its

implementation in the Church health facilities towards total quality management• To provide an overview of CHAK secretariat programmes/projects achievements, challenges and

lessons learnt• To facilitate networking

Why the theme on devolution?Kenya now has 47 counties, each of which will have a county executive health committee. A proposal hasbeen made for one person to be in charge of health at the technical level in the counties. There will be healthsector structures at both the county and national levels. There is a push towards moving technical staff fromadministrative positions to service delivery. There is therefore a need to begin developing relationships at thecounty level.

County Health ManagementThe health sector acknowledges that the County Executive Committee shall determine the organization ofthe county and its various departments. The Health sector proposes that the county health services bemanaged by a Chief Officer for Health, who shall be recruited by the County Public Service Board, andappointed by the Governor in accordance with Article 45 of the County Government Act.

The health service delivery system has been re-structured into four tiers. An important question is whetherCHAK and its health facilities will be recognized under each of these levels. Additionally, what will being ateach of these levels mean for funding, support, facilitiation, e.t.c from the Government?

Devolution has been enshrined in the Constitution with county governments in charge of key functions.There is therefore need for CHAK and her member health facilities to be proactive in negotiating, demandingand finding their space in the new order.

There is opportunity and potential to maintain a strategic leadership role of Churches Health Services in thenew devolved health system.

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The Kenya Health Policy 2012-2030• Policy Goal

– “Attaining the highest possible standard of health in a manner responsive to the needs of thepopulation”

• Policy Focus– Realization of the right to health – as outlined in the Constitution 2010– Contribution to development – towards attainment of the country’s long-term development

Agenda outlined in Vision 2030

KHP Policy Orientations• Service delivery systems – how service delivery is organized• Leadership and governance• Health workforce• Health financing• Health products and technologies – Essential medicines, medical supplies, health technologies• Health information systems• Health infrastructure – buildings, equipment, transport and ICT

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Four-tier health service delivery system• Community services• Primary care services – Dispensaries, Health Centres and Maternity Homes of Government and

Private• County Referral Health Services – Hospitals• National Referral Services

Devolution of health services between national and county governments: Role of FBOfacilities

Dr Ruth Kitetu – Ministry of Public Health and Sanitation, Technical Planning Department

IntroductionThe Kenya Constitution 2010, Article 43 provides for the right to the highest attainable standard of healthto every Kenyan. The Health Sector has a fundamental duty to take legislative, policy and other measures,including the setting of standards, to achieve progressive realization of these rights. Schedule 4 of the KenyaConstitution 2010 assigns to the county governments the function of delivering essential health services, andto the national government the functions of stewardship for health policy and oversight of national referralhealth facilities.As Kenya transits to the devolved government system and cognizant of the constitutional provisions on rightto health, it is imperative to outline clear policies and guidance for the sector in order to ensure continuity ofhealth services throughout the transition to a devolved health sector as well as ensure that mechanisms arein place to anticipate and expeditiously resolve gaps around devolution and health.

Function unbundling and assignmentThe health sector through Function Assignment and Competency Team (FACT) has prepared a policy paperon function unbundling and assignment using guidelines from Transition Authority (TA).Its objective is to provide the rationale and justification for: Devolving functions to counties Delegating (under the provisions of Article 187 of the Constitution) to county governments Retention of services by the National level as residual functions

Unbundling and assignment of functions – Constitutional rationale

Classification Description Implication

Exclusive functions Functions assigned exclusively to one level ofgovernment (according to Schedule 4)

Should be transferred to therespective level

Residual functions Functions not assigned by the Constitution ornational legislation to a county (CoK, art. 186 (3)

Assigned to the national level

Concurrent functions Functions assigned to both levels of governmentthrough ‘unbundling’

To be performed collaboratively by bothGovernments

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Criteria for function assignment Constitutionality: Whether or not the activity has been unambiguously assigned in the constitution. Subsidiarity: A public service activity should be assigned to the lowest level of government that is

capable of delivering it. Alignment of Capital and Recurrent Expenditures: The responsibility of both capital and recurrent

expenditures should be provided by one level of government. Therefore, if a development cost isassigned to the counties, the associated recurrent cost should also be assigned to the counties.

Economies of Scale: When a service is demanded by a larger unit of government, it usually becomesmore efficient to provide. Counties can retain control over responsibility and funding and delegatecertain components to the national government.

Spill overs: Counties responsible for providing a service that also benefits residents beyond their countyboundaries may avoid moral hazard by delegating these services to a larger unit of government.

Exclusive functions of national and county departments of health (CoK, Schedule 4)

National County: County health services including:

1. Health Policy2. National referral health facilities3. Capacity building and technical assistance to

counties

1. County health facilities andpharmacies

2. Ambulance services3. Promotion of primary health

care4. Licensing &control of

undertakings that sell food tothe public

5. Veterinary services (excludingregulation of the profession);

6. Cemeteries, funeral parloursand crematoria; and

7. Refuse removal, refuse dumpsand solid waste disposal

Exclusive functions of state and county departments of health

National County: County health services including

Kenyatta National Hospital (KNH) 0016 Provincial Health Services

Moi Teaching and Referral Hospital (MT&RH) 0017 District Health Services

Kenya Medical Training College (KMTC) 0005 Environmental Health Services

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Kenya Medical Supplies Agency (KEMSA) 0006 Communicable Disease Control

National Hospital Insurance Fund (NHIF) 0008 Nutrition

National Quality Control Laboratory (NQCL) 0009 Family Planning Maternal and Child Health

National Blood Transfusion Services 0010 Health Education

Pharmacy and Poisons Board 0015 Health Informative System

National Public Health Laboratory 0018 Food Control Administrative Services

Government Chemist 0022 Vector Borne Disease Control

Radiation Protection Board 0023 Communicable Disease Control and Management

Kenya Medical Research Institute (KEMRI) 0028 Provincial Administration and Planning

Mathari Mental Hospital 0029 Rural Health Centres & Dispensaries

Spinal injury Hospital 0030 Rural Health Training and Demonstration Centre

Concurrent functions

Functions National County: County health services including

Concurrent Resource mobilization Resource mobilization

Quarantine administration Quarantine administration

Disaster preparedness Disaster preparedness

Emergencies/outbreaks Emergencies/outbreaks

Partnerships (Public and Private) includingintergovernmental relations

Partnerships (Public and Private) includingintergovernmental relations

Planning and budgeting Planning and budgeting

Legislation Legislation

Procurement of health products andtechnologies

Procurement of health products andtechnologies

Disease prevention & control (policy &coordination)

Disease prevention & control

Monitoring and Evaluation Monitoring and Evaluation

Health Information systems Health information systems

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Health financing (Policy & regulation) Health financing (implementation)

HRH management and development HRH management and development

Residual functions (national level)

Residual functions Regulation of Health Products & Technologies

Regulation, setting norms and standards

Regulation of Health Professionals & Services (Boards & Councils)

Port health services

International health relations and diplomacy

(International Health Regulations (IHR)

Regulation of medical training (tertiary & middle level)

Health Research

Food Safety Policy & Regulation

Regulation of the veterinary profession

Transition periodTransition period means the period between commencement of the Transition Act (2012) and three yearsafter the first elections under the Constitution (county assemblies in place). The transition period has twophases:1. Phase one: the period between commencement of the Act and the date of the first elections under the

Constitution2. Phase two: the period between the date of the first elections and three years after the electionsThe transfer of assigned functions will take place over time. The 6th Schedule calls for a three-year period oftransfer of functions. Function assignment and transfer is not a one-time exercise, but rather an ongoingpolicy dialogue.

Role of FBO health facilities in a devolved health systemFBO facilities under various counties just like public facilities are expected to adhere to schedule 4 and KHP2012-2030 functions-county health services (Preventive, promotive and clinical health services). Thisdepends on the following levels (tiers) of care: Tier 1: Community Level Tier 2: Primary Care Level – Provision of basic outpatient health services – previous KEPH levels 2 and 3 Tier 3: County Level – Provision of primary referral services – previous KEPH level 4 Tier 4: National Level: Provision of secondary and specialized services – previous KEPH Level’s 5 and 6

National referral services

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The national referral services comprise all secondary and tertiary referral facilities which provide highlyspecialized services. These include (1) general specialization (2) discipline specialization, and (3)geographical/Regional specialization. They are constitutionally defined and include: Highly specialized health care, for area/region of specialization Training and research services for issues of national importance

County health unitsThese will be responsible for preventive and promotive health services, clinical services, county healthplanning and monitoring and veterinary services.County health services comprise all level 4 (primary) hospitals and services in the county, including thosemanaged for non-state actors. Their roles are constitutionally defined and include: Comprehensive in patient diagnostic, medical, surgical and rehabilitative care, including reproductive

health services Specialized outpatient services Facilitate, and manage referrals from lower levels, and other referralsPrimary care services comprise all level 2 (dispensary) and 3 (health centres) facilities, including thosemanaged by non-state actors. Their roles are constitutionally defined and include: Disease prevention and health promotion services Basic outpatient diagnostic, medical surgical and rehabilitative services Inpatient services for emergency clients awaiting referral, clients for observation, and normal delivery

services Facilitate referral of clients from communities, and to referral facilitiesCommunity health services comprise community units in the county. They are to: Facilitate individuals, households and communities to carry out appropriate healthy behaviour Provide agreed health services Recognize signs and symptoms of conditions requiring referral Facilitate community diagnosis, management and referral.

Responsibilities of County Health Management Teams (CHMT) Provide leadership and stewardship for overall health management in the county Provide strategic and operational planning, Monitoring and Evaluation of health services in the county Provide a linkage with the national Ministry responsible for health. Collaborate with state and non-state stakeholders at the county and between counties in health services Mobilize resources for county health services Establish mechanisms for the referral function within and between the counties, and between the

different levels of the health system in line with the sector referral strategy Coordinating and collaborating through County Health Stakeholder Forums (CHMB, FBOs, NGOs, CSOs,

development partners) Supervise county health services

Sub county health managementEach county department of health shall decentralize its functions and the provision of its services to theextent that it is efficient and practicable to do so (COK 176(2). The sector proposes to use facility based staffto perform coordinating functions at the sub county level, where and when required. The sector also

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proposes to conduct staff rationalization at current district level by transitioning the staff at that level to theservice delivery units so as to enhance efficiency in service delivery and health systems management.

Responsibilities of County Health Facility Management Teams (CFMT) Developing and implementing facility health plans (FHPs) Supervising and controlling the implementation of FHP (M&E) Coordinating and collaborating through County Health Stakeholder Forums ( FBOs, NGOs, CSOs,

development partners) Training and developing capacity (in-service) Maintaining quality control and adherence to guidelines

Coordination mechanisms at county levelState actors and no- state actors will collaborate through County Health Stakeholder Forums (FBOs, NGOs,CSOs, development partners) to ensure: Delivery of services in all health facilities (levels 1–3) Development and implementation of facility health plans (FHPs) Supervising and controlling the implementation of Facility Health Plans (M&E) Training and developing capacity (in-service) Maintaining quality control and adherence to standard guidelines

ConclusionImplementation of the devolved government system started in March 2013. For the health sector to besuccessfully devolved, it is imperative to ensure: continuity and quality of services throughout the transition to a devolved health sector clear priorities for the transition period; gaps around devolution and health are anticipated and expeditiously resolvedGenerally, the Health Sector has made tremendous progress towards devolution and is committed tofacilitate seamless transition to a devolved health system.

Questions and discussions It was observed that county health coordinators, who had already posted, would help improve health

service delivery. It was felt that the role of FBOs in the county health policy and management and representation was not

clear. The CHAK MHUs sought to know what would happen next after they had given information to thecounty health data team, specifically, how they would go about pulling the county resources.

Another area of concern was the free services in government facilities. Was it possible for the FBOs to besupported to give the same free services? Could the FBO facilities be upgraded to offer referral services?The meeting was told that an organisational structure for the counties had already been developed. Itwas expected that the FBOs would be well represented in the county system. Guidelines were beingdeveloped to enable the county director to ensure the membership of the forums involved all players.However, it would not be possible to force the governors to use the guidelines. An MOU was also beingdeveloped although it was not a legal document.

Is vetinary services part of health service provision? Discussions were held the vetinary department and itwas agreed that operationally, the service should be delivered through the ministry of livestock.

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The meeting heard that since the two ministries of health were merged, CHAK facilities had lost theirrepresentation in District Health Management Boards. It was however reported that policy required FBOsto be well represented in County Health Management Teams.

The meeting wanted to know how ambulance services, which are currently facility based, would workwithin the counties. It was reported that guidelines were being developed on the issue.

Criteria for selection of county health coordinators: The meeting heard that this was a temporaryposition as the country waited for county public service boards to be established. These boards would bethe ones to hire county staff. The governor would determine county structure with guidance from thenational level. However, the county health coordinators had been selected from professionals alreadyworking in the county. During the selection process, all provincial directors of health, District MedicalOfficers of Health, among others, had been considered.

On facility categorization it was reported that a criteria was being updated for upgrading facilities thatmet certain norms and standards.

Members also wanted to know how they could ensure they were considered in the county budgets,specifically at the formulation stage. The meeting heard that county budget allocations would be at thediscretion of the governor and the county assembly. They were advised to make themselves heard at thebudget preparation stage.

The Ministry of Health was still grappling with implementation of free maternity services and hadpresented a budget of Ksh600m to the Treasury. It was therefore too soon to include CHAK facilities inthis arrangement.

Members also sought to know whether there would be extra charges to accessing health care acrosscounties. The meeting was told that Kenyans would be free to access health care across counties. Thegovernment was looking at the workloads of each facility and the cost implications. A user fee guidelinewhich would be implemented in all counties had been developed. Hospitals, it was said, should not beseen as a way to make profits and no Kenyan should be denied access to health care due to unfairmedical fees.

The Constitution provided that no Kenyan should be denied emergency care in any health facility. Themeeting sought to know who would pay for this care. It was felt that this matter needed to be discussedby all health sector stakeholders.

CHAK has had an arrangement with the government where a large chunk of dispensaries and healthcentres receive drugs KEMSA. The meeting expressed fears that this support would be withdrawn oncethe counties took over the role of availing drugs and medical supplies. It was acknowledged that therewere several such areas in which CHAK had good understanding with the government. Such areasincluded internship for doctors, staff secondment, supply of commodities, including drugs and vaccines,training of health workers, the District Health Information System (DHIS), among others. Discussions onsupport to FBOs through the Health Sector Service Fund (HSSF) were also on-going. It was important toensure that services were not disrupted due to the move to the counties. It was reported that this issuewould be taken up with the Ministry of Health. CHAK MHUs were also encouraged to approach thecounty governments for partnership and cooperation. The Health ministry had continued to advise thatKEMSA should do drugs procurement, especially because economies of scale would be essential forproper procurement, but the counties continued to demand their commodity money. It was thereforeexpected that county governments would begin to receive their drugs procurement budgets in the nextfinancial year. However, for the moment, KEMSA was still supplying drugs to the health facilities. Thecounties were free to order their drugs from KEMSA but would be required to pay for the same.

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Overview of the Kenya Health PolicyDr. Isabella Maina – Ministry of Medical Services

Historical backgroundThere have been several previous Strategic Planning Frameworks in the health sector in the past. These are: The Kenya Health Policy Framework, 1994 – 2010 which provided overall strategic policy direction. The

NHSSP 1, 1999-2004 and NHSSP 2, 2005 – 2012 provided medium term sector-wide strategic focus The MoMS and MoPHS Strategic Plans and MTP 1, 2008 – 2012 which provided ministry-specific

investment focus within the grand coalition government Annual Operational Plans which are developed each year have been providing annual operational focus.

Planning in the Kenya Health SectorThe current and future planning frameworks are: The Kenya Health Policy, 2012 – 2030: This is the formal sector policy document, endorsed by cabinet in

September 2012 and was the product of Sessional Paper No 6, 2012. It was developed in line with the 2010Constitution and the Kenya Vision 2030 and captures sector wide long term policy intents relating tohealth. It will provide overall sector-wide policy direction. The Kenya Health Strategic and Investment Plan (KHSSP), 2012 – 2017 and Medium Term Plan 2 (MTP2)

which are in advanced stages of development. They will provide medium term sector strategic focustowards the implementation of the new Constitution and realization of Vision 2030 goals. Annual Work Plans will continue to provide operational focus each year

Highlights of the Kenya Health Policy 2012-2030Its development was based on: The 2010 Constitution of Kenya The Kenya Vision 2030 economic blueprint The KHPF 1994-2010 end term review report

It is aimed at facilitating the health sector’s implementation of the provisions of the new constitution, andthe realization of the country’s vision 2030 objectives. It is a comprehensive national health policy thatprovides direction for all issues that have an impact on health. It includes all actions, across all sectors, thatimpact on health.

Policy directionsPolicy goal: ‘attaining the highest possible health standards in a manner responsive to the population needs’.

Policy aim: supporting provision of equitable, affordable and quality health and related services at thehighest attainable standards to all Kenyans.

Policy target: to attain distribution of health at a level commensurate with that of a middle income country.Key targets are: 16 per cent improvement in expectation of life (LE) 50 per cent reduction in annual deaths 25 per cent improvement in Years Lived with Disability

Policy focus: Achieving two obligations of the health sector:

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Human rights based approach (alignment to 2010 constitution) Health contribution to development (alignment to Vision 2030)

Policy Actions: Six health service objectives and seven health investment orientations

Policy objectives1. Eliminate communicable conditions: Reduce burden till they are not a major public health concern2. Halt, and reverse rising burden on non-communicable conditions: All NCD conditions addressed3. Reduce burden of violence and injuries4. Provide essential health services: affordable, equitable, accessible, and responsive to client needs5. Minimize exposure to health risk factors: Health promotion services6. Strengthen collaboration with health related sectors: Adoption of a ‘Health in all Policies’ approach

Policy orientationsSeven health investment targets sought during KHP implementation are:1. An efficient service delivery system that maximizes health outcomes.2. Comprehensive leadership that delivers on the health agenda.3. Adequate and equitable distribution human resources for health4. Adequate finances mobilized, allocated and utilized, with social and financial risk protection assured5. Adequate Health information, for evidence based decision making.6. Universal access to essential health products and technologies7. Adequate and appropriate Health Infrastructure

Policy principles• Equity in distribution of Health and health interventions• People-centred approach to health and health interventions• Participatory approach to delivery of interventions• Multi-sectoral approach to maximizing health goals• Efficiency in application of health technologies• Social accountability

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The policy will be implemented through five-year strategic plans and annual work plans.

Questions and discussions What is the role of counties vis-à-vis the national government in health? The counties should not be

considered as another government but as one with the national government. The county governmentshave been established by the Constitution and consensus and collaboration with the national governmentis key. One level of government cannot impose itself on the other as their functions and operations aregoverned by the law. In matters of health, the national government will be responsible for policy directionwhile the functions of county governments have been clearly spelled out. There is an inter-governmentalrelations Bill that details how the two levels of government will work together.

A client satisfaction survey being carried out by Synovate will point the way forward on serviceimprovement. It is available on-line. CHAK MHUs were encouraged to participate in the county healthforums to discuss issues impacting on health service delivery.

The meeting heard that FBOs representation and involvement with government in health service deliverycame about as a result of service contracts given to permanent secretaries. The permanent secretariesneeded data to show the extent of service deliveries and challenges. Unfortunately, the devolvedgovernment does not have performance contracts yet.

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Had any evaluation been done on the country’s performance in health over the past five years? If there is,who gets the feedback? Evaluation is done constantly with the data feeding into the strategic planningprocess. Annual operational plans guide implementation each year. At the end of each AOP a report iscompiled and published. An annual report shows the contribution of all players including FBOs. The annualreport is released in a stakeholders’ forum where CHAK is represented.

The Kenya demographic health survey that is done every five years is also a good source of data. There arealso reports showing where we are with all the indicators. In the new policy there is a lot of emphasis onoperational research which has not been done very well in the past.

The meeting felt that CHAK needed to be strategically represented in all the 47 counties. It was suggestedthat the big hospitals and Regional Coordinating Committees represent the CHAK network at the countylevel.

How will M&E be conducted with the county governments in place? Each county will be required to havean M&E team. It is expected that the health cabinet secretary will sit in the summit while the DHIS will stillbe operational. However, the government is looking at having a national information system instead ofthe DHIS. The M&E programme is also included in the strategic plan.

It was also felt that the government’s policy to allow free deliveries for expectant mothers wouldnegatively affect patient numbers in FBO facilities. CHAK and other FBOs were advised to lobby thegovernment for inclusion in this policy although implementation was already at an advanced stage.Further engagement was needed on policy issues to ensure FBOs’ inclusion where possible.

Fears were expressed that the CHAK health facilities would no longer be able to benefit from the essentialdrugs kits distributed by KEMSA as the counties would be responsible for procurement of drugs andmedical supplies. The meeting was told that the national government would continue to negotiate for acentral procurement system due to economies of scale and quality issues.

The CHAK health facilities were advised to partner more with the government, ensuring that they alsomade a significant contribution in all areas of health care delivery.

Performance contracts, it was reported, would be introduced for all accounting officers.

Dr Bruce Dahlman from INFA-MED reported that the organization had adopted a curriculum to produceChristian family doctors. Under the arrangement, 75 per cent of the trainee’s salary would be donorsupported and tuition also paid. The participating hospital would be required to raise the remaining 25 percent salary support. CHAK hospitals were encouraged to apply through INFA-MED whose offices were locatedin CHAK.

The Health Sector Service Fund (HSSF)Dr Kibias Simon, MPH, Deputy Head, Department of Primary Health Services, Ministry of Public Health andSanitation

The HSSF was created through Legal Notice No. 401, Kenya Gazette Supplement No.123 of 21, December2007, and amended through Legal Notice No. 79 of June 2009. It was made by the Minister for Finance inexercise of powers conferred by Section 26 of the Government Financial Management Act, 2004.

Basis of the policy Direction The need to achieve Millennium Development Goals Focusing on the Government of Kenya Vision 2030

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Kenya Health Policy Framework 1994-2010 Second National Health Sector Strategic Plan (NHSSP II) 2005-2010 Ministry of Public Health and Sanitation (MoPHS) Strategic Plan 2008-2012

Purpose of the fund Expedite the process of transfer of funds to facilities Reduce the bureaucracy in the transfer and utilization of the funds by direct transfer to the user points Ensure efficient and accountable use of funds Achieve equity in resource allocation and quality of service Foster partnership , community participation and ownership (SWaP)

Benefits of the fund• Improve the scope and quality of health service provision at community, dispensary and health centre

levels• Help integrate health service provision into the community fabric as an essential good to which people

have rights and responsibilities• Transform the way health services are provided as well as the relations between providers and receivers

and how health is perceived• Delegation of a wide range of health related activities to the community so that they move from being

mostly passive recipients to active participants

Sources of funding GOK appropriations by Parliament Development partners World Bank loans User fees charged Donations and grants received Proceeds from the operations of the account

Summary of disbursement of funds to date

HSSF Secretariat 56,481,868.65 3.3 GOK DHMTs 379,491,000.00 22.4 GOK Health Centres 846,032,000.00 49.9 GOK Dispensaries 405,157,500.00 23.9 UNICEF 5,000,000.00 0.3 PBF Pilot in Sambury 1,862,819.00 0.1 Social Accountability 1,179,810.00 0.1 Replacement of cheques - -

Grand-total K.Shs. 1,695,204,997.65 100.0

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Facilities receiving funds Health Centers – 774 Dispensaries – 2,389 District Health Management Teams - 268

Challenges Establishing an accurate database of facilities Ensuring that facilities have opened current accounts in commercial banks Timely reporting and accounting for funds disbursed

Future Consolidate the gains made in establishing the fund Scale up efforts to include FBO Facilities Foster private sector partnerships

Questions and discussions Are FBOs assured of getting HSSF grants, especially given that policies are formulated for the entire

health sector? FBOs are yet to even be trained on HSSF. Are the funds a grant from the ministry or an entitlement from Treasury?

The meeting was told that FBOs had been designated to receive HSSF funding in phase three onperformance based arrangements. The FBOs would be required to report on certain indicators and be paidan agreed amount based on achievement of the indicators. The FBOs had met and put forward theirthoughts on the indicators.

Any disbursement of funds to CHAK MHUs would be done through the Secretariat. The initial agreementwas that funds disbursement begin in January although this has been pushed to quarter 4 in May. The rollout for FBOs was scheduled to begin in the arid and semi-arid areas in facilities that are included in theMaster Facility List. The roll out is supported by the Government of Kenya and Danida. Hope was expressedthat HSSF funds would be released to FBOs as this had already been gazzetted.

Transforming social health insurance in KenyaMr Kirgoty, CEO, National Hospital Insurance Fund (NHIF)

Health remains a social and economic issue. Kenya’s population currently stands at 40 million up from 10.9min 1963. About 68 per cent of Kenya’s population lives in the rural areas. Kenya’s economy is characterized byhigh levels of inequality. The country has been ranked 128th out of 169 countries with a life expectancy of55.9, which is quite low.

About 80 per cent of Kenyans work in the informal sector. The 2010 economic survey shows the formalsector is generally stagnant while the informal sector is growing. The level of unemployment in the country is

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quite high. About 20 per cent of the population lives below a dollar a day. This means that they cannot payfor health care, hence the need for innovative funding models.

Health care financing is determined by a wide variety of factors including revenue collection, pooling, fundallocation to show what to buy and for who, purchasing (passive and strategic), among others. Any goodfinancing system has to be equitable and sustainable.

A key challenge facing health care financing is inadequate policies. Additionally, there is low utilization ofservices available. Reliable information and data remains a key challenge. Currently, there are 76 differentICT systems in the public health system.

About 30 per cent of health funds in Kenya come from donors. Yet donor funding will dwindle. There istherefore need for a social health insurance that takes care of all citizens regardless of their economic orsocial status. A national insurance scheme will ensure equitable financing of health care for all as required bythe Constitution.

We need to form a large pool of mergers and synergies of all stakeholders, restructure to business modelsand ensure complimentary roles for all. There is also need for an efficient payment mechanism as well asefficiency in the entire health system.

Questions and discussions CHAK member hospitals were of the opinion that rebates offered by NHIF were too low and failed to

cater for rising costs of health service provision. The meeting was told that once the cases in courttouching on NHIF contributions were over, there was a possibility that the rebates would increase.

There was also a problem with the timeliness of reimbursements. Members complained that someclaims had been pending for one year. Additionally some claims were being rejected and returned to thefacilities. The facilities asked to be given immediate communication on returned and rejected claims.However, the meeting was told that an ICT system that allowed patients to click in and out of hospitalhad been installed. The change-over to this ICT system was however experiencing some hiccups.

The Kenya Model for Health QualityDr Lucy Musyoka - Head, Department of Standards, Research and Inspectorate & Annette Eichhorn-Wiegand – Health Quality Management Systems Advisor, CHAK

Historical backgroundThe Division of Health Standards, Research and Inspectorate was established in 1991 and upgraded to adepartment in 1996. Between 2001 and 2003, the Kenya Health Standards were developed under the KenyaQuality Model (KQM) framework. In 2005, the second Health Sector Strategic Plan (HSSP 11) which definedthe Kenya Essential Package for Health (KEPH) levels of care was developed. Identification of KEPH levels ofcare led to revision of the KQM between 2007 and 2009.In 2009, the revised KQM was approved by the Permanent Secretaries in MOMS and MOPHS) and renamedKenya Quality Model for Health (KQMH). Implementation of KQMH guidelines began in 2011 while a launchwas held in 2012. Dissemination of KQMH has been on-going.

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What is Kenya Quality Model for Health (KQMH)?It is a conceptual framework for an integrated approach to improved quality of health care. It holistically andsystematically addresses a range of organizational quality issues with the main aim of delivering positivehealth impacts.KQMH recognises the paradigm shift in quality. From we know best what is good for you to customer orientation From postproduction evaluation to prevention and continuous improvement From external focus on control through inspection to design and self-assessment

The seven underlying principles of the KQMH are: Leadership Customer orientation (external and internal) Involvement of people and stakeholders Systems approach to management Process orientation Continuous quality improvement Evidence based decision making

The KQMH has three components, namely: Evidence-based medicine (EBM) through wide dissemination of public health and clinical standards

and guidelines Total Quality Management (TQM) Patient Partnership (PP)

Evidenced based medicine involves using best available evidence from epidemiological surveillance, surveys,empirical research studies, operational research e.t.c to ensure standards and guidelines used are proven tobe:

effective efficient affordable accepted and user-friendly

Patient partnership emphasizes customer focus, recognizing that patients/clients are co-producers of healthoutcomes. Information for improvement should be derived from customers e.g. through patient satisfactionsurveys while the community needs to be involved in designing, planning, implementation includingMonitoring and Evaluation of quality improvement initiatives. Patients’ rights and views should be respectedthrough institute service delivery charters/patient rights.

Tools used to attain patient partnership Service charters-institutional, Departmental Patients’ rights Information pamphlets/brochures Feedback mechanisms-Suggestion/complaint boxes Citizen score card/board Joint membership of health facilities committees/health boards

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Total Quality Management (TQM) can be broken down as follows: Total - everyone is involved in Quality - continously improving service to patients Management with data and profound knowledge

Total Quality Management (TQM) is a management philosophy that represents the most advanced state ofquality development today. It aims at long term success for development of organizational quality culture.TQM involves application of quality management principles in the choice of quality managementmethodologies, tools and techniquesThere are two major characteristics of Total Quality Management: Focus on serving customers Use of systemic problem solving teams made up of front line workers (Quality Improvement

Teams/Work Improvement Teams)

Tools used to achieve Total Quality ManagementKQMH has 12 dimensions defined using Donabedian`s classification:

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Tools used to achieve Total Quality Management5S-CQI (KAIZEN)-TQM approach tools 5s-Work Environment Improvement (WEI) CQI tools for problem identification and process improvement-Cause and Effect, Pareto Chart The Plan-Do-Check (study)-Act PDSA/PDCA (Deming) cycle is the backbone of Continuous Quality

Improvement activities

KQMH uses a checklist to ‘score’ performance of an organization against established standards which can befound in the booklet ‘Standards’.

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Quality improvement is a never ending journey. Continuous improvement of the organization and overallperformance should be the permanent objective of the organization. The end results are: Loyal, happy customers; no complaints and increased business No complaints and increased business leads to happy management Happy management leads to happy employees Happy employees drive great customer experiences Great customer experiences lead to loyal happy customers

Way forwardThe Ministry of Health with the Department of Standards and Regulations launched the KQMH in May 2012.A technical working group will be formed to spear head implementation of the KQMH and dissemination willbe undertaken in all counties besides Nyanza, Eastern and North-Western.

KQMH implementation

Stakeholder responsibilities

National Health System County /Associations (CHAK)HealthSystem

Institutional Service deliveryLevel

Quality Improvement Policyand Investment Plan

Development ofImplementation Plan

Providing Leadership inQuality Improvement-Vision, Mission,Principles and Values

Altitude Change-Sorting , Setting theMind to orient it toa Quality Culture

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Regulatory Framework forRegistration, Licensing and

Accreditation

Technical Assistance toInstitutions

Organizing Knowledge sharingnetwork

Development of Actionplans-Budgeting for QIactivities-Planning, WorkImprovement initiatives,Innovation

Adherence to Clinical,Public Health andProfessionalStandards

Technical Assistance toCounty Health System-

• Provision of Trainingmaterials

• Training of County TOTs• Organizing Knowledge

sharing network

Establishing Regional ToTs Formation of QualityImprovement Teamsand Work ImprovementTeams

Inculcating a learningculture-participatingin ContinuousProfessionalDevelopment,conferences etc

Performance monitoring-External Assessments

Performance monitoring-External Assessments

Performance Monitoring-Peer Assessment, Self-Assessment

PerformanceMonitoring-PeerAssessment, Self-Assessment

Other steps forward include: Finalizing the training package (curriculum, Facilitators manual, participants handbook) Training of the TOTs

What does this mean for CHAK members? Members were advised to get the booklets and the soft copy of the KQMH from the stand at the CHAK

AHC/AGM exhibition Get the new CHAK TIMES with a comprehensive chapter about KQMH Fill in the questionnaire and hand it back so that CHAK is able to support MHUs as per received requests CHAK is able to hold in-house trainings for all levels of health facilities on KQMH and Quality Management

in general. CHAK can support health facilities in building up a functioning CQI system on a hospital or on a health

facility network level. Further support in building up a quality improvement system and implementing KQMH on request; Contact

annette@chak.or.ke Members were advised to get feedback from their clients through feedback forms and questionnaires to

inform quality improvement efforts

Questions and discussions Does a facility move to a lower level if staff leave? The level of a facility is determined by the norms and

standards that are currently being revised. However, documents are different from the reality. The healthsector is faced with many HR challenges. In such a scenario, the level of care does not change.

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How are the KQMH trainings conducted? One type of training has been piloted for five days in one healthfacility. However, the meeting was told that preparations for the trainings were being finalized and acurriculum for TOTs had already been developed. Government facilities had been encouraged to organizein-house trainings with the department providing facilitation and reference materials. CHAK MHUs reported that they were yet to receive the KQMH reference materials, yet the launch had

been done in a number of regions. The MHUs were advised to report the same to the regional ministryoffices to ensure they were included in the list of participants. Some provinces had FBO representation inthe KQMH launches. The department ensures synergy with what other partners so they can also be aligned to KQMH. Some aspects of KQMH can be implemented even with limited resources.

Good Dispensing Practice – Rational Use of MedicinesDr Andreas Wiegand – Ecumenical Pharmaceutical Network (EPN)

Good dispensing practice has the following components: Correct medicine Right patient Correct dosage and quantity Clear instruction Good packaging with accurate labelling

It needs to be done in the right environment and with the right equipment.

Cleanliness of dispensing equipment Measuring cylinders should be cleaned with soap, water and a brush and stored to dry. They should be

clearly labelled for internal (oral) and external (topical) preparations. These should not be usedinterchangeably.

Counting devices are to be wiped with a soft dry cloth after each use and periodically cleaned with soapand water and wiped dry.

Spatulas should be cleaned with isopropyl alcohol after each use.

Preparation of medicineIs it hygienic to count in your hand? Are you eating from your neighbour’s hand?

Information on the medicine label Label the container with:a) The name of the patientb) The name of the medicinec) The strength of the medicined) The quantity of the medicine dispensede) The dosage instructions or frequencyf) The date of dispensingg) Any special instructions e.g. take after food

Check all the details again against the prescription.

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Steps involved in dispensing Receipt of a prescription Interpreting a prescription Filling of a prescription Packing and labelling Giving instructions to the patient and counselling Documentation

Questions What is the diagnosis?a) Indicationb) Dosec) Duration of therapy Who is the patient?a) Ageb) Weightc) Sized) Impairmentse) Gender

Filling prescriptions for childrenThey are usually prescribed in liquid form. Liquids include syrups, suspensions and mixtures. Suspensions areoften in powder form and require reconstitution. A mark on the bottle is indicated for measuring the waterrequired. The water used should be freshly boiled and cooled to reduce the number of vegetative micro-organisms.The ideal children's medicine: Suits the age, physiological condition and body weight of the child Is available in a flexible solid oral dosage form that can be taken whole, dissolved in a variety of

liquids, or sprinkled on foods, making it easier for children to take Is sweetened

Issues with children’s medicines Crushing tablets and unencapsulating capsules Some tablets lose their properties when crushed Some medicine is lost when crushed Exposure to the environment may lead to loss of some properties of the medicine If mixed with water, it may not dissolve completely thus some medicine may be lost

Formulations for children Dispersible tablets Syrups and suspensions Suppositories Powder or granules in sachets Inhalers with spacers

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Oral dropsDispersible tablets Examples include paracetamol (such as efferalgan) and artemether+lumefantrine dispersible tablets Tablet is put in a cup of water and easily dissolves The child is then given the water with the medicine fully dissolved to drink Dose can be easily divided

Syrups and suspensionsThese are liquid formulations that are easy for the child to take. Many have a sweetener to enhance the tasteand some come in the form of a powder to be reconstituted on dispensing. It is important to follow themanufacturer’s instructions to reconstitute the medicine.

SuppositoriesThese are inserted into the anus and are useful if a child is vomiting, irritable or unwilling to swallow anymedicine. Some medicines are formulated as a suppository. One should not attempt to use anotherformulation as a suppository.

Powders and granulesThese include medicines such as oral rehydration salts (ORS). The powder is added into a specified volume ofwater and dissolved. The solution can be easily drank by the child as most of the formulations have apleasant taste and colour.

DosagesDosages for children should be determined according to the body weight. This is unlike adults who usuallyhave standard dosages for medicines. In many references such as the WHO essential medicines list forchildren, the dosages are given per kilogram body weight. The weight of the child has to be determined inorder to calculate the specific dose for the child.

The elderlyRenal impairment is a key consideration for the elderly.Risks of renal impairment Reduced excretion of a medicine or metabolite Sensitivity to some medicines is higher More side effects may occur The efficacy may be diminished

Another key consideration is hepatic impairment. This is characterised by: Impaired hepatic elimination/metabolism Impaired biliary elimination (biliary obstruction) Impaired hepatic blood flow, poor perfusion, cirrhosis Decreased protein binding Increased bioavailability through decreased first pass metabolism Decreased bioavailability due to malabsorption of fats in cholestatic liver disease

PregnancyStages of pregnancy 1st trimester – highest risk.

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2nd trimester – the maturation of already formed organs are affected 3rd trimester – some medicines given at this stage may affect labour and the last steps of foetal

development.

Categorisation of medicines for pregnancy A – Very low or no risk for malformations B – Low risk for malformations C – Risk level has not been established D – Foetal risk shown in humans. X – Contraindicated; very high risk and proven to cause congenital malformations. Benefit does not

outweigh riskFor pregnant women, prescribe as little as possible or as much as may be required to reduce risk for motherand child

BreastfeedingBreastfeeding mothers may be on treatment for one condition or another. Medicines in the mother may passinto the milk and a suckling baby may thus take in the medicine the mother is taking. Medicines used whilebreastfeeding: May be harmful to the suckling May have no effect May reduce the breast milk produced

a) Iodine: Stop breastfeeding: danger of neonatal hypothyroidismb) Praziquantel: Avoid breastfeeding during and for 72 hours after treatment; considered safe to continue

during treatment of schistosomiasis

MEDS: Ensuring Access to reliable, quality and affordable essential medicines and othermedical commodities in a devolved health sector

Presented by Jonathan Kiliko - Head of Customer Services, MEDS

About MEDSMEDS was established in 1986 as an ecumenical partnership of KEC and CHAK to ensure quality healthcaredelivery. It is a Christian not-for-profit Drug Supply Chain Organisation (DSO) based in Nairobi, Kenya. Theregistered trust owned (50:50) by the two church secretariats (KEC & CHAK) is currently serving 1,815corporate clients (FB, Public, NGOs & Private) in Kenya and beyond with a warehouse capacity of 10,000 m2

MEDS strategic directionVision: A world class faith based medical supply chain & capacity building organizationMission: to provide reliable, affordable, quality essential medicines, medical supplies, capacity building andother pharmaceutical services guided by Christian and Professional values.Core functions – Supply Chain, QC Laboratory Services and Capacity Building for health personnel

Enhancing capacity for Growth Strategy

Major achievements

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ISO 9001:2008 Certified in December 2012 Quality Management System (QMS) in place WHO Pre-qualified QC Laboratory Experienced in the supply chain (since 1986) Customer Relationship Management (CRM) Solution Provision of reliable, quality and affordable

– Essential Medicines and Medical Supplies,– Quality Control Laboratory Services– Capacity Building Services

Part of the warehouse - 10,000 m2

MEDS Centre - Office block

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WHO pre-qualified quality control laboratory - Confirmation of quality products

60%12%

28%

Faith Based Government Others

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MEDS clientele

Challenges facing the health sector in Kenya1. Financing difficulties at patient and institution levels2. High staff turnover3. Limited capacity of majority of private health providers4. Inadequate capacity of healthcare providers5. Increased demand for healthcare services6. Low household incomes and poor physical infrastructure7. Characteristics of MEDS clients – operate in difficult-to-reach and hardship areas, serve low/poor income

population, serve disaster stricken areas

Major Challenges facing MEDS1. High debt levels as illustrated below

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2. Reduced support from Church Health Facilities which can be attributed to the following:a. Economic hardships and effects of the 2013 General Electionsb. Rising debt levels with MEDS as a result of which health facilities are buying from other

sources to avoid settling their debts with MEDSc. Despite the loyalty from Church Health Facilities, there is increased competition in the

marketd. MEDS previous inefficiencies led to loss of some clientse. Improved service delivery in public health facilitiesf. Making QC Laboratory and Capacity Building functions sustainable

3. Devolution: The roles and responsibilities of County and Central Governments are still not clear.

Possible solutions Prompt payment of MEDS outstanding debts Strengthening MEDS-health facilities’ relationships Jointly fighting against the menace of counterfeit medicines Church Health Facilities are MEDS ambassadors at county level. Plans to have strategic partners in

each county will be rolled out soon. Health facilities are requested to continue giving MEDS feedback on areas that require improvement.

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Access to quality and affordable commodities

The access framework; Source: WHO

Barriers to medicines accessAccess to medicines is part of the fulfillment of the right to health. Some Factors which affect access tomedicine include: high cost, insufficient production, and lack of research and development, All these contribute to inequitable access to medicines to millions in urban and rural KenyaMedicine prices are a major barrier to access to quality medicines, especially for the poor and sick.Access to medicines is becoming a growing challenge in Kenya particularly due to inadequate knowledge onselection, quantification, procurement and ordering of quality medicine by the personnel involved in thesupply chain of medicine. Poor infrastructure in Kenya is also a contributing factor. Advocacy on theimportance of using medicines of good quality has increased the community’s awareness.Increased infiltration of substandard and fake medications is life-threatening. The major challenge is lack of adefined system capable of detecting counterfeited medicines

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MEDS interventions to increase accessCapacity Building for Health Personnel Residential courses Facility based interventions Consultancy services Mentorship programmes

Improved supply chain component WHO pre-qualified quality control laboratory which helps in the fight against counterfeits Differentiated pricing for KEC and CHAK facilities Stocking: MEDS has over 900 products (with 3 months’ buffer stock) under the following categories:

– Medicines– Surgical supplies and laboratory reagents– Medical equipment and other general supplies

Focus on the customer

The devolved health sectorSchedule IV of the Constitution provides that: Counties will coordinate health activities in order to ensure complementary inputs, avoid duplication

and provide for cross-referral, where necessary to and from institutions in other counties County Governments will facilitate accreditation of health facilities and providers according to

standards set nationally by the Ministry of the National Government responsible for health andrelevant regulatory bodies.

County Health Coordinators and County Pharmacist in Charges have already been appointed.

Alignment with county governmentsMEDS is already doing business in the 47 counties. There is however need for strategic partnership withexisting key health facilities to leverage on faith based facilities in the respective counties.Faith based facilities are encouraged to procure from the MEDS supply chain to mitigate influx of new playersand more importantly, to protect the consumer from counterfeit medicine. It is also important to strengthen

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current collaborative arrangements with KEMSA and the National Quality Control Laboratory to optimize onsynergies of supply chain organizations and product testing by the WHO prequalified laboratories.

Questions and discussions Participants wanted to know where they could get the WHO formulary and were told that it was

available on-line and also from EPN. A few printed copies were available in MEDS and efforts would bemade to print them with one CHAK Times issue.

After how often can a patient repeat a dose of drugs if he or she did not complete the previous one?Participants were advised to continue with the normal schedule as directed by the physician if they failedto take a drug as scheduled.

Injectables are useful where a patient is vomiting. Where a patient is able to keep fluids down, analternative would be to dissolve tablets that are not film coated in water before asking them to swallowthe mixture.

Is it possible to fight counterfeit drugs selling in chemists and pharmacies as many patients access drugsfrom these sources and are likely to be getting conned off their money? With the advent of countygovernments, it is expected that some people will seek to influence decision making. More chemists andpharmacies will come up for the sole purpose of making profit, thus it is expected that incidences ofcounterfeit drugs will rise. MEDS works with the Pharmacy and Poisons Board where they jointly inspectmanufacturers to ensure they adhere to quality standards. It is therefore advisable that Church HealthFacilities buy from MEDS to ensure quality and avoid counterfeits. A list of manufacturers who have beenblacklisted by MEDS would be made available to the health facilities.

MEDS works closely with KEMSA and the government. It is also anticipated that there will be intensenetworking with the county governments.

Participants sought to know if it was possible to order drugs on-line and were informed that there is acustomer relations module on the MEDS website from where they could order the drugs. The meetingwas informed that on-line orders get priority since processing begins immediately.

Lead time for orders had improved significantly although there were a few delays which could beattributed to stockouts, among other factors.

Stock outs affect operations. For some of the items that have been out of stock, sources in India andChina have been identified. Visits would be arranged to companies selling their products in the countryand a report compiled.

A member reported that the amount on an invoice sent to his health facility had been adjusted withoutprior communication.

Participants reported that delivery time for reagents was too long and were told that MEDS did not stockall reagents and therefore took time to source for the ones that were not in stock upon order. Where ordered drugs were unavailable, customers were not being informed about the prices of the

alternatives. It was therefore necessary to improve communication along these lines and also frequentlysend reminders to debtors. Participants were informed that they could check their debt levels on-linefrom the MEDS website. Capacity building was needed for health workers to be able to identify counterfeits. Is quality control done also on medical supplies? Participants were told this depended on customer

feedback. Action would be taken where defects were identified on medical supplies. Constant feedbackwas therefore very helpful.

Members reported that the MEDS ordering template did not include some items. Additionally, the itemcodes were not distinct. MEDS promised to look into the issue.

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Patients who cannot swallow are given medicine in a nasal gastric tube. Does this give optimumtherapy? There are some medicines available for this kind of treatment. MEDS and EPN would come upwith a list of these medicines after clarifying with the necessary literature and manufacturers.

Members were challenged to fight counterfeits by getting the medicines available from localpharmacies tested, then sharing the results with the Pharmacy and Poisons Board and otherstakeholders.

Participants were advised to read the MEDS Update for further information on drugs and medicalsupplies and related issues.

They were also advised to avoid keeping IV lines too long on patients as there was a possibility ofinfections.

Psycho-spiritual approach in management of HIVPresented by Susan Muriuki on behalf of Brother Kisavi - APHIA PLUS KAMILI Zone 4

ApproachThe project targets already existing congregations and church groups in HIV testing, care and treatment forpeople living with HIV with the church leadership taking the lead in giving the information to thecongregation.

Opportunities in the Church Church Membership and attendance Existing church groups (women, men and youth) The congregation has faith in church leadership Many couples are found in the church Coverage - Churches can be found everywhere.

OutcomeThe approach was piloted in two facilities in the Central region, St Mulumba and Brothers of St Joseph.Outreaches were carried out in the two facilities and mobilization done by the church leaders. In the twooutreaches, a total of 729 clients were tested, 422 were new testers translating to 57.9 per cent and twowere found to be HIV positive. About 30 couples were tested.

Challenges A number of church leaders still have a negative attitude towards HIV and those infected HIV related stigma A number of Christians do not perceive themselves to be at risk.

Lessons learned The Church has strong potential in HIV prevention, care and treatment. More than 50 per cent of the church members do not know their HIV status. The church plays a great role in stigma reduction.

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Questions and discussions Announcements in the church are taken positively. In the Church, there are couples and a ready

congregation. When the congregation sees church leaders getting tested, they take testing positively.Many congregants do not know their HIV status.