report on the review of the kisumu county health …...“report on the review of the county health...

Report on the Review of the

Kisumu County Health Sector

Strategic and Investment Plan

Report on the Review of the KCHSSIP 2013–2017

Report on the Review of the Kisumu County

Health Sector Strategic and Investment Plan

2013-2017

i Report on the Review of the KCHSSIP 2013–2017

The Kisumu County Department of Health and Promotion of Health Investments

“Report on the Review of the County Health Sector Strategic and Investment Plan

2013-2017” has been supported by the United States Agency for International

Development (USAID) under the terms of MEASURE Evaluation-PIMA associate

award AID-623-LA-12-00001. Views expressed are not necessarily those of

USAID/PEPFAR or the United States government.

www.measureevaluation.org/pima Any part of this document may be freely reviewed, quoted, reproduced or translated in full or in part, provided the source is acknowledged. This document may not be sold or used in conjunction with commercial purposes or for profit. Published by: Kisumu County Department of Health and Promotion of Health Investments ©2017

http://www.measureevaluation.org/pima

ii Report on the Review of the KCHSSIP 2013–2017

FOREWORD

The Kisumu County Health Department in collaboration with MEASURE Evaluation PIMA conducted a

review of the progress of implementation of the Kisumu County Health Sector Strategic and Investment

Plan (KCHSSIP) 2013-2017. The KCHSSIP was developed in 2013 and was to be implementation for a

period of five (5) years from the financial year 2013/2014 to 2016/2017. The KCHSSIP provides the overall

strategic and implementation framework for the health sector priorities and is aimed at contributing towards

the overall development goal of the County in line with the County’s long-term development agenda, Vision

2030, the Constitution of Kenya 2010 and national commitments.

The report uses data from different sources including the health management information system, the

Kenya demographic health survey and various household surveys to provide a comprehensive overview of

the current status of performance of the health sector in Kisumu County. The primary focus of the report

is on the core indicators and targets of the KCHSSIP 2013-2017. The report also looks at additional

indicators that help to assess progress towards achieving county priorities and global goals that came into

effect after development of the KCHSSIP 2013-2017.

This review report will prove handy to the senior management and technical experts of the County

departments of health, other government ministries, departments and agencies that have an impact on the

health sector. The report will also be useful for policy makers, the civil society and the community at large

and will also inform the development of the next KCHSSIP i.e. the KCHSSIP 2018-2022. It is my

anticipation that future reports from the County Health Department will contain a similar level of analytical

thinking with comparative and equity considerations.

At a personal level, the report provides me with an audit of where we are and what I need to focus on as a

leader in the health sector. It is my hope therefore that all stakeholders in the health sector will use the

report to increase efforts in service provision and raise standards for recording, documenting and reporting.

We look forward to using the report to improve performance of the Kisumu health sector as we strive to

continue improving the health of people in Kisumu.

On behalf of the Kisumu County Health Department, I would like to express my appreciation to all the

partners for providing both technical and financial support for the review of the Kisumu Health Sector

Strategic and Investment Plan 2013-2017.

Dr. Elizabeth Ominde-Ogaja

County Executive Committee Member for Health

Kisumu County.

iii Report on the Review of the KCHSSIP 2013–2017

ACKNOWLEDGMENTS

The review of progress and performance of the KCHSSIP 2013–2017 is an important undertaking of the

Kisumu County Department of Health. The department is indebted to all those who participated in the

development of this report, which was done through a collaborative process. Special thanks and

appreciation goes to the County Executive Committee, Member for Health, Dr. Elizabeth Ominde-Ogaja,

Chief Officer of Health, Dr. Ojwang’ Lusi for providing overall leadership and to the County Director of

Health for technical guidance during the review process.

Special recognition for provision of financial and technical support goes to MEASURE Evaluation PIMA.

I would also like to extend gratitude to partners who offered technical support during the review process

including Maternal and Child Survival Project (MCSP), AMPATH, Family AIDS Care and Education

Services (FACES), The Kenya AIDs Response Program (KARP) and AIDS, Population and Health

Integrated Assistance (APHIA) plus. Additionally, I would like to recognize and commend all individuals

that contributed to the analysis and writing of this review report. These include staff from the County

Health Department and health data collaborative partners, who participated in the review process and made

invaluable contribution through availing and reviewing data, contributing to the discussions that improved

the quality, accuracy and completeness of data, and information used in the report.

The report will guide the department of health in delivering quality health services in accordance with the

county mission and vision, the KCHSSIP 2013-2017, the Kenya health policy framework and the

Constitution of Kenya. The recommendations from this report will be implemented to better the health of

Kisumu County residents.

County Director of Health

Dr. Dickens Onyango

Kisumu County

iv Report on the Review of the KCHSSIP 2013–2017

CONTENTS

Abbreviations ........................................................................................ vi

Executive Summary ............................................................................. vii

Background ....................................................................................................... vii

Purpose, Objectives, and Methodology ....................................................... vii

Findings ............................................................................................................ viii

Recommendations ............................................................................................. x

1. Introduction ........................................................................................ 1

1.1 Background .................................................................................................. 1

1.2 The Review Process .................................................................................... 3

1.2.1 Document Review .............................................................................. 4

1.2.2 Quantitative Data Analysis ............................................................... 4

1.2.3 Qualitative Study ................................................................................ 4

2. Findings .............................................................................................. 5

2.1 Demographic Profile .................................................................................. 6

2.2 Health Service Outcomes .......................................................................... 7

2.2.1 Eliminate Communicable Conditions ............................................. 7

2.2.2 Halt and Reverse the Increasing Burden of Non-Communicable Diseases 13

2.2.3 Reduce the Burden of Violence and Injuries ............................... 15

2.2.4 Provide Essential Health Services ................................................. 17

2.2.5 Minimize Exposure to Health Risk Factors ................................. 20

2.2.6 Strengthen Collaboration with Health-Related Sectors ............. 21

2.3 Trends in Health Status and Impact Indicators ................................... 22

3. Recommendations ............................................................................ 23

4. Conclusion ........................................................................................ 26

References ............................................................................................ 27

Appendix 1. Qualitative Study Key Informant Interview Guide ......... 29

Appendix 2. List Of Contributors ........................................................ 31

v Report on the Review of the KCHSSIP 2013–2017

FIGURES

Figure 1. Framework for health .............................................................................. 2

Figure 2. Framework for policy direction ............................................................. 3

Figure 3. Trends in child immunization coverage by subcounty ..................... 10

Figure 4. Proportion of children under five years diarrhea cases reported at

OPD .......................................................................................................................... 11

Figure 5. Proportion of HIV-positive pregnant mothers receiving ARVs .... 11

Figure 6. Proportion of eligible HIV clients on ARVs ..................................... 12

Figure 7. TB treatment completion rate .............................................................. 12

Figure 8. Percentage of pregnant women receiving IPT1 and IPT2 and first

ANC attendance ...................................................................................................... 19

Figure 9. Skilled service delivery attendants and four ANC visit coverage ... 19

TABLES

Table 1. Summary achievements by strategic objectives..................................... 5

Table 2. Catchment population by year ................................................................. 7

Table 3. Population by cohorts ............................................................................... 7

Table 4. Objective 1 indicators: Eliminate communicable conditions ............. 9

Table 5. Objective 2 indicators: Halt and reverse the increasing burden of

NCDs ........................................................................................................................ 14

Table 6. Objective 3 indicators: Reduce the burden of violence and injuries 16

Table 7. Objective 4 indicators: Provide essential health services .................. 18

Table 8. Health status and impact ........................................................................ 22

vi Report on the Review of the KCHSSIP 2013–2017

ABBREVIATIONS

ANC antenatal care

ARV antiretroviral

BMI body mass index

eIDSR integrated electronic disease surveillance system

HEI highly exposed infants

IPT intermittent preventive treatment

IPV inactivated polio vaccine

JOOTRH Jaramogi Oginga Odinga Teaching and Referral Hospital

KCH Kisumu County hospital

KCHSSIP Kisumu County Health Sector Strategic and Investment Plan

KDHS Kenya Demographic and Health Survey

LLIN long-lasting insecticide-treated net

M&E monitoring and evaluation

MPDSR maternal and perinatal deaths surveillance and response

MTP Medium-Term Plan

NCD non-communicable disease

OPD outpatient department

SDGs sustainable development goals

SGBV sexual and gender-based violence

TB Tuberculosis

WASH water, sanitation and hygiene


vii

EXECUTIVE SUMMARY

Background

The Kisumu County Health Sector Strategic and Investment Plan (KCHSSIP) (2013-2017) was developed

to address health priorities in line with the Kenya Health Sector Strategic and Investment Plan and has

provided strategic direction and informed the development of the Kisumu County annual workplans during

the implementation period. The strategic plan has provided a framework that guides service delivery and

implementation of health interventions for the significant improvement in overall health status of the

people in the county. The overall goal of the KCHSSIP 2013-2017 is “to transform the livelihood of the

people of Kisumu County through responsive and sustainable technological driven evidence-based and

client-centered health system for accelerated attainment of highest standards of health.” Implementation

of the plan sought to achieve the following six policy objectives: (1) eliminate communicable conditions,

(2) halt and reverse the increasing burden of non-communicable conditions, (3) reduce the burden of

violence and injuries, (4) provide essential health services, (5) minimize exposure to health risk factors, and

(6) strengthen collaboration with health-related sectors.

Purpose, Objectives, and Methodology

In 2016, MEASURE Evaluation PIMA, in collaboration with the county health department leadership, led

the review process of the KCHSSIP 2013-2017. The purpose of the review was to assess progress in the

implementation of the KCHSSIP, guided by the six policy objectives of the strategic plan, learn from past

efforts and experiences, and make recommendations on strategies and targets with a focus on service

delivery.

The review adopted a comprehensive participatory approach under the leadership of the county director of

health with involvement of the county health department leadership, county health management team,

subcounty health management team, select health facilities, and health stakeholders. The monitoring and

evaluation technical working group was tasked with the responsibility of guiding the process and ensuring

quality control during the review process.

The review process adopted a mixed methods approach, which included the following: (1) a desk review of

documents that informed the development and implementation of the KCHSSIP, (2) a quantitative study

in which secondary data analysis was conducted with several data sources to provide information on the

implementation progress of the indicators in the KCHSSIP, and (3) a qualitative study with representatives

of the Kisumu health sector to explore their views on the development process and implementation of the

strategic plan as well as gaps and recommendations for improving the development and implementation of

the next strategic plan.

The review serves as a basis for making adjustments in program approaches to more efficiently address the

issues that affect the health of the population in Kisumu County, in addition to addressing sustainable

development goals and alignment of the health system strengthening efforts to facilitate effective

operationalization of the new directions at global, country, and county levels.

viii Report on the Review of the KCHSSIP 2013–2017

Findings

Eliminate communicable conditions

As per the review of KCHSSIP 2013-2017, coverage of fully immunized children increased from 38 percent

to 82 percent, diarrheal cases declined from 20 percent to 10 percent, confirmed malaria cases remained

high at 61 percent, and initiation of HIV-positive clients improved from 73 percent to 91 percent. Highly

exposed infants issued with prophylaxis experienced an upward trend. Tuberculosis (TB) treatment

completion rates remained steady at more than 80 percent.

In the qualitative study, policy objectives were rated on a scale of 1 to 5, where 1 was excellent and 5 very

poor. This objective was rated as follows: 60 percent (21 respondents) rated the achievement as good,

37 percent (13 respondents) rated it as fair, and 3 percent (1 respondent) rated it as excellent.

Halt and reverse the increasing burden of non-communicable diseases

Respondents in the qualitative study gave varied responses regarding their views on the county’s progress

in implementation of objective 2 on halting and reversing the rising burden of non-communicable

conditions. Based on the ratings, many of the respondents felt that the implementation of this objective

has been fair (36 percent) and poor (33 percent). Not much effort has been put on non-communicable

diseases (NCDs) in Kisumu County, compared to efforts toward eliminating communicable diseases. The

most common NCDs in Kisumu County are hypertension, diabetes, cancer, and mental illness, which are

mainly attributed to lifestyle, lack of awareness, poor infrastructure, inadequate staffing at facilities, lack of

knowledge and skills among health care providers specifically on dealing with NCDs, inadequate supplies

for screening and testing, and weak referral systems. Two main facilities in the county—Jaramogi Oginga

Odinga Teaching and Referral Hospital (JOOTRH) and Kisumu County Hospital (KCH)—are well

equipped to manage NCD services, and the remaining facilities have referral systems in place.

The main challenge with this objective is the lack of data on almost all the service areas and indicators. The

available data used to calculate the targets over time were mainly obtained from JOOTRH and KCH, based

on the total number of patients at the outpatient department and the number of patients screened for a

specific indicator.

Reduce the burden of violence and injuries

Reporting on gender-based violence improved from 552 cases reported in 2013/2014 to 814 in 2014/2015;

however, the number declined to 348 in 2015/2016. The proportion of new outpatient cases attributed to

road traffic accident injuries was around 0.7 in 2014/2015, but this proportion declined to 0.6 in 2015/2016.

The proportion of new outpatient cases attributed to other injuries increased from 0.5 in 2013/2014 to 0.6

in 2015/2016. The proportion of deaths due to injuries increased from 4.6 in 2013/2014 to 6.4 in

2015/2016; however, the proportion of deaths due to injuries decreased to 5.7 in 2015/2016.

Respondents in the qualitative study rated the reduction of the burden of violence and injuries objective as

follows: good (6 respondents), fair 15 (respondents), poor (11 respondents), and very poor (1 respondent).

Among the six policy objectives, this one was rated lowest. The major violence or injury cases mentioned

were gender-based violence and road accidents involving cars and boda bodas (bicycle and motorcycle taxis).

Some of the reasons given for the low rating were that proper attention had not been given to this strategic


ix

objective because it was spontaneous and because sexual and gender-based violence (SGBV) cases were

not reported when it happened at the household level and not dealt with in a timely manner when reported.

Provision of essential health services

The fourth strategic objective comprises reproductive, maternal, newborn, and child health services, with

the aim of ensuring a more comprehensive approach to customer care and response. The results show

improved coverage of deliveries conducted by skilled attendant, from 68.2 percent in 2013/2014 to

70.2 percent in 2015/2016. Coverage for women of reproductive age receiving family planning

commodities and services also improved, from 59.6 percent in 2013/2014 to 68.2 in 2015/2016.

Findings from the qualitative study rated the provision of essential health services as follows:

excellent—7 respondents, good—23 respondents, fair—4 respondents, and

no comment—3 respondents.

Minimize exposure to health risk factors

The indicators under minimizing exposure to health risk factors can only be measured through surveys that

are irregularly conducted. The indicators include the following: percentage of population who smoke,

percentage of infants under six months on exclusive breastfeeding, percentage of population aware of risk

factors to health, percentage of salt brands iodized, and couple year of protection due to condom use.

Findings from the qualitative study rated the achievement on minimizing exposure to health risk factors as

follows: excellent—1 respondent, good—12 respondents, fair—12 respondent, poor—5 respondents, and

no comment—7 respondents. The study revealed that some effort had been made to minimize health risk

factors at the facility level, such as training on infection prevention, decontamination using jik, use of

incinerators to burn hospital waste, ensuring that dumping sites are dug deeply for proper waste disposal,

and using special coats for protection when taking x-rays. At the community level, efforts on minimizing

exposure to health risk factors included advocacy on HIV testing, such as the promotion of home testing,

and health promotion messages passed by community health volunteers, such as the prevention of TB in

public matatus. There is still a need to collect data to measure the progress on this objective.

Strengthen collaboration with health-related sectors

Kisumu County has undertaken a number of actions toward achieving the objective of strengthening

collaboration with health-related sectors. The county has established a Nutrition Technical working Group,

whose membership includes the Department of Agriculture and civil society organizations, among others.

A partial, social, and environmental determinants of malnutrition survey was carried in Nyando Subcounty,

Kisumu County in May 2016 with technical support from the United Nations Children’s Fund and support

from the Kenya Medical Research Institute. In 2016, of kitchen gardens were established in Chulaimbo and

JOOTRH Hospitals in partnership with the Kenya—integrated water, sanitation, and hygiene project and

the Department of Agriculture. In addition, antenatal care demonstration sites for mothers to reduce

malnutrition were established in Kisumu County.

Findings from the qualitative study rated this strategic objective on strengthening collaboration with other

sectors as follows: excellent—3 respondents, good—20 respondents, fair—8 respondents,

poor—2 respondents, and no comment—4 respondents. The study revealed that there was collaboration

with various stakeholders, including development partners and nongovernmental organizations;

x Report on the Review of the KCHSSIP 2013–2017

government ministries, notably the Ministry of Education and Agriculture; private hospitals; family-based

organizations; administration police; and ward administrators. Stakeholder forums and meetings were used

to establish the roles various stakeholders would play, set terms of reference, and agree on memoranda of

understanding. As a result of collaborations with various partners, a number of activities and programs

were run at the sub-county or community levels, such as programs to provide health education in schools

with the help of teachers as ambassadors and programs to provide youth-friendly services.

Recommendations

Conduct targeted support supervision to streamline issues regarding service delivery and data

management and enhance monitoring of service delivery indicators.

Hold quarterly meeting at the subcounty and county levels to review the health indicators with

leadership from programmatic focal persons with the support of the implementing partners.

Strengthen NCD awareness among the population (community and facility) through advocacy by

holding stakeholder meetings; providing information, education and communication materials;

sensitizing the public through the media; and organizing NCD health days.

Scale up screening services for all NCDs. Every health facility should screen for major NCDs, such

as blood pressure, diabetes, cancer and mental illness.

Establish comprehensive SGBV centers in all subcounties to improve the accessibility and

provision of SGBV care.

Strengthen and establish centralized ambulance services with skilled staff, and operate 24 hours to

support emergency response services and referral services.

Create community awareness through community health volunteers on the rights of and legal

procedures for SGBV victims.

Incorporate traditional birth attendants in maternal referrals, including involving them as birth

companions and establishing a system to reward traditional birth attendants who refer mothers for

services.

Pay community health volunteers a stipend to enable them to perform their duties effectively and

enhance the performance of community health services.

Scale up training of health care providers on long-acting reversible contraceptives to gain

knowledge of and skills for providing them effectively.

Strengthen maternal and perinatal deaths surveillance and response (MPDSR) at all levels, including

at the community, facility, subcounty, and county levels, through regular MPDSR committee

meetings.

Strengthen collaboration between the civil registration department and the health department to

report vital events captured at the community level

Support the county health department in conducting surveys monitoring indicators that include

the percentage of the population who smoke, the percentage of infants under six months on

exclusive breastfeeding, the percentage of the population aware of risk factors to heath, the

percentage of salt brands iodized, and couple year of protection due to condom use.

Strengthen collaboration between the Department of Education and the Department of Health by

incorporating health records and information unit staff during deworming campaigns to capture

service data and update reports in DHIS 2.

Reactivate the school health program coordination mechanism for effective implementation of the

school policy.


1

1. INTRODUCTION

1.1 Background

The promulgation of the Constitution of Kenya 2010 led to the devolution of health services to the

counties. The National Health Policy Framework (2013-2030) developed by the national government guides

the county governments on the health priorities on which they need to focus. Counties therefore implement

policies with a focus on specific local priorities. The Kisumu County Health Sector Strategic and Investment

Plan (KCHSSIP) (2013-2017) was developed to address Kisumu County’s specific health priorities in line

with the National Health Sector Strategic and Investment plan and has provided strategic direction and

informed development of the county annual workplans during the implementation period. It has also been

incorporated into the County Integrated Development and Investment Plan to inform the Kisumu County

government investments in the health sector. The KCHSSIP is also aligned with the Kenya Health Sector

Strategic and Investment Plan (2014-2018) and Kenya Health Policy Framework (2013-2030), and it was

influenced by the process of operationalizing the Constitution of Kenya 2010 and specifically the devolution

of health services and implementation of the right to health. It formed the basis for the county’s investment

priorities in health. The plan continues to provide a framework that guides service delivery and

implementation of health interventions for the significant improvement in overall health status of the

people in the county. The overall goal of the KCHSSIP was “to transform the livelihood of the people of

Kisumu County through responsive and sustainable technological driven evidence based and client-

centered health system for accelerated attainment of highest standards of health.” Implementation of the

plan sought to achieve the following six policy objectives:

Eliminate communicable conditions

Halt and reverse the increasing burden of non-communicable conditions

Reduce the burden of violence and injuries

Provide essential health services

Minimize exposure to health risk factors

Strengthen collaboration with health related sectors

The KCHSSIP 2013-2017 provides the county health sector with a medium-term focus, objectives, and

priorities to enable a move toward attainment of the Kenya Health Policy Framework 2013-2030. It brings

together information on the following:

A vision for the definition and organization of health outcomes

Priority health investments needed to attain health and other related outcomes

Resource implications and a financing Strategy to ensure the availability of required investments

Organization and management of the sector to enable it to efficiently and effectively attain its

objectives

The strategic plan was aimed at ensuring linkage across different sectors on matters that affect health. It

purposed to organize the delivery of health services through subcounty health management teams that work

with community units toward achieving the health policy’s overarching goal of “attaining the highest

possible health standards in a manner responsive to the populations needs.” It outlined the need for

medium-term plans to develop a comprehensive medium-term strategic and investment focus for the health

sector to be applied annually over the five years of the plan, as it moves toward attaining the overall policy

2 Report on the Review of the KCHSSIP 2013–2017

directions. The plan was aligned to the government Medium-Term Plan to ensure its integration into the

overall government agenda, as outlined in Figure 1.

Figure 1. Framework for health

The KCHSSIP 2013-2017 focuses on seven investment areas:

Service delivery systems: how health service delivery will be organized

Leadership and governance: how health service delivery will be managed

Health workforce: human resources required for the provision of health services

Health financing: systems required to ensure adequate resources for service provision

Health products and technologies: essential medicines, medical supplies, vaccines, health

technologies, and public health commodities

Health information: system for generating, analyzing, distributing, and using health-related

information

Health infrastructure: physical infrastructure, equipment, transport, and information

communication technology needed for the delivery of health services

The Kenya Health Policy Framework (2013-2030) focuses on the overall policy goal, objectives, principles,

and orientations. In order to achieve the ultimate goals in health, the policy consisted of six objectives, as

shown in Figure 2.


3

Figure 2. Framework for policy direction

The policy goal defines the overarching intent and impact that the policy is designed to accomplish

regarding health of Kenyans. The KCHSSIP 2013-2017 sets clear annual targets that formed the basis for

performance appraisal for the sector.

1.2 The Review Process

In 2016, MEASURE Evaluation PIMA, in collaboration with Kisumu County leadership, initiated the

review process of the KCHSSIP 2013-2017. The purpose of the review was to assess progress in

implementation of the KCHSSIP 2013-2017, learn from past efforts and experiences, and make

recommendations on strategies and targets with a focus on service delivery. The specific objectives of the

review include:

Assessing and making recommendations on progress made in the implementation of KCHSSIP

2013-2017 strategic objectives and targets.

Assessing and making recommendations on the alignment of the strategic plan with the county

and national commitments and international health obligations, including the county development

agenda, the Constitution of Kenya 2010, the Kenya MTP II, Kenya health policy, Vision 2030, and

achievements of the sustainable development goals (SDGs).

Documenting challenges and lessons learned during implementation of the KCHSSIP 2013-2017.

Identifying recent external changes (e.g., environmental, administrative, political, economic,

sociocultural, demographic) to the health sector that should be taken into account for

implementation of the health sector strategic plan implementation.

The review adopted a comprehensive participatory approach under the leadership of the county director of

health, with involvement of the county health department leadership, county health management team,

subcounty health management team, select health facilities, and health stakeholders. The monitoring and

evaluation (M&E) technical working group was tasked with the responsibility of guiding the process and

ensuring quality control.

The review process adopted a mixed-methods approach that consisted of the following: (1) a desk review

of documents informing the development and implementation of the KCHSSIP, (2) a quantitative study in


which secondary data were analyzed from several data sources providing information on the

implementation progress of the indicators in the KCHSSIP 2013-2017, and (3) a qualitative study with

representatives of the Kisumu County health sector on their views on the development process and

implementation of the strategic plan as well as gaps and recommendation for improving the implementation

of the next strategic plan.

The review was expected to provide information for improving and further strengthening targeted health

interventions and programs. It serves as a basis for making adjustments in program approaches to more

efficiently address the issues that affect the health of the population in Kisumu County, in addition to

addressing SDGs and alignment of the health system strengthening efforts to facilitate effective

operationalization of the new directions at global, country, and county levels.

1.2.1 Document Review

The KCHSSIP 2013-2017 review process began with a review of documents that informed the

development process and implementation of the KCHSSIP. Following the review, a summary was drafted

that informed the introductory sections of the review report. Documents reviewed included the following:

KCHSSIP and M&E Plan 2013-2017

County integrated development and investment plan

County annual health sector performance reports and annual workplans

The Intergovernmental Relations Act (2012)

Kenya Health Sector Strategic and Investment Plan 2014-2018

Kenya Health Policy Framework 2013-2030

Vision 2030 and MTP II

Constitution of Kenya 2010

1.2.2 Quantitative Data Analysis

The quantitative study involved measuring targets that were described in the KCHSSIP 2013-2017. Several

data sources were used for secondary analysis and focused on the status of the indicators in the strategic

plan. Key data sources for the quantitative review included the DHIS 2, integrated electronic disease

surveillance system (eIDSR), the tuberculosis (TB) electronic recording and reporting system, the Kenya

Demographic and Health Survey, and the Kenya AIDs Indicator Survey, among others.

1.2.3 Qualitative Study

The qualitative study involved in-depth interviews guided by semi-structured interview guides (provided in

the Appendix) to measure views on the development of the KCHSSIP, progress in achieving the set targets,

adherence to principles of service delivery, and gaps and recommendations regarding the development and

implementation of the plan.

The qualitative review focused on all six subcounties of Kisumu County: Kisumu West, Kisumu East,

Muhoroni, Nyakach, Nyando, and Seme. A total of 38 interviews were conducted with the 8 members of

the county health management team and 5 representatives from each of the 6 subcounties of Kisumu.


5

2. FINDINGS

Table 1. Summary achievements by strategic objectives

Strategic

objective Key achievements Challenges

Eliminate

communicable

conditions

Fully immunized children under one year of

age is above 80 percent.

Diarrheal trends are positive—surpassed

endline with 30 percent.

HIV prevention and care above the

90 percent target line.

Highly exposed infants started on prophylaxis is

above 95 percent.

Test and treat still meeting

resistance and affecting

90-90-90.

Interventions have not

reversed the burden of

malaria.

Behavior change in hygiene

practice despite

deworming.

Halt and

reverse

increasing

burden of NCDs

Three out of five indicators have surpassed the

endline targets: proportion of cancer patients

admitted, adult population with body mass

index (BMI) over 25kg/m2, and new

outpatients with high blood pressure.

Purchase of cervical cancer screening

equipment by the government and partners

(14 cryotherapy machines, speculums, and

reagents) distributed in all six subcounties.

Procurement of blood pressure machines

(135 machines) to be distributed as needed.

Low awareness on cancer

screening.

Inadequate advocacy on

BMI.

Poor infrastructure.

Staff shortages.

Lack of routine checkups

among the population.

Inadequate resource for

community awareness.

Inadequate cancer

screening equipment,

especially for other cancers

(e.g. breast cancer, prostate

cancer, throat cancer).

Inadequate resource

allocation for mental health

services.

Lack of mental health data

collection tools.

Inadequate mental health

specialists, equipment,

wards and rehabilitation

services.

Reduce the

burden of

violence and

injuries

Improved reporting on cases of sexual and

gender-based violence [SGBV], other injuries,

and road traffic accidents.

Increased number of SGBV cases.

Existence of SGBV recovery center at

Jaramogi Oginga Odinga Teaching and

Referral Hospital (JOOTRH).

Improved referral of SGBV cases from various

health facilities to JOOTRH.

Training of health staff on SGBV.

Availability of commodities and reporting

tools.

Purchase of eight ambulances.

Weak mechanism for

ambulance services,

including establishment of

control room and provision

of ambulance staff.

Only one SGBV center

serving the county.

Inadequate staffing in

critical care.

Lack of information on rights

of and legal procedures for

victims.

Lack of funds for

operationalization of

emergency preparedness to

respond to accidents.


Strategic

objective Key achievements Challenges

Provide

essential health

services

Substantial increase in skilled deliveries from 68

percent to 72 percent.

Delayed reimbursement of

free maternity funds.

Traditional birth attendants

still conducting deliveries

instead of referring

expectant women to the

health facilities.

Ambulances in place but

there is no ambulance call

center.

Improved family planning uptake from 59.6

percent to 68.2 percent.

Lack of reporting

mechanism for family

planning commodities

dispensed in the private

chemists.

Method mix not been

achieved.

Low uptake of long-acting

reversible contraceptives.

Minimize

exposure to

health risk

factors

A household survey on Iodized salts

conducted in the six subcounties of Kisumu.

Baby-friendly hospital initiatives implemented.

Unavailability of data for

most of the survey indicators.

In the Ministry of Health

reporting systems indicators

are missing and not routinely

collected.

Strengthen

collaboration

with health-

related sectors

Improved collaboration with health-related

sectors.

Establishment of demonstration kitchen

gardens.

Established nutrition technical working group.

Developed a water, sanitation, and hygiene

network strategic plan

2015-2019.

Drilled water borehole at Ober Kamoth.

Established one health initiative with the

Department of Veterinary Services.

Data for deworming

campaigns are not shared

with the Department of

Health.

Implementation of school

health policy not fully

operational after devolution.

2.1 Demographic Profile

Tables 2 and 3 summarize the population of Kisumu County by subcounty and cohort over the period

under review.


7

Table 2. Catchment population by year

Subcounty 2012/13 2013/14 2014/15 2015/16

Kisumu Central 346,837 354,276 361,875 368,971

Kisumu West 147,146 145,817 148,879 150,280

Muhoroni 147,665 152,385 158,998 162,971

Nyakach 144,699 147,720 150,912 153,874

Nyando 153,396 156,651 159,985 163,122

Seme 107,372 109,725 112,079 114,276

Total 1,047,115 1,066,574 1,092,728 1,113,494

JOOTRH 116,210 114,443 71,858 81,921

JOOTRH = Jaramogi Oginga Odinga Teaching and Referral Hospital

JOOTRH serves the neighboring counties of Bungoma, Busia, Homa Bay, Kakamega, Kisii, Migori, Siaya, and Vihiga.

Table 3. Population by cohorts

Description 2013/14 2014/15 2015/16

Total population 1,044,979 1,064,221 1,090,374

Number of households 185,515 191,686 162,948

Elderly (ages 60+) 46,344 47,016 46,505

Adults ages 25–59 286,583 291,919 311,369

Adolescents ages 15–24 245,137 239,951 245,798

Children under 15 years of age 321,773 457,556 468,881

Children under 5 years of age 178,979 182,391 186,988

Children under 1 year of age 36,437 36,752 37,653

Women of child bearing age (ages 15–49) 254,933 259,542 269,094

Estimated number of pregnant women 40,021 40,748 41,888

Estimated number of deliveries 39,552 40,269 41,398

Estimated number of live births 38,291 38,970 40,046

2.2 Health Service Outcomes

2.2.1 Eliminate Communicable Conditions

Overview of the Findings

The county government has channeled most of its resources into the elimination of communicable

conditions. Infectious diseases remain the leading cause of morbidity in Kisumu County (Kenya National

Bureau of Statistics & ICF International, 2015). During the period under review of the KCHSSIP

2013-2017, the percentage of fully immunized children increased from 48 percent to 82 percent, and the

number of diarrheal cases is decreasing. The percentage of confirmed malaria cases remains high at

61 percent, despite interventions being put in place, such as testing (microscopy and rapid diagnostic tests)

and provision of long-lasting insecticide-treated nets (LLINs). Ninety-nine percent of HIV-positive clients

have started antiretrovirals (ARVs). There is an upward trend on highly exposed infants (HEI) started on

prophylaxis.

In the qualitative review, the policy objectives were rated on a scale of 1 to 5, with 1 being excellent and

5 being very poor. Respondents rated the strategic objective on eliminating communicable disease as

follows: 60 percent (21 respondents) rated the achievement as good, 37 percent (13 respondents) rated it

as fair, and 3 percent (1 respondent) rated it as excellent. During the strategic plan implementation period,


various interventions were put in place by the county government and implementing partners to eliminate

communicable conditions. Some of these efforts included health awareness talks; advocacy, such as in HIV

prevention; campaigns, such as polio campaigns carried out throughout the county; provision of TB testing

kits by the county and TB surveillance in which screening is done at household level and followed up once

detected; operationalization of community units and the use of community health extension works on the

ground; improved management of outbreaks such as cholera through immunization and community

involvement to help in prevention; use of vaccines, such as rotavirus in minimizing cases of diarrhea; and

increased HIV testing. Table 4 summarizes the findings for the strategic objective.

9

9

9

Table 4. Objective 1 indicators: Eliminate communicable conditions

Service area Indicator

Baseline

(2012) 2013/14 2014/15 2015/16

Endline

target

(2018)

Child health Proportion of fully immunized children 48 73 78 82 85

Inactivated polio vaccine immunization coverage in children

under 1 year of age

0 0 0 23 85

Proportion children under 5 treated for diarrhea—Proportion of

children under 5 diarrhea cases reported at the outpatient

department

20 12 11 10 15

HIV prevention and care Proportion of HIV-positive pregnant mothers receiving ARVs 87 77 95 99 90

Proportion of HEI issued with infant prophylaxis 80 94 98

Proportion of eligible HIV clients on ARVs 73 76 82 91 90

TB treatment and success rate Proportion of TB patients completing treatment 82 82 85 85 86

Malaria control, case

management, and treatment Proportion of health facilities offering malaria diagnostics 76 67 76 79 99

Proportion of tested malaria cases confirmed positive 43 42 61

Proportion of suspected malaria cases tested 85 124 115

Proportion children under 1 year of age provided with LLINs 77 66 62 51 85

Proportion of pregnant women receiving IPT 2 71 42 38

Proportion of targeted pregnant women provided with LLINs 73 76 85 87 85

Control and prevention of

neglected diseases

Proportion of dewormed school-age children 7 33 16 95


Child Health and Immunization

There has been an improvement in child health and immunization services, as shown in the three service

areas in Table 4. The three service areas include those fully immunized, IPV immunization coverage, and

children under 5 years of age treated for diarrhea. For fully immunized children, coverage has increased

from 48 percent at baseline to 82 percent at 2015/16, with a target of 85 percent by 2018. Inactivated polio

vaccine (IPV) immunization started in 2015 and has been on the rise. Diarrhea cases are decreasing as a

result of the rotavirus vaccine and co-packaging oral rehydration salts with zinc.

Measures put in place to improve this indicator include system strengthening, an increase in immunization

sites (from 127 to 164), increased purchase of cold chains equipment, improved data collection and entry,

improved frequency of immunization services to clients, increased oral rehydration therapy corners, and

education in nutrition and hygiene.

Areas that are contributing to low target achievement include a lack of regular programmatic support

supervision, staff shortages, and erratic supply of some immunization antigens (e.g., Bacillus

Calmette-Guérin and IPV).

Proportion of fully immunized children: The sub-county trends of immunization coverage are presented

in Figure 3. Three subcounties—Kisumu East, Nyakach, and Nyando—reported a decrease in the

percentage of fully immunized children in 2013/14. This was attributed to transition, re-drawing of

boundaries, health worker strikes, and reduced outreach in these areas.

Figure 3. Trends in child immunization coverage by subcounty

Proportion of children under five years of age diarrhea cases reported at the outpatient department

(OPD): The trends for under-five diarrhea cases reported by subcounties are varied, as shown in Figure 4,

but generally the county is showing a declining trend. The decreasing rates are attributed to the rollout of

the rotavirus vaccine and the co-packaging of oral rehydration salts with zinc given to children.


Figure 4. Proportion of children under five years diarrhea cases reported at OPD

HIV prevention and care: The three indicators under HIV prevention and care—proportion of

HIV-positive pregnant mothers receiving ARVs, HEI issued with infant prophylaxis, and eligible HIV

clients on ARVs—are recording upward trends and have surpassed the target of 90 percent as shown in

Figures 5 and 6.

Figure 5. Proportion of HIV-positive pregnant mothers receiving ARVs


Figure 6. Proportion of eligible HIV clients on ARVs

Measures put in place to achieve these indicators include involving implementing partners, building the

capacity of health care workers and community health volunteers, micro teaching with audio visual aids,

sensitizing communities, improving infrastructure through integrated comprehensive care clinics,

strengthening data collection, reporting and analysis and ensuring a regular supply of ARVs from the

National AIDS and STD Control Program.

TB treatment: The trends for TB treatment completion rate reported by subcounties showed an increased

completion rate, as shown in Figure 7.

Figure 7. TB treatment completion rate

Malaria control, case management, and treatment: According to the 2014 national policy guidelines

for diagnosis, treatment, and prevention of malaria, all health facilities should be diagnosing malaria either

through microscopy or malaria rapid diagnostic tests. In Kisumu County, all the government facilities and

facilities funded by faith-based organizations (138 facilities) are adhering to this policy, but not all of the


private facilities (69) adhere to the policy. In 2012, 76 percent of health facilities were diagnosing malaria;

this increased to 89 percent in 2016. The proportion of the suspected malaria cases tested should be

100 percent, according to the 2014 national policy guidelines for malaria; the current proportion for Kisumu

is 115 percent, indicating that more clients are being tested for malaria than those suspected to have had

malaria. The disparities in testing more than 100 percent for malaria maybe due to self-requests,

inappropriate use of rapid diagnostic tests, and issues with data quality.

Data from the 2015 Kenya Malaria Indicator Survey show that the national malaria prevalence is 8 percent,

with 27–40 percent for the endemic zones (National Malaria Control Program, Kenya National Bureau of

Statistics, & ICF International., 2015). The same report indicates that Kisumu County has a malaria

prevalence rate of 27 percent. The eIDSR indicates that the county prevalence is at 61 percent, with the

highest prevalence in Nyando (above 63%).

The LLIN provision among pregnant women is at 87percent, but a declining trend is being observed

through the years under review for children less than 1 year of age provided with LLINs.

Control and prevention of neglected diseases: The neglected tropical diseases in Kisumu County

include soil-based helminthes, schistosomiasis (bilharzia), lymphatic filariasis, onchocerciasis (river

blindness), and hydatid disease. The Mass Drug Administration done by Kisumu County is a school-based

deworming program for children ages 2–14 years of age. The 2018 target for the proportion of dewormed

school-age children is 95 percent. The current rates indicate a declining trend, which is below the set target:

7 percent for 2013, 33 percent for 2014, 16 percent for 2015, and 10 percent for 2016.

2.2.2 Halt and Reverse the Increasing Burden of Non-Communicable Diseases


Respondents in the qualitative study rated objective 2 on halting and reversing the rising burden of non-

communicable diseases (NCDs) as follows: excellent—2 respondents, good—8 respondents,

fair—12 respondents, poor—11 respondents, and no comment—4 respondents. Respondents generally

viewed the achievement of this policy objective as being between fair and poor. Facilities at the subcounty

level do not have the capacity to handle NCDs and usually refer them to Jaramogi Oginga Odinga Teaching

and Referral Hospital (JOOTRH) or Kisumu County Hospital (KCH). The most common NCDs in

Kisumu County are hypertension, diabetes, cancer, and mental illness, as shown in Table 5. The two main

facilities in the county, JOOTRH and KCH are well equipped to manage NCDs services, but the remaining

facilities have referral systems in place, which are not adequate.

The main challenge with this objective is that there is low reporting or no data on almost all the service

areas and indicators. The available data used to calculate the performance over time were primarily obtained

from JOOTRH and KCH based on the total number of patients at the OPD and the number screened for

a specific indicator.

The proportion of new outpatients with high blood pressure has increased slightly over the years, from

1 percent at baseline to 2 percent in 2015/2016. The endline target is 3 percent. There has been an intensive

micro teaching at the OPD, but there is still a need to strengthen the public health education. According to

the Service Availability and Readiness Assessment Mapping report, health promotion education for NCDs

in Kisumu County was 80 percent, and institution screening was 54 percent (Government of Kenya, 2014).


Table 5. Objective 2 indicators: Halt and reverse the increasing burden of NCDs


Baseline

(2012) 2013/14 2014/15 2015/16

Endline

target

(2018)

Screening and

care for NCDs

Proportion of women of

reproductive age screened

for cervical cancer

3 4.0 3.5 2.7 10

Proportion of cancer

patients admitted

1 0.2 0.1 0.2 2

Proportion of adult

population with BMI over

25kg/m2

0.7 0.7 0.5 TBD

Proportion of new

outpatients with high blood

pressure

1 1.2 1.3 1.4 3

Proportion of new

outpatients with mental

health conditions

0.09 0.1 0.1 0.1 0.05

Food quality

and safety

Proportion of salt brands

adequately iodized

85 ND ND ND TBD

Health

promotion

and

education

Proportion of the population

aware of health risk factors

30 ND ND ND TBD

ND= no data; TBD= to be determined

Screening and care for NCDs: The KCHSSIP has five indicators under screening and care for NCDs,

each of which has endline targets (2018), as shown in Table 5. The 2018 target for the proportion of women

of reproductive age screened for cervical cancer in Kisumu County is 10 percent; in 2012 the proportion

was at 3 percent, and this decreased to 2.7 percent in 2015/2016. Some of the interventions that have been

put in place to achieve this target are training of healthcare workers, procurement of equipment and

screening reagents in the health facilities, and sensitization of the population on cervical cancer, such as the

community level by community health volunteers. The challenges regarding the screening of and care for

cervical cancer include lack of routine checks, low levels of awareness, inadequate capacity building among

healthcare providers, poor infrastructure, staff shortages, and inadequate supplies.

The data for proportion of cancer patients admitted as shown in Table 5 are from JOOTRH. The targets

are calculated using the number of cancer patients over the total number of patients admitted in the facility.

The target for the proportion of adult population with body mass index (BMI) over 25 is 35 percent by

2018. The proportion is calculated using the number of adults with BMI over 25 compared to total

population at the OPD.

The proportion of new outpatients with mental health conditions is constant, as shown in the data

presented in Table 5. This may be due to inadequate resource allocation for mental health services; lack of

mental health data collection tools; and inadequate mental health specialists, equipment, wards, and

rehabilitation services.

Food quality and safety: There are no data available on the indicator under food quality and safety, which

is the proportion of salt brands adequately iodized to help establish the county estimates. Public health

officers did not report these data in MOH 708.


Some of the challenges that may be experienced in implementing indicator are inefficiencies in inspection

of food plants, food handling warehouses, and transit.

Rehabilitation: No data were found for rehabilitation services in DHIS 2, so this column is blank and has

not been monitored over the years in review.

Health promotion and education: The proportion of the population aware of health risk factors of

NCDs was 30 percent in 2012. Since then, data have not been collected to measure the progress of this

indicator. This needs to be considered in the tools.

In terms of health promotion and education, the public should be sensitized on dietary considerations;

lifestyle, such as exercise; reduction of tobacco and alcohol use; and unregulated prescription use, such as

use of Diazepam.

2.2.3 Reduce the Burden of Violence and Injuries


Respondents in the qualitative study gave the following ratings for reducing the burden of violence and

injuries: good—6 respondents, fair—15 respondents, poor—11 respondents, very poor—1 respondent.

This policy objective was rated lowest among the six strategic objectives. Some of the reasons given for the

low ratings are that proper attention had not been given to this area because it was spontaneous, and in the

case of sexual and gender-based violence (SGBV), it is not reported when it occurs at the household level

and when it is reported, it may not be dealt with in a timely manner. Some of the efforts made to address

this issue include setting up a unit in JOOTRH that deals with SGBV. Human rights groups have also set

up youth centers through community-based organizations to sensitize girls on SGBV. One respondent

noted that there was a need for collaboration to reduce the burden of violence and injuries because road

accidents and SGBV cases also involved the police, courts of law, and human rights groups.

There was increased reporting on gender-based violence, from 552 cases reported in 2013/14 to 814 in

2014/15; however, in 2015/16, the number of cases reported decreased to 348. The proportion of new

outpatient cases attributed to road traffic accident injuries was 0.7 percent in 2014/15, and this decreased

to 0.6 percent in 2015/16.

The proportion of new outpatient cases attributed to other injuries increased from 0.4 percent in 2013/14

to 0.6 in 2015/16. The proportion of deaths due to injuries increased from 4.6 percent in 2013/14 to

5.7 percent in 2015/16. Table 6 provides more comprehensive results for the period of review.


Table 6. Objective 3 indicators: Reduce the burden of violence and injuries

Service

area Indicator

Baseline

(2012) 2013/14 2014/15 2015/16

Endline

target

(2018)

Service

utilization

Proportion of new outpatient

cases attributed to gender-based

violence

0.05 0.0

(552

cases)

0.0

(814

cases)

0.0

(348

cases)

0.02


cases attributed to road traffic

accident injuries

1.3 0.7

(8,658

cases)

0.7

(9,823

cases)

0.6

(9,002

cases)

2


cases attributed to other injuries

1.3 0.4

(5,293

cases)

0.5

(7,770

cases)

0.6

(9,281

cases)

0.5

Proportion of deaths due to injuries 0.3 4.6

(166

cases)

6.4

(238

cases)

5.7

(220

cases)

0.2

Service utilization: Improved reporting on SGBV may be attributed to community sensitization;

availability of reporting tools; and improved collaboration among other sectors, such as the national police

service, civil society, and the Department of Gender and Social Services. JOOTRH has established a

gender-based violence center that operates 24 hours a day. All county and subcounty hospitals have

sufficient reporting tools, and staff have been trained on SGBV. Facilities offering SGBV services have

integrated inpatient and outpatient services.

Road traffic injuries increased due to investment in boda bodas (bicycle and motorcycle taxis); however, road

traffic accidents decreased in 2015/16, which may be attributed to other non-health related measures in

prevention, such as new highway code regulations. A high increase of road traffic accidents was reported

in Kisumu East/Central due to high population, poor road maintenance, and lack of safety measures by

boda riders. The proportion of new outpatient cases attributed to other injuries may have increased due to

accessibility to public and private health facilities, availability of commodities, and public awareness. Other

injuries were higher in Muhoroni and Nyakach in 2015/16 due to cattle rustling and border clashes.

The increase in deaths due to other injuries can be attributed to lack of basic life support, lack of advanced

trauma life support skills and competencies, shortage of human resources, and inadequate infrastructure.

The decrease in deaths, however, may be attributed to investment and capacity building to staff in intensive

care unit at JOOTRH and the provision of ambulatory services countywide. Other non-health interventions

such as new traffic regulations may have also contributed to the decrease in deaths in 2015/16.

Data for road traffic accidents do not segregate the type of accidents, which is a challenge in planning.

Emergency preparedness: Emergency prepared response teams, both public and private, are in place,

but some are inactive. There is inadequate human resources and skills in critical care, and poor client attitude

toward public facilities. There is also a weak mechanism for coordination of ambulatory services.

Emergency preparedness has not been institutionalized into community health services.

The County has not set aside funds for operationalization of emergency preparedness at the county and

subcounty levels .Linkages with non-health-related departments, such as Transport, Fire Brigade,

Department of Veterinary Services, National Environmental Management Authority, and Metrology and

Maritime, are weak and not structured.


2.2.4 Provide Essential Health Services


The fourth strategic objective of KCHSSIP 2013-2017 includes numerous health interventions that aim to

improve access to and quality of care for individuals seeking healthcare services within the county. The

indicators under this strategic objective focus on the quality of reproductive, maternal, and child healthcare.

Respondents in the qualitative study rated the provision of essential health services as follows:

excellent—7 respondents, good—23 respondents, and fair—4 respondents. There was consensus that

Kisumu County had made significant effort in achieving this objective. The county ensured that health

services were brought closer to the community by opening several health centers and dispensaries in hard-

to-reach areas that can provide basic health services. Community outreach was expanded, such as using the

Beyond Zero mobile clinic. Improvements in infrastructure included setting up maternity facilities and

increasing availability of staff.

Deliveries conducted by skilled personnel have been on an upward trend, increasing from 68 percent in

2013/14 to 70 percent in 2015/16.

The proportion of women of reproductive age receiving family planning commodities has been steadily

increasing from 2013 to 2016. This has been attributed to the following: provision of outreach through the

Beyond-Zero mobile clinic, training of healthcare providers on long-acting family planning methods,

improved family planning commodity security due to improved commodity management practices at the

facility level championed by the commodity technical working group, and family planning advocacy by the

family planning technical working group.

Maternal mortality increased from 43 cases in 2013 to 67 cases in 2016. This could be attributed to improved

reporting at the facility and community levels.

Proportion of newborns with low birth weight decreased, from 7.3 percent in 2013/14 to 6.9 percent in

2015. This is due to improved antenatal care (ANC); provision of intermittent preventive treatment (IPT);

provision of nutrition supplements, such as iron and folic acid supplementation; and promotion of the

kitchen garden concept in high-volume facilities, such as JOOTRH and Chulaimbo Hospital.

Coverage of four ANC visits is increasing but fell short of the target; however, the first ANC coverage

remains above 80 percent.

Proportion of health facility-based stillbirths remained steady, between 1.3 percent and 1.5 percent.

Perinatal death reviews in the facilities are still a challenge due to the number of cases.


Table 7. Objective 4 indicators: Provide essential health services


Baseline

2012/13 2013/14 2014/15 2015/16

Reproductive,

maternal,

newborn, and

child health

Proportion of deliveries

conducted by skilled

attendant

64.0 68.2 72.2 70.2

Proportion of women of

reproductive age

receiving family planning

commodities and

services

72.0 59.6 67.0 68.2

Proportion of facility-

based maternal deaths

0.2 0.1

(43 cases)

0.1

(53 cases)

0.2

(67 cases)


based under-five deaths

5.0 0.1 0.2 0.3

Proportion of newborns

with low birth weight

5.0 7.3 6.9 6.6


based fresh stillbirths

14.7 1.3 1.4 1.5

Proportion of pregnant

women attending at

least one ANC visit

86 83 82

Proportion of pregnant

women attending four

ANC visits

36.0 43.6 50.4 49.7

Reproductive, maternal, newborn, child, and adolescent health: Current use of contraceptives is the

most widely employed and valuable measure of the success of family planning programs. The contraceptive

prevalence rate is usually defined as the percentage of currently married women who are currently using a

method of contraception. The contraceptive prevalence rate for Kisumu County was at 54 percent, which

is above the national figure of 53 percent, according to 2014 Kenya Demographic and Health Survey

(KDHS). This trend is similar to the contraceptive uptake by women of reproductive age, which has been

on an upward trend, from 60 percent in 2013/14 to 68 percent in 2015/16.

ANC from a skilled provider is important to monitor pregnancy and reduce the risk of morbidity for mother

and baby during pregnancy and delivery. ANC quality can be monitored through the content of services

received and the kind of information mothers are given during their visit. The 2014 KDHS reports that 98

percent of pregnant women in Kisumu County receive ANC from a skilled provider, which is above the

national figure of 96 percent. Kisumu County had an improvement in the fourth ANC visit coverage, from

44 percent in 2013/2014 to 48 percent in 2015/16, but there was a slight decline in first ANC visit coverage.

Figures 8 shows IPT uptake and first ANC attendance for the period under review.


Figure 8. Percentage of pregnant women receiving IPT1 and IPT2 and first ANC attendance

The percentage of deliveries with a skilled attendant increased, from 69 percent in the 2014 KDHS to

70 percent in 2016. Kisumu East contributed significantly to this noted improvement at more than

96 percent over the years under review; Kisumu West recorded below 50 percent on average. Figure 9

shows the coverage of skilled deliveries and fourth ANC uptake.

Figure 9. Skilled service delivery attendants and four ANC visit coverage

The estimates for maternal mortality in Kisumu County remained high during the period of review,

increasing from 43 cases in 2013 to 67 cases in 2016. This could be attributed to improved reporting at the

facility and community levels. The county has come up with interventions to reverse this trend, such as

conducting regular maternal and perinatal deaths systemic review (MPDSR) meetings at the facility,

subcounty and county levels for all public, faith-based organization, and private sector facilities; conducting

intercounty referral meetings; improving referrals through the purchase of eight new ambulances; training

of health care workers on emergency obstetrical and newborn care; and scaling up of basic and

comprehensive emergency obstetrical and newborn care in the county health facilities.

Client satisfaction: The first county-wide health client satisfaction survey conducted in government

facilities within Kisumu County since the devolution of the health sector was conducted in March 2016.

Kisumu County health client satisfaction survey of March 2016 report which was the first county‐wide The

study team found that respondents appreciated the survey. As described in the survey report findings, 20

percent of the clients (n=223) were very satisfied with the health services offered in the facilities, 66 percent


(n=719) were satisfied, and 13 percent (n=144) were dissatisfied. Ninety percent (n=130) of those

dissatisfied were outpatients. Fourteen percent (n=130) of outpatients were dissatisfied, compared to 10

percent (n=14) of inpatients (p value=0.19). Twenty-six percent of the respondents (n=38) were dissatisfied

with the OPD, 24 percent were dissatisfied with the pharmacy (n=35), 21 percent were dissatisfied with the

laboratory (n=30), and 11 percent were dissatisfied with the maternal and child health clinic (n=16).

Reasons for dissatisfaction included long waiting time (49%, n=70), reported drug shortages (21%, n=30),

and not being examined adequately (6%, n=8).

Regarding satisfaction levels with the major hospitals in the county, 44 percent (n=49) of the respondents

from JOOTRH were very satisfied, followed by 28 percent (n=12) from Nyahera County Hospital, and 20

percent (n=15) from Kombewa County Hospital. Twenty‐seven percent (n=27) of respondents from

Kisumu County Hospital were dissatisfied, followed by 26 percent (n=19) from Nyakach County Hospital.

In general, the majority of the study group was satisfied with services offered at the health facilities;

however, a small proportion of respondents was very dissatisfied with services. The major reasons for

dissatisfaction included long wait times in the facilities, drug shortages, and a lack of specialized services.

Regarding client satisfaction by service delivery point in the health facility, dissatisfaction levels were highest

in casualty, clinics, and pharmacy.

2.2.5 Minimize Exposure to Health Risk Factors

The five indicators under minimizing exposure to health risk factors listed as follows are survey indicators,

but surveys are conducted regularly:

Percentage of the population who smoke

Percentage of infants under six months on exclusive breastfeeding

Percentage of population aware of risk factors to health

Percentage of salt brands iodized

Couple year of protection due to condom use

Respondents in the qualitative study rated KCHSSIP’s achievement on minimizing exposure to health risk

factors as follows: excellent—1 respondent, good—12 respondents, fair—12 respondents,

poor—5 respondents, and no comment—7 respondents. The study revealed that some effort had been

made in minimizing health risk factors at the facility level, such as by providing training on infection

prevention, decontaminating using jik, using incinerators to burn hospital waste, ensuring that dumping

sites are dug deeply for proper waste disposal, and using special coats for protection when taking X-rays.

At the community level, efforts to minimize exposure to health risk factors included advocacy on HIV

testing, such as by providing home testing, and the sharing of health promotion messages by community

health volunteers, for example for prevention of TB in public matatus. Although a lot of investments have

been made in curative aspects of care, the county has not invested enough in the area of public health.

There is a need to declare Kisumu County defecation free in order to prevent diseases such as cholera and

typhoid, and a need to educate the community on the use of mosquito nets and the importance of drinking

safe clean water. Although health workers are aware of the importance of infection prevention,

understaffing sometimes forces them to expose themselves to risks in the course of providing services to

patients. There is need to train staff on infection prevention because there has not been a training on this

topic in some time.


2.2.6 Strengthen Collaboration with Health-Related Sectors


Nutrition: The county has established a nutrition technical working group, whose membership includes

the Department of Agriculture and civil society organizations, among others. A survey of partial, social, and

environmental determinants of malnutrition was carried in Nyando in May 2016 with technical support

from the United Nations Children’s Fund and support from the Kenya Medical Research Institute. In 2016

kitchen gardens were established in Chulaimbo Hospital and JOOTRH in partnership with the Kenya—

integrated water, sanitation, and hygiene project and the Department of Agriculture. Demonstration sites

for mothers receiving ANC were established to reduce malnutrition in Kisumu County.

Water and sanitation: A water, sanitation, and hygiene (WASH) network has been established and met

quarterly in 2014/15. The Department of Health serves as secretariat, the Department of Water serves as

chair, and other members include SAGA and civil society organizations. The network has developed a

WASH network strategic plan 2015/2019 and has held stakeholders meetings in 2014 and 2016.

Infrastructure: Most access roads to the health facilities have been improved by the Department of Roads

since devolution in 2013/2016. Pediatric lunar parks supported by Family AIDS Care and Education

Services have been established in six facilities: Ahero, Masogo, Muhoroni, Nyakach, Nyangoma, and

Rabuor. Tullows supported drilling of a water bore hole with a high-rise steel tank in Ober Kamoth. The

Lake Victoria South Water Services Board provided water tanks at Ahero County Hospital in 2016. The

Kisumu Water and Sewerage Company reticulated water supply in Kirembe in Kisumu West and parts of

Manyatta in Kisumu East as part of response during a cholera outbreak

in 2015.

Education: Two symposiums on adolescent sexual reproductive health were held in 2015 and 2016 and

supported by the U.S. Agency for International Development. A national deworming program has been

conducted annually since 2013 in partnership with the Ministry of Education. Supplementary

immunizations have being carried out since 2013 with support of the Ministry of Education and other line

ministries. Data management for dewormed children has not been shared with the Department of Health

in all of the campaigns, however. Commemoration of Health days, such as Global Hand Washing day, are

done annually with involvement of partners and line departments.

The Department of Health and the Department of Veterinary Services have collaborated under the One

Health initiative in control and management of zoonotic diseases. The two departments controlled an

outbreak of rabies and anthrax in Kisumu East and Nyakach in 2015.

Respondents in the qualitative study, rated KCHSSIP’s achievement on strengthening collaboration with

other sectors as follows: excellent—3 respondents, good—20 respondents, fair—8 respondents,

poor—2 respondents, and no comment—4 respondents. The study revealed collaboration with various

stakeholders, particularly with development partners or nongovernmental organizations. Other

collaborations included government ministries, such as the Ministry of Education and Agriculture, private

hospitals, faith-based organizations, administration police, and ward administrators. Stakeholder forums

and meetings were used to establish the roles various stakeholders would play, set out terms of reference,

and agree on memoranda of understanding. There is a system in place where partners such as

nongovernmental organizations start by informing the county about activities they would like to do, and

once they get approval from the county health department, they are directed to the subcounties or their

areas of operation. One respondent noted that the distribution was done equitably; however, another


respondent noted that a need for streamlining and coordination because partners specialized in specific

health-related areas, and if they are not coordinated well they might concentrate in a particular geographical

area and other areas would miss out. As a result of collaboration with various partners, a number of activities

or programs were being run at the subcounty or community level, such as health education in schools with

the help of teachers as ambassadors and the provision of youth-friendly services

2.3 Trends in Health Status and Impact Indicators

Life expectancy at birth: One of the objectives of the KCHSSIP 2013-2017 is to increase the average life

expectancy at birth from 59 years in 2012 to 67 years in 2017. Life expectancy data are missing for Kisumu

County.

Child mortality: To assess the performance of efforts toward improving child health in Kenya, the

KCHSSIP 2013-2017 selected two child mortality indicators: infant and under-five mortality rates per 1,000

live births. In the 2014 KDHS, the infant mortality rates were 50 per 1,000 live births in Nyanza, and the

under-five mortality rates were 82 per 1,000 live births in Nyanza. This means is that about 1 in every 20

children born in Kenya dies before age 1, and 1 in every 12 children does not survive to age 5. Table 8

provides facility-based mortality statistics for Kisumu County.

Maternal mortality: One of the key KCHSSIP 2013-2017 objectives is to reduce the maternal mortality

ratio per 100,000 live births. In the 2014 KDHS, the national maternal mortality ratio was 362 deaths per

100,000 live births. Population-level data needed to estimate the maternal mortality ratio during the review

period were not available by the time of this review. Table 8 reports only facility-level data, which represents

50 percent of all maternal deaths as reported in the Kenya 2015 vital statistics report.

Table 8. Health status and impact

Description

Baseline

(2012) 2013/14 2014/15 2015/16

Life expectancy at birth (years) 58.9

Annual deaths per 1,000—crude mortality 7 4 4 4

Neonatal mortality rate per 1,000 births 31 7 6 8

Infant mortality rate per 1,000 births 29 24 26

Under-five mortality rate 74 3 8 20

Maternal mortality ratio per 100,000 live births 488 115 136 170

Adult mortality rate per 1,000 30

Years of life lived with illness/disability 12

Note: Community-level data are not included in the data reported.


3. RECOMMENDATIONS

Strategic Objective 1: Elimination of communicable conditions

Provide programmatic support supervision to streamline issues on service delivery and data

management. Currently there is integrated support supervision from the county health

management team to the facilities that does not allow detailed assessment of service provision in

specific service areas. This has led to inadequate monitoring of indicators in these service areas,

and there is a need for targeted support supervision to enhance intensive indicator monitoring.

Allocate resources through the county government for preventive and promotive health services.

Most public health services rely heavily on the national support and are not necessarily sensitive to

county-specific needs. In order to control the communicable conditions and attain the set targets,

the county government needs to provide 25 percent of the operation and maintenance funds to

support public health activities to influence community knowledge, attitudes, and practices.

Hold programmatic performance review meetings. Quarterly meetings should be held at the

subcounty and county levels to review the indicators. The program focal persons should take the

lead and organize these review meetings at both levels with the support of the implementing

partners.

Strategic Objective 2: Halt and reverse the increasing burden of NCDs

Strengthen awareness of NCDs among the population (community and facility) through advocacy

by holding stakeholder meetings; providing information, education, and communication materials;

sensitizing the public through the media; and organizing NCD health days.

Scale up the screening services for all NCDs. Every health facility should be able to screen for

major NCDs (i.e., blood pressure, diabetes, cancer, and mental illness). This requires the

procurement of equipment and reagents; infrastructure improvement; and capacity building of

health care providers through formal training, on-the-job training, mentorship, continuous medical

education, and exchange programs.

Procure diagnostic and treatment equipment for NCDs, especially for breast, prostate, and

esophagus cancer; diabetes; mental illness; and cardiovascular conditions.

Allocate resources through the county government for the improvement of infrastructure and

equipment for NCD management, especially mental health and rehabilitation services for all

survivors of NCDs.

Strategic Objective 3: Reduce the burden of violence and injuries

Establish comprehensive SGBV centers in all subcounties to improve accessibility and provision

of SGBV care. The SGBV centers will include trained staff, equipment, adequate rooms for

counseling, reporting tools, and rescue services. The centers will also strengthen collaboration with

non-health-related sectors

Strengthen and establish centralized ambulance services, complete with staffing, that operate

24 hours a day.

Create awareness through community health services by building the capacity of community health

volunteers on the rights of and legal procedures for victims of SGBV.


Strategic Objective 4: Provision of essential services

Establish a county ambulance call center. The county government purchased eight ambulances that

were distributed in all the subcounties with focal persons at the subcounty and county levels.

Establishing the ambulance call center will enhance the effectiveness and efficiency of the referral

system.

Disburse free maternity funds in a timely manner. Free maternity funds have always been disbursed

from the free maternity secretariat, but there have delays in disbursement of these funds to the

health facilities. This should be improved to enable health facilities to offer free delivery services

effectively. The national health insurance fund has been mandated to manage these funds in the

current financial year, but there is a need to sensitize the community about this new development.

Incorporate traditional birth attendants in referrals and include their involvement as birth

companions. Traditional birth attendants are still delivering mothers. There is a need for the county

Health Department to bring them on board so that they refer mothers in labor to hospitals for

skilled deliveries. They should also be allowed to act as birth companions. There should be a system

of reward for traditional birth attendants who refer mothers.

Train community health workers on the danger signs during pregnancy to enable them identify and

refer mothers appropriately.

Plan and conduct maternity open days to diminish the negative perception of the community

toward healthcare services. Maternity open days conducted in health facilities have proved to be

important in reassuring mothers receiving ANC services and encouraging them to deliver in a

health facility. During maternity open days, the mothers receiving ANC services are taken on a

tour of the labor ward and given information concerning labor and delivery. This should be done

regularly in all health facilities that conduct deliveries.

Strengthen the community strategy by making an adequate budgetary allocation for community

health services. Currently only a few community units are supported by partners, whereby

community health workers are given a stipend. Those who do not receive a stipend are

demotivated, which affects the performance of community health services. There is a need for the

county government to pay the community health workers a stipend to enable them perform their

duties effectively.

Scale up the training of healthcare providers on long-acting reversible contraceptives to give them

the knowledge and skills to provide long-acting reversible contraceptives effectively.

Scale up the training of healthcare providers on emergency obstetrical and newborn care to give

them the knowledge and skills for obstetrical and neonatal emergencies.

Strengthen MPDSR at all levels, including the community, facility, subcounty, and county. The

county has adapted MPDSR guidelines and ensured that MPDSR committees are formed at county,

subcounty, and health facility levels.

Train community health workers on verbal autopsy. This will ensure accurate reports on

community-based maternal mortality rates. Currently only a few community health workers have

been trained on verbal autopsy.

Strengthen the collaboration between the civil registration department and the health department

to report vital events captured at the community level.

Objective 5: Minimize exposure to health risk factors

Conduct surveys through the county health department of monitoring indicators that include the

percentage of the population who smoke, the percentage of infants under six months on exclusive


breastfeeding, the percentage of the population aware of risk factors to heath, the percentage of

salt brands iodized, and couple year of protection due to condom use.

Strategic Objective 6: Strengthen collaboration with health-related sectors

Strengthen collaboration with the Department of Education and the Department of Health by

incorporating health records and information unit staff during deworming campaigns to capture

service data and update reports in DHIS 2.

Reactivate the school health program coordination mechanism for effective implementation of the

school policy.


4. CONCLUSION

The KCHSSIP review provides information for improving and further strengthening targeted health

interventions and programs. It serves as a basis for making adjustments to program approaches to more

efficiently address the issues that affect the health of the population in Kisumu County, in addition to

addressing SDGs and alignment of the health system strengthening efforts to facilitate effective

operationalization of the new directions at the global, country, and county levels. This review report will be

useful to the senior management and technical experts at the county departments of health, and other

government ministries, departments, and agencies that have an impact on the health sector and will also

inform the development of the KCHSSIP 2018-2022. The report provides an audit of where the Kisumu

County is and the areas that need focus. It will guide delivering of quality health services in accordance with

the county mission and vision, the KCHSSIP 2013-2017. The recommendations from this report will be

implemented to better the health of Kisumu County residents.


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APPENDIX 1. QUALITATIVE STUDY KEY INFORMANT INTERVIEW GUIDE

Kisumu County Health Sector Strategic & Investment Plan (KCHSSIP) 2013-2017 Review Key Informant Interview Guide

Introduction and Consent: My name is ______________________ from MEASURE Evaluation, PIMA

project. We are carrying out an assessment of the KCHSSIP 2013-2017 and I would like to ask you some

questions about the KCHSSIP. Your views will be useful in helping us assess the effectiveness of the

KCHSSIP and help improve the next strategic plan.

Background Information

Sub-County:

Name:

Job title:

Sex: Male Female

Facility/Organization:

1. In your opinion were all relevant stakeholders involved in the development of the KCHSSIP

2013 – 2017?

a) Yes b) No c) Don’t know

Please explain________________________ (probe: Whether the process involved a comprehensive all

inclusive participatory approach; find out whether they or their institutions were involved and the nature of their

involvement.)

2. In your opinion has the KCHSSIP adequately addressed the County’s health priorities in order to

improve service delivery?


Please explain________________________(Probe: Would you say the plan has contributed to the

efficiency, transparency and accountability in activities implemented?)

3. a) In your opinion was the KCHSSIP widely disseminated to ensure ownership by the different

stakeholders?


3b. Why do you think they were involved/ not?

3c. What would you like to see improved with regards to the dissemination of the strategic plan?

4. Do you think the targets set in the KCHSSIP were realistic and can they be achieved in the 5-year

period allocated?


Probe: Why or why not?

5. Have you referred to the SP in your day to day activities? Probe: How often; which areas have required

you to refer to the SP in carrying out your work?


6. List 3 key areas in your work that have been influenced by the KCHSSIP.

1. ________________________

2. ________________________

3. ________________________

7. One of the key targets identified in the plan is to promote data use for decision-making. Would

you say this has been achieved?


Probe: Why/why not?

8. How would you rate the progress towards implementation of the strategic objectives and

achievement of the set targets?

Very Poor Poor Fair Good Excellent

1 2 3 4 5

Please explain_______________________

9. Please rate to what extent the KCHSSIP has achieved the desired health outcomes (6 policy

objectives or) on a scale of 1 to 5 where 1 signifies poor while 5 signifies excellent.

Probe on each policy objective

Very

Poor Poor Fair Good Excellent

a. Elimination of communicable conditions 1 2 3 4 5

b. Halt and reverse the increasing burden

of non-communicable conditions 1 2 3 4 5

c. Reduce the burden of violence and

injuries 1 2 3 4 5

d. Provide essential health services 1 2 3 4 5

e. Minimize exposure to health risk factors 1 2 3 4 5

f. Strengthen collaboration with health

related sectors 1 2 3 4 5

Please explain

10a. Looking at the KCHSSIP, are there gaps you would want to see addressed in order to

achieve the desired health outcomes (policy objectives)?


10b. If yes, please list and explain the gaps identified ________________________

10c. How would you like to see the gaps addressed ____________________ ?

11. What roles can different stakeholders play to ensure proper implementation of the SP? Probe for

different categories including: manager, community, employer, GoK, county government

12. Do you have any recommendation to improve the development process of the KCHSSIP?

Thank respondent and end interview.


APPENDIX 2. LIST OF CONTRIBUTORS

1. James Otieno MOH Kisumu County 2. Nelly Rangara MOH Kisumu County 3. Elly Nyambok MOH Kisumu County 4. Jane Owuor MOH Kisumu County 5. Lawrence Otieno MOH Kisumu County 6. Linda Odaga MOH Kisumu County 7. Hellen Ogollah MOH Kisumu County 8. Peter Nyaberi MOH Kisumu County 9. Peter Sirima MOH Kisumu County 10. Perez Akello MOH Kisumu County 11. Linda Odaga MOH Kisumu County 12. Caroline Soita MOH Kisumu County 13. Rinnie Juma MOH Kisumu County 14. Philip Odhiambo MOH Kisumu County 15. Julius Ominde MOH Kisumu County 16. Larry Mwallo MOH Kisumu County 17. Jane Owuor MOH Kisumu County 18. Elizabeth Mbawi MOH Kisumu County 19. Christine Oyuga MOH Kisumu County 20. Peter Nyaberi MOH Kisumu County 21. Paul Ochola MOH Kisumu County 22. John Olongo MOH Kisumu County 23. Japheth Terer MOH Kisumu County 24. Peter Nasokho MEASURE Evaluation PIMA 25. Karen Owour MEASURE Evaluation PIMA