Impact of decentralization on immunization services in kenya
Transcript of Impact of decentralization on immunization services in kenya
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Immunization work in Kenya
Impact of decentralization on immunization
services in Kenya
Mokaya Evans
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Introduction
The Consti tution of Kenya 2010 provides for a two -tier
system of government (National and County respectively)
The reasons for devolving power set out in Chapter 11 are
To promote people’s participation in governance;
To promote equitable development and the sharing of resources
throughout the country;
To take services closer to the people;
To enhance the system of checks and balances; and
To foster unity by recognising diversity.
Each county have an elected assembly, elected governor
and deputy governor
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Exclusive Functions for National and County
Departments of Health (CoK, Schedule 4)
National
1. Health Policy
2. National referral health
facilities
3. Capacity building and
technical assistance to
counties
County health services 1. County health facilities and
pharmacies;
2. Ambulance services;
3. Promotion of primary health care;
4. Licensing &control of undertakings that sell food to the public
5. Veterinary services (excluding regulation of the profession);
6. Cemeteries, funeral parlours and crematoria; and
7. Refuse removal, refuse dumps and solid waste disposal
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Pros & Cons of County health services
Pros
• Infrastructure
improvements and additions
• Procurement of ambulances
• Procurement of diagnostic
equipment
• Some counties - replaced
exiting staff
Cons
• Unpredictable resources for salaries and service delivery - !!lump sum financing (outreaches, supportive supervision, gas)
• Mass exodus of health work force - real and perceived threats
• Inadequate M& E tools - lack of prioritization
• Inadequate vaccine syringes, safety boxes etc
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Improving Coverage in Under-reached
Populations: Using The REC Approach in
Selected Sub-Counties In Kenya
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Kenya immunization coverage performance
trend, 1992-2013X
0
20
40
60
80
100
120
1992 1993 1994 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Measles BCG DPT3 Fully Im
RED
Post Election
PCV
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Reaching Every District (REC) Approach
Objectives of REC approach
• Empower districts to plan, implement and monitor their own immunization services
• Promote partnerships between districts, health workers and communities to improve the population’s access to and utilization of services
• Promote continuous use of programme data to monitor progress and solve problems
Components of REC approach
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Operationalizing the REC Approach
Continuous monitoring
process includes:
• Review meetings
• Peer-learning
• Self-assessment
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Impact of the REC Approach Implementation in
Focus Districts
-1000
0
1000
2000
3000
4000
5000
6000
Bungomasouth
Vihiga BungomaNorth
Siaya Bondo Rachuonyo Kisumu East
No
. Of c
hild
ren
District
Number of unvaccinated children (with Penta 3), 2009-2012
2009
2010
2011
2012
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Impact of the REC Approach Implementation –
Adaptation in Additional District
0
10
20
30
40
50
60
70
80
Penta 3coverage
OPVcoverage
Measles
Immunization Coverage Trend; Igembe North District - 2012 and
2013
2012
2013
0
10
20
30
40
50
60
70
Measles Penta 3 Penta 1
% c
ove
rage
Vaccine
Immunization Coverage Trend; East Pokot - 2013 and 2014 ( Jan
- April)
2013
2014
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Data Quality Self Assessment
2011 2013
-
2.00
4.00
6.00
8.00
10.00 Recording
Archiving
Reporting
Demographi
cInformation
CoreOutputs
Evidence ofUsing Data
Bondo District Quality Chart - May 2010
-
2.00
4.00
6.00
8.00
10.00Recording
Archiving
Reporting
Demographic
Information
CoreOutputs
Evidence ofUsing Data
Bondo District Quality Chart – June 2013
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Lessons Learnt From REC Approach
• To improve equity in vaccination, need to deliberately target populations not normally reached
• Continued advocacy and support for the approach at district level is important for sustainability (REC is not a project) • UVIS to advocate for use of HSSF to fund immunization
operational costs
• Advocate with county health services to pay CHV stipends
• Community engagement : use of CHVs, village elders to create demand and track defaulters
• Need to maintain vaccine supplies and logistics (including for outreach) for the approach to succeed
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Summary
• The REC approach is
practical and effective in
reducing the numbers of
unvaccinated children in
Kenya.
• REC has been adapted to
other health interventions
in MCHIP
- Increase uptake of ANC,
PMTCT and deliveries in
Facilities.
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New vaccines introduction
• PCV10 & Rotavirus
vaccines
• Provided momentum for
KAPPd discussions at
national level and roll out
at selected district level
- Prevent, promote & treat
diarrhoea and pneumonia
President launching PCV 10
1st lady launching Rota vaccine
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Pneumococcal vaccine introduction
• After a 20 year lull in new vaccine introduction, Kenya introduced Hib and HepB vaccines in routine immunization in 2001.
• In 2011, Kenya introduced pneumococcal vaccine (10-valent PCV) to address a leading cause of child mortality.
• Country-led process: High level advocacy & participation; multi-agency partnership; effective social mobilization that created demand for the vaccine.
President of Kenya and Minister of Health
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Polio Eradication Support
• Kenya at risk of importation of WPV - last case in
2013
• MCHIP/MCSP support:
• Technical discussions in TWG to plan and implement
polio SIAs
• Support and supervision of Polio SIAs with focus on
strengthening routine immunization
• Participation in horn of Africa TAG meetings
• Supporting UVIS prepare for IPV intro. In July 2015
• Training operational level H/W on VPD surveillance
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EPI Prototype curriculum
implementation status in Kenya
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Training Needs Assesment
Assessment of pre-service training conducted 2005
• No harmony between pre-service and in-service training.
• Time allocated to EPI theory was inadequate and the practical sessions were not adequately supervised
• EPI content was incomplete or outdated
• Reference materials and demonstration equipment were lacking.
• Lecturers and tutors not abreast with new developments in vaccination
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EPI Training in KMTC
• In 2006, the prototype curriculum was widely distributed to all African countries and health training schools were required to initiated revision of their institutional curricula to incorporate EPI
• In 2008: Nursing Council of Kenya adopted EPI Prototype curriculum (custodians of the Nurse training syllabus, regulate nurse training and practice)
• Dissemination of the curriculum was hampered by lack of funding
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Prototype Curriculum Evaluation
In 2011-2012, evaluations were carried out in
9 countries, to find out whether they are
teaching the updated EPI curriculum. From
the 61 schools visited, 16 were medical
schools, 45 were nursing schools.
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Protoype Curriculum Evaluation
“Big Five” challenges identified include:-
• Inadequately trained pre-service teachers
• Lack of updated reference materials and tools
• Lack of detailed lesson plans with objectives,
content, teaching methods, etc.
• Lack of supervision by schools at field
placement sites
• Lack of updated Curriculum with current
advancements in EPI.
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EPI Prototype Curriculum Review
In 2013 review of the prototype curriculum
was done with the supported of
WHO/AFRO in collaboration with the
Ministry of Health of Ivory Coast, GAVI
Alliance, UNICEF, MCHIP/USAID, AMP and
NESI/UA
Kenya was represented by KMTC (Nairobi) in
this forum with support from MCHIP
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KENYA ACTION PLAN
• MOH in collaboration with partners to update
lectures/tutors through MLM Trainings - end of
March 2015 a total of 82 lecturers (GOK, FBO,
Private) nurse lectures will have undergone the
MLM Training
• Finalise the EPI manuals - printed and shared
• Equip the skill labs - proposals to KMTC,
meanwhile link institutions with health facilities
• MOH/Partners to periodically facilitate
selected topics in nursing schools/medical
schools - on going
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Nursing tutors participate in a Cold chain demo during an MLM training
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Timeliness of vaccination in selected
districts in western Kenya
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Objective & Rationale
Rationale
In readiness for Rota vaccine introduction;
- Age restriction, later lifted
- Importance of early vaccination; children
vulnerable > 3 months
• To determine timeliness of infant
immunization with pentavalent vaccine in
selected districts
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Penta 1 at 6 and 15 weeks
n = 14,000
0 20 40 60 80 100
Bondo
Bungoma Kimilili
Bungoma North
Bungoma South
Kisumu East
Kisumu North
Rachuonyo North
Rachuonyo South
pent1 at 6wks penta 1 at 15 wks
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Penta 2 and Penta 3 at 32 weeks
10 20 30 40 50 60 70 80 90 100
Bondo
Bungoma Kimilili
Bungoma North
Bungoma South
Kisumu East
Kisumu North
Rachuonyo North
Rachuonyo South
penta 2 at 32 wks Penta 3 at 32 wks
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Conclusions and Recommendations
• Even with the age restriction; it will be
possible for Kenya to achieve a high coverage
with rotavirus vaccine.
• Low proportion of children who begin the
schedule (6wks) on time suggests a need to
educate the caretakers on the need for
starting the schedule on time.
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Use of Phone Contacts to Increase The Return Rates
For Immunization Services
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Background Information
why the 4 sub counties
• High drop out rate (> 10%)between Penta 1 and penta 3 was a problem in Rachuonyo N, Rachuonyo S, Kisumu East and Kisumu North sub
counties (MOH - DHIS, 2011, 2012)
• Ownership of phones > 65% (Wesolowski et
al, 2012)
• Uncoordinated use of phone contacts to trace
defaulters for different interventions implemented
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Objectives of Study
• To test the feasibility of using cellular telephone contacts to trace immunization defaulters in four districts in Western Kenya.
• To document lessons learned and challenges in using cellular telephone contacts to trace immunization defaulters.
• To document barriers to continued utilization of immunization services in the four districts in Western Kenya.
• Estimate the cost of implementing this strategy at district level to inform future scale up efforts.
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Results (“Ownership” of Phone Number)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Mother Father Close relative Neighbour Don’t have
Series1 48% 27% 10% 7% 9%
%
Ownership of phones numbers among caregivers
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Results (Pre - Post intervention Drop-out Rates)
0.0 5.0 10.0 15.0 20.0 25.0
Kisumu D.H
Rachuonyo D.H.
Kosele Disp
Nyangande H/C
Nyahera SDH
Rabuor H/C
Homahill Disp
Kendu SDH
Ober H/C
Othoro SDH
Kauma Disp
Miriu H/C
%
Faci
litie
s
Penta 1 - Penta 3 drop out rates
pre drop out rate Post drop out rate
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Results (Reasons given for Defaulting)
0
50
100
150
200
250
300
350
400
450
500
Competingtasks
Vaccinatedelsewhere
Sick childand vaccineside effects
Notknowing orForgot thereturn date
No reason Cultural/religious beliefs
No. of respondents 469 191 152 59 28 15
No
. of r
esp
on
den
ts
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Results (Apparent Defaulter Rates vs Actual
Defaulter Rates)
0 5 10 15 20 25
Kisumu D.H
Rachuonyo D.H.
Kosele Disp
Nyangande H/C
Nyahera SDH
Rabuor H/C
Homahill Disp
Kendu SDH
Ober H/C
Othoro SDH
Kauma Disp
Miriu H/C
% drop out
Faci
liti
es
Baseline
ApparentDefaulter rate
TrueDefaulter rate
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Cost of Tracking Defaulters (Time and Money)
Time
• On average - 3 minutes to establish status of
vaccination
Money cost
• High volume - Ksh 270 ($3)/visit
• Low volume - Ksh 45 ($0.6)/Visit
• High volume - Ksh 810 ($9)/ year
• Low volume - Ksh 135 ($1.8)/year
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Conclusions & Recommendations
• Use of phone contacts is a feasible options for tracking defaulters
• “Ownership” of phones is above 80%
• Caregivers were willing to give their contacts
• Calls were well received by the caregivers
• Health workers appreciated the use of phone contacts to track defaulters: health workers used their phones
• The cost is manageable
• With proper planning HSSF could be used to fund this approach
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Conclusions & Recommendations
• Competing tasks is a leading cause of defaulting of vaccination
services:
• need to scale up social mobilization activities
• Forgetting the return date was not a major reason for
defaulting: SMS based platforms
• Observation that when the recipient of the call were males, the
children were more likely to be returned to the facility faster:
• need for male involvement in MCH activities
• Apparent defaulters: need for a forum for health workers to
share and exchange details of defaulting children
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Thank you