PIMA Afya Project

The problem being targeted in this proposal is lack of social accountability in primary healthcare service delivery in Vihiga County Kenya. Vihiga County has a population of about 650,000 people. The County has 74 public health facilities. We estimate an annual health facility utilization rate to be 2.0. Quality of services is normally measured from the service provider's point of view. The beneficiaries of the services who are community members rarely have a say in defining what is quality, measuring the quality of services and providing feedback to improve service delivery. Majority of the people in communities go to health facilities and receive services at the mercy of healthcare workers. In many cases, there is no social accountability from the side of service providers back to the community or patients who receive services. Service providers handle patients as inferior in the patient-provider relationship, sometimes not bothering about the patient's history or background. This leads to wastage of resources, poor service delivery and in most cases increased morbidity and mortality.  

The national ministry of health has developed tools to be used by community health workers. However, due to lack of support the tools have not been used. Majority of CHVs use ordinary exercise books to document the services they are rendering in communities. This makes it difficult to assess performance of primary healthcare services as most indicators are left out. 

Through the Costitution of Kenya 2010, health services were fully devolved to 47 County Governments. Vihiga is one of the 47 County Governments.  Vihiga County is 100% community services covered. The County has established 150 community health units with 1500 community health volunteers (CHVs). The CHVs report to 50 Community health assistants who report to 5 subcounty community health focal persons. The subcounty focal persons report to the County community health coordinator who reports to the County Director of Health. Vihiga County is the first county to enact the Community health services Act (2022) in Kenya. The division of health information, Monitoring and Evaluation supports the Community health strategy by measuring performance on key indicators. 

We propose to leverage this structures to improve social accountability in primary healthcare services (PIMA project) by:

1. Strengthening use of Ministry of Health tools in the community. This will provide robust standardized data that can be used to measure performance of healthcare services at community level. This intervention will involve digitalization of the tools. 

2. Integrated quarterly community score cards. These will be score cards around key sub-programs for example maternal and child health, nutrition, immunization or malaria. These scorecards will pull data from existing Ministry of Health tools. 

3. Using simple technology to conduct monthly patient and service provider surveys (PS-Surveys). This will be implemented using hoji application and a simple USSD code for clients who will have basic phones. Currently we are conducting the survey manually using paper. Although we have conducted this in most of our health facilities, the manual process has proven difficult to achieve 100% facility coverage. The use of mobile technology will make it much more cost efficient. The surveys will measure performance of services and provide feedback from the clients and service providers on best ways to improve.  

4. Conducting quarterly fishbowl discussions in community units between the communities and the health facilities. This will provide a platform for discussion on the status of services being provided to the communities, identification of gaps, recommendations and monitoring improvements. Key issues of discussion shall include data collection at community level using MOH tools, access to services, performance on score cards and results from the P-S surveys. This intervention which will take sought of townhall discussions will be organized on a quarterly basis to assess performance of both facility and community services. We intend to start community health committees as stipulated in the Community health services Act of (2022). This committee will be responsible for organizing the fishbowl discussions. 

The solutions described above are aimed at positively impact the entire population accessing services in both health facilities and community units in Vihiga County. The solutions will not only measure but also improve the quality of services. it is estimated that there are about 2million visits in health facilities in Vihiga annually in the outpatient departments. About 155,000 households with an average of 4.4 people are visited by the CHVs on a quarterly basis. 

The health service providers, department of health and County Government of Vihiga will be able to receive the feedback from the community and be accountable to the people they serve. The feedback will drive decisions aimed at improving service delivery in the primary healthcare. 

This project is developed and shall be executed through the department of health in Vihiga County. The department of health in Vihiga County is mandated with the sole responsibility of ensuring that the community or people in Vihiga receive the healthcare services to the highest standards.  The department manages the infrastructure, human resources, technologies health information systems, and coordinates all services both in health facilities and the community health units. The department has a clear structure from the County Executive member for health, the Chief officer for health, the County Director for Health, Heads of divisions/directorates, county health management team (CHMT), the subcounty health management communities, the facility in charges to the community health focal persons and community health volunteers. The County has established the office of the County community health services coordinator who reports to the County Director of health and sits in the apex decision making organ of the department (CHMT). Currently, the community health volunteers are critical in providing services to the community including malaria testing, first aid and referral to health facilities. 

Vihiga County is the only County in Kenya that has enacted the Community health services Act. This confirms community volunteers as employees of the county with a stipend thus legalizing all their operations. The Act clearly outlines the responsibilities of the CHVs including regular data collection, feedbacking from the communities, linkage and health information provision to communities.

The department considers CHVs as the critical needed link to both providing services to the community, assessing quality of services in the health facilities and ensuring ownership of the department's projects. 

Given that the solution (PIMA) shall be implemented by the County Government of Vihiga, there are no cultural barriers expected. Moreover, the Community health volunteers who will be the main drivers of the innovation come from the community and are selected by the community members. The department has also enacted the community health services act which then ensures that there is legal basis for implementation of the solutions. 

This proposal requests for technical and/or financial support. Even though the county with support from the ministry of health has build the capacity, there is need for technical support on the issue of fishbowl discusions. Currently, this has been done in one subcounty of Hamisi and specifically with the youth on the sexual reproductive health sub-program. We intend to scale this to all programs and this would require techniques of ensuring we achieve holistic coverage. The other aspect requiring technical support is how to assess financial performance of primary health services provision from the community perspective. Currently we do financial assessments from the service providers alone and basically measuring consumption of budgets provided. 

The County government of Vihiga has also ensured that the health budget is maintained above 25% of the total County budget for the last three  financial years. However, with staff shooting beyond 2000 individuals, 75% of the department's budget goes into payment of salaries leaving a paltry 25% for development and operations. This is not enough to initiate some interventions that are critical in improving service delivery.

Use of community health volunteers; use of Patient- Service provider surveys; employing technology; integrated program score cards and fishbowl discussions are novel models of measuring performance in primary health care.

Particularly with anchorage into law of community health services, this is likely to revolutionize the utilization of community health volunteers to improve services. 

This solution aims at three key impact goals:

1. Reduction in morbidity 

2. Reduction in mortality

3. Satisfaction with service delivery in primary healthcare

PIMA will measure performance using four key strategies described. The findings will be discussed between community members and service providers within the community units. This platform will provide for feedback sharing aimed at improving the quality of services being provided. Better quality of services at facility and community levels is likely to increase the level of satisfaction with services, reduce the number of sick people or eliminate certain preventable and treatable disease thus reduce mortality.

The progress shall be measured using the following indicators:

1. Type and number of services being provided across health facilities

2. Type and number of services being provided in community units

3. Number of people accessing services in health facilities by type of conditions

4. Rate of recoveries by type of conditions

5. Average hospital stay by type of conditions 

Improving linkage between community and health facilities and involving the community to define, measure and contribute to performance of health services has the potential to improve quality of services leading to increased satisfaction  and access to health services hence reduced morbidity and mortality. 

PIMA shall utilize USD and applications especially on the patient and service provider surveys. Access to Mobile phone penetration in Vihiga County is estimated to have surpassed the 100% mark indicating that everyone has access to one or more sim-cards. This provides an easy way of reaching the population for the surveys. 

Instead of the traditional suggestion boxes which no one opens, we intend to use SMS technology and application to capture the views of the clients and present results on live dashboards in real-time. these will be shared by the department's top leadership and the community leaders for decision making.

Community health workers collect data using manual registers. The registers are supposed to be the MOH certified ones. These filled in forms are aggregated by community extension workers. The community extension workers present the aggregated data to Community health assistants who validate and present to Subcounty Health records and information officers who key into the Kenya health information system (KHIS) or the DHIS. 

The community health volunteers are given a monthly stipend of Kenya Shillings 2000 by the County government of Vihiga. Other incentives include protective gears and regular trainings. 

The County Government of Vihiga employs staff through the County Service Public service board. The board recruits all individuals in a competitive manner beginning with assessing the need for the position, advertising in local dailies, shortlisting publicly and interviewing. As a government entity the county does not discriminate on the basis of gender, color or religion. The county endeavors to follow all the laid down procedures during employment for example achieving the two-thirds gender rule as stipulated by the constitution of Kenya. 

Department of Health is a service provider entity. Being government services are provided to all without discrimination. Vihiga County government provides free services  at primary healthcare level (150 community units and all 54 dispensaries). The public facilities through a facility improvement act provides funds to all facilities and also prescribes the ceiling for services being provided in health facilities. This is to ensure that individual facilities do not overcharge clients and that facilities are sustained by the County government. The county partners with several development partners through full funding or co-funding mechanisms to bridge the financial gap in service provision. The county places the client's satisfaction and care at the fore-front.

Facilities from level three upwards sustain service provision through out of pocket payments. The FIF act also ensures that revenues collected by the County government are injected back into facilities for improvements. The county receives funding through special grants from national government and donors. Currently, the department  of health works with over 24 partners who support various sub-programs logistically or technically. 

The department is pushing the idea of universal health coverage by ensuring that all its residents are registered on the national health insurance fund. 

Below are a few examples:

The national government of Kenya allocates each County Government including Vihiga County an equitable amount. This is usually based on populations and geographical size.

UNICEF has partnered with the County Government to improve maternal and child health since 2018

Nutrition International from Canada through co-funding works with the County to improve nutrition 

USAID, through Boresha Jamii project provides care to more than 17,400 individual living with HIV in the County

USAID through Afya Ugavi supports health commodities management

AMREF supports community health services and neglected tropical diseases in the County

Momentum Country Governance and Leadership supports health system strengthening in the county