The effect of enhanced public–privatepartnerships on Maternal, Newborn andchild Health Services and outcomes inNairobi–Kenya: the PAMANECHquasi-experimental research protocol

Pauline Bakibinga, Remare Ettarh, Abdhalah K Ziraba, Catherine Kyobutungi,

Eva Kamande, Nicholas Ngomi, Jane Osindo

To cite: Bakibinga P,Ettarh R, Ziraba AK, et al. Theeffect of enhanced public–private partnerships onMaternal, Newborn and childHealth Services andoutcomes in Nairobi–Kenya:the PAMANECHquasi-experimental researchprotocol. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608

▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2014-006608).

Accepted 30 September 2014

Health Challenges andSystems Research Program,African Population & HealthResearch Center, Nairobi,Kenya

Correspondence toDr P Bakibinga;paulabak80@gmail.com

ABSTRACTIntroduction: Rapid urbanisation in Kenya hasresulted in growth of slums in urban centres,characterised by poverty, inadequate social servicesand poor health outcomes. The government’s initiativesto improve access to quality healthcare for mothersand children are largely limited to public healthfacilities, which are few and/or inaccessible inunderserved areas such as the slums. The ‘Partnershipfor Maternal, Newborn and Child Health’ (PAMANECH)project is being implemented in two Nairobi slums,Viwandani and Korogocho, to assess the impact ofstrengthening public–private partnerships for thedelivery of healthcare on the health of mothers,newborns and young children in two informalsettlements in Kenya.Methods and analysis: This is a quasi-experimentalstudy; our approach is to support private as well aspublic health providers and the community to enhanceaccess to and demand for quality healthcare services.Key activities include: infrastructural upgrade of selectedPrivate Not-For-Profit health facilities operating in thetwo slums, building capacity for healthcare providers aswell as the Health Management Teams in Nairobi,facilitating provision of supportive supervision by thelocal health authorities and forming networks ofCommunity Health Volunteers (CHVs) to create demandfor health services. To assess the impact of theintervention, the study is utilising multiple data sourcesusing a combination of qualitative and quantitativemethods. A baseline survey was conducted in 2013 andan end-line survey will be conducted at least 1 year afterfull implementation of the intervention. Systematicmonitoring and documentation of the intervention is on-going to strengthen the case for causal inference.Ethics and dissemination: Ethical approval for thestudy was obtained from the Kenya Medical ResearchInstitute. Key messages from the results will be packagedand widely disseminated through workshops, conferencepresentations, reports, factsheets and academicpublications to facilitate uptake by policymakers.Protocol registration number: KEMRI- NON-SSC-PROTOCOL No. 393.

BACKGROUNDLike many other sub-Saharan African coun-tries, Kenya is experiencing rapid urbanisa-tion growth characterised by matchingexpansion of informal settlements.1 2 Slumsand slum-like settlements are home to about60% of urban residents in Kenya.3 However,the public healthcare delivery system has notkept pace with urban population growth,being neither accessible nor responsive tothe critical health needs of slum residents.4 5

This is, in part, due to the fact that the exist-ing public health facilities were onlyintended to serve the formal settlements andnot the large concentrations of peoplewithin informal settlements. In addition, theinformal nature of slums and, by implication,the uncertainty about the legal status of thesettlements has for a long time made theimprovement of public social services inthese areas difficult.6 The Kenyan govern-ment’s commitment to improve access toquality healthcare for mothers and childrenis demonstrated by such initiatives as freeaccess to maternity care available at publichealth facilities. However, public health facil-ities are almost non-existent and inaccessibleto most mothers and their children in

Strengths and limitations of this study

▪ The project seeks to address most challenges inthe healthcare system in a slum context: infra-structural, human resource, information, finan-cing, technologies and supplies.

▪ It demonstrates in action that intervention basedon research evidence can change the health out-comes of a community.

▪ Compliance by all actors is very important forthe success of this project.

Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608 1

Open Access Protocol

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

underserved areas such as in the urban informalsettlements.5

Research conducted in two slums of Nairobi(Korogocho and Viwandani) over the past decade hasdocumented the near absence of public health facilitiesin these settlements and the health consequences ofthis.5 7 8 Korogocho slum is served by two public healthfacilities while Viwandani is served by one, all located onthe outskirts of the slums. In 2008–2009, a service provi-sion assessment conducted by the African Populationand Health Research Center (APHRC) in these and oneother slum showed that less than 1% of health facilitiesserving these settlements were public.9 The gap left bythe near absence of the public sector has been filled bya vibrant private health sector, which is largely unregu-lated and unsupported. Although private providers caterfor a significant proportion of slum residents, healthcareworkers in this sector rarely benefit from in-service train-ing to update their skills to offer essential services suchas basic and comprehensive emergency and obstetriccare, family planning and management of commonchildhood illnesses. The linkages between the health-care delivery system and other health-producing systemsare also weak. In addition, costly health services with ahigh societal benefit, such as vaccination and familyplanning are usually provided at public facilities, whichare largely inaccessible to slum residents.The Kenyan Public–Private Partnership Bill 2011 and

its policy framework opened up the provision of publicservices for private capital and expertise, creating afavourable environment for private sector participationin the provision of public services.10 The government ofKenya has put in place mechanisms through whichprivate providers can meaningfully participate in theplanning, monitoring and provision of health services atdifferent levels through so-called health stakeholderforums. Private providers who are part of a DistrictHealth Stakeholders Forum are eligible to receivesupport in the form of essential supplies such as vac-cines, tuberculosis drugs, family planning commoditiesand drugs for treating sexually transmitted infections.This support is contingent on meeting other qualitystandards and criteria such as staffing, infrastructure andthe submission of timely reports from the routineHealth Management Information System (HMIS). TheWHO11 (figure 1) has described the building blocks ofa health system that, when working as a whole toproduce services that are accessible, reaching mostpeople, of good quality and with the right safeguards,will lead to a well-functioning system that will producegood health for the people it is intended to serve.Against this background, drawing on the aforemen-

tioned government initiatives and the WHO frameworkto improve private provider health services, and on thebasis of the evidence generated from over a decade ofresearch in the two slums, APHRC decided to design,implement and evaluate a package of interventionsaimed at improving healthcare delivery. The Partnership

for Maternal, Newborn and Child Health (PAMANECH)project was designed and rolled out in July 2012 by theAPHRC in Korogocho and Viwandani with a broaderaim of strengthening the healthcare delivery system inurban informal settlements to be more responsive to thehealthcare needs of mothers and their children.The proposed work is grounded in classical systems

thinking but within the WHO systems strengtheningframework (figure 2).11 Classical systems’ thinkingacknowledges that ‘problems’ are part of the systemand...“the component parts of a system can best beunderstood in the context of relationships with each otherand with other systems, rather than in isolation…”.11 TheWHO health systems framework describes six buildingblocks that may be viewed as inputs and processes aimedat delivering outputs, outcomes and impact (figure 1).The effect of the inputs and processes may be assessed atthe system level or by examining results in the populationthe system is intended to serve. Extending this frameworkto classical systems thinking (figure 2) recognises that thehealth system’s ‘problems’ or its outputs, outcomes andimpact are not only influenced by the system, but theymay shape the kind of system that exists. For example, thehigh levels of morbidity, mortality and low utilisation ofpreventive services among slum residents are a result ofinadequate inputs and processes in the public andprivate health system that serves this population. Othersystems or factors may influence inputs, processes,outputs and outcomes at the system and population level.For instance, insecurity in the slums and poor social infra-structure affect the ability of private providers to attractstaff and impede the population’s ability to access healthservices. Other factors, including poor water and sanita-tion infrastructure, and food insecurity have a directeffect on health outcomes. The PAMANECH initiativeseeks to directly address the following critical elements ofthe system: (1) service delivery; (2) leadership and gov-ernance; (3) health workforce; and (4) health informa-tion system. The initiative will also indirectly address theelements of healthcare financing, medical products, vac-cines and technologies through strengthening leadershipand management of healthcare services.

Figure 1 Health systems building blocks (WHO).

2 Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

PROJECT DESIGN AND LEARNING QUESTIONThe project utilises a quasi-experimental design. Themain learning question is: ‘Does strengthening theprivate sector with support from the public sector forthe delivery of quality health services for slum residentshave an impact of Maternal, Newborn and Child Health(MNCH) outcomes?’

Specific learning questionsThe specific learning questions of primary interest are:1. What effect has material support to private providers

had on quality of care?2. What is the effect of training in service guidelines on

provider skills for the provision of MNCH services?3. What is the effect of a network of CHVs on uptake of

MNCH services in slum settlements?4. What is the cost-effectiveness of the proposed

intervention?In addressing these questions, we will try to under-

stand how or the ways through which a public–privatepartnership can contribute to service delivery to disad-vantaged populations and the impact of such a partner-ship on MNCH indicators.

METHODS AND ANALYSISProject settingThe intervention site covers two informal settlements inNairobi, namely Korogocho and Viwandani, whereAPHRC has been operating the Nairobi Urban Healthand Demographic Surveillance System (NUHDSS) since2003. The NUHDSS has been described in detail else-where and for this intervention and correspondingplanned evaluation provides a reliable sampling frame.12

Viwandani and Korogocho settlements are togetherhome to approximately 70 000 residents and, like otherslums, are characterised by poverty, poor coverage ofsocial services and poor MNCH outcomes. More than adecade of research by APHRC in Viwandani andKorogocho slums shows that the two areas exhibit poorchild, neonatal and maternal health indicators includinghigh levels of maternal mortality (706/100 000 com-pared to 488/100 000, the national average), high infantand under-five mortality.8 13 In addition, stillbirth ratesare unacceptably high.8 Whereas the proportion ofbirths taking place in health facilities has increased sig-nificantly over the last decade (52% in 2000 to 81% in2012),14 15 about 60% of health facilities in this settinglack trained staff and equipment to handle basic emer-gency obstetric and neonatal complications.4 All factorsconsidered, the dismal state of maternal and child careservices in this setting is a major contributor to theobserved high maternal and under-five mortalityobserved in the slums of Nairobi.12

PartnersImplementation of the PAMANECH project is a jointcollaboration among several partners including APHRC,the City County of Nairobi, sub-County HealthManagement Teams (Kasarani and Makadara subcoun-ties), community leaders in Korogocho and Viwandani,private providers, youth leaders and Community HealthVolunteers.

Facility selectionSix credible and established (not-for-profit) health facil-ities were selected in Korogocho and Viwandani (three

Figure 2 Classical systems

thinking applied to the WHO

health system strengthening

framework.

Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608 3

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

in each site) for transformation into ‘one-stop primarylevel centres’ for preventive and curative MNCH ser-vices. The selection criteria were based on the NationalHealth Insurance Fund (NHIF) Accreditation Manual16

for maternal health services at level 2 and enhancedwith items from the SAFECARE manual.17 The NHIFaccreditation manual is used in Kenya for accreditinghealth facilities at different levels for eligibility to receiveNHIF refunds. SAFECARE is a continuous qualityimprovement tool to improve healthcare delivery inresource-restricted settings. It aims to support healthproviders and consistently improve quality to meet thehealthcare needs of the population they serve.The assessment criterion was reviewed by the

sub-County Health Management Teams (sCHMTs) ofMakadara and Kasarani to determine the relevance andcompleteness of the tool. The final assessment had twosections: an oral interview section, which covered thehealth facility details (ownership, relationship withsCHMT), registration of health facility, power supply,presence of qualified registered health personnel, andguidelines and procedures used in MNCH. The secondsection was an observation checklist, which covered theenvironment of the health facility, physical structure ofthe facility, water supply, equipment in consultationroom, labour ward and laboratory, availability of a func-tional ambulance and availability of wards. Each item onthe list was scored using a 5-point scale with themaximum score (best score) per item being 1 andminimum score (worst score) per item being 5. A list with53 health facilities was generated by members of theproject management committees from the two communi-ties and validated by the sCHMTs. Twenty two of thelisted facilities were not assessed as they were stand-alonelaboratories or pharmacies that offered treatment forminor ailments and occasionally offered delivery services.For each health facility, a sum of all the scores was gener-ated and this was used to rank the 31 assessed facilities.The top three health facilities in each settlement wereselected for support and the results communicated to thecommunity leaders, sCHMTs and all assessed facilityheads at a meeting organised by APHRC.

Key project activitiesThe activities below are aimed at improving access toquality healthcare and reducing the financial burden ofhealth expenditure for the two slum communities inNairobi mentioned in this study.

Infrastructural upgrade of selected private not-for-profithealth facilities that already operate in the two slumsSix credible and established private not-for-profit(PNFP) providers were selected; however, due to finan-cial constraints, only five have received infrastructuralupgrade. Each selected facility will be supported toprovide: (1) essential and basic obstetric care; (2) ante-natal care; (3) maternity care; (4) postnatal care; (5)diagnosis and treatment of common childhood illnesses;

(6) vaccination; and (7) HIV/AIDS-related services suchas Voluntary and Routine Counselling and Testing andelimination of mother-to-child transmission of HIV. Thesupport to be provided is based on the identified needsof each facility and includes expansion/renovation ofexisting facilities, provision of basic equipment, andwater and electricity connections, among others. Theproviders were selected in a consultative manner thatinvolved all the relevant stakeholders. The support isbeing provided in a phased manner contingent onmeeting set criteria for quality improvement. The ration-ale for this infrastructural support is based on: (1) theneed to meet Ministry of Health standards and accredit-ation criteria, (2) the need for space to offer the envi-saged expanded range of services and (3) the need toensure long-term sustainability of the programmethrough linkages to other funding streams. Adequateinfrastructure is a key accreditation criterion accordingto guidelines formulated by the NHIF. It is importantthat these facilities are accredited by the NHIF, not onlyto benefit from their health insurance scheme, but tobenefit from other initiatives such as the output-basedaid voucher scheme for reproductive health services cur-rently being piloted in the two slums. There is alsopotential to benefit from other health insuranceschemes such as one offered by Jamii Bora—one of thelargest microfinance organisations targeting slum dwell-ers and street families.

Capacity building for healthcare providersClinical personnel of the selected facilities are beingtrained using the most appropriate and current clinicaland practice guidelines for MNCH. Training is con-ducted gradually to ensure that what is learnt is institu-tionalised and practiced before additional training isprovided. The private health providers are to receivetraining and support to generate routine HMIS data andreports that will feed into the district monthly reports.

Capacity building for health management teamsThe sub-County (Kasarani and Makadara) and County(Nairobi) health authorities are being facilitated to offersystematic supportive supervision to the ‘One-StopPrimary Level Centres’ to ensure that guidelines areadhered to, skills are reinforced and ultimately high-quality services are offered. In addition, the healthauthorities are to ensure access to high-quality, low-costmedicine and supplies by the five health centresthrough existing channels, such as recommendation tothe largest supplier of high quality low cost medicinesand supplies to the PNFP sector in the country (Missionfor Essential Drugs and Supplies—MEDS). Somemembers of the health management teams have beensupported to receive training on supervision, leadershipand management to enhance their capacity to effectivelymanage health services in the districts under which thetwo slums fall.

4 Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

Engagement of CHVsUnder the Ministry of Health community health strategyfor improving health, CHVs have been identified in allvillages in the country. These, with some facilitation,help implement public health activities including report-ing on health events in the community. Owing to highattrition rates of these volunteers, we found it necessaryto train more CHVs in order to reconstitute the commu-nity units. Ten CHVs per village were selected from thetrained pool within the two slums (a total of 180 from280 trained) to work with the private providers and tocreate linkages with the public sector. Their main rolesinclude household monitoring for childhood illness andvaccination status, referrals to a primary healthcare facil-ity (public or private), registration of pregnant womenin the designated households, referrals for antenatalcare and skilled attended delivery at the upgradedprivate health facilities, assisting mothers with birth plan-ning and postnatal visits, and distribution of contracep-tives. These activities, drawing on proven approaches inthe utilisation of community health workers, will provideevidence to guide the implementation of the nationalcommunity strategy.

Engagement of youth groupsYoung men in each village, who are already in organisedgroups, have been mobilised to work as security escortsfor women in need of urgent medical attention eitherfor themselves or their young children at night.Insecurity at night is one of the reasons women deliverat home and why they delay seeking care when it isneeded. We are piloting this context-specific securityservice organised and run by young people to determinethe feasibility of the service, to set up the most appropri-ate mechanisms for contracting the youth groups, and toestablish payment modalities, sustainability and bestcommunication practices between the users and provi-ders. Youth groups have been linked to CHVs withwhom they liaise to get information on which mother orchild requires their services.

Establishment of ambulance servicesAn emergency referral system is crucial in improvingMNCH outcomes. This is especially so during hourswhen public transporters are no longer operating, forexample, at night. On the other hand, at the time whenpublic transport is available, it would be difficult for anon-emergency vehicle to navigate Nairobi’s traffic jamswhereas emergency vehicles are given priority. Referredpatients can also obtain care (such as intravenous fluids,oxygen, injections) en route to the next level facility in awell-equipped ambulance as opposed to a privatevehicle. An ambulance system will be set up building onexisting ambulance services in the community. Theambulance will be used to transfer mothers and childrenwho need referral to the nearest maternity hospital. Ineach of the target slum settlements, one ambulance willbe provided by the programme to serve the network of

private providers in the area. The ambulances will becentrally located and managed from two of theupgraded health facilities. Priority will be given to facil-ities or organisations that already run some form ofambulance service since they may be best placed tomanage the service. Appropriate communicationmechanisms will be put in place to ensure that theambulance is accessible at all times whenever it isneeded. Obstetric emergency transportation systemshave been plagued by problems of non-sustainabilityeither as a result of high cost or the rarity of emergencyevents in the face of continued inputs.18 It is recom-mended that such transport systems should be comple-mented by quality improvements in the primary referralsystem and the system should be open to other users toensure sustainability.19 20 To mitigate against the risk ofnon-sustainability we propose to diversify the client basefor these ambulances to include non-obstetric and non-child emergencies. Different cost structures will be putin place whereby obstetric and child emergencies willpay half the price and the others will pay full price.

Establishment of outreach specialist servicesThe project team will work with professional associationsin Kenya, such as the Kenya Obstetrical andGynaecological Society (KOGS) and Kenya PaediatricAssociation (KPA) to run outreach clinics for womenand children in slum settlements. This programme willwork with the private providers to set out defined sche-dules for specific services and to coordinate these withKOGS and KPA specialists. The outreach clinics will addvalue by offering services that may not be routinely pro-vided at level 2 facilities such as treatment for sexuallytransmitted infections, cervical cancer screening, long-term family planning and breast cancer screening,among others.

Support to other credible PNFP providersThe above activities, though aimed at strengthening theservice delivery system serving slum residents, may endup interfering in the healthcare market and squeezingout credible private providers not selected for support.To guard against this, we propose to create opportunitiesfor other eligible but unselected providers to benefitfrom other means of support. These will include sup-portive supervision from the sCHMT, participation intraining programmes, support to generate routine HMISthat enhances their chances to get essential suppliesfrom the public sector, participation in monthly meet-ings between private providers in each district, which areorganised by the sCHMT.In figure 3, we summarise the intervention: aiming to

improve the quality of services offered, improve accessi-bility to these services and improve efficiency in deliveryof these services thereby enhancing sustainability. Theproposed initiative will not create a new system, rather itwill enhance the hitherto untapped synergies betweenthe public and private sector in health service provision,

Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608 5

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

strengthen existing governance structures, promote com-munity involvement in health through the provision ofcritical non-health support and improve capacities togenerate and utilise health information for planning,monitoring, evaluation and advocacy. As shown infigure 3, we propose that a high-quality system, accessibleand in demand, will result in improved MNCHoutcomes.

Intervention monitoring and evaluationThe intervention has preintervention and postinterven-tion project assessments for changes, if any, on theMNCH health services and population health outcomes.We conducted a baseline survey in August 2013 andplan to conduct an end-line at least 1 year after the fullimplementation of the intervention. In order to be ableto strengthen the case for causal inference we are con-ducting systematic monitoring and documentation ofthe intervention based on our intervention (figure 3).The monitoring and documentation will also captureany other contextual factors that may influence thesame outcomes as our intervention.

Data collection and analysis planThe effects and impact of the programme will be deter-mined by triangulating data (quantitative and qualita-tive) and information from different sources, examiningtrends where possible, and trying to find and supportexplanations for the observed findings (figure 4).Internationally recognised principles and standards fordata collection and analysis will be followed.Several data sources have been identified:1. The Nairobi Urban Health and Demographic

Surveillance System (NUHDSS): For secondary dataanalysis to assess preintervention, intervention andpost-intervention trends of antenatal care, obstetriccare (skilled attended delivery), immunisation cover-age, neonatal mortality (including stillbirths) andchildhood mortality. Under the NUHDSS, every fourmonths, all households are visited and information onthe status of members including migrations, births,deaths and healthcare use is ascertained. For deaths, acause of death is ascertained using verbal autopsy.

2. Quantitative assessments: These will be carried outthrough household surveys of women in reproductiveage and children aged under five years to determine

Figure 3 Summary of the

PAMANECH Intervention.

6 Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

changes in healthcare utilisation patterns (if any) forpreventive and curative services, interactions withCommunity Health Volunteers (CHVs), user satisfac-tion, healthcare costs and referral patterns. Thesedata are not captured under the NUHDSS.

3. Routine HMIS: HMIS data from the selected andupgraded health facilities will be collated and quantita-tively analysed to estimate attendance rates, case manage-ment practices against guidelines, supplies acquisitionand uptake of different MNCH services, and referral pat-terns especially with regard to two-way referral by CHVs.

4. Qualitative assessments: These will be used to collectand analyse data from key informant interviews,in-depth interviews and focus group discussions withservice providers and clients about the quality andaccessibility of MNCH services, as well as the qualityof interactions with CHVs.

5. Cost evaluation: This will entail a compilation of costsof goods and services from the provider perspective.Apart from programme costs from the project, datawill be collected from the in-charges of the selectedhealth units as to the inputs into their facilities. Thecost evaluation data will be combined with the healthoutcome data to compute the cost-effectiveness ana-lysis of the intervention.Quantitative data (from the surveys) entered in net-

books will be synchronised with the master database inAPHRC head office every day. Where data is missing orobvious inconsistencies are noted, the office editor willinform the data manager who will then contact the fieldteams for clarifications and, where need arises, sendback queries to the field teams for completion of incom-plete data or correction of the inconsistencies. Cleandata will be exported for analysis to statistical software(STATA V.11.0; StataCorp LP, Texas, USA) for advanced

cleaning and analysis. We will conduct basic tabulationsand regression analyses comparing differences in theproportions of women in reproductive age and childrenunder five years at baseline and end-line for variablessuch as contraceptive prevalence, vaccination coverage,skilled attended delivery, care-seeking for childhood ill-nesses, among others. These analyses will control for anydifferences in the samples (if any) at the two time pointsas well as the contribution of contextual factors that mayhave occurred in the course of the implementation.Quantitative data from the health facilities, CHVs and

the client satisfaction survey will be entered into Excelwork books monthly. Basic analyses of the collated datawill be conducted, including the methods of median,mean and range.Qualitative data will be transcribed and saved in Word

format. Transcribed Word files will be imported intoNVIVO software (QSR International Pty Ltd) for codingand further analysis. Analysis across all transcripts will beconducted using a constant comparative method to iden-tify themes and their repetitions and variations. The ana-lysis will also aim to identify changes, if any, in variousindicators, which could be attributed to the intervention.

Project timeline and beneficiariesThe project started in July 2012 and will last a total of54 months (figure 5). The direct beneficiaries of theproject are women of reproductive age and childrenunder the age of 5 years in the two informal settlementswho make up 20% and 14% of the population, respect-ively.12 In addition, five health facilities are beingupgraded and the healthcare providers in the selectedPNFP and other public and private health facilities arebenefitting from training and skills upgrade. CHVs, thesCHMTs of the two subcounties where the study sites are

Figure 4 PAMANECH Project

Data collection plan.

Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608 7

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

located as well as the Nairobi County HealthManagement leadership are other direct beneficiaries.Residents of areas outside the NUDHSS as well as resi-dents of the two slums who are male and/or older than5 years but less than 15 years and/or older than 50 yearsare the indirect beneficiaries.

ETHICS AND DISSEMINATIONEthical approval for the PAMANECH study was obtainedfrom the Kenya Medical Research Institute. Study docu-ments and consent forms detailing the scope of theproject, activities and participant roles have been devel-oped. All study participants and facilities in this researchwill be assigned unique study identifiers. The data setwill be stored in a computerised database and studydocumentation and materials (including informedconsent forms) will be stored in locked file cabinetswhen not in use at APHRC. Only the research team willhave access to this information. Audio-taped interviewswill also be labelled with the study identifier, rather thanwith names. The audio-taped interviews and informedconsent forms will both be retained for a 2-year period,after which they will be destroyed. Data entry staff forthis project will only have permission to retrieve/placematerials with the authorisation of the investigators andunder the condition that the staff members understandand have signed the confidentiality agreement.Before presentation and or publication, participant

and facility information will be de-identified. The find-ings will be summarised and packaged appropriately tofacilitate uptake by policymakers. The findings will alsobe widely disseminated through workshops, conferencepresentations, newsletters, factsheets, internet blogs andacademic publications.

DISCUSSIONThe programme will demonstrate how access and utilisa-tion of healthcare services by women of child-bearing ageand children in the slums have improved as a result ofthe establishment of the six one-stop primary levelcentres. It is expected that the key outcomes in thesegroups will be reduced maternal and child deaths, lowerincidence of childhood illnesses and improved maternalhealth. These changes will be brought about through thedirect implementation of the interventions in the shortterm and indirectly by influencing government policythereby ensuring sustainability of the programme in thelong term. In addition, the programme will impact posi-tively on the relationship between private and public pro-viders in the districts, resulting in a common purposeand joint responsibility for improving the health of slumresidents in the two districts. The programme will alsostrengthen the functioning of the community units inthese settlements with improved supervision of CHVs andgreater involvement of the communities in ensuringaccess to health services. The establishment of emer-gency transport systems and community security systemsto support access to health services, especially at night,will provide learning opportunities for these and similarcommunities on effective approaches to reducing mater-nal and childhood morbidity and mortality caused by bar-riers to appropriate healthcare. One of the strengths ofthis project lies in linking learning with policy and action.It completes the triple helix of learning-policy-action.This project not only directly contributes to the well-being of slum dwellers, but will also facilitate interactionsbetween all health sector players. Conventional projectsare unidirectional; this project is multidirectional. Itseeks to address most challenges in the healthcare systemin a slum context: Infrastructural, human resource,

Figure 5 PAMANECH Project timeline.

8 Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

information, financing, technologies and supplies. Itcreates goodwill from policymakers and implementers.At the same time it demonstrates in action that interven-tion based on research evidence can change the healthoutcomes of a community. The initiative will bringtogether private healthcare providers, local healthauthorities, CHVs and community groups. It is, therefore,all encompassing and its success is necessarily tied to theextent and depth of interactions between all thesegroups. Through these interactions, all stakeholders—including the slum dwellers themselves—will play a rolein creating the systemic change desired and will formlong lasting relationships that could be used in scaling upthe project. In addition, the inter-linkages with policy-makers will catalyse a policy discourse and action on howto improve the health conditions of the urban poor.One possible risk of the proposed intervention is inter-

ference with the health care market in the slums. By sup-porting a few credible providers, the remaining credibleprovider may lose clientele and be forced out of busi-ness. There are no guarantees that the supported provi-ders will still be operating beyond the life of the project.To mitigate against this risk, we will extend somesupport to other credible providers such as supportivesupervision from the sCHMTs, training sessions,improvements in HMIS systems and recommendationsto MEDS for low-cost drug purchases. Finally, compli-ance by all actors is very important for the success of thisproject.

CONCLUSIONThe study outlined in this protocol will assess the impactof strengthening of components of the healthcaresystems on the MNCH services and population healthoutcomes in two informal settlements in Kenya. Thestudy’s findings will contribute to the body of knowledgeon the effectiveness of public–private partnership inimproving MNCH services and outcomes in urban infor-mal settlements. Implementation of the protocol will gen-erate evidence on the effectiveness, if any, of theintervention and possibly provide a model of public–private engagement for adoption by the local and centralgovernments for under-served populations like slums inKenya and other sub-Saharan African countries.

Acknowledgements We extend our sincere gratitude to the Viwandani andKorogocho communities for their continued support and participation in ourresearch projects.

Contributors PB drafted the manuscript. CK, RE and AKZ conceived theproject and its design, and participated in refining the manuscript. EK, JO andNN participated in refining the protocol. All authors read and approved thefinal manuscript.

Funding This project is supported by Comic Relief, UK, grant numberGR002-12547. The funder had no role in the decision to write and publishthis protocol. This work is also made possible through the generous corefunding to APHRC by the William & Flora Hewlett Foundation and theSwedish International Development Agency.

Competing interests None.

Ethics approval Kenya Medical Research Institute.

Provenance and peer review Not commissioned; internally peer reviewed.

Data sharing statement Additional information on the project can beobtained from Pauline Bakibinga: pbakibinga@aphrc.org.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

REFERENCES1. UNICEF. Information by country Kenya statistics. New York:

UNICEF, 2010.2. Kenya National Bureau of Statistics (KNBS). 2009 Population and

housing census results Kenya. Kenya National Bureau of Statistics(KNBS). 2010.

3. UN-HABITAT. The state of African cities 2010: governance,inequality and urban land markets. UN-HABITAT, 2010.

4. Ziraba AK, Mills S, Madise N, et al. The state of emergency obstetriccare services in Nairobi informal settlements and environs: resultsfrom a maternity health facility survey. BMC Health Serv Res2009;9:46.

5. Bazant ES, Koenig MA, Fotso JC, et al. Women’s use of private andgovernment health facilities for childbirth in Nairobi’s. InformalSettlements. Stud Fam Plann 2009;40:39–50.

6. UN-HABITAT. Sustainable urbanization: local action for urbanpoverty reduction, emphasis on finance and planning. UN-HABITAT,2007.

7. Fotso JC, Mukiira C. Perceived quality of and access to care amongpoor urban women in Kenya and their utilization of delivery care:harnessing the potential of private clinics? Health Policy Plan2012;27:505–15.

8. Kyobutungi C, Ziraba AK, Ezeh A, et al. The burden of diseaseprofile of residents of Nairobi’s slums: results from a demographicsurveillance system. Popul Health Metr 2008;6:1.

9. Ekirapa A, Mgomella GS, Kyobutungi C. Civil society organizations:capacity to address the needs of the urban poor in Nairobi. J PublicHealth Pol 2012;33:404–22.

10. GOK. Draft public private partnership bill (February 2011). Nairobi:Treasury, 2011.

11. WHO. Everybody’s business: strengthening health systems toimprove health outcomes-WHO’s framework for action. Geneva:World Health Organization, 2007.

12. Emina J, Beguy D, Zulu EM, et al. Monitoring of health anddemographic outcomes in poor urban settlements: evidence fromthe Nairobi Urban Health and Demographic Surveillance System.J Urban Health 2011;88:200–18.

13. Ziraba AK, Madise N, Mills S, et al. Maternal mortality in the informalsettlements of Nairobi city: what do we know. Reprod Health2009;6:4755–6.

14. African Population and Health Research Center. Population andhealth dynamics in Nairobi’s informal settlements. Nairobi: AfricanPopulation and Health Research Center (APHRC), 2002.

15. African Population and Health Research Center. Population andhealth dymanics in Nairobi’s informal settlements. Nairobi: AfricanPopulation and Health Research Center (APHRC), 2014. Underpreparation.

16. NHIF. NHIF accreditation manual. 1st edn. Nairobi: NHIF, 2005.17. SafeCare basic health care standards.18. Jahn A, De Brouwere V, eds. Referral in pregnancy and childbirth:

concepts and strategies. In: Safe motherhood strategies: a review ofthe evidence Antwerp: ITG Press 2001.

19. Samai O, Sengeh P. Facilitating emergency obstetric care throughtransportation and communication, Bo, Sierra Leone. Int J GynaecolObstet 1997;59:S157–64.

20. Macintyre K, Hotchkiss DR. Referral revisited: community financingschemes and emergency transport in rural Africa. Soc Sci Medk1999;49:1473–87.

Bakibinga P, et al. BMJ Open 2014;4:e006608. doi:10.1136/bmjopen-2014-006608 9

Open Access

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from

research protocolKenya: the PAMANECH quasi-experimental

−Health Services and outcomes in Nairobipartnerships on Maternal, Newborn and child

private−The effect of enhanced public

Kyobutungi, Eva Kamande, Nicholas Ngomi and Jane OsindoPauline Bakibinga, Remare Ettarh, Abdhalah K Ziraba, Catherine

doi: 10.1136/bmjopen-2014-0066082014 4: BMJ Open 

http://bmjopen.bmj.com/content/4/10/e006608Updated information and services can be found at:

These include:

References #BIBLhttp://bmjopen.bmj.com/content/4/10/e006608

This article cites 9 articles, 1 of which you can access for free at:

Open Access

http://creativecommons.org/licenses/by-nc/4.0/non-commercial. See: provided the original work is properly cited and the use isnon-commercially, and license their derivative works on different terms, permits others to distribute, remix, adapt, build upon this workCommons Attribution Non Commercial (CC BY-NC 4.0) license, which This is an Open Access article distributed in accordance with the Creative

serviceEmail alerting

box at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in the

CollectionsTopic Articles on similar topics can be found in the following collections

(808)Public health (495)Health services research

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

group.bmj.com on October 27, 2014 - Published by http://bmjopen.bmj.com/Downloaded from