Immunization work in Kenya

Impact of decentralization on immunization

services in Kenya

Mokaya Evans

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

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

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

Improving Coverage in Under-reached

Populations: Using The REC Approach in

Selected Sub-Counties In Kenya

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

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

Operationalizing the REC Approach

Continuous monitoring

process includes:

• Review meetings

• Peer-learning

• Self-assessment

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

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

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

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

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.

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

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

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

EPI Prototype curriculum

implementation status in Kenya

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

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

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.

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.

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

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

Nursing tutors participate in a Cold chain demo during an MLM training

Timeliness of vaccination in selected

districts in western Kenya

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

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

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

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.

Use of Phone Contacts to Increase The Return Rates

For Immunization Services

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

31

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.

32

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

33

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

34

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

35

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

36

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

37

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

38

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

39

Thank you