Plain English summary
Background
Problem statement
Conceptual framework
Hypothesis
The intervention: Enhanced health care package (EHC)
-
Early identification and surveillance of the pregnant woman and newborn babies
-
Recognition and management of pregnancy-related complications, particularly pre-eclampsia, haemorrhage, premature rupture of membranes and infection
-
Recognition and treatment of underlying or concurrent illness in pregnancy – malaria, anaemia, infection among others
-
Screening for conditions and diseases such as syphilis, HIV infection and hepatitis B
-
Preventive measures through administration of tetanus toxoid, immunisation, de-worming, iron and folic acid supplementation, intermittent preventive treatment of malaria in pregnancy (IPT), prenatal vitamins provision and use of Long Lasting Insecticides Treated Nets (LLITNs)
-
Developing a birth and emergency preparedness plan
-
Immunization of all young infants and under-five children born during the study period including Vitamin A administration at 6 months of age and yearly
-
Obtain weights for all newborns, infants, under five children and pregnant mothers in the community and health facilities by providing weighing scales (infant, adult).
-
Malaria diagnosis using the rapid diagnostic tests in the community and health facilities
-
Haemoglobin estimation using Haemocue in the community and at the facilities
Project goal
Specific objectives
Methods
-
Implementation of the EHC through the FLTR strategy in one cluster (Obekai) in Busia.
-
Facilitation of IGAs/CBOs in the implementation of the health care system in one cluster(Kabula) in Bungoma.
-
Use of four control sites of Kiminini in Trans Nzoia,Chesunet in UasinGishu, Nyaporo in Kakamega and Nyaru in ElgeyoMarakwet county.
-
We are implementing the project in a phased manner:
-
◯ Phase1: In year one we shall carry out a baseline survey in all the six clusters.
-
◯ Phase 2: We shall initiate interventions in two clusters (EHC/FLTR in Obekai and IGAs/CBOs in Kabula through community participation and ownership. These interventions will be implemented in year 2 toyear 4.
-
◯ Phase 3: Will consist of an endline survey and evaluation of the project in year 5.
Setting
Study population
Inclusion criteria
-
All pregnant women in the study clusters who give written consent.
-
All newborn babies, infants and under five children born during the life of the study within the study cluster.
Exclusion criteria
-
Women not resident in the cluster during the study period.
-
Newborns, infants and underfive children not resident in the study cluster.
-
Infants and underfive children born before onset of the study in the study clusters
-
Women living in the cluster that decline to give written consent
Study approach and analysis
Design and analysis
-
Increase in antenatal care attendance by pregnant women in the health facilities
-
Increase in proportion and number of women delivering in health facilities
-
Reduction in the rate of low birth weight and premature babies born
-
Reduction in the rates of poor pregnancy outcomes including birth asphyxia, neonatal sepsis, neonatal mortality, maternal mortality, near miss maternal morbidity among pregnant women
-
Exclusive breastfeeding rate, immunization completion rate, Infant and Young Children Feeding (IYCF) and IMCI parameters, anthropometric indicators.
Objective 6
Anticipated outputs and outcomes
Major research outputs/ products | Expected outcomes | Likely policy influence – outcome challenges on targeted audience |
---|---|---|
Reports (3) | Mapping of gaps from baseline indicators and benchmarking for priority interventions in various contexts EHC through FLTR strategy contextualized (if necessary) Case studies and best practices for the intervention defined | Community/beneficiaries sensitized for ownership and effective participation in programme Stakeholders sensitized on benchmarks and priority interventions from baseline findings Policy makers sensitized innovations around implementation of the EHC / FLTR strategy Evaluation findings packaged to reveal best practices for possible scale up to other areas |
Phase 1: baseline report | ||
Phase II: Intervention report | ||
Phase III: Evaluation report | ||
Policy briefs (4) | Documentation on how implementation of EHC through the FLTR strategy (1st arm of the intervention) and innovations through CORPs (2nd arm of the intervention) lead to improvements access to and quality of care by pregnant women, neonates and infants reductions in morbidity among pregnant women, neonates and infants referral services for MNNH at county level (tier 1 to 3) | It is anticipated that the three briefs aimed at policy makers should demonstrate *How investments in EHC through the FLTR strategy triggers health system changes that lead to improvements in access and quality of care for pregnant women, newborn and infants. *How innovations in resourcing CORPs can incentivize CHWs, CHCs and CHEWs, enhance access via innovative transport arrangements through sustainable birth preparedness plans at tier 1 of the health system *How application of ICT / mobile health at tier 1 to improve quality of care through efficient clinical decision support systems that are cadre specific and aligned to MOH DHIS tools *CORPs used as birth companions leading to timely and appropriate referrals that minimize maternal and newborn morbidity and mortality between tier 1 and 3 |
Abstracts and posters (12) presented at Moi University annual scientific conference and other conferences by project staff (6) and post graduate students (6) | Demonstrated effect of interventions on intermediate (access and quality of care) as well as long-term outcomes (Maternal, neonatal and infant health indicators) as per study objectives | The abstracts will communicate to national and international audience of policy makers, planners and implementers on best practices and share lessons as per programme objectives |
Peer reviewed Journal articles(7) | Several publications from study: 1. Document situation analysis (at baseline) on maternal, neonatal and child health 2. How FLTR strategy and EHC lead to improvements in access 3. How FLTR strategy and EHC improve quality of care 4. How interventions lead to improvements in maternal, neonatal and infant health 5. How innovations incentivize CORPs and lead to their sustainable engagement 6. How integrating eHealth using mobile phone technology improves HMIS and quality of care 7. systematic reviews from masters and doctoral students | Publishing peer reviewed articles will help policy makers articulate quality of evidence from the study and lead to evidence-based planning, policy making and practice Help raise the profile and role of University as partner in health towards achieving the Vision 2030 |
Thesis at masters level (6) Dissertations at doctoral (2) | Raise the knowledge base and skills of students and health workers in health systems research (HSR) Encourage placement and internships with policy making institutions (public and private) | Policy makers to invest in health systems research and support university chair in future HSR initiatives Improve ranking and image of University as a hub/centre for excellence in HSR |
3 Guidelines / SOPs on EHC using the FLTR strategy | Efficiency of County referral services for MNH and referral strategy | New guidelines will help implementers improve performance and policy makers decide on approaches to scaling up intervention after the pilot phase will benefit from improvements |
3 Curricula: New doctoral level (HSM) – 2 students Revised MPH (HSM) – 6 students Revised short course (HSR) – 10 students | Enhanced competencies – knowledge, skills and attitudes in HSR through the short course, MPH in HSM, and Doctoral programme in HSM Competent and performing graduates placed appropriately in the health system | Policy makers will lobby for and support scholarships in HSR relevant training – Implementers will be motivated to come and study – certificate, masters, doctoral level Document best practices in curriculum for HSR - core competencies and share with network of academic institutions implementing HSR relevant curriculum |
Advocacy materials include: • pamphlets on programme interventions & practices – (produced bi-annually); • project web page to link to Moi University website updated regularly; • Press releases – TV and print media • Talks through bazaars etc. | Effective communication of stakeholders in the project planning, implementation and evaluation; Effective and sustained community engagement through the talks and other press releases; Enhances project governance - transparency & accountability to stakeholders | Policy makers can monitor and engage in analysis of policy such as Community health strategy Share programme knowledge with communities enhancing the learning curve from best practices and lessons for scale up of interventions in similar or other contexts |
Dissemination plan
Target audience | Key message | Proposed channels of communication |
---|---|---|
NACOSTI | All matters of the project as specified in the agreement | Seminars, meetings, reports, financial and technical reports; registration of patents and innovations |
Policy makers and decision makers | Evidence that informs rationale for policy change, need for reforms; innovations; cost-effective interventions; updates on specific project portfolios | Policy briefs, stakeholder forums, website, dialogue days, newsletters |
Project staff and sponsors and project stakeholders | project organization and governance structure; vision, mission, objectives, scope of project activities; legal provisions (agreements signed); stakeholders and roles; progress on implementation; project products; | Project website; newsletter, brochures, public meetings, press/media briefs; twitter or other appropriate feedback from the public; dialogue days |
Media | Messages on project progress/ updates; announce conferences, seminars, innovations; advocacy messages will depend on target audience; | Print and audio channels; press/briefs; seminars national conference |
Advocacy groups and civil society | Messages that require dialogue with various stakeholders | Public forum, media, website, twitter and other appropriate social media to get feedback |
Students | curriculum, recruitment and implementation, fee structure, requirements for various programs; evaluation and feedback; upcoming seminars, student exchanges, other collaborations, seminar opportunities, funding for HSR activities; awards etc | Website, approved senate curriculum, official advertisements on enrolment and graduation lists; student discussion forums on the websites; class schedules, formal examination, transcripts and certificates; thesis and published papers in journals |
Regulatory bodies such as Commission for University Education, Medical Practitioners and Dentist Board, Nursing Council, Pharmacy and Poison Board, Lab; Legal | Establishment and monitoring of standards and norms; guidelines for various programmes on certification and licensing; legal procedures and MoUs/MOAs | Site visits, share SOPs reports; documents; meetings; certificates of approval; registration of patents and innovations on the project |
Mobile phone provider | Guidelines, SOPs, information required, source; timing and target stakeholders | phone, SMS, discussion forums, alerts, help lines (hot lines); other services |
Community/ public | Relevance of project priorities; role in project implementation; project products; co-funding where appropriate; issues that require consensus; right to representation on project committees; accountability and transparency of project /governance structures | Public forums; brochures; meetings, membership to committees; progress on implementation; project products; seminars to train selected members on committees; minutes of key committees and reports on progress; |
Dissemination targets from the key objectives to cluster populations
-
Results of the baseline and endline surveys for all clusters will be provided to the respective counties (Table 3).
Name | County | Sub-County | Division | Type | Subcounty referral facility | County referral facility | |
---|---|---|---|---|---|---|---|
1 | Obekai (FLTR/EHC) | Busia | Teso South | Chakol | Dispensary | Nambalesubcounty hospital | Busia county hospital |
2 | Kabula (IGAs/CBOs) | Bungoma | Bungoma South | Bumula | Dispensary | Bungoma county hospital | Bungoma County Hospital |
Health facilities for Health systems control arm | |||||||
Name of dispensary | County | Sub-county | Division | Type | Owner | ||
1 | Nyaporo | Kakamega | Mumias | East Wanga | Dispensary | MoH, Kakamega County | |
2 | Kesses | UasinGishu | Eldoret South | Kesses | Dispensary | MoH, UasinGishu County | |
3 | Matunda | Trans Nzoia | Trans Nzoia West | Kiminini | Dispensary | MoH, Trans Nzoia County | |
4 | Nyaru | Keiyo Marakwet | Keiyo South | Chepkorio | Dispensary | MoH Keiyo Marakwet County |
-
Results of the baseline and endline surveys in the intervention cluster
-
Health facility outputs and outcomes
-
Exit survey results
-
Results of the baseline and endline surveys in the one cluster that this will be implemented
-
IGAs/CBOs established and sustained and income generated
-
Proportion of motivated volunteers and members of CHCs
-
Improved performance targets amongst volunteers comparing intervention and control clusters
-
Increase in the referrals to county facilities
-
Proportional increase in referrals
-
Pregnancy outcomes for women referred over study period compared to baseline
-
Number of trained health workers, CHWs, CHU officials, County health officers
-
Number of degree graduates trained
-
Number of certificate graduates
-
Number of guidelines developed
-
Results of the endline surveys for all clusters
-
Study outputs and outcomes
-
Lessons learnt
-
Areas for improvement
-
Areas for further research and study.
Projected and possible levels of achievements at end of the study
Starting point (baseline) | Low outcome level | Moderate outcome level | High outcome level |
---|---|---|---|
Average figures from KDHS which will be confirmed at baseline) | |||
Antenatal care attendance by pregnant women in the health facilities (currently about 46%) | 50 | 60 | 85 |
%of pregnant women completing 4 ANC visits (45%) | 50 | 70 | 90 |
Reduce the rate of low birth weight and premature babies born in the study population (LBW currently is about 4.1%) | 4.1 | 3.8 | 1.8 |
Reduce the rates of poor pregnancy among pregnant women in the study population from | |||
birth asphyxia from 25%, | 23.5 | 17.5 | 10 |
neonatal sepsis - 25%, | 23.5 | 17.5 | 10 |
neonatal mortality −35%, | 32.5 | 24.5 | 15 |
maternal mortality – 488/100,000, | 400 | 350 | 250 |
Proportion of skilled health workers trained to provide quality health care (%) | 8 | 10 | 15 |
Proportion of women satisfied with quality of services provided at primary care facilities (%) | 35 | 55 | 80 |
Increase the number of health personnel with competencies participating in health systems research and using evidence to make decisions | |||
• certificate | 5 | 10 | 30 |
• masters | 3 | 6 | 10 |
• doctoral | 1 | 2 | 3 |
Improve efficiency of the referral system between the community (tier 1), primary care facilities (tier 2) and County referral facilities (tier 3) for pregnant women in the intervention area (currently unknown) | Qualitative | ||
Accountability, transparent, participation in decision making, client satisfaction | |||
Sustained engagement of motivated CHWs, CMws making timely referrals of pregnant women and mothers with under 5 years (%) | 30 | 50 | 80 |
Proportion of timely referrals between tier 1 & 2 | |||
Proportion of established IGUs/CBOs are functional Nature of governance structures and processes, leadership and management practices as well as viability/sustainability of the established IGUs/CBOs post URCP programme | 30 | 60 | 80 |
Monitoring and evaluation strategy
Goal: | ||||||||
---|---|---|---|---|---|---|---|---|
To contribute to improvement of maternal and child health in Kenya through health system strengthening initiatives at community and primary care levels | ||||||||
Objective 1:Conduct a baseline survey on maternal and child health interventions to improve access and quality of care at tiers 1 and 2 in select counties | ||||||||
Activities/inputs | Output/Deliverables | Means of verification | Objectively Verifiable Indicators | Timelines | ||||
2015 | 2016 | 2017 | 2018 | 2019 | ||||
Review and develop tools | Reviewed tools Develop tools | Survey tools | # tools | |||||
Recruit survey team | Survey team in place | Advertisements, Interviews | letters of appointments | |||||
Train survey team and pilot tools | Trained RAs | Logistics Venue | # trainings, # staffs trained | |||||
Prepare for Community entry | Logistics and costs Set dates for entry | Sensitized community | # meetings with the community and county | |||||
Conduct the survey | Survey instruments | Baseline data | # field tools | |||||
Develop data entry template | Software | Ready template | Templates for qualitative & Quantitative data | |||||
Data entry and interpretation | Data clerks Software | Entered data | Data in template | |||||
Analyze and write report | Draft report | Findings/Report | # Reports | |||||
Disseminate the findings | Write ups | Reports | # dissemination meetings # media appearances # policy briefs | |||||
Objective 2:Adapt and implement the EHC package using the FLTR strategy to improve access and quality of care of maternal and child health at level 1 (community) and level 2 (primary care facilities) in the intervention cluster, | ||||||||
1. Identification CORPs-Domiciliary nurses and CHVs in specified counties | Write ups | MOUs Contract letters | #CORPs | |||||
2. Training | Curriculum | Pre & post assessment | #trainings #staffs trained | |||||
3. Review HMIS forms | Forms | Types of forms | #forms reviewed | |||||
4. Prepare the community for intervention | Minutes/ reports | #sensitization meetings Budgets | ||||||
5. Roll out the intervention | Intervention in place | HF records, endline evaluation | changes key indicators | |||||
Objective 3: To explore and facilitate partnerships for innovative approaches (IGAs and Chama) to incentivize CORPs (Community owned resource persons - volunteers), CHWs and Community Midwives (CMWs) to effectively participate in increasing access and retention of pregnant women and children in the intervention cluster. | ||||||||
6. Review documents and identify potential partners | Functional CBOs, Chamas, SACCO | Agreements/ MOUs | #partners #MOUs #Meetings with partners | |||||
6.Develop advocacy communication and social mobilization strategy for the programme | sensitized community, policy makers, healthworkers | Meetings Minutes Reports Documents | #meetings #media appearances #ACSM strategy | |||||
7. Create partnerships | private sector engaged | Minutes MOUs | #CORPs engaged #Task shifting- CORPs as birth a | |||||
8. Review documents and identify potential partners | sustainable partnerships | Agreements/MOUs | #partners #MOUs #Meetings with partners | |||||
Objective 4: To assess the effectiveness and sustainability of the implementation of FLTR and EHC in the improvement of the efficiency of the referral system between the community (level 1), primary care facilities (level 2) and County referral facilities (level 3) for pregnant women in the intervention area | ||||||||
Activities | Output | Means of verification | Objectively Verifiable Indicators | Timelines | ||||
2015 | 2016 | 2017 | 2018 | 2019 | ||||
Develop advocacy communication and social mobilization strategy for the programme | sensitized stakeholders | Meetings Minutes Reports Documents | #meetings #media appearances #ACSM strategy | |||||
Provide Mobile telephony to CORPs | quality data collected & used | Numbers Timely referrals Usage | #mobile phones provided | |||||
Conduct a customer satisfaction survey and use lessons learnt to improve service | satisfied pregnant women & mothers | Report Survey Tools | Report #recommendations Improvement in quality | |||||
Determine numbers of still births | reduced no. still births | Numbers | #still births | |||||
Objective 5: To build capacity of health workers to conduct health systems research and inculcate a culture of use of evidence to strengthen the performance of health systems through on-job training, in-service certificate and degree programmes | ||||||||
Recruit program staff and monitor their performance | SHWs | Appointment letters Reports | #staffs recruited Improved service | |||||
Develop short courses and enhance capacities in leadership, governance and management of systems | HSR, LMG skills | Curriculum Trainings | #Curriculum #Trainings | |||||
Admit 4 masters’ students into the program and assist them choose topics relevant to the program, determine gaps and propose interventions | graduates, thesis and publications | Graduates Titles of study | #graduate students admitted Progression rates #intervention gaps Policy influence Abstracts Manuscripts Conference appearances | |||||
Admit 2 PhD candidates within the 5 year period and involve them in identifying research problem and designing interventions | admissions graduates thesis articles | Candidates Titles of study | #candidates admitted Progression rates #intervention gaps Policy influence Abstracts Manuscripts Conference appearances | |||||
Sensitize CORPs on safe motherhood | sensitizes CORPs | Sensitization sessions Numbers Reports | #trainings Change in knowledge & attitudes | |||||
Training on indications for referral of pregnant mothers and sick child | KSP for CHWs & CORPs | enhanced Curriculum | #CORPs trained #health talks | |||||
Objective 6:Conductendline survey/evaluation on levels of maternal and child health indicators, status of health system and existing programs in the study areas at the end of the project in all the study clusters. | ||||||||
Review baseline tools to include indicators on program relevance and effectiveness | revised tools | hard copies | # of tools | |||||
Recruit and train RAs | trained RAs, tools | survey teams | minutes, letters, list | |||||
Collect data | completed tools | field schedule | letters of release and payment schedule | |||||
Analyze and interpret data | tables, results | hard copies | outputs and verification forms | |||||
Write evaluation report documenting findings; project report (overall) | reports | draft reports | submission of drafts, feedback, meeting with stakeholders | |||||
Disseminate findings to appropriate audience and partners | report briefs | minutes, emails, feedback | letters/emails submission, final feedback |
Ethical considerations
Consent process
Declaration
Project timelines
Project activities | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 |
---|---|---|---|---|---|
Planning meetings with project partners
| |||||
IREC Proposal approval
| |||||
Implementation planning meetings by study team
| |||||
Implementation planning meeting with stakeholders (MOH, County Health teams, NACOSTI, IDRC etc)
| |||||
Community entry
| |||||
Piloting study instruments
| |||||
Start of study proper – intervention
| |||||
Monitoring
| |||||
Data collection control clusters
| |||||
Data collection intervention clusters
| |||||
Data entry
| |||||
Data cleaning
| |||||
Data analysis
| |||||
Training of masters and doctoral degree students
| |||||
Training of CORPs & CHEWs
| |||||
Final report writing and study closure
|