EmONC Scale-up In Kenya Results of Health Facility Assessments EmONC Toolkit Appendix 12 EmONC Scale-up In Kenya Results of Health Facility Assessments February 2017

Activity Objective To increase the proportion of sampled facilities with capacity to offer all the signal functions for basic emergency obstetric and newborn care (BEmONC) to at least 50% from baseline

EmONC Signal Functions BEmONC 1 Administer parenteral antibiotics 2 Administer uterotonic drugs 3 Administer parenteral anticonvulsants 4 Perform manual removal of the placenta 5 Remove retained products of conception 6 Perform assisted vaginal delivery 7 Perform basic neonatal resuscitation CEmONC: All seven BEmONC signal functions plus 8 Perform Caesarean delivery 9 Provide blood transfusion

Scale-Up Coverage Areas 17 counties selected based on mortality burden and geographical spread

Counties Targeted for EmONC Scale-Up Muranga Busia Tharaka Nithi Nyamira Meru Nairobi Kitui Mombasa Samburu Kilifi Wajir Turkana Mandera Kakamega Baringo Narok Trans Nzoia

Number of Facilities Surveyed by County (Available data as of August 2016) County Tier 2 Tier 3 /4 Total Baringo 15 5 20 Busia 36 4 40 Kitui 32 9 41 Mandera 27 6 33 Meru 28 55 Muranga 3 Narok 10 13 Nyamira 26 Samburu 18 Tharaka Nithi 7 Trans Nzoia 23 8 31 Wajir 17 142 63 335

Conceptual Framework High-quality data for decision making Make equipment available IV Provide monitoring, supervision and feedback Improved process of care (service delivery) Improved outcomes (reduced morbidity and mortality) II Make guidelines and job aids available III Provide training for health workers High-quality data for decision making

Results of Wave II Facility Assessments

Availability of Guidelines Guidelines & Job Aids Surveyors were asked to confirm the availability of the National Guidelines for Quality Obstetric and Perinatal Care by visual inspection Availability varied from 20% to 100% with better general performance in hospitals than in health centres/dispensaries

Availability of Guidelines Guidelines & Job Aids

Staff Training on BeMONC Train Health workers The proportion of staff trained on BEmONC is generally low in all counties except Murang’a. No health workers have been trained on BEmONC in hospitals surveyed in Narok County.

Staff Trained on BEmONC Train Health workers (in Preceding 12 months) OVERALL % BAR 28% BUS 37% KIT 19% MAN 27% MER 11% MUR 67% NAR 4% NYA 35% SAM 34% THA 13% TRA 14% WAJ 21%

Availability of Equipment/Drugs Available Equipment Health facilities were assessed for the availability of key drugs and equipment required to provide the seven signal functions of BEmONC Surveyors were required to record the availability of various items after visual confirmation

Signal Function 1: Availability of Parenteral Antibiotics Average performance in hospitals Generally poor performance in health centres/ dispensaries Complete absence of broad-spectrum antibiotics across Tier 2 facilities in Muranga and Narok counties

Signal Function 2: Availability of Oxytocin Oxytocin generally widely available across surveyed facilities Data missing for a few facilities in Baringo and Meru

Signal Function 3: Availability of Anticonvulsants Magnesium sulphate generally widely available across hospitals Tier 2 facilities showed average performance

Signal Function 4: Manual Removal of Placenta (MRP) Elbow-length sterile gloves are recommended for manual removal of the placenta. These gloves were not available in many lower level (Tier 2) facilities.

Signal Function 5: Removal of Retained Products of Conception Hospitals performed better than Tier 2 facilities Data missing for some facilities in Meru and Busia counties

Signal Function 6: Assisted Vaginal Delivery Good performance for Baringo, Kitui, Muranga, and Trans Nzoia counties Tier 2 facilities across all regions performed below 50%

Signal Function 7: Newborn Resuscitation Neonatal BVM device generally widely available at both Tier 2 and hospital levels Tier 2 facilities in several counties performing below 75%

Conclusions A multipronged approach is required to achieve the overall objective, targeting availability and use of guidelines/job aids and training to use them and also availability of appropriate, functional equipment and consumables. Training needs require urgent attention. High-quality, timely data allow for rapid and appropriate action planning.

Next Steps Finalize data analysis and develop facility/county profiles. Convene county teams for action planning. Incorporate quality improvement in work plans and implementation. Implement these steps. Evaluate performance over time: Only possible for facilities included in successive surveys Refine tools based on continuous feedback.

MEASURE Evaluation PIMA is funded by the U. S MEASURE Evaluation PIMA is funded by the U. S. Agency for International Development (USAID) through associate award AID-623-LA-12-00001 and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership with ICF International; Management Sciences for Health; Palladium; and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States government. www.measureevaluation.org/pima