Making it Happen (MiH) programme Maternal and Neonatal Health Human Resource Capacity Building Good morning everyone….thank you Mr Chairman for those kind words of introduction and warm well come. My name is Charles Ameh clinical lecturer, Obstetrician, public health specialist, deputy Head of CMNH LSTM, a WHO collaboration centre for research in maternal and newborn health with various research activities in 11 countries in Asia and sub-Saharan Africa I thank the organisers of this meeting for the opportunity to talk about our work in Kenya. I hope to share the experience of CMNH supporting MoH of Kenya to build the capacity of skilled health care workers to provide better quality of care for women and their newborns over the last 8 years It’s a pleasure to be back in Kenya, supporting the great work of colleagues at the MoH and department of health at the counties Charles A Ameh MB.BS, MPH, DRH, FWACS (OBGYN) Deputy Head, Centre for Maternal and Newborn Health

Presentation outline Introduction CMNH MNH interventions LSTM in Kenya Challenges Opportunities As we move from promises to action, I hope that at the end of this presentation that I will have described a background to our work in Kenya, our experience supporting MoH at various levels, key challenges and opportunities to accelarate progress Today is all about how, rather than does it work, so I will keep stats to a minimum

Background 98.7% of maternal deaths occur in 15 counties Only 50% of government own hospitals have ANC, normal delivery and C/S services (n=690) 80% have EmoC drugs Newborn respiratory support available in 72% Assisted vaginal delivery available in only 13% Brief recap of relevant stats from yesterday Insert differential graph or picture of MMR in Kenya 7% of sample hospitals UNFPA 2014, KDHS 2008/9, KSPA 2010

Background Low EmOC knowledge N=881 (PPH=7%, Obstructed labour= 5% ) <20%of health care workers be trained in EmONC

Determinants of maternal morbidity and mortality We were reminded by various speakers yesterday that there are several determinants of maternal health and they interact at various levels to affect the outcomes. So we need multidimentional approach to improving maternal health LSTM intervenes at phase 3 and trys to coordinate with other stakeholders/partners working to prevent phase 1 and 2 delays via MoH fora Thaddeus and Maine 1994

Key CMNH interventions EmONC training TOT Training equipment Facility improvement fund equipment CD/quality assurance training EmONC training Package Quality improvement workshops MPDSR Standard based audits Quality improvement package Making it Happen with Data workshops Monitoring and evaluation +supervision Monitoring and evaluation Effect of EmONC training and QI training on SBR, CFR, EOC Signal functions, deliveries Knowledge and skills retention study Operational research

EmONC training “Great emphasis on acquiring skills through repetition and in hands-on practice” Based on the ‘Behaviorist approach’ to learning Learners are rich resources CBT uses a problem rather than a subject centered approach Adult learning is collaborative Uses experiential techniques of inquiry (Knowles 1978)

Trained trainers and Course Directors Quality assured process, multidisciplinary, aim to get 10 trainers per county, 8 trainers and 1 Course Director required per course, database maintained of certified trainers by RMHS unit and LSTM

Training Equipment/Mannequins Airway Management Trainer Uterine Pelvic Model (Boney Pelvis) Obstetric Phantom & Fetal Doll Cost One Full Set of Equipment - £18,500 ≈ Kshs. 2,692,675 Lucy & Lucy’s Mum - £3,000 ≈ Kshs. 436,650 Obstetric Phantom - £700 ≈ Kshs. 101,885 Venous Cut Down Pad - £60 ≈ Kshs. 8,733 Logistics Items not always available locally Replacement Mannequins from the UK Value No other training equipment at facility/venue Large numbers of participants trained Lucy & Lucy’s Mum,

Facility improvement fund equipment

Making it Happen with Data workshop One day workshop To increase the awareness of good quality data collected in facilities To improve the skills of health care providers to manage and use the data collected So that is a bit about LSTM, what have we done in Kenya so far

LSTM in Kenya MiH II 2012-15 Western Central EHS 07-10 Nyanza MiH I 09-11 10 Level 5 HCF Kenya Harmonized curriculum 2012 MiH II 2012-15 Western Central Competency based training in Kenya since 2007 DFID funded HSS programme, limited to six districts in Nyanza province, Introduced EmONC Training, equipment, SS, Support to MDR

Essential Health Services Kenya DFID funded HSS programme, limited to six districts in Nyanza province, Introduced short competency based EmONC training programme EmONC training equipment, Supported MOH to analyze national maternal death reviews Based on this success of the short EmONC training package, it was to be scaled up and evaluated at level 5 hospitals nationwide

LSTM in Kenya MiH II 2012-15 Western Central EHS 07-10 Nyanza MiH I 09-11 10 Level 5 HCF Kenya Harmonized curriculum 2012 MiH II 2012-15 Western Central Competency based training in Kenya since 2007 DFID funded HSS programme, limited to six districts in Nyanza province, Training, equipment, SS, Support to MDR

MiH programme Goal: Reduce Maternal and Child mortality Objective: To improve the availability and quality of Emergency Obstetric Care and Newborn Care Multi-country MiH: Maternal and Neonatal Health Human Resource Capacity Building Aim: The Making it Happen programme, funded through DFID, contributes to a reduction in maternal and newborn mortality and morbidity (MDG4 and MDG5) by increasing the availability and improving the quality of Essential (Emergency) Obstetric and Newborn Care (EOC&NC).

‘Making it Happen’ programme Introduced and evaluated simultaneously in Kenya and 5 other countries from 2009 (countries in red) and from 2012 six other countries were added all in SSA and Sasia. This is achieved by delivering a country adapted competency based training package to improve healthcare providers’ capacity to deliver EOC and early NC.

University of Zimbabwe Making it Happen delivered in partnership with: FMOH Nigeria HMB FCT Abuja Nigeria University of Zimbabwe Funds for implementation are largely from UK Aid, UNICEF and UNFPA Acknowledgement and implemented through the RH/MNH programmes of the various National governments, UN agencies, research institutions and professional medical associations in these countries With funds gratefully received from

MiH outputs Output 1: Increased health service provider capacity to provide Emergency Obstetric and Newborn Care (EmONC) Output 2: Increased availability of EmONC for mothers and babies Output 3: Strengthened accountability for results with increased transparency Output 4: Strengthened capacity to sustain improvements in maternal and newborn health service delivery Output 5: Evidence generated by programme disseminated in order to inform national, regional and global agenda MIH implemented in country x from 2012 to 2015 has 5 outputs

MiH Phase 1: 2009-2011 All 8 provinces 10 level 5 CEmOC hospitals EmONC training Master trainers and training equipment Supportive supervisors Monitoring and evaluation So back to Kenya 5 sets of training equipment, distributed to 10 intervention sites, used for primary training and retraining by trained supervisors and Master trainers within those institutions. Capacity of MoH in terms of supervision was strenghtened

Lessons learnt from MiH phase 1 Optimal training impact: Critical numbers need to be trained Local supervision capacity critical EmOC equipment provision in sync with training Pre-service training input required Health system challenges Poor coordination of in-service EmOC training Poor quality of HCF records Weak maternal death review system These formed the basis for design of phase 2 Based on the results from phase 1, there was enough evidence and momentum to revised the national uorriculum, and harmonise the various EmOC training packages

LSTM in Kenya EHS 07-10 Nyanza 10 Level 5 HCF MiH I 09-11 10 Level 5 HCF Kenya Harmonized curriculum 2012 MiH II 2012-15 Western Central But harmonisation of all EmONC training programmes in the country had to be achieved, improving coordination, developing training standards and monitoring these standards

National EmONC training Curriculum The EmONC curriculum was launched in 2012 Standards for EmONC training Mentorship package LSTM supported MoH to formally adapt the LSTM EmOC training package, the national curriculum was published in 2012, other training materials have been adapted similarly from the LSTM materials with some input from other existing materials. LSTM has supported MoH to draft standards for running such training based on her extensive experience in internationally and in Kenya FHI WHO Jiepigo/MCIP

LSTM in Kenya EHS 07-10 Nyanza 10 Level 5 HCF MiH I 09-11 10 Level 5 HCF Kenya Harmonized curriculum 2012 MiH II 2012-15 Western Central Competency based training in Kenya since 2007 DFID funded HSS programme, limited to six districts in Nyanza province, Training, equipment, SS, Support to MDR

15 Counties 3 Provinces Level 3-5 HCFs MiH phase 2: 2012-15 15 Counties 3 Provinces Level 3-5 HCFs Counties located in 3 former provinces were selected for support of MiH by DFH MOPHS

MiH phase 2: Key challenges so far Poor coordination of MNH partners Low standards of trainings among MNH implementing partners Poor maintenance of EmOC training equipment Lack of investment in EmOC training equipment and TOT pool Obtaining permission for training from MoH in timely manner Poor retention of trained maternity care workers post training However key challenges encountered are….

Coordination and mapping Who, what, where? 11 organisation providing EmoNC trainings 3 providing country wide coverage Most Nairobi & Rift Valley (6) Least in Eastern/Coast counties (1) Follow up with partners, to update and share information regularly

Key achievements in phase 2 Database of Master trainers created for MoH and counties CMNH provides technical advice to other EmONC implementation partners Sharing training equipment Supports MoH to map and coordinate EmONC training partners Identify input for support to pre-service training PS Kenya DANIDA SC AMREF World bank ICAP Christian Aid Funzo Kenya Universities UoN and Musindo Muliro University FH/Options Kenya

DFID MNH programme (2014-2018) Management oversight role LSTM EmONC training National scale up UNICEF HSS Bungoma, Turkana, Homabay Kakamega, Garissa, Nairobi Coordination role TBD SP Innovations fund Bungoma county Management oversight role

MiH national expansion phase: 2014-18 All 47 counties in Kenya Support to National level MPDSR/QI coordination Support programme M&E Support pre-service EmONC training Office expansion consistent with scale up. By region: all the 5 additional regions in Phased approach Commences 1 Region Q1 2014 (Nairobi) Three additional Regions in Q2 ( NE/RV/Coast ) 1 Region in Q 3 (Eastern) Q3 2014: All regions active.

DFID MNH Programme coordination Steering group Implementation working group

Coordination: County input DFID Kenya MNH SP LSTM UNICEF SP Innovation fund County Health forums CHMTs MoH TWG RH/MNH HRH/RH ICC Implementing so far started from 15 counties and good welcome, support and engagement with counties so far

MiH national scale up phase: Challenges so far Training quality Poor selection of trainees Training impact Poor staff retention after training Lack of EmOC equipment post training Training cost Security concerns Lack of investment in training equipment and Master trainers Training venues

Summary Multi-dimensional approach to improving maternal health needed Quality of care determines 3rd delay Knowledge and skills of SBA in EmOC is poor Both pre and in-service interventions required Structures for sustained in-service training system set up at county levels

Recommendations for action and sustainability National policy to consolidate and sustain intervention Designated accredited training centres Compulsory periodic training in EmOC-with shared responsibility Annual practice license linked to appropriate CPD training Modified staff rotation policy to ensure staff retention post training

Action for counties for accelerated impact Support/provide venues for training Proper staff selection for EmONC trainings Support and synchronize delivery of EmOC equipment with training Improved coordination of EmOC training partners Storage and maintenance of training equipment Advocate with relevant bodies for policies to sustain interventions

Acknowledgements Division of family health Reproductive and Maternal Health Services Unit County RH coordinators County Directors of Health DFID, UNICEF LSTM Kenya and Liverpool Teams

Asante sana! www.mnhu.org charles.ameh@lstmed.ac.uk Thank you

Additional slides: Scaling up targets 2012-2015 2014-2018 Regions 3 + 5 EOC training sites 6 + 41 (37 additional sets) EOC 3500 (6200) 5504 (7520) TOT 180 CD 40 + 128 MiH data 166 + 480 QI Baseline surveys 4 10