Management of sick young infants with PSBI where referral is not feasible in Kenya:

Using Implementation Research to guide programming in Kenya

Presentation made during the CoP Webinar 25th September 2019

Wilson Liambila1, Timothy Abuya1, Jesse Gitaka2, Fred Were3, Keziah K’Oduol3, Charity Ndwiga1, George Odwe1, Samuel Mungai2, Alice Natecho2, Peter Mwaura2, Jackline Nyaberi2 and Charlotte Warren1

1=Population Council; 2 = Mount Kenya University; 3=Kenya Paediatric Research Consortium

IntroductionKenya NNM rate is 22/1000 live births. Sepsis causes 20% deaths. Supportive policies and strategies exist to reduce NNM (12/1,000), IMR (20/1,000) and Under-5 MR (25/1,000)/live births by 2030.

Ponya Mtoto: project goal, sites and partnerships

Goal To contribute to reductions in young infant deaths Sites: Bungoma, Turkana, Mombasa and Kilifi countiesPartnership:

• Population Council • KEPRECON• Mount Kenya University (MKU)

Implementation• MOH HQs (NCAHU)• County HMT & sub County HMTs• Health Facility Management

Teams• Implementing partners in MNH

Using Implementation Research (IR) to guide programming

Governance & Organization

Human resourceCosting & financing

Supply chain management

Supervision & M&E

Service delivery

SYIs, family & community

“ The basic intent of IR is to understand not only what is and isn’t working, but how and why implementation is going right or wrong, and testing approaches to improve it.” Peters D.H. et al 2013

IR aims to identify:- Service delivery and

programmatic barriers that prevent SYIs with PSBI from accessing care

- Appropriate solutions in partnership with the local teams

Elements of learning to guide programming

• Formative assessment to• Understand context• Facilitate health systems

strengthening• Inform implementation process • Assess performance &

outcomes • Six monthly Assessments (Initial

plan)

• Quarterly monitoring process & occasional site visits/call in

• Kenya Community of Practice (CoP)

Using IR data to guide programming: Supply side

Key supply side gaps Strategies to improve gaps

Inadequacies in provider knowledge and skills in IMNCI/PSBI

-Working with county teams to induct primary care providers on IMNCI/PSBI

-Make available simplified provider job aids to support management of SYIs

Inadequate monitoring and support supervision Using technical briefs for:

-Advocacy at county and sub county level to functionalize support supervision

-Quarterly monitoring

-Developing dashboard to encourage use of data for action (Kenya-CoP)

Sub-optimal functionality of quality improvement teams

Frequent stockouts of antibiotics & other supplies

Poor governance and coordination structures

Using IR data to guide programming: Demand side Key demand gaps Strategies to improve gapsCaregivers associate illness with cultural practices, myths and misconceptions

Developed job aids and pamphlets to:-Dispel myths -Reinforce positive behaviors on care-seeking

-Support danger sign recognition Inadequate knowledge and skills to recognize danger signs among CHVs and caregivers

Caregivers decline referral for a variety of reasons delaying prompt care seeking for SYIs

-Identify opportunities for educating caregivers on need for referral- Link with QA efforts- Provide simplified antibiotic treatment PSBI when referral is not feasible

Inadequate follow up of SYIs by CHVs due to weak community-facility linkages

-Adapt existing MOH check list for improving danger sign recognition by CHV-Advocate for improved community-facility linkages including referral -Develop a follow-up tool to link with existing community tools

Supply side tools to support providers PSBI Management Flowchart To assist providers (assess, classify and treat

SYIs or recommend referral) Iterative process of pre-testing cycles with

providers at different levels of care Placed in consultation rooms for providers to

refer

Provider pamphlet contextualizes facts on: What providers should know about

communities’ understanding of SYI Information to dispel myths and

misconceptions on causes of illnesses and to educate the community to influence care seeking behavior for the SYI

Distributed to facilities and used by providers to counsel caregivers

Supply side tools to support providers and managers

PSBI/IMNCI assessment/ follow up tool: Provides basic demographics on infant &

caregiver Symptoms, classification & treatment given; Details of action taken during follow up-Adapted from existing IMNCI forms -Distributed and inducted PHC providers

Technical briefs to guide advocacy in: Resource allocation for support supervision Functionality of quality improvement teams Management of stocks of supplies Improve on coordination and governance

Caregiver pamphlet to support caregivers and CHVs• Provides information on what needs to be known about

SYI aged 0-2 months: Signs that tell caregivers a young infant has a serious

illness Provides common reasons why young infants fall sick Outlines situations which could worsen the condition

of the SYI Helps to demystify misconceptions, cultural beliefs as

causes of illness• Provides guidance on how to keep young infants healthy: Developed from formative data and pre-tested via a

series of caregiver engagements Translated into Swahili and Turkana Distributed through facility & community units Monitoring its utility through site visits and planned

qualitative case studies

PART II: Monitoring IMNCI/PSBI in early implementation sites: Processes and Learnings

Timothy Abuya1, Wilson Liambila1, Jesse Gitaka2, Fred Were3, Keziah K’Oduol3, Charity Ndwiga1, George Odwe1, Samuel Mungai2, Alice Natecho2, Peter Mwaura2, Jackline Nyaberi2 and Charlotte Warren1

1=Population Council; 2 = Mount Kenya University; 3=Kenya Paediatric Research Consortium

Recognition of changes & adaptations of Theory of Change

Elements of learning to guide programming

• Formative assessment to• Understand context• Facilitate health systems

strengthening• Inform implementation process • Assess performance & outcomes

• Six monthly Assessments (Initial plan)

• Quarterly monitoring process & occasional site visits/call in

• Kenya Community of Practice (CoP)

Process of setting up monitoring system

Feedback mechanism

through interactive

dashboard & Quarterly meetings

Iterative process of developing

monitoring tools

Review of Existing newborn

indicators-registers and other sources

On going monitoring process & development of Kenyan COP platform

Examples of indicators being tracked Indicator Definition

# of facilities using IMNCI/PSBI guidelines to treat SYIs

Availability of any of the following guidelines in consultation areas and reported use by providers -IMNCI booklet, PSBI flow chart /newborn care handbook

# of facilities correctlyassessing, classifying and treating SYIs appropriately

Facilities with records that show how they identified the symptoms, classified and treated with recommended antibiotics

# of facilities with functionalQITs

Facilities where staff members/management committees actively participate in QIT activities or generate ideas for better management of SYI

# of SYI treated for any illness Number of SYI treated in the health facility

# of SYIs identified & treatedwith: SYI identified, classified as having any of the

categories and treated with recommended antibiotics

Pneumonia Severe pneumonia/ illness Critical illness

Examples of indicators being trackedIndicator Definition # of SYI treated with PSBI returning for follow up on day 4

Cases of SYI brought back in day 4 for assessment at the PHC

# of SYI treated with PSBI who return for follow-up on day 8

Cases of SYI brought back in day 8 for assessment at the PHC

Average # of days facilities had stock out of: Reported stock out days for each

type of antibiotics over a period of assessment

Oral amoxicillin Ampicillin Gentamycin Benzyl penicillin

# of infants referred by CHVs from the community

Any form of referral for SYI conducted by a CHV over the assessment period (asked to go to facility for treatment)

1135

2047

1425

2196

0

500

1000

1500

2000

2500

Bungoma Kilifi Mombasa Turkana

Num

ber o

f sic

k yo

ung

infa

nts

County

# of sick young infants per county

1581

2747

2475

0

500

1000

1500

2000

2500

3000

Dispensary Health center Hospital

Num

ber o

f sic

k yo

ung

infa

nts

Facility type

# of Sick young infants per facility type

Number of SYI treated (Q4 2018- Q2 2019)

Data from 48 facilities 12, hospitals, 18 health centers & 18 dispensaries

0

200

400

600

800

1000

1200

1400

Q4 2018 Q1 2019 Q2 2019

Num

ber o

f SYI

Quater

# of SYI per quarter by facility type

Dispensary

Health center

Hospital

0

200

400

600

800

1000

1200

1400

1600

1800

Q4 2018 Q1 2019 Q2 2019

Num

ber o

f SYI

Quater

# of SYI in each county by quarter

Bungoma

Kilifi

Mombasa

Turkana

Number of SYI treated by Quarter

0.1

0.0

0.3

0.9

0.7

0.6

1.0 1.

1

0.8

0.7

0.7

0.6

0.0

0.2

0.4

0.6

0.8

1.0

1.2

Dispensary Healthcenter

HospitalAv

erag

e nu

mbe

r of d

ays

Facility type

Average # of days without essential antibiotics

Bungoma

Kilifi

Mombasa

Turkana

19.0

8.8

19.1

1.6

0.0

5.0

10.0

15.0

20.0

25.0

Bungoma Kilifi Mombasa Turkana

Aver

age

num

ber o

f day

s

County

Average # of days without essential antibiotics

Stock outs of essential antibiotics for managing SYI

Cumulative average # of days with reported stock outs between Q4 2018-Q2 2019

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Q4 2018 Q1 2019 Q2 2019

Num

ber o

f day

s

Quarter

# of days without essential antibiotics by facility type by

quarter

Dispensary

Health center

Hospital

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Q1 2019 Q2 2019 Q4 2018

Num

ber o

f day

s

Quarter

# of days without essential antibiotics in each county by

quarter

Bungoma

Kilifi

Mombasa

Turkana

Stock outs of essential antibiotics for managing SYI

Key challenges from the monitoring process

• Capacity building gaps on IMNCI among frontline staff• Few providers inducted on IMNCI • Inducted providers move for further studies, other departments,

leave, etc• Few providers working in PHC, increasing workload

• Inadequate documentation of SYI treated and use of follow-up forms

• Poor and incomplete filling of forms/registers • Workload, staffing, motivation are key drivers for not documenting

• Essential medicines for SYI:• Erratic supplies of essential medicines affects service provision

Examples of challenges and solutions

Key challenges Suggested solutions

Stock-out of drugs andother essentialcommodities

-Timely stock ordering & follow-up-Partner support-WhatsApp groups to report shortages andredistribute drugs

Loss of follow ups on clients with SYI treated with PSBI

-Attach clients to CHVs-Enhance health talks for mothers when inthe waiting bays-Incentives for CHVs (some counties)

Inadequate staffimpacting adequatedocumentation

-Propose counties to deploy more providers

-Appoint focal person for PSBI to support implementation

Inadequate training on SYI/PSBI/IMNCI for Outpatient staff

Train staff through CMEs and other platformssuch as workshops

Key components of local Community of Practice

Data and feedback

Online capacity building process

Peer learning &

engagement

Advocacy for improving

IMNCI

Improved capacity of providers to manage SYIs

Changes and Adaptations of Theory of Change

Next Steps

• Establish Kenya CoP as platform for:• Capacity building (participate in distance learning modules

mounted by professional bodies• Peer learning to share experiences • Data review and feedback• Advocacy for IMNCI/PSBI

• Track utilization of job aids and their effect on management of SYI

• Incorporate feedback from CHMTs/SCMTs/HF teams into job aids for providers, caregivers

• Feedback from Technical advisory group

• Develop research papers from the formative phase

The Ponya Mtoto project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of USAID AID-OOA-A-17-00031. The contents of this presentation are the sole responsibility of the Ponya Mtoto project and the Population Council and do not necessarily reflect the views of USAID or the United States Government.

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