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Can health service devolution strengthen accountability?

Nurses check expectant mother in Kisumu clinic

Western Kenya’s quest for a culture of constructive criticism in healthcare

In the face of alarming numbers of maternal death, everyday corruption and too many unsatisfied service users, Kisumu’s health minister decided that it was time for comprehensive changes. With German support, she has begun to introduce a culture of accountability – and her determination is having surprising effects.

For Christians throughout the world, Christmas is of course a time of celebrating the birth of Jesus Christ. But whatever their faith, the 30 or so mothers in Western Kenya who were in labour at Kisumu’s main hospital last Christmas, with only two overstretched nurses on duty to look after them, will have felt as unwelcome and uncared for as Mary when the innkeeper sent her to the stable.

57 unnecessary maternal deaths

At least 57 women died while giving birth in hospitals in Kisumu last year, most of them unnecessarily from preventable conditions, according to a report released by Deputy Governor Ruth Odinga, who said giving birth was often a “nightmare” for many women in the county. She urged health practitioners to break their silence on maternal mortality, and to ensure that when deaths occur, timely reporting and review procedures are followed so that problems can be identified and corrective measures be put in place (Daily Nation, 31st May 2016).

Commissioned by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH supported the local health authorities in organising a four-day training for medical staff from Kisumu County to help improve the audit, review and reporting of maternal and perinatal mortality in health facilities, and to conduct clinical refresher courses addressing the main courses of maternal mortality. This has been just a small part of the county’s far-reaching collaboration with German Development Cooperation in the health sector aimed at strengthening accountability and a culture of constructive criticism in Western Kenya’s health service.

A culture of Kitu Kidogo – a ‘little something’

According to Dr Elizabeth Ogaja, the County Minister for Health, the devolution in health care service provision, instituted in 2010 under the new Constitution, has empowered the County Government to address specific local needs and gaps, for example in drug procurement, by addressing supply management systems in the County’s pharmacies. Beyond such specific problems, the devolution also highlighted the need to improve monitoring and reporting procedures so that anomalies in the governance and management of health services, and misuse or misappropriation of scarce resources, can effectively be addressed.

According to Transparency International’s corruption index, Kenya now ranks 139th out of 168 countries, well below its East African neighbours. Corruption is a key constraint not only to greater growth and prosperity, but also to effective service delivery in health and other sectors. The Kenya Anti-Corruption Commission says that corruption undermines government efforts in realizing its vision of providing equitable and affordable health care to all Kenyans and it compromises the quality, effectiveness and equity of the health care system. This corruption ranges from “kitu kidogo” (“a little something”) to get a service provided or a document stamped, to large-scale corruption involving , for example, fictitious companies being paid for non-existent contracts or public purchases made at greatly inflated prices.

A County Taskforce to enhance accountability

In January 2016, the County Government of Kisumu with support of the Kenyan-German Good Governance and Health Sector Programmes established a Taskforce aimed at enhancing accountability and good governance in the Health Sector in Kisumu County. The Taskforce, comprised of 20 or so senior members of County’s Department of Health and health service providers, focuses on leadership and integrity to enhance accountability in the utilization of public resources within the health sector and supports Kisumu County in its efforts to provide the highest attainable standards of health.

Dr. Elizabeth Ogaja and GIZ counterpart Dr Heide Richter-Arijoki
Dr. Elizabeth Ogaja and GIZ counterpart Dr Heide Richter-Arijoki

The Taskforce received a BMZ grant of 50,000 Euros to assist with improved auditing and procurement, financial reporting, preventing corruption and ensuring the health service providers adhere to delivery protocols and are more responsive to public concerns, complaints management and so on. Kisumu’s County Government has also strengthened its governance and management systems by adopting a performance contracting system to ensure greater accountability in health-care service provision.

The German support has been “critical” throughout, says Dr Ogaja, especially in helping the taskforce members to draw up guidelines and a new monitoring and evaluation framework, which has enabled local managers to identify and address problems, sometimes even before they come before the taskforce monthly meetings. When local solutions cannot be found, an important aspect of the collaboration has been to facilitate effective access to the national Ombudsman, says Dr Dickens Onyango, the Kisumu County Director of Health.

Strengthening financial management

Given the variety of partner funding and accounting mechanisms employed, one of the key problems identified by the Taskforce was the need for strengthened financial management at local level, and establish a unified reporting system to enable effective oversight. The Kenyan-German programme has assisted with strengthening finance administrative units and capacity building of staff and Dr Ogaja says that what she calls “this German efficiency” has made a big difference.

New Service Charters for hospitals

The programme also supported eight Kisumu county hospitals to update and implement new, standardised service charters that explicitly state what a hospital should be delivering to its patients. With GIZ support, this involved conducting an review of the existing service charters and all the gaps and inconsistencies that existed. This was conducted through an observational survey of the eight hospitals as well as interviews with staff and local community representatives to identify gaps in awareness on any national or county level policies and legal framework relating to service provision charter and on the reporting and feedback processes these entail.

Kisumu County Hospital’s old service charter
Kisumu County Hospital’s old service charter

Revised service charters and standards of operations guidelines were then drawn up on the basis of the survey evidence, and from the beginning of 2017, all eight hospitals will be required to display the charters in a prominent place in the hospital.

Patient Satisfaction Surveys were also conducted throughout the county’s hospitals in March 2016 to assess patients’ awareness of the service charters, on whether they received receipts for all payments they made for services, whether clients are satisfied with services, and if not what could be improved.

As a result of the problems highlighted by these surveys, some important changes have been made says Dr Dickens Onyango. For example, in response to patient’s complaints about long waiting times, additional medical staffs have been deployed in inpatient departments, and additional pay-points have been set up within departments, rather than patients having to face long queues to settle their accounts.

Learning from mistakes in a ‘no blame’ environment

Dr Elizabeth Ogaja, the County Minister for Health, says there has been a significant improvement in reporting procedures as a result of the measures taken, and that this has enabled managers to make better decisions based on timely and accurate information about many aspect of health service delivery. In particular, the 30 women who were in labour last Christmas would, she says, see some notable changes in maternal health care.

In accordance with Kenya’s national policy on maternal deaths, a technical group has been set up in Kisumu comprised of medical staff from both private and government hospitals who meet monthly (as opposed to the national requirement for quarterly meetings) to study cases of maternal deaths, find out what happened, learn from the process and where possible to put measures in place to prevent future mistakes. GIZ has provided financial support for and helped to facilitate these monthly meetings. Although wilful negligence has to be held to account, says Dr Ogaja, what is important is that these discussions take place in a “no blame” environment so that lessons can be learnt from constructive criticism.

These regular monthly meetings have made an enormous difference, says Dr Dickens Onyango, Kisumu’s Director of Health. “When we started the review process we found that the most common cause of maternal death was haemorrhaging and a shortage of blood supplies, but after working with the blood bank on improving inventory management, these deaths have now reduced.” The reviews also identified weaknesses in managing pre-eclampsia, so with German assistance, health managers have instituted a programme of on-the-job refresher courses for staff.

The first month with zero maternal deaths

Nurse weighs new born baby in Kisumu clinic
Nurse weighs new born baby in Kisumu clinic

Quality improvement measures have also been put in place to ensure that women in labour are properly assessed and monitored when they first arrive at hospital, and treatment protocols are followed, especially when women have special needs, such as HIV positive mothers who were found to be disproportionally at risk during labour. The county has also purchased several ambulances that make it possible to women who experience complications in labour at smaller health centres to be transferred quickly to the referral hospital for life-saving interventions. These measures are making a “huge difference” says Dr Ogaja: For the first time ever, in July 2016 Kisumu’s County referral hospital recorded no maternal deaths at all.

This is a remarkable result, says Dr Amos Otedo, the Chief Executive Officer of the hospital, given the large area that the referral hospital serves, even though he cautions that it is too early to say whether this reduction in maternal deaths was a one-off result, or indicates a general decline in maternal mortality.

Dr Dickens Onyango describes the collaboration with the German partners as “excellent because it was not prescriptive” – it has enabled health managers like him to discuss and address the problems they face and come up with potential solutions. A year and a half after it was set up the Taskforce is clearly having an effect, he says, although it continues to be a “work in progress”.

A recruitment campaign has now been launched to try to address some of the staff shortages facing the county’s hospitals, not only during holiday periods like last Christmas, but all year round. Dr Dickens, echoing his literary namesake, hopes that this will mean that the problems experienced on the labour ward in Christmases past, will not be repeated in Christmases of the future and will soon be a thing of the past.

Ruth Evans
December 2016

© GIZ Kenya
© GIZ Kenya
© GIZ Kenya
© GIZ Kenya
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