Hospital Services Assessment Report 2014

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An Assessment
Reportfor Hospitals
MINISTRY OF HEALTH
STATE OF HEALTH SERVICE DELIVERY
SEPTEMBER 2014
Health Sector Monitoring & Evaluation Unit

ii An Assessment Report for Hospitals
State of Health Service Delivery

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An Assessment Report for Hospitals
FOREWORD
The constitution of Kenya 2010 guarantees Kenyans the Right to health. In addition, the constitution further
guarantees the right to the highest attainable standards of health, including reproductive health. In the
current devolved system of Government, it is imperative that the two levels of Government work together
to guard this constitutional right. One of the ways of moving towards this aspiration is through monitoring
and evaluation of service delivery. This not only helps in redirecting resources but also helps identifying areas
that may require improvement in an effort to offer quality services to Kenyans. Innovative initiatives such
as the free maternity services and the free services at the Primary care facilities among others have been
implemented in the health sector. Concerted efforts therefore are required by all the players in health to
sustain these innovations in order to improve health indicators and attain health goals. In addition, progress
made in delivery of quality health services in the last decade need to be sustained.
The primary objective of the monitoring exercise was to track the delivery of health services in the
facilities for purposes of providing information to policy makers both at National and county Government,
the implementers in the facilities and the community at large. Such information would in return help in
decision making towards improving delivery of health services to Kenyans. In addition, the information is
useful in identifying the investment that is required to improve the service delivery. Since 2008, enhanced
supportive supervision had been carried out on regular basis in facilities especially in the hospitals. Hence
the monitoring exercise was important in ensuring that the gains made through this exercise are not lost
and that other facilities that may not have benefited as much are not left out. The expected outcomes are
improved efficiency in service delivery and improved quality of care while improved health status of Kenyans
is the ultimate goal.
Hence the National and the County Government carried out a joint exercise in the month of July 2014. This
report highlights key achievements in various aspects of service delivery, strengths, challenges identified
during the exercise as well as recommendations for purposes of improvement. It shall form the basis for
future such exercises in order to track progress. I wish to encourage Continuous monitoring and evaluation
of health services delivery by both counties and National for better health outcomes.
DR NICHOLAS MURAGURI
DIRECTOR OF MEDICAL SERVICES

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ACKNOWLEDGEMENT
The successful completion of the monitoring exercise in the health facilities in Kenya was made possible
by both individual and collective efforts of various players in the health sector for the period of 2013/14
Financial Year.
Special thanks and appreciation go to the Health Cabinet Secretary James W. Macharia, Permanent Secretary
Khadijah Kassachoon for their able leadership, guidance and support during the exercise of monitoring of
service delivery in facilities within the country.
We are also indebted to Dr. Nicholas Muraguri, the Director of Medical Services for his overall coordination
of the exercise as well as offering technical guidance during the exercise.
We acknowledge the commitment of the monitoring teams for working tirelessly and for their commitment.
These team members included, Dr David Kiima, Dr John Odondi, Mrs Zipporah Wanderah, Mr Joseph Baraza,
Dr Osore, Dr Kibias, M/s Rose Kuria, John Kabanya, Dr Phillip Mbithi, Dr Izaq Odongo, Manasseh Mbocha,
Ann Kibet, Dr Thiongo, Dr Jackline Kisia, Sr Agnes Khati, Eunice Ambani, Dr Antony Miano, Milka Kuloba, Mary
Wachira, Dr Riara Nthuraku, Dr Pacificah Onyancha, Nafatri Murage, Dr Pauline Duya, Dr Shikely, Dr Gachari,
Sammy Muia, Dr Amin, Dr MaryAnn Ndonga, Dr Nancy Njeru, Dr John Kihama, Betty Samburu, Dr Elizabeth
Onyiego,, Dr Brenda Makhoha, Dr Simon Mueke, Susan Otieno, Mr Mutiso and Dr Lusi Ojwang. In addition
we recognize the staff in the health facilities for their assistance.
Many thanks also go to the Health Sector Monitoring and Evaluation unit Staff for their coordination of the
activity and the subsequent production of this report. These include Dr Maina Isabella, Dr Hellen Kiarie, Mr
Pepela Wanjala, Tom Mirasi, Beatrice Muraguri as well as the interns in the unit namely Joseph Mwangi and
Michael Onyango.
Finally we are indebted to World Health Organization (WHO) for their support of the entire exercise both
financially and technically.
DR ISABELLA MAINA
HEAD; HEALTH SECTOR MONITORING AND EVALUATION UNIT

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TABLE OF CONTENTS
FOREWORD............................................................................................................................................ iii
ACKNOWLEDGEMENT............................................................................................................................. v
LIST OF TABLES........................................................................................................................................ix
LIST OF FIGURES......................................................................................................................................xi
LIST OF ACRONYMS...............................................................................................................................xiii
EXECUTIVE SUMMARY............................................................................................................................xv
CHAPTER 1: INTRODUCTION.................................................................................................................... 1
1.1 Background.............................................................................................................................................1
1.2 Monitoring Services in Facilities.............................................................................................................1
1.3 Objectives...............................................................................................................................................1
CHAPTER 2: METHODOLOGY................................................................................................................... 3
2.1 Assessment Framework..........................................................................................................................3
2.2 Sample Size.............................................................................................................................................3
2.3 Assessment Process and Principles........................................................................................................3
2.4 Data Processing and Analysis.................................................................................................................3
CHAPTER 3: FINDINGS............................................................................................................................. 5
3.1 OVER-ARCHING ISSUES...............................................................................................................................5
3.1.1 Human Resource for Health....................................................................................................................5
3.1.2 Healthcare Financing...............................................................................................................................6
3.1.3 Leadership and Governance....................................................................................................................6
3.2 DELIVERY OF HEALTH OF SERVICES.............................................................................................................8
3.2.1 Compliance with service delivery charters..............................................................................................8
3.2.2 Timely provision of Health services.........................................................................................................8
3.2.3 Average Length of Stay (ALOS) in Hospitals...........................................................................................10
3.2.4 Quality Clinical, Nursing and Nutritional Care.......................................................................................10
3.2.5 Access to Specialized Services through Reverse Referral and Emergency services in hospitals............11
3.2.6 Forensic, diagnostic and blood services................................................................................................13
3.2.7 Commodity Supply Management..........................................................................................................16
3.2.8 Hospital Environment, water and hygiene............................................................................................17
3.2.9 Safety in Hospitals.................................................................................................................................19
3.2.10 Child Health.........................................................................................................................................20
3.2.11 Maternal Health and reproductive health services.............................................................................23
3.2.12 HIV/AIDS, TB and Malaria....................................................................................................................25
3.2.13 Palliative Care in Hospitals..................................................................................................................26
3.2.13 Oral Health..........................................................................................................................................27
3.2.14 Disability Mainstreaming.....................................................................................................................28
3.2.15 Gender Mainstreaming.......................................................................................................................29
3.2.16 Rehabilitative health Services..............................................................................................................30
3.2.17 Mental Health Services........................................................................................................................30
3.2.18 Automation and Efficient Medical Records and Information Systems.................................................30
3.2.19 Human Resource Management and Development.............................................................................31
3.2.20 Hospital Assets....................................................................................................................................32
3.2.20 Innovations..........................................................................................................................................33
CHAPTER 4: RECOMMENDATIONS......................................................................................................... 35
ANNEXES............................................................................................................................................... 37
Annex 1: Performance by Hospitals and Counties......................................................................................37
Annex 2: Regional Specific Reports............................................................................................................43

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LIST OF TABLES
Table 1: Staffing in Hospitals..........................................................................................................................5
Table 2: Healthcare Financing- Hospitals.......................................................................................................6
Table 3: Waiting Time for provision of services............................................................................................9
Table 4: Average length of stay.....................................................................................................................10
Table 5: Quality of Medical Records.............................................................................................................10
Table 6: Quality of clinical, nursing and nutritional care........................................................................11
Table 7: Access to specialized services in hospitals......................................................................................11
Table 8: Forensic and diagnostic services....................................................................................................14
Table 9: Maternal Health...............................................................................................................................23
Table 10: HIV/AIDS, TB and Malaria...............................................................................................................25
Table 11: Palliative services...........................................................................................................................26
Table 12: Other performance areas on Gender Mainstreaming................................................................28
Table 13: Rehabilitative Health......................................................................................................................29
Table 14: Human Resource Development......................................................................................................32

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LIST OF FIGURES
Figure 1: Hospitals with at least one specialist_______________________________________________5
Figure 2: Hospital holding management committees meetings__________________________________7
Figure 3: Hospital supervision and planning_________________________________________________7
Figure 4: Compliance with Service Delivery Charter___________________________________________8
Figure 5: Survey on waiting time done in the last 6 months____________________________________9
Figure 6: Referral Services in hospitals____________________________________________________12
Figure 7: Emergency preparedness and timely response in hospitals_____________________________13
Figure 8: Forensic services in hospitals_____________________________________________________14
Figure 9: Availability of Lab tests 24 hours in Hospitals_______________________________________15
Figure 10: Blood Stock Levels in hospitals__________________________________________________15
Figure 11: Availability of tracer drugs_____________________________________________________16
Figure 12: Commodity Supply Management_________________________________________________17
Figure 13: Store Management____________________________________________________________17
Figure 14: Waste management____________________________________________________________18
Figure 15: Water, hygiene and Power______________________________________________________19
Figure 16: Adherence to guidelines________________________________________________________20
Figure 17: Child mortality_______________________________________________________________21
Figure 18: Newborn Unit________________________________________________________________22
Figure 19: Paediatric ward based care_____________________________________________________23
Figure 20: Labour, delivery and post natal ward based care___________________________________24
Figure 21: Reproductive Health service____________________________________________________24
Figure 22: Breast and Cervical cancer screening____________________________________________25
Figure 23: Palliative care units___________________________________________________________26
Figure 24: Oral Health__________________________________________________________________27
Figure 25: Disability Mainstreaming_______________________________________________________27
Figure 26: Gender Mainstreaming_________________________________________________________28
Figure 27: Rehabilitative Health Services___________________________________________________29
Figure 28: Mental Health Services_________________________________________________________30
Figure 29: Automation__________________________________________________________________31
Figure 30: Efficient Medical Records and Information Systems________________________________31
Figure 31: Human Resource Management and development___________________________________32
Figure 32: Hospital Assets________________________________________________________________32
Figure 33: Innovations__________________________________________________________________33

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LIST OF ACRONYMS
AIDS Acquired Immunodeficiency Syndrome
ALOS Average Length of Stay
CME Continuous Medical Education
CTEV Club Foot clinics
ENT Eye Nose Throat
FIF Facility Improvement Fund
GBV Gender Based Violence
GOK Government of Kenya
HIV Human Immunodeficiency Virus
HMT Hospital Management Team
MDGs Millennium Development Goals
MTC Medicines Therapeutic Committee
NHIF National Hospital Insurance Fund
NBU New Born Units
NHIF National Hospital Insurance Fund
OPD Outpatient Department
PAS Performance Appraisal System
PDMS Provincial Director of Medical Services
PEP Post Exposure Prophylaxis
SGBV Sexual and Gender Based Violence
SOPs Standard Operation Procedures
TB Tuberculosis
VIA Visual Inspection with Acetic acid
VILI Visual Inspection with Lugose Iodine
WHO World Health Organization

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EXECUTIVE SUMMARY
This report presents the findings of an assessment that was done in health facilities by a team that consisted
of National and County Government officials. A total of 221 facilities were assessed of which 66 were primary
level facilities (26 Dispensaries and 40 Health Centres) and 155 were hospitals (142 level 4 hospitals and 13
level 5 hospitals). This report is unique in that it was carried out about one year after devolution of health
services.
The assessment was heavily based on key reform areas that were anchored on public sector reforms.
Previously, similar assessments had been done in hospitals (levels 4-6) with the preceding assessment having
been done in June 2013.
SUMMARY OF KEY FINDINGS
Overall, there was a general trend of decline in most areas assessed.
1. Human resource for Health
Generally, there was an increase in the staffing levels for the different cadres of staff in both level 4 and
level 5 hospitals in 2013/14 as compared to 2011/2012 financial year. However the numbers still fall below
the recommended norms. For example Level 5 hospitals had and an average of 17 Medical officers and 215
nurses, against the recommended norms of 50 medical officers and 842 nurses recommended for level 5
hospitals in the health sector norms and standards 2014-2018. Level 5 hospitals had an average of 25 clinical
officers against the 44 recommended in the norms.
2. Healthcare Financing
Management of finances in the devolved system was one of the most common challenges reported, with
staff in most hospitals expressing the need for further capacity building in financial management and the
need for guidelines to guide them on the same. Only 43% of the hospitals had at least 100% of FIF ploughed
back to the facility. Financial records and systems to manage the finances were noticeably poor in most
facilities; expenditure returns for free maternity Services funds, as an example was evident in 65.8% of
hospitals.
3. Leadership and governance
Supervision from county and sub-counties had been done in 59.4% of facilities while 66.5% of facilities had
work plans. Overall implementation of planning, management and governance including management
meeting and training for management was at 26% down from 35% in the previous assessment.
4. Timely provision of services
Although there was noticeable deterioration in implementation of surveys to establish waiting times in
hospitals, average waiting times for provision of services within the various departments remained within
the recommended norms, and largely unchanged from the previous assessment.
5. Quality of care – Clinical, Nursing and Nutritional Care
There was a retrogressive trend in the percentage of hospitals complying with set norms for adult Clinical
records in OPD, ward and in the nursing care plans and nutritional care.OPD records were the poorest in
hospitals. Quality of clinical and nursing care in the wards declined slightly with the number having regular
ward rounds, specialized clinics, proper nursing care plans and nutritional care going down.
6. Emergency Preparedness and Timely Provision of Health care Services
Gains were made in hospitals with functional ambulances though the referral process was still not well
implemented in hospitals. The number of hospitals having a mass casualty incidence plan, fully equipped

xvi An Assessment Report for Hospitals
crush box, fully equipped and functional emergency response teams declined from the previous assessment.
7. Forensic, diagnostic and blood services
Forensic services were generally poor in hospitals; about a third of mortuaries were holding more bodies
than the capacity. A half of hospitals were offering 24 hour laboratory services, down from 58% previously.
Availability of laboratory tests declined over the one year period. Serum bilirubin and Urea & electrolytes
were the least available tests in the hospital laboratories.
8. Blood Stock Levels
By and large, the number of units available at the time of the assessment met the norms of 10 units for level
4 and 20 units for a level 5 hospital. However, an average of 10.4 units of blood were expired in the high
volume hospitals.
9. Commodity Supply Management
There was a mixed picture in availability of commodities where there was a slight decrease in availability of
non-pharmaceuticals in 2013/2014 compared to 2012/2013 (60% to 55.5%), while tracer drugs increased
(40% to 52.9%).
10. Hospital Environment and Infection prevention in hospitals
Availability of water, soap, toilets, proper management of waste performed poorly while barrier nursing
was weakly implemented. Level 5 had well maintained Hospital compounds and proper waste management
structures compared to the other levels.
11. Child health
There was a significant decline in all child related death rates (percent of those admitted who died) in
hospitals from the previous assessment in 2013. However, the quality of newborn units had declined with
only few hospitals (26%) having the minimum number of incubators and dedicated nurses for the units.
12. Maternal Health
Ward based care was very poor with less than 20% of hospitals implementing required standards including
proper documentation. Fresh still births consisted of 56.7% of all still births. However, hospital based
maternal death rate (per 100,000 deliveries) reduced significantly from 741 in 2013/14 to 227 in 2013/14.
Reproductive health services were available in most hospitals with youth friendly services being the least
available at 31%.
13. HIV/AIDS, TB and Malaria
Mortality among HIV admissions decreased from 33.3% in 2012/2013 to 21.8% in 2013/14; while other
indicators - proportion counselled and tested for HIV, proportion of eligible patients put on ART and
Tuberculosis mortality rates - showed a slight decline.
14. Palliative services
Palliative care units were available in 40% of hospitals; the number of health workers trained on palliative
care totalled to 305 while total patients seen in the units were 622.
15. Oral Health
There is an outstanding improvement from previous assessment on the Availability of dental cartridges and
needles from 25% in previous assessment to 51% this year while there is a retrogressive trend in availability
of 24 hour dental services from 51% to 11.61%.

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16. Disability Mainstreaming
Implementation of disability mainstreaming remained generally unchanged from previous assessment, with
only 45% of facilities meeting the requirements in mechanisms and structures to support persons with
disability in hospitals.
17. Gender Mainstreaming
A decline was noted in compliance with gender mainstreaming standards from the previous assessment (46
to 29.8%). This is against a backdrop of an increase in gender related cases including number of rape, gender
based violence and child sexual abuse cases.
18. Rehabilitation of Health Services
Availability of Physiotherapy, orthopaedic technology and occupational therapy services including staff and
infrastructure was fair at 70%.
19. Mental Health Services
The assessment revealed that, few Low volume hospitals offer Mental Health Services at 1.7%; overall, only
36.1% of hospitals were providing comprehensive mental health services.
20. Automation
Half of high volume hospitals (Levels 4&5) were automated while low volume level 4 hospitals had lower
automation levels in comparison at 20%. Overall, 35.4% of hospitals are automated.
21. Efficient Medical Records and Information Systems
Only a third of hospitals were submitting service delivery reports to-sub counties, counties and to National
level through established mechanisms such as District Health Information System (DHIS). In addition, only a
third of the hospitals were sharing data within the hospitals.
22. Human Resource Development
Overall implementation of performance appraisal system and competence development was at 67.4% in
hospitals.
23. Hospital Assets
High volume level 4 hospitals were the most compliant in hospital assets management with 76% complying
by repairing of identified equipments, vehicles and buildings repair, while Low volume hospitals were the
least compliant at 41.1%.
24. Innovations
The assessment reveals that Kitchen gardens and fish ponds were the most preferred innovations, each
present in at least 5% of hospitals.

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CHAPTER 1: INTRODUCTION
1.1 Background
The Constitution of Kenya 2010 provides for the right to the highest attainable standard of health to every
Kenyan. It further guarantees the right to health including reproductive health services. Schedule 4 of the
constitution assigns to the County Governments the function of delivering health services and to the National
Government the functions of stewardship for the health policy including standards and guidelines. Kenya
Health Policy (2014-2030) aims at the attainment of the highest standard of health in a manner responsive to
the needs of the Kenya population. This makes health care provision one of the key components of conveying
the social pillar of Vision 2030.
1.2 Monitoring Services in Facilities
Monitoring the delivery of health services is crucial for the health sector and for Kenyans at large as it aims
in identifying areas of performance, any challenges faced and hence aiding in coming up with remedial
measures to ensure continuity of delivery of high quality services. Given that it has been over one year since
the devolution of health services, there was need to take stock of the gains made during the process, as well
as identify any gaps, that may be existing, that may potentially hinder smooth running of services, and hence
compromise quality of services to Kenyans.
In this regard, the Ministry at the National level and county level carried out a monitoring/assessment
exercise that was implemented by teams drawn from the two levels of government. Tools were developed to
assess the delivery of health services at the hospitals and primary level facilities.
1.3 Objectives
The goal of the assessment included;
1. Document gains made one year after devolution of health services
2. Identify best practices for purposes of sharing
3. Identify performance gaps /any challenges for purposes of sharing
4. Give recommendations for improvement in service delivery
5. Build capacity of county/facility teams in carrying out assessments

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CHAPTER 2: METHODOLOGY
2.1 Assessment Framework
This evaluation linked National government to County level health systems, by relating standards and norms
to service delivery. The framework facilitated standardization of assessment of a number of different facilities.
The supportive nature of the assessment ensured that health workers in facilities were mentored on
implementation of reforms in their facilities in a bid to ensure increased improvement of quality of services
offered to Kenyans.
The Ministry at the National level in collaboration with the counties developed an assessment tool to
accurately capture data collected from facilities. The instrument was made up of twenty seven (27) and
twenty two (22) result areas for hospitals and primary facilities - respectively.
2.2 Sample Size
A total of 155 public Health facilities were sampled purposively to include all hospitals with theatres. These
included 13 level 5 facilities, 24 High volume level 4 hospitals (The internship centres) and 118 low volume
level 4 hospitals. Sixty six Primary Health Facilities were assessed, (26 Dispensaries and 40 Health Centres).
The sampled hospitals had also been covered in the previous assessment in order to ensure consistency in
tracking performance.
2.3 Assessment Process and Principles
Integrated assessment tools were developed to for hospitals and primary health facilities. The
tool’s scope of assessment covered all areas within a health facility. The process was done
by a team constituted from both the National and County levels of government. This team
contributed in developing the tools, which were pretested before use in the field.
A tool to capture data from facility records had been sent in advance to allow facilities to input data. The
assessment process involved walking through all hospital, departments, observing and filling the assessment
tool. Hospital staff were also interviewed on various aspects of the hospital, including environment, service
delivery, finances, leadership and governance among others.
At the end of the assessment, the team had a meeting with hospital managers to discuss key issues from
the activity to highlight issues that may needed attention. An action plan was then developed outlining how,
when and by whom the highlighted key issues would be addressed by.
2.4 Data Processing and Analysis
Data was captured using Research Electronic Data Capture (REDCap) - an online data management software.
The software allowed for robust methods of data cleaning and quality checks to assure integrity of data.
Analysis was done using Stata 13. This allowed for extraction of core themes related to the objectives and
overall goal of the assessment. The results were presented by categorization of key result areas, which was
then compared with the previous assessment to assess progress in performance. Analysis was additionally
done per county and hospital.

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CHAPTER 3: FINDINGS
3.1 OVER-ARCHING ISSUES
3.1.1 Human Resource for Health
Level 5 hospitals had and an average of 17 medical officers and 215 nurses, against the recommended norms
of 50 medical officers and 842 nurses for level 5 hospitals in the ‘Health Sector Norms and Standards 2014-
2018’. Level 5 hospitals had an average of 25 clinical officers against the 44 recommended in the norms. Table
1 illustrates that high volume level 4 hospitals had the highest average of clinical officers standing at 26.2
while level 5 and low volume-level 4 recorded an average 25 and 7.8 respectively. Medical officer interns are
significantly more in both high volume-level 4 and level 5 hospitals as compared to low volume level 4 which
is at only 1.4. Generally, compared to the year 2011-2012 there was an increase in the distribution level of
human resource in both level 4 and level 5 hospitals.
Table 1: Staffing in Hospitals
Health worker distribution
by level
Low volume
level 4
High volume
level 4
Level 5
O v e r a l l
2013/14
2011/12
Medical officers 3.4 9.7 17 5.7 3.0
Medical Officers interns 1.6 11.5 12.2 5.7 0.0
Nurses 33.8 115.8 214.8 58.8 37.0
Clinical officers 7.8 26.2 25 11.9 7.0
Lab personnel 4.6 12.75 20.2 9.6 -
Pharmacists 1.9 5.9 7.8 3 2.0
Dentists 0.7 1.9 2.8 1.3 1.0
At least 30% of the hospitals had general surgeons, paediatricians, obstetricians/gynaecologists and
physicians (figure 1). At least 15.5% of the hospitals had ENT surgeons with the least available specialists
being orthopaedic surgeons 5.5%. (See figure 1 below). On average, high volume level 4 hospitals had the
same number of specialists as level 5 hospitals.
Figure 1: Hospitals with at least one specialist

3.1.2 Healthcare Financing
On average 90.4% of Facility Improvement Funds (FIF) was ploughed back to facilities, with 43% of the
hospitals having had at least 100% of FIF ploughed back. In addition, only 40.6% of facilities had received AIEs
from counties at the time of the assessment. This was accompanied by poor records; expenditure returns for
free maternity services funds were evident in 65.8% of hospitals whereas, High volume level 4 hospitals had
better scores in finance management including basing projections on official formula, updated cash analysis
and involving HMT in budgeting (Table2).
All regions reported challenges with the management of finances in the devolved system. This was
accompanied by lack of guidelines of how to manage finances at the counties in almost all regions. Most
facilities were required to deposit FIF in a common county account resulting in underfunding
in some hospitals, while on the other hand, some hospitals reported having more funds (than FIF collected)
invested back, mostly for development purposes.
Table 2: Healthcare Financing- Hospitals
Hospitals performance No %
Received AIE from county Government 63 40.6
Proportion of FIF ploughed back to the hospital
Of (85
respondents)
90.4
At least 100% ploughed back to Hospital 67 43.2
Performance area
Low vol.
Level 4
High vol.
Level4
Level 5 Overall
Evidence that targets/projections are based on official
formula
43.2 87.5 61.5 51.6
Presence of an updated cash analysis summary-fully
completed
57.6 95.8 84.6 65.8
Evidence of involvement of HMT / HMC in budgeting 77.1 91.7 92.3 80.7
Bank reconciliation up to date 50.0 79.2 38.5 53.6
Expenditure returns for Free maternity Services funds 62.7 66.7 92.3 65.8
Computerization of cash collection system 67.3 87.5 100.0 73.6
3.1.3 Leadership and Governance
Good planning, management and governance are critical in hospitals. Hospitals are therefore required to
adhere to minimum standards including implementation of work plans, regular management meetings
including those of Management committee, Medicine Therapeutics, FIF, catering, advisory, Infection
Prevention Committee and nutrition among other committees. Training for management and supervision
from sub-county and county levels is also key to ensuring good governance.

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Figure 2: Hospital holding management committees meetings
Figure 2 also demonstrates that Hospital’s general and specific management meetings were only held by
an average of 26% of hospitals, a drop from 35% in the previous assessment. High volume level 4 hospitals
compliedmostat41%.TheproportionofHMTMemberstrainedatleast6weeksHealthSystemsManagement
Strengthening course was 19% overall with a third in high volume hospitals (levels 4 &5) trained in the course.
Figure 3: Hospital supervision and planning
Figure 3 reveals that on average 59.4 % of hospitals had had supportive supervision from the county or
Sub County in the preceding quarter. The most supervised departments were was laboratory while half of
facilities had pharmacy and records supervision done. Facility statistics were displayed by very few hospitals
with an average of 24 % and annual work plans were available in 66.5% of hospitals.

3.2 DELIVERY OF HEALTH OF SERVICES
3.2.1 Compliance with service delivery charters
Ministry of Health service charter spells out the patients’ rights and assigns health care workers key
obligations which ensures effective delivery of health care services. This makes compliance with the service
delivery charter a crucial part of its implementation. Figure 4 below reveals that, hospitals compliance level
with service charters was at 72.6%, while implementation of departmental charter was at 73.4%. Thirty one
percent had feedback mechanisms. Performance in this area was generally comparable to that in June 2013.
Figure 4: Compliance with Service Delivery Charter
3.2.2 Timely provision of Health services
Customer satisfaction and efficiency is the desired output in service delivery at all levels of health care. This
has remained a major challenge as our hospitals continue to struggle with huge service delivery demand
amid inadequate, less skilled health workforce, equipment as well as scarce budget allocation. Waiting time
in hospitals is one of the measures of efficiency in service delivery. It is an indicator of the extent to which
available resources are efficiently utilized. E.g. human resource, equipments, time etc. In addition, waiting
time is a key determinant of the overall customer satisfaction.
A patient’s experience in waiting time will radically influence his/her perceptions on quality of the service.
Hospitals are required to carry out biannual surveys, ideally conducted by an independent entity, in order
to establish the waiting time, and assess progress towards the established norms. In addition, a survey on
customer satisfaction helps a hospital evaluate to what extent it is meeting the needs of its clients, as well as
identifying the areas that need most improvement.

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Figure 5: Survey on waiting time done in the last 6 months
Figure 5 shows that only 12.9% had done a survey on waiting time in the preceding 6 months in 2013/14
compared to 70% in June 2013, while 20% had done a survey on customer satisfaction. Among the level 5
hospitals, 15.4% had a survey on waiting time in the last 6 months in comparison to 25% and 1.07% in high
volume and low volume level 4 hospitals respectively. On customer satisfaction, implementation in levels 5
and 4 hospitals differed by 29.8% with low volume level 4 hospitals trailing at only 1.88%.
Table 3: Waiting Time for provision of services
Waiting time for: (minutes) norm
Low vol.
level 4 n=7
High vol.
level 4 n=5
Level 5
n=2
Overall 2014 June 2013
Registration 5 7.2 6.4 1 6.5 6.1
Laboratory Services 30 27.8 16.5 10 21.3 21.5
Pharmacy 20 17.1 6.9 8 12.2 9.6
X-Ray-Services 20 20.8 16.5 17.5 18.7 22.6
Maternity Services 15 15.4 11 15 13.9 14.6
Emergency Admissions 10 9.29 6.5 10 8.5 11
Table 3 above revealed that timely provision of services generally remained unchanged from the previous
assessment in June 2013 with only a slight decline noted in most areas including X-ray, maternity and
emergency admissions. On the other hand, a slight increase was noted in waiting time for pharmacy services
from an average of 9.6 minutes to 12.2minutes. Waiting time in various departments in the hospitals was
withinthenorms.Inmostareas,waitingtimewasnotablylowerinlevel5hospitals,beinglowestinregistration
(average of one minute). Low volume level 4 hospitals recorded high waiting time in the laboratory of about
27.8 minutes, this being 6 minutes above the average.

3.2.3 Average Length of Stay (ALOS) in Hospitals
There was an improvement in the average length of stay from the previous assessment as shown in table 4
below. General ward, maternity and orthopaedic wards recorded reduction of at least one and a half days in
hospital. On average, patients stayed most in Level 5 hospitals apart from psychiatric and orthopaedic wards,
where they stayed most in high volume level 4 hospitals.
Table 4: Average length of stay
ALOS (Days) Norms Low Vol. L4 High Vol. L4 Level 5 Overall 2012/13
General ward 5 4.58 5.30 7.67 4.74 6.0
Surgical ward 5 4.28 8.46 11.69 6.90 7.0
Paediatric ward 5 4.26 4.83 6.06 4.33 5.0
Maternity ward 4 3.73 4.08 4.31 3.62 5.0
Psychiatric ward 30 19.23 24.40 8.65 13.12 20.0
Orthopaedic ward 7 5.53 22.86 8.67 12.28 19.0
3.2.4 Quality Clinical, Nursing and Nutritional Care
Presence of the expected records in specific service delivery areas e.g. nursing care plans, daily diet sheets
etc depicts quality of care in the hospitals. It is from these records that a hospital can derive an improvement
strategy in various areas of service delivery .The quality of clinical records and other documentation was
generally better in the wards than in outpatient department. The weakest point with documentation was
recording, signing and timing of records, as shown in table 5 below. Overall performance in quality of records
dropped, from 74% in both outpatient departments and wards in 2013 to 37.8% and 54.3% in outpatient
department and wards respectively in the current assessment (2014).
Table 5: Quality of Medical Records
June 2014 Achievement.
Quality of medical records OPD Wards
History well documented 33.5 60
Examination documented 38.7 56.1
Vital signs recorded 32.9 51.0
Appropriate investigations done 32.9 57.4
Clear diagnoses made 52.3 63.9
Records signed, dated and timed by clinicians 30.3 37.4
Treatment sheet clear and signed 43.9 54.2
Percentage of hospitals with good adult clinical records Low vol. level 4 High vol. level 4
OPD 34.1 52.4
Ward 48.9 68.5

11
Table 6: Quality of clinical, nursing and nutritional care
Percentage of hospitals complying with
norms
Low
vol.
level 4
High vol.
level 4
Level 5
Overall
Achievement
2014
June
2013
Daily ward round 72.03 100 100 78.9 80
Major ward rounds per week 32.2 79.17 84.62 43.9 55
Daily/Weekly diabetic clinics 37.65 85.12 89.01 49.31 60
Nursing care plans for all inpatients
40.8 62.5 65.4 46.2 70
Quality Nutritional Care 50.95 86.98 80.77 59.03 66
High volume hospitals (levels 4&5) had a higher score in quality of care indicators. Daily ward rounds were
done by all high volume hospitals while overall achievement for daily ward rounds was comparable to the
previous assessment. Major ward rounds were still a weak area in most hospitals. A slight retrogressive trend
as shown in Table 6 from the previous assessment was noted for most indicators. There was a notable decline
in presence of nursing care plans in hospitals.
3.2.5 Access to Specialized Services through Reverse Referral and Emergency services in
hospitals
3.2.5.1. Referral Services in hospitals
The Ministry has recently launched a new referral strategy which aims to ensure accessible specialised
services to Kenyans. The strategy’s priority is to have outreach specialist services from higher hospitals to
lower ones in their jurisdiction and capacity build officers working in those hospitals.
Table 7: Access to specialized services in hospitals
Access to specialized services through reverse referral in
hospitals
% t offering service
2014 2013
Surgery services to lower hospitals / facilities 7.3 29
ENT services to lower hospitals / facilities 2.7 22
Obs/gyn services to lower hospitals / facilities 3.6 33
Ophthalmology services to lower hospitals / facilities 10.9
25
Physicians services to lower hospitals / facilities 3.6 23
Paediatric services to lower hospitals / facilities 3.6 -
Psychiatry services to lower hospitals / facilities 1.8 25
Oral Health outreaches done per quarter / facilities 2.7
33
Community Based Rehab. Services / facilities 2.7 -

Table 7 shows that generally, there was a decrease in the percentage of hospitals that were offering specialized
services to the lower levels. The largest drop in specialized service provision to lower level hospitals was seen
in oral health outreach and Obstetrician/gynaecologists services, which saw a drop of about 30 percentage
points in hospitals offering these services.
Figure 6: Referral Services in hospitals
Figure 6 above shows that hospitals scored well in having functional ambulances. At least 92.3% of level
5; 79.2% of high volume level 4 had functional ambulances. Overall 72.3% of hospitals had functional
ambulances. In addition, hospitals were generally fair in implementing referral services with most indicators
scoring about 50%. Only about a third had a dedicated area for referral while documentation was also a weak
area (47.1%).
3.2.5.2. Emergency preparedness
Hospitals play a critical role in providing essential medical care during all types of emergencies. As a result,
functional capacity of hospitals is critical in handling all types of emergencies.

13
Figure 7: Emergency preparedness and timely response in hospitals
As displayed in Figure 7, a decline was noted in all the indicators; hospitals having one functional emergency
response from 46% in 2013 to 32.9% in 2014; the number of hospitals having a mass casualty incidence
plan from 23% in 2013 to 13.5% in 2014, and fully equipped crush box from 64% in 2013 to 47.1% in 2014.
In addition, a decrease was noted in the number of hospitals with fully equipped and updated emergency
tray with a checklist from 53% to 37.7% and emergency preparedness and timely response from 53% to
20%. There is dire need for hospitals to improve on emergency preparedness especially in this era of many
emerging global threats.
3.2.6 Forensic, diagnostic and blood services
Forensic, diagnostic and blood services are crucial in health care service delivery system. Generally,
hospitals are expected to have functional mortuary, functional laboratories as well as blood stocks as per the
recommended norms.
About 40% of hospitals had functional mortuaries. This is a decrease from 58% as recoded in the previous
assessment (see table 8 below).

Figure 8: Forensic services in hospitals
Quality of forensic services was generally poor especially in low volume hospitals. The weakest area was in
availability of dissecting kits for post-mortem. Furthermore, 37% of hospitals reported holding more bodies
in the mortuary than their capacity, with some reporting an excess of up to 50 Bodies (fig.8).
Table 8: Forensic and diagnostic services
Improved forensic, diagnostic and
blood services (%)
Low vol. level 4 High vol. level 4 Level 5
Overall 2013
Functional mortuary 28.8 76.4 71.8 39.6 58
24 hour lab services 47.4 84.7 82.1 51 75
SOPs present in the lab 66.7 87.5 78.8 71 82
Laboratory supervision 39.8 53.5 56.4 43.3 49
Presence of SOPs in the laboratory remained high at the high volume Level 4 hospitals (87.5%) although
a slight decrease was noted in laboratory supervision from 49% in 2013 to 43.3% in 2014. On average,
availability of 24 hour lab services was low at 51% decreasing from 75 % in previous assessment, with Low
volume Level 4 hospitals at 47 %. Generally, high volume-level 4 hospitals scored better in provision of these
services than both low volume-level 4 and level 5 hospitals (Table 8).

15
Figure 9: Availability of Lab tests 24 hours in Hospitals
Availability of laboratory tests declined over the one year period. Serum bilirubin and Urea & electrolytes
were still the least available tests at 38.1% and 34.8% respectively (Fig 9).
3.2.6.3 Blood Management in Hospitals
As Figure 10 below displays, the average number of pints of blood in hospitals was at 14 overall. Generally,
the number of units available at the time of the assessment met the norms of 10 units for level 4 and 20
units for a level 5 hospital, considering low volume hospitals were just below the 10 unit threshold. However
Level 5 hospitals had on average 10.8 expired blood units whereas low volume level 4 hospitals recorded an
average of 1.3 units.

Figure 10: Blood Stock Levels in hospitals

3.2.7 Commodity Supply Management
Commodity management forms a vital part of service delivery in a facility. A well managed commodity system
ensures equity as all patients are able to access drugs and other interventional products leading to better
outcomes. Concerning availability of commodities, figure11 below shows a mixed picture where there was
a slight decrease in availability of non-pharmaceuticals from 60% in previous assessment (2013) to 55.5% in
2014, while that of tracer drugs had increased from 40% in 2013 to 52.9%.
Figure 11: Availability of tracer drugs
Figure 12 below shows that 24 hour pharmacy services had remained largely unchanged at an average of
30% with 77% of level 5 hospitals offering 24 hour pharmacy services. Reconstitution of children’s medicine
was poorest in level 5 hospitals at 38.5%. Hospitals scored well in good dispensing practices that included
using tablet counters and keeping registers for antibiotics, narcotics and insulin.

17
Figure 12: Commodity Supply Management
Figure 13: Store Management
Hospitals scored fairly well in maintainace of commodities’ stores; Noticably, 42% of hospitals did not have a
functional fridge and bin cards were maintained in 65.8% of hospitas (fig.13).
3.2.8 Hospital Environment, water and hygiene
Hospitals are expected to maintain a clean and friendly environment. In addition they are expected to

implement proper waste management as a way of reducing infections within hospitals as well as have clean
wash rooms for all wards, departments for patients/staff. In addition, they are expected to have reliable
water supply to all clinical areas.
Figure 14: Waste management
A general decline was noted in all indicators relating to waste management in hospitals. Only about a half of
hospitals had a set of 3 colour coded bins to segregate waste, well protected ash pit and functional incinerator
(fig.14).

19
Figure 15: Water, hygiene and Power
There was a general decline in the proportion of hospitals having hand washing soap for staff and patients
from 89 in 2013 to 65% in 2014; running water in sinks from 87 to 76.1%. Clean functional toilets declined
from 83 to 76% and 92 to 85.8% for patients and staff respectively (fig 15).
With respect to well maintained compounds, level 5 had well maintained Hospital compound at 95% while
low volume hospitals had the least well maintained compounds.
3.2.9 Safety in Hospitals
Hospitals are expected to have all major buildings labelled and with unobstructed fire exits; have fire fighting
equipment in all areas and more so in sensitive areas such as the stores, kitchen, laboratory, wards among
others. In addition, the fire fighting cylinders should be fully services and that there should be a clear outlined
procedure on what to do in-case of fire.


Figure 16: Adherence to guidelines
Figure 16 reveals that level 5 hospitals adhered most to safety guidelines with a 72.7% having fire fighting
equipment available while Low volume level4 hospitals scored the poorest at 39%. Slightly above half of high
volume hospitals (level 4&5) had fire exits. The overall score on fire safety had remained the same as in the
previous assessment. On adherence to barrier nursing, high volume level 4 had declined significantly from
68% to 51.4% in the current assessment.
3.2.10 Child Health
There was a significant decline in all child related death rates (percent of those admitted who died) in
hospitals from the previous assessment in 2013. Pneumonia related mortality and under one death rate
showed the most decline from an average of 6% and 11% in the previous assessment to an average of 0.1 and
6.6% respectively in the current assessment. Notably, high volume level 4 hospitals recorded significantly
high under 1 death rates compared to the other levels. (See Figure 17).

21
Figure 17: Child mortality
3.2.10.1 Newborn unit
High volume hospitals (level 4&5) had better scores in newborn Unit compared to other levels (Fig18). The
most poorly performing areas were on presence of functional incubators, where on average only 26% of
hospitals had the minimum required number compared to 41% in the previous assessment. Having fully
dedicated nurses to the newborn unit however had improved from 36% to 53%. Overall, compliance to the
standards in newborn unit had gone down from previous assessment from 52% to 41%.

Figure 18: Newborn Unit
3.2.10.2 Paediatric ward based care
Quality services for the paediatrics in the wards are of utmost importance. Documentation of the clinical
notes is a good pointer to quality services in the wards. Hence Hospitals were assessed on presence complete
Nursing Cardexes, documentation of history, clarity of diagnosis in the records, ward round among other
parameters.
As shown in figure 19 below, performance in this area was quite poor with only a third if hospitals meeting
the standards. The worst scoring areas were clear diagnoses (11.6%) and clear signed treatment sheets.

23
Figure 19: Paediatric ward based care
3.2.11 Maternal Health and reproductive health services
Table 9 below indicates that about half of all still births in hospitals were fresh, an indication of poor
management of labour; Hospital based maternal death rate (deaths/100,000 deliveries) had significantly
declined from 741 in 2012 to 227.6 in 2014. Audited maternal deaths consisted of 86.6% of all maternal
deaths while ANC attendees delivering in hospitals were 55.6%. There is need for hospitals to find means
of improving on management of mothers in labour including through capacity building of staffs, prompt
referrals among other strategies. In addition all maternal deaths have to be audited as a standard.
Table 9: Maternal Health
Performance area (%)
Low
volume
level 4
High
volume
level 4
Level 5 overall 2012/2013
Fresh Still births rate (fresh Still birth/
Still births)
56.3 48.7 53.5 56.4 -
Hospital maternal death rate (per
100,000 deliveries)
144.5 200.8 225.6 227.6 741
% Maternal deaths audited 64.7 60.0 55.2 86.6 -
Still births rate 2.2 3.6 4.3 2.5 -
ANC attendees delivering in hospital 113.5 205.5 130.4 55.6 N/A
CS section rate 9.8 20.0 28.1 17.0 17
3.2.11.1 Labour, delivery and post natal ward based care
In as far as maternal health is concerned, ward based care was very poor with less than 20% of hospitals

implementing required standards including proper documentation. Baby examination and postnatal mother
examination were the poorest scoring indicators with 5.2% and 7.1% of hospitals implementing them. In
general, less than 20% of hospitals were complying with the standards in labour, delivery and post natal ward
based care (fig.20).
Figure 20: Labour, delivery and post natal ward based care
3.2.11.2 Reproductive Health services
Figure 21: Reproductive Health service

25
Figure 21 reveals that most hospitals were providing most reproductive health services apart from youth
friendly services which were present in a third of hospitals. Among the hospitals that screened for breast
cancer, clinical breast examination was the most used method (71%) while mammography was the least used
(11.6%). On the other hand, most facilities (66.5%) were using VIA/VILLI as opposed to PAP smear (17.4%) to
screen for cervical cancer (fig 22).
Figure 22: Breast and Cervical cancer screening
3.2.12 HIV/AIDS, TB and Malaria
Table 10 shows that there was a slight decline in the performance of the most indicators for HIV/AIDS and TB,
with proportion of those counselled that had been tested for HIV dropping from 98.3% to 89; proportion of
eligible patients put on ART declining from 55.3% to 47.9 while Tuberculosis mortality rates slightly increased
over the year with the bulk of these fatalities occurring in level 5 hospitals. Nevertheless, some gains were
made with deaths among HIV admissions decreasing from 33.3% in 2012/2013 to 21.8% in 2013/2014. Level
5 hospitals had a significantly high proportion counselled tested for HIV; while low volume level 4 had very
low Proportion of eligible patients put on ART at 22.9%.
Table 10: HIV/AIDS, TB and Malaria
Performance area
Low Vol
L4
High Vol
L4
Level 5
Overall
(%)
2012/13
Prop. of Counselled tested for HIV 79.1 54.9 98 89 98.3
Prop. of eligible patients put on ART 22.9 60.5 61.6 47.9 55.3
Prop. of deaths among HIV admissions 21 27.7 31.3 21.8 33.3
TB case fatality 22 16 32.3 21.31 20
Malaria Mortality
Low Vol
L4
High Vol
L4
Level 5
Overall
(%)
2012/13
Under fives inpatient due to malaria 2.54 4.9 2.03 2.89 3.3
Over fives (children and adults) inpatient
due to malaria
3.03 5.4 3.24 3.38 3.3
Pregnant women due to malaria . . . . 0
Proportion of Malaria deaths audited 37.1 . 37.12 N/A

With respect to Malaria, high volume level 4 hospitals had the poorest performance. There was improvement
on mortality rates among under fives, which decreased from 3.3% to 2.89% with high volume level 4 hospitals
having the highest rates (4.9%). There was a marginal increase in malaria related mortality in children and
adults (from 3.3% to 3.38%). Data submitted on proportion of malaria deaths audited by high volume
hospitals was insufficient while low volume hospitals performed poorly at 37.1%.
3.2.13 Palliative Care in Hospitals
With the rising burden of non-communicable diseases, cancer has become a cause of concern to the Health
sector. Given the costly nature of treatment, there is need to have quality palliative care services accessible
to all Kenyans. The Ministry has put in place initiatives to integrate palliative care in all level five and 30
level four Hospitals in the counties. This includes establishing a palliative unit, training staff and having the
necessary commodities to provide palliative services. Figure 23 indicates that 69% of level 5 hospitals had
palliative care units and a similar number had the drugs required for palliative care. Overall, palliative care
units were available in 40% of hospitals.
Figure 23: Palliative care units
Table 11 below shows that the number of health workers trained on palliative totalled to 305 while total
patients seen in the units were 622.
Table 11: Palliative services
Indicator (No.)
Low vol.
Level 4
High Vol.
Level 4
Level 5 Total
No. trained on palliative care 3 4 5 305
No. of patients seen in palliative care units 4.4 6 102 622

27
3.2.13 Oral Health
Figure 24 below reveals that there was an outstanding improvement from previous assessment on the
availability of dental cartridges and needles from 25% in previous assessment to 51% this year while there is
a retrogressive trend in availability of 24 hour dental services from 51% to 11.6%. The number of functional
dental units improved on average from 1.0 to 1.13 from the previous assessment.
Figure 24: Oral Health
3.2.14 Disability Mainstreaming
Figure 25: Disability Mainstreaming

Figure 25 indicates that 45% of hospitals compiled with disability mainstreaming standards which was similar
to the previous assessment 46%. This included having functional disability assessment teams/committees in
place, designated a car park for PWDs, disability friendly toilet, disability friendly Walkway, disability friendly
delivery bed (appropriately adjustable in labour ward) and At least 1 wheelchair in OPD.
3.2.15 Gender Mainstreaming
Figure 26: Gender Mainstreaming
Implementation of gender mainstreaming encompasses having a designated focal person for handling
gender issues with an office, relevant Information Education and Communication (IEC) materials available in
the gender office, a designated consultation room for ensuring privacy in handling Sexual and Gender Based
Violence (SGBV) cases and guidelines for screening and care of SGBV survivors available and in use.
Figure 26 shows that there was a general decline in implementation of gender mainstreaming from the
previous assessment with only a third of hospitals achieving targeted indicators.
Table 12: Other performance areas on Gender Mainstreaming
Performance area
Low
Vol L4
High Vol
L4
Level 5
Achievement.
2013/14
2012/13
No. Of Rape cases -Adults 8.9 18.9 48.9 11.8 5.9
Prop. of Rape cases audited – Adults 90.7 77.2 100 87.2 91.7
No. Of Gender Based Violence 18.4 20.7 26.8 19.4 8.7
No. Of child sexual abuse cases 7.8 17.5 34 10.5 7.5
No. committees complying with
affirmative action (at least 30%
representation of either gender)
20.9 13.6 32 19.3 5.5
Table 12 shows that there was an increase in the number of rape cases from 2012/13 to 2013/14 from an
average of 5.9 to 11.8 respectively. Of these rape cases 87.2% of them were audited (a drop of 4.5% from the

29
previous year’s score of 91.7%). Low volume level 4 hospitals received the lowest number of cases concerning
child sexual abuse while the number of gender based violence cases reported were almost the same within
low volume level 4 and high volume level 4 hospitals. High volume level 4 had a lower number of committees
complying with affirmative action than in low volume level 4 hospitals. However, there was an increase in
the average of the overall number of committees that are affirmative action compliant from 5.5 % to 19%.
3.2.16 Rehabilitative health Services
Hospitals are required to offer Physiotherapy Services, Orthopaedic Technology and Occupational Therapy
Services and in addition ensure availability of staff and infrastructure for smooth provision of these services.
On average, 70% of hospitals met requirements for rehabilitative health Services, with 85.7% of high volume
level 4 hospitals complying compared to 41% of Low volume level 4 hospitals. Level 5 had a score of 82.4%
in this area (fig 27).
Figure 27: Rehabilitative Health Services
Table 13: Rehabilitative Health
Performance area
Low Vol
L4
High Vol
L4
Level 5
Achiev.
2013/14
2012/13
No. CTEV (Club Foot) clinics conducted
/ year
11 34.7 43.9 22.1 5.4
total CTEV cases attended 15.4 66.6 218 34.0 18.8
Proportion of clients receiving
orthopaedic appliances
47.3 50.8 86.5 54.0 70.3
Table 13 above indicates a progress in both number of CTEV (Club Foot) clinics conducted and total CTEV
cases attended, while the proportion of clients receiving orthopaedic appliances declined from 70.3% to
54%.
Level 5 hospitals had more than double the total number of CTEV cases attended to by both high volume

level 4 and low volume level 4 hospitals.
3.2.17 Mental Health Services
Provision of proper mental health services in a hospital entails having outpatient mental health services,
Outreach mental health services, separate Male & Female psychiatric wards as well as Substance abuse and
dependence treatment and rehabilitation unit.
Figure 28 above reveals that only 1.7% of Low volume level4 hospitals had Mental Health Services with level
5 hospitals having a higher score on offering mental health services at 50% and high volume level4 at 37.5%.
Figure 28: Mental Health Services

3.2.18 Automation and Efficient Medical Records and Information Systems
3.2.18.1 Automation
Automation entails an integrated electronic system with necessary functions for capturing and reporting
clinical services, supply and financial information among others in the Hospital. For the purpose of this
assessment, hospitals were assessed on having at least four functional modules for the key departments in a
hospital including a billing/financial module, OPD, registration, pharmacy, laboratory and inpatient. Figure 29
below shows that about a half of high volume hospitals (Levels 4&5) were automated while low volume level
4 hospitals had lower automation levels in comparison at 20%. Overall, 35.4% of hospitals are automated.

31
Figure 29: Automation
3.2.18.2 Efficient medical records
Hospitals are required to submit monthly service delivery reports to counties and headquarters through DHIS
and ensure data sharing during monthly management meetings. This is in a bid to ensure data generated in a
facility is used for decision making within the facility and at the higher levels of reporting as well as cultivate
ownership of the data. Figure 30 below shows that only a third of hospitals (33.5%) were meeting these
requirements.
Figure 30: Efficient Medical Records and Information Systems
3.2.19 Human Resource Management and Development
Implementation of performance appraisal system and competence development, including undertaking
Continuous Medical Education (CME) ensures that health workers are equipped with relevant skills to
discharge their duties while also ensuring those who perform well are recognized.

Figure 31: Human Resource Management and development
Figure 31 reveals that High volume level 4 hospitals were the most compliant in human resource development
at 79.2% while Low volume level4 were the least compliant at 52.8%. The overall score was 67.4%.
Table 14: Human Resource Development
Variable Low vol. level 4 High vol. Level4 Level 5 Overall
Use of Performance Appraisal System 64.4 70.8 69.2 65.8
One CME every week for the hospital 61.9 100 84.6 69.7
Evidence of rewards & sanctions 32.2 66.7 69.2 40.7
Table 14 shows that between 64% and 71% of hospitals use the performance appraisal system. In relation
to Continuous Medical Education (CMEs), all high volume level 4 hospitals conducted at least one CME per
week with the overall average being 69.7%. The lowest proportion was with low volume level 4 at 61.86%.
Similarly, low volume level four hospitals had the lowest proportion for evidence of rewards and sanctions.
3.2.20 Hospital Assets
Hospital assets including buildings and equipment should be well maintained to secure their long term use
and ensure they conform to acceptable standards. In view of this, hospitals should ensure that an

33
Figure 32: Hospital Assets
inventory of hospital assets is maintained each financial year, annual preventive maintenance plans are
drawn for equipment and that repair and maintenance of all identified equipment, vehicles
and buildings is done in a timely manner. In addition, all identified idle assets should be disposed off following
the standard procedure.
Figure 32 reveals that High volume level 4 hospitals had the highest score in hospital assets at 76% with Low
volume level 4 having the lowest at 41.1%.
3.2.20 Innovations
Hospitals are required to be innovative in order to improve quality, efficiency and effectiveness in service
delivery. Some areas of innovations include: Energy (solar, wind, bio-gas); Water supply (Roof water
catchment, borehole); Oxygen supply (oxygen concentrators) and income generating activities among others.
Figure 33: Innovations
Figure 33 demonstrates that Kitchen gardens and fish ponds were the most common innovations across all
the levels of hospital.

35
CHAPTER 4: RECOMMENDATIONS
Giventhegeneraldeclineinperformanceofmostindicators,thereisneedforhospitalsandCounties
to improve the quality of services offered; specifically, the following areas need to be addressed;
• Improve financial management and financing level to facilities; There is need to address
gaps in management of finances by providing guidelines on financial management to staff in
the hospitals, and strictly applying these guidelines with a view to improve accountability
and transparency. In addition, at least 100% of FIF collected should be ploughed back to the
facilities.
• Human resource management; County Governments need to ensure that Health workers
are motivated and supported to carry out their respective roles in facilities. In addition,
more staff need to be hired and to address shortages especially for nurses and clinicians.
This will ensure that the sector is moving towards achieving the set human resource norms.
• Strengthen leadership and governance; Hospital managers need to be equipped with
requisite skills through specific training in leadership and management. Management
meetings ought to be held regularly in hospitals to ensure emerging issues are addressed in
a timely manner.
• Improve management of information; Data from hospitals should be properly shared and
used within the hospital to make informed decisions. In addition, there is need to streamline
reporting mechanisms both to the sub counties, counties and National level through the
existing platform e.g. DHIS.
• Institute mechanisms to ensure services are provided in a timely manner in public facilities;
including having regular surveys to establish waiting times, improving efficiency in order to
serve clients within a shorter time and having sufficient number of staff to attend to patients.
• Improve quality of patient records; This is especially for outpatient records to ensure
patients are well managed.
• Improve quality of care; Weekly major ward rounds, diabetic clinics and quality of nursing
care need to be improved. Daily ward rounds need to be implemented in all low volume
hospitals, as this was evidently not being fully implemented.
• Invigorate referral services in Counties; Both upward and downward referral services need
to be supported especially in terms of resources (Financial & Human). This will decongest
larger hospitals while increasing access to specialized services to all Kenyans. This also
includes improving preparedness of hospitals to handle emergencies.
• Improve laboratory and forensic services; Forensic services, including number and quality
of functional mortuaries need to be improved in most hospitals. Availability (hours services
are available), number of tests and management of blood in hospitals needs to be enhanced.
• Strengthencommoditiesmanagement;Thereisneedtoenhanceavailabilityofcommodities
in hospitals, including drugs and non-pharmaceuticals. Pharmacy services should be

improved so that patients can access drugs from hospitals at all times, especially in high
volume hospitals.
• Infection prevention in hospitals, including availability of water, soap, toilets, proper
management of waste was a weak point. Barrier nursing was weakly implemented. Given
the existing threat of Ebola in the country, there is need to ensure these areas are given
proper attention to prevent spread of diseases in our hospitals.
• Improve the standard of newborn units; Functional incubators need to be increased in most
hospitals as well as have nurses dedicated to the unit.
• Improve quality of maternal services; Management of labour, delivery, newborn and post
natal mothers were among the poorest managed areas, including proper documentation.
There is need to urgently improve these areas for the free maternity services to add value
to Kenyans.
• Mainstream health gender in hospitals; With the increase in gender related violence cases,
hospitals need to institute proper structures to ensure these cases are attended efficiently
to prevent further suffering for the victims.

37
ANNEXES
Annex 1: Performance by Hospitals and Counties
Facility Name County Overall % Score
Marigat Sub-district hospital Baringo 29.7
Karbanet DH Baringo 56.7
ELDAMA RAVINE CH Baringo 50.9
Karbatonjo sub-county hospital Baringo 33.7
Chemolingot sub-district hospital Baringo 19.1
Baringo Average 38.0
LONGISA Bomet 100.9
Sigor Sb Dist Hosp Bomet 21.6
Bomet Average 61.3
KIMILILI DISTRICT HOSPITAL Bungoma 54.2
WEBUYE D/H Bungoma 60.3
MT.ELGON Bungoma 40.4
BUNGOMA CRH Bungoma 46.5
Bungoma Average 50.3
BUSIA D/H Busia 50.5
KOCHOLYA D Busia 28.4
Busia Average 39.5
TOT SCH Elgeyo Marakwet 20.5
TAMBACH Elgeyo Marakwet 32.0
ITENDH Elgeyo Marakwet 50.7
Kamwosor sub-district hospital Elgeyo Marakwet 21.1
Kaptarakwa Elgeyo Marakwet 27.3
CHBIEMENIT Elgeyo Marakwet 33.9
KOCHOLWO SDH Elgeyo Marakwet 11.5
Elgeyo Marakwet Average 28.1
Embu Level 5 Embu 79.1
Runyejes DH Embu 59.8
Kianjokoma Embu 57.5
ISHIARA Embu 57.4
Siakago Hospital Embu 59.5
Embu Average 62.6
Modogashe Garissa 37.7
Balambala Sub Dist Hosp Garissa 37.4
Ijara Sub County Hosp Garissa 40.2
Garrisa county referral hospital Garissa 61.6
Bura sub-county hospital Garissa 25.9
Daadab Garissa 37.7

Garissa Average 40.1
HomaBay County Referral Homabay 72.2
RACHUONYO Homabay 57.3
Homabay Average 64.8
ISIOLO COUNTY HOSPITAL Isiolo 54.5
GARBATULLA SCH Isiolo 27.7
Isiolo Average 41.1
Kajiado Kajiado 51.4
Ngong SDH Kajiado 71.1
OLOITOKTOK Kajiado 49.3
Kajiado Average 57.2
LUKUYANI Kakamega 48.5
KAKAMEGA Kakamega 73.9
BUTERE Kakamega 46.6
MALAVA Kakamega 51.0
LUMAKANDA Kakamega 52.5
Kakamega Average 54.5
KERICHO Kericho 82.8
KAPKATET Kericho 88.1
Londiani Dist Hosp Kericho 50.9
Kericho Average 73.9
Igegania Kiambu 34.0
Kihara DH Kiambu 44.2
Gatundu DH Kiambu 77.6
Thika Level 5 hospital Kiambu 73.9
Ruiru Kiambu 52.0
Tigoni District Hospital Kiambu 62.4
Nyathuna Kiambu 39.6
Kiambu DH Kiambu 65.7
Kiambu Average 56.2
MALINDI Sub-County Hospital Kilifi 64.8
Mariakani Kilifi 55.7
KILIFI COUNTY HOSPITAL Kilifi 65.6
Kilifi Average 62.0
Kianyaga Kirinyaga 47.5
Kimbimbi sub-county hospital Kirinyaga 47.9
Kerugoya County Hospitals Kirinyaga 56.6
Kirinyaga Average 50.6
Kisii L5 Hosp Kisii 58.3
IYABE SDH Kisii 30.5
Kisii Average 44.4
Jaramogi Oginga Ondinga RH Kisumu 81.7

39
Kisumu East District hospital Kisumu 67.2
Kisumu Average 74.5
KITUI D/H Kitui 71.1
Mwingi District Hospital Kitui 40.7
Kitui Average 55.9
Kinango dist Hosp Kwale 49.4
MSAMBWENI DH Kwale 51.8
Kwale Dist Hosp Kwale 50.4
Kwale Average 50.5
Nanyuki Laikipia 73.8
Nyahururu sub-county Laikipia 77.2
rumuruti sub county Laikipia 48.1
Laikipia Average 66.4
Mwala Dist Hosp Machakos 53.9
Machakos Hosp Machakos 86.8
Kangundo Hosp Machakos 63.5
Machakos Average 68.1
Tawa Makueni 43.5
Kibwezi Sub Dist Hosp Makueni 47.3
Mbooni Hosp Makueni 54.6
Makindu Dist Hosp Makueni 62.4
SULTAN Hamud Hosp Makueni 41.4
Makueni Average 49.8
madera County Hospital Mandera 44.9
Takaba sub-county referral hospital Mandera 33.6
Mandera Average 39.2
MARSABIT COUNTY HOSPITAL Marsabit 50.1
Marsabit Average 50.1
Mikumbune sub-county hospital Meru 40.0
Meru Level 5 Meru 78.0
MIATHENE DIST. HOSP Meru 57.2
KIBIRICHIA SDH Meru 36.3
Mikinduri Meru 47.2
NYAMBENE SCH Meru 58.5
Timau sub-county hospital Meru 37.2
GITHONGO SCH Meru 47.3
KANYAKINE SCH Meru 55.0
Meru Average 50.7
Migori DH Migori 72.2
Rongo DH Migori 56.4

Migori Average 64.3
Tudor District Hospital Mombasa 41.2
Likoni Sub District Mombasa 50.8
Coast P.G.H Mombasa 68.5
portreitz DH Mombasa 51.8
Mombasa Average 53.1
Maragua Sub County Muranga 78.2
Muriranjas Sub County Muranga 63.8
Muranga County Muranga 72.0
Muriranjas county Muranga 64.3
Muranga Average 69.6
mbagathi Nairobi 63.6
Mama Lucy Kibaki Hosp Nairobi 54.9
PUMWANI MATERNITY HOSPITAL Nairobi 48.1
Nairobi Average 55.5
Molo Dist Hosp Nakuru 71.3
Nakuru County Referral Hosp Nakuru 100.5
Naivasha County Referral Hosp Nakuru 87.8
OLENGURUONE SUB-DISTRICT Nakuru 75.0
Gilgil Sub Dist Hosp Nakuru 72.7
Nakuru Average 81.4
KAPSABET Nandi 61.5
NANDI HILLS Nandi 67.0
Nandi Average 64.2
Narok County Referal Hosp Narok 97.0
Transmara Dist Hosp Narok 85.2
Narok Average 91.1
Manga DH Nyamira 35.5
Nyamira District Hospital Nyamira 57.4
Nyamira Average 46.4
OLKALAO J.M KARIUKI Nyandarua 66.2
ENGINEER Nyandarua 39.5
Nyandarua Average 52.8
Nyeri Nyeri 77.0
Karatina Nyeri 74.0
Mukurweini Nyeri 58.0
Othaya Nyeri 58.5
Nyeri Average 66.9
Maralal Dist Hosp Samburu 63.6
Samburu Average 63.6
BONDO SCH Siaya 50.8
SIAYA DH Siaya 69.6

41
Siaya Average 60.2
WUNDANYI S. D.H Taita Taveta 25.2
Wesu District Hospital Taita Taveta 42.4
TAVETA SUB DISTRICT HOSPITAL Taita Taveta 63.5
Moi Voi County Hosp Taita Taveta 55.1
Mwatate Sub County Hosp Taita Taveta 25.8
Taita Taveta Average 42.4
Hola District Hospital Tana River 58.5
Tana River Average 58.5
Kibunga sub-county hospital Tharaka Nithi 34.7
MAGUTUNI SCH Tharaka Nithi 60.5
MARIMANTI SCH Tharaka Nithi 48.8
Tharaka Nithi Average 48.0
ENDEBESS SCH Trans Nzoia 44.1
KAPSARA DIST. HOSP Trans Nzoia 56.5
KITALE DIST. HOSP Trans Nzoia 66.1
SABOTI SDH Trans Nzoia 38.3
Trans Nzoia Average 51.2
LOKITAUNG SDH Turkana 13.3
LOPIDING SDH Turkana 14.1
LODWAR DH Turkana 42.3
Turkana Average 23.2
Huruma Sub District Hospital Uasin Gishu 33.9
Burn Forest SDH Uasin Gishu 20.7
Ziwa Sub County Hospital Uasin Gishu 58.8
Moi teaching and Refferal Hospital Uasin Gishu 85.5
Uasin Gishu District Hospital Uasin Gishu 45.8
Uasin Gishu Average 48.9
EMUHAYA Vihiga 39.3
VIHIGA Vihiga 64.9
Vihiga Average 52.1
Wajir County Referral Hosp Wajir 56.8
Habasweni sub-county hospital Wajir 31.2
Grifh DH Wajir 52.6
Wajir Average 46.8
KACHELIBA SDH West Pokot 19.3
CHEPAREKIA SDH West Pokot 18.5
SIGOR SDH West Pokot 16.9
KAPENGURIA DH West Pokot 53.3
West Pokot Average 27.0
Grand Average 52.8

43
Annex 2: Regional Specific brief Reports from the monitoring teams
CENTRAL REGION
Counties covered
Nyeri; Nyandarua; Laikipia; Kirinyaga; Murang’a
Facilities Covered
1. Nyeri County- Nyeri County referral, Othaya SCH, Mukurweini SCH , Karatina SCH, Kangocho
Community Dispensary
2. Nyandarua county- Engineer SCH, J M Kariuki (Olkarau) County hospital
3. Laikipia County- Nyahururu SCH, Rumuruti SCH, Nanyuki County Hospital.
4. Kirinyaga County- Keruguya County, Kianyaga SCH, Kimbimbi SCH, Thiba Health centre.
5. Murang’a County- Murang’a CH, Muriranja SCH, Maragua SCH, Kirwara SCH and Sabasaba HC.
Leadership Issues
 InallthecountiestheHealthManagementCommitteewasyettobeputinplaceexceptinNyandarua
County.
 In Kirinyaga County it was reported that HMC had been appointed and were undergoing induction
during our visit.
 All the hospitals visited had active hospital management teams.
FIF and Hospital AIEs
 Only hospitals in Nyeri County were getting 100% of the FIF and were also given additional AIE
from the county.
 Hospitals in Nyandarua County were ploughing back 100% of FIF but they had not received any
AIE from county.
 Hospitals in Laikipia, Kirinyaga and Murang’a counties were not able to plough back 100% FIF
and they have also not received any AIE from the county.
Free maternity funds
 All Counties were getting free maternity refund.
 Hospitals in Laikipia, Kirinyaga and Muranga counties were not able to utilize the free maternity
funds.
Staffing
 Generally there was reported acute shortage of human resource for health across all Counties.
 Health workers expressed concerns about their career progression and training opportunities.
Key issues
 Only Olkarau, Karatina and Kerugoya hospitals had conducted customer satisfaction and waiting
time survey.
 Majority of the hospitals did not have ‘time’, ‘name’ and ‘signature’ of the clinicians indicated
in the patients’ notes.
 History taking of the patient was below par in some of the patients’ files.
 Nursing care plans were not present in most of the patients’ files.
 Hospital menu was not displayed in the wards in most of the facilities visited.
 Most of the hospitals were ill prepared for emergencies and timely response.

 In most hospitals post natal examination of mothers and new born were not documented in
the files.
 Health centres and dispensaries
 Thiba Health centre in Kirinyaga County were not receiving free maternity refund and patients
were buying non pharmaceutical and drugs to be attended to.
 Despite being gazetted as a health centre, it (Thiba) continues to receive the dispensary kit
hence keep running out of stock for essential commodities forcing the patient to buy them.
COAST REGION
Number of Counties in the region - 5
Number of Health facilities;
• Level 4 and Level 5- 20
• HMTs – in place but demoralized, majority of staff feel they should be under the national
government.
• Health workers claim not to have seen or felt any positive impact of devolution
Facilities visited
• A total of 22 Health facilities were visited and evaluated.
• Two facilities, Lamu and Mpeketoni hospitals were visited on Monday 16th
June 2014 but could
not be evaluated due to the prevailing unfavourable environment following a terrorist attack
the previous evening.
• Hospitals (Level 4 and Level 5) ---15; Health centres ---5; Dispensaries ----3
• Out of the 15 hospitals visited only 3 had their Medical Superintendents physically present. It
was noted that doctors make local arrangements to be absent leaving one or two to cover the
hospital.
Findings
• Two facilities, Taveta sub-county hospital and Kinango sub county hospital were difficult to
reach due to very poor road network.
• In almost all the hospitals visited in this region the service delivery charters:
 Were in one language;
 Had the contact address but no contact person;
 Had not been revised;
 Some facilities did not have departmental service delivery charters; and
 Majority of the facilities had their suggestion boxes rarely opened, and where this was
done, no records were filed.
• None of the facilities visited had done a survey on waiting time in the preceding one year
• Quality clinical care especially by clinical officers was extremely poor by all standards.
• Hospitals’ emergency preparedness and timely response was generally poor in this region.
• No emergency response teams
• No mass casualty incidence plans
• No fully equipped and updated emergency trays as required.
• Supervision of facilities by the counties appears inadequate.
• Commodity supply management system seems to be generally weak
• Not all tracer drugs and non pharmaceutical items are in stock.
• Automation: Very few hospitals have an integrated electronic system in place
• Many pharmacy departments have computers (donations) with software to dispense and
monitor ARVs only.

45
• Many pharmacy departments are not reconstituting children’s powder medicines before
dispensing to clients.
• Majority of the hospital compounds are generally clean and well maintained
 All wards and clinical departments in many of the facilities do not have sets of 3 colour
coded bins
 Almost all facilities have reliable source of water and power supply.
• Adherence to safety guidelines in most of the facilities visited is minimal
• Almost all facilities visited use screens for barrier nursing
• None has a barrier nursing notice
• They have no single use aprons
• Majority of all visited facilities have archaic fire fighting equipment with no SOPs and no marked
fire exits, and others have none.
• Majority of all visited hospitals are not fully compliant on disability mainstreaming
• Gender mainstreaming has not taken root in almost all facilities.
• Availability of occupational therapy services is at level 5 hospitals and very few level 4 hospitals.
• Mental health services are generally provided in OPD and patients referred for specialized
treatment
Key issues
 Almost all facilities in this region got their last AIE (3rd
quarter) when the county director had
the authority to issue.
 HRM&D – CMEs not documented.
 PAS for 2013/014 FY is not in use and no evidence of rewards or advisory committee meetings.
 Hospital planning, management and governance - quarterly and monthly meetings (where
held) are irregular and inadequately documented.
 All FIF collections and reimbursements (HSSF, free maternity) for all health facilities are banked
in one pool account in the county.
Key issues – Action points
o Performance Appraising of officers - facility in charges to ensure that it is done as required.
o Training-Facility training committees to discuss, regulate and recommend training requests
(Action-Facility in charges)
o Funding for facilities –Facility incharge and HAOs to follow up with the county government.
o Quality case management - (Action-Facility in charges)
o Strengthen internal supervision of hospitals (Action - Facility in-charge).
NYANZA REGION
Kisumu County
Visited facilities: Jaramogi Oginga Odinga TRH, Kisumu East DH and Rabuor (Model) Health Centre.
Key Findings:
1. Diagnostic (CSF) tests for Meningitis and 24-hour dental services are still not available at JOOTRH
despite previous advice to the hospital administration;
2. While Specialized Expertise is supposed to be where there is Inpatient Care, it is not the case at
JOOTRH or Kisumu East DH (KEDH); the psychiatrist sits at JOOTRH (where outpatient services
are) while inpatient psychiatric care is at KEDH;
3. Rabuor Health Centre had 4 innovations, 2 of which have raised Skilled Birth Attendance uptake
from 19 to 54 deliveries in the last 6 months.

Homa Bay County
Visited facilities: Homa Bay County Referral Hospital, Rachuonyo Sub County Hospital and Ober
Health Centre
Key Findings:
1. A recent change of leadership was negatively affecting service delivery performance of Homa
Bay CRH
2. Homa Bay CRH had successfully eliminated the stench from decomposed/police bodies using
Calcium-based Chlorine powder –a notable innovation.
3. Aside from patients’ care level being low at Rachuonyo SCH, the hospital’s compound
(cleanliness) may also need some attention;
4. Ober health centre is a model HC yet there is no RCO posted there; the facility is managed by
nurses only.
Migori County
Visited facilities: Migori CRH, Rongo Sub C Hospital, Uriri Health Centre and Suna Ragana Dispensary.
Key findings:
1. A vibrant and focused County Health Services team;
2. Migori CRH – Unplanned facility layout leading to poor access to services, e.g. mortuary (no
formal access);
3. Rongo SubCH - Inadequate key infrastructure affecting services, e.g. Theatre, New Born Unit,
Mortuary, etc;
4. Suna Ragana Dispensary - Lack of documentation of services offered, due to poor supervision;
5. Uriri Health Centre - Leadership and governance is wanting.
Kisii County
Visited facilities: Kisii Level 5 Hospital, Iyabe Sub-County Hospital, and Bitare Dispensary
Key findings:
1. Kisii L5 H– Generally, the quality of services in the hospital have deteriorated, e.g. maternity,
NBU, paediatric and surgical wards, etc;
2. Eyabe SCH – Infrastructure and services are at KEPH Level 3, yet this is a hospital;
3. Bitare Dispensary – Has an unsuitable and wrongly placed labour room (Maternity).
Nyamira County
Visited facilities: Nyamira DH, Manga DH and Ting’a HC; also visited was Nyamaiya HC on a Saturday
(14.6.14) and found were many patients waiting to be served by the only nurse on-duty, hence
could not be assessed;
Key findings:
1. Nyamira DH - Generally, leadership & management levels of the facility are low;
2. Manga DH – Un-upgraded infrastructure (to a hospital) and poor leadership & management;
3. Ting’a HC – Leadership and Management levels are low
Siaya County
Visited facilities: Siaya DH, Bondo DH, Gobei HC and Bar Agulu Dispensary;
Key findings:
1. Siaya DH – Hospital management committee meetings not consistent.
1. Congested and poorly managed mortuary (stench)
2. Bondo DH – Inadequate infrastructure which limits the facility from running as level four

47
3. Gobei HC – Low levels of leadership and governance ( inadequate management skills)
4. Bar Agulu Dispensary – High workload
Cross-Cutting Issues
1. Facility leadership/governance – poor
2. Availability of EMMS – generally excellent!
3. HRH Staffing levels – still low in all counties!
4. Infrastructure status – poor in upgraded hospitals!
5. Quality of devolved health services – deteriorating
6. County government support – poor.
7. Free maternity services – numbers increased but quality has deteriorated!
8. Referrals from Homa-Bay and Migori counties are frustrated at Kisii level 5, hence the delay to
address emergencies.
Recommendations
 The Administrator, JOOTRH should ensure that testing for Meningitis and 24-hour dental
services are available;
 The Director, Kisumu CHS should ensure that the psychiatrist is based at Kisumu East DH where
there are inpatient mental health services;
 All county governments are obliged to ensure a strong coordination of the existing health
systems through a sustainable good leadership and management in all the hospitals and
primary facilities in the region;
 Capacity in health systems management is low, therefore need for more trainings
 Updating of Bank reconciliations delayed by district treasuries and therefore need for regular
reconciliations
 Acknowledge
 For the success of the exercise, we cannot fail to acknowledge the support received from the
Director, Kisumu CHS and all other staff from the health facilities visited.
LOWER EASTERN: KITUI, MAKUENI & MACHAKOS COUNTIES
Commodities
Adequacy of commodities:
Pharmaceuticals: adequate
Non-pharmaceuticals: adequate
Power medicines reconstitution was not done in the facilities
Bin cards: Up to date
Delivery notes: well filed
Upgrading of the Facility
Upgrading of facility
Most of the health centres have been upgraded to sub-county hospitals.
Partners are supporting some key elements e.g. waiting time survey (AMREF) and payment of
stipend to the community health workers
Most of these facilities have shortage of equipments
Environment
Cleanliness was acceptable
Layouts: organised, directions lacking,
Disabled facilities: except Machakos level 5, others inadequate
10% tree acreage: achieved
Flowers well manicured

Waste management: proper
Incinerators
Placenta pits
Ash pits
Water supply: challenge in Kitui & parts of Makueni
Power supply: most connected to power grid & with alternative power (Generator/solar)
Emergency Preparedness and Timely Response
Ambulance:
Most have ambulances
Those without have access to one.
Too many ambulances in some counties have increased costs (fuel and staff).
Some cases: ambulances (2 months old) vandalised (looks like a matatu without medical equipment)
Emergency response teams/ plans: not established
Crash box: Machakos excellent, Makindu - disorganized
Emergency tray: present in most but incomplete
Mass Incident casualty plan: Machakos only
Staffing
Severe staff shortages: all cadres especially nurses
In Makueni County a laboratory technician was seeing patients when we visited the facility
(Kambimawe Dispensary)
Staff attitude: good
Staff morale: average
Job insecurity
Frustration by county
Efficient Health Care Financing
FIF (facility Improvement fund)
Most FIF accounts retained at the facility level
Few are depositing the FIF at the county government account.
S11 generated by the county e.g. Machakos County
AIEs (authority to Incur Expenditure)
Some facilities were given power by the county governments to incur expenditure but there are still
problems in payments, e.g. Kangundo
In others no any AIEs for last 1 year now e.g. Kitui hence facilities forced to use money from the
source i.e. the facility
Infrastructure
Most of the county and sub-county hospitals are putting up new structures e.g. theatres, mortuary,
kitchen, wards, Laundry.
Special attention is needed for Mwingi hospital. The all facility needs a facelift.
Child Health
New born unit: not present in all level 4
Most of the facilities are lacking
Baby cots: babies sharing
Incubators: babies sharing
resuscitaire,
Warmer

49
Emergency trays
Separate Nursery laundry facilities
Service Charter/ Clinical Quality Care
Service charter
Not in two languages; and
Do not have address of contact person
Clinical quality care:
Most of the patient notes were incomplete, no signing and indication of clinician name.
Treatment sheets: not signed, no drug duration
Nursing plans: present
Nursing cardex: up to date
Palliative care /Gender based violence /Disability mainstreaming /Youth friendly services
Palliative care
Only two facilities had two staffs trained in palliative care.
A lot need to be put in palliative care
Gender based violence
No focal persons.
Disability mainstreaming
Still lagging behind
No disability friendly pathway, toilets etc.
Youth friendly services
Not available in most of the facilities
Challenges
There is lack of co-operation from some counties.
Difficulties to do this activity over weekend
Recommendation
o Employment more staff: especially nurses
o Cost rationalization: e.g. excess ambulances funds to hire nurses.
o Equipment purchase expensive but hiring may be a good alternative
o Infrastructure and rehabilitation of facilities should be done.
o Water Boreholes and piped water should be made available to the facilities
o Water harvesting should be done at the facility level
o Regular supervision should be done by county team
o Better value for money target measures to evaluate counties. e.g. ambulance cost/
evacuation
NAIROBI REGION
• Nairobi County
• Hospitals
– Mama Lucy Kibaki Hospital
– Mbagathi District Hospital
– Pumwani Maternity Hospital
• Primary healthcare Facilities
– Loco Dispensary
– Westlands Health Centre

• Kiambu County
• Hospitals
– Thika Level 5 Hospital
– Kiambu District Hospital
– Gatundu District Hospital
– Tigoni District Hospital
– Igegania SDH
– Kihara SDH
– Nyathuna SDH
– Ruiru SDH
• Primary Health Facilities
– Githunguri Dispensary
– Riabai Dispensary
– Kajiado County
• Hospitals
– Kajiado District Hospital
– Loitokitok District Hospital
– Ngong SDH
• Primary Health Facilities
– Kimana health Centre
– Ilbissil Health Centre
• Kajiado County
• Kajiado County is a county in the Rift valley Province of Kenya. It has a total population of
687,312; Households and covers an area of 21,902.9 SQ. KM.
• Some Strengths of Kajiado County include:
• Natural resources as wildlife, open grasslands, wooded bush lands, open bushes, woodlands
and forests.
• Main Economic Activities include pastoralist livestock herding, tourism, agriculture and urban-
life activities like cattle trading.
• General Observations:
• Leadership and management:
– HMC meetings held were few and most had their terms expired
– However, most HMTs held their meetings regularly except in Igegania where
management meetings were not satisfactory
• General Observations:
Human Resource: Availability of HMT/staff on duty, Team work, Internal
supervision of hospital
– Nairobi region: Formerly MOH and Nairobi County Council have not yet adequately
integrated
– Inadequate in all areas
– PAS is conducted in most of the facilities visited
– Staff were available on duty in the stations visited
– Internal supervision were inadequate as well as external supervision
– Team work among the staff in the various departments was good
– General Observations: leadership and management
• Finance:
– Bank Reconciliation of some Hospitals were not up-to-date e.g. Kiambu county where

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