Primary Facilities Assessment Level Report 2014 _2

MINISTRY OF HEALTH
STATE OF HEALTH SERVICE DELIVERY
SEPTEMBER 2014
Health Sector Monitoring & Evaluation Unit
An Assessment Report
for Primary Level Facilities

ii An Assessment Report for Primary Level Facilities
State of Health Service Delivery

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An Assessment Report for Primary Level Facilities
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. However this was
the first such exercise to be carried out in the primary care facilities. Hence the monitoring exercise was
important in ensuring these facilities that may not have benefited as much earlier on, 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 FIGURES.............................................................................................................................................. ix
LIST OF TABLES ................................................................................................................................................ xi
LIST OF ACRONYMS ...................................................................................................................................... xiii
EXECUTIVE SUMMARY.................................................................................................................................... xv
CHAPTER 1: INTRODUCTION...................................................................................................................1
1.1 Background .............................................................................................................................................. 1
1.2 Objectives and scope of the reforms assessment exercise...................................................................... 1
CHAPTER 2: METHODOLOGY..................................................................................................................3
2.1 Assessment Framework............................................................................................................................ 3
2.2 Process .................................................................................................................................................... 3
2.3 Sample Size............................................................................................................................................... 3
2.4 Data Processing and Analysis .................................................................................................................. 3
CHAPTER 3: PRIMARY LEVEL FACILITIES PERFORMANCE..........................................................................5
3.2 Compliance with Service Delivery Charter............................................................................................... 6
3.2 Timely delivery of health services ........................................................................................................... 6
3.3. Quality Clinical care (OPD)....................................................................................................................... 6
3.4 Improved Nutrition care........................................................................................................................... 7
3.5 Outreach services..................................................................................................................................... 8
3.6 Community Involvement and Participation.............................................................................................. 8
3.7 Emergency Preparedness and Timely Response in Facility...................................................................... 9
3.8 Diagnostic and Blood Services.................................................................................................................. 9
3.9 Commodity supply Management........................................................................................................... 10
3.10 Child Health ........................................................................................................................................ 11
3.11 Maternal Health ................................................................................................................................. 13
3.12 Disability Mainstreaming ..................................................................................................................... 16
3.13 Gender Mainstreaming........................................................................................................................ 16
3.14 Quality of Mental Health ..................................................................................................................... 17
3.15 Improved Facilities Environment ......................................................................................................... 17
3.16 Adherence to safety guidelines............................................................................................................ 19
3.17 Automation .......................................................................................................................................... 20
3.18 Efficient Records and Information System............................................................................................ 20
3.19 Human Resources Management.......................................................................................................... 20
3.20 Facility assets........................................................................................................................................ 21
3.21 Efficient Healthcare Financing ............................................................................................................. 22
3.22 Facility Planning, Leadership and Management ................................................................................. 22
3.23 Innovations........................................................................................................................................... 23
CHAPTER 4: RECOMMENDATIONS AND CONCLUSION...........................................................................25
4.1 Recommendations.................................................................................................................................. 25
4.2 Conclusion.............................................................................................................................................. 26

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LIST OF FIGURES
FIGURE 1: IMPLEMENTATION OF SERVICE DELIVERY CHARTER 6
FIGURE 2: QUALITY OF CLINICAL RECORDS (OPD) 7
FIGURE 3: NUTRITION SERVICES 8
FIGURE 4: OUTREACH SERVICES 8
FIGURE 5: COMMUNITY SERVICES 9
FIGURE 6: EMERGENCY PREPAREDNESS AND RESPONSE 9
FIGURE 7: AVAILABLE LABORATORY SERVICES 10
FIGURE 8: COMMODITY SUPPLY MANAGEMENT 10
FIGURE 9: NEWBORN CARE 12
FIGURE 10: AVAILABLE VACCINES AND SUPPLEMENTS 12
FIGURE 11: HOURS SKILLED BIRTH ATTENDANTS’ AVAILABLE 14
FIGURE 12: FAMILY PLANNING 15
FIGURE 13: DISABILITY MAINSTREAMING 16
FIGURE 14: GENDER MAINSTREAMING 17
FIGURE 15: FACILITY POWER SOURCE 19
FIGURE 16: BARRIER NURSING 19
FIGURE 17: PERFORMANCE APPRAISAL SYSTEMS 20
FIGURE 18: FACILITY ASSETS 21
FIGURE 19: HEALTH CARE FINANCING 22
FIGURE 20: PLANNING, MANAGEMENT & GOVERNANCE 22

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LIST OF TABLES
TABLE 1: STAFFING IN PRIMARY FACILITIES......................................................................................................5
TABLE 2: HEALTHCARE FINANCING- PRIMARY FACILITIES.......................................................................................5
TABLE 3: SERVICE DELIVERY DATA (OPD)..........................................................................................................7
TABLE 4: NEONATAL RESUSCITATION...............................................................................................................11
TABLE 5: IMMUNIZATION SERVICE DELIVERY DATA.........................................................................................13
TABLE 6: GROWTH MONITORING....................................................................................................................13
TABLE 7: MONITORING OF LABOUR................................................................................................................14
TABLE 8: ANC SERVICES...................................................................................................................................14
TABLE 9: ANC SERVICE DELIVERY DATA............................................................................................................15
TABLE 10: AVAILABLE GUIDELINES, POSTERS AND JOB AIDS...........................................................................15
TABLE 11: REPORTED DELIVERIES....................................................................................................................16
TABLE 12: SGBV SERVICE DELIVERY DATA........................................................................................................17
TABLE 13: MENTAL REFERRAL CASES SERVICE DELIVERY DATA.......................................................................17
TABLE 14: IMPROVED FACILITY ENVIRONMENT..............................................................................................18
TABLE 15: FIRE SAFETY....................................................................................................................................19
TABLE 16: EFFICIENT RECORD SYSTEMS..........................................................................................................20
TABLE 17: KEY STAFF CLINICAL OFFICERS AND NURSES...................................................................................21

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LIST OF ACRONYMS
AIDS Acquired Immunodeficiency Syndrome
ANC Antenatal Care
ARVs Anti-Retroviral
BCG Bacille Calmette-Guerin
CME Continuous Medical Education
DOT Directly Observed Therapy
GOK Government of Kenya
HIV Human Immunodeficiency Virus
IPT Intermittent Preventive Therapy
ITN Insecticide Treated (Mosquito) Nets
MDGs Millennium Development Goals
OPD Outpatient Department
PMTCT Prevention of Mother To Child Transmission
SOPs Standard Operation Procedures
SP Sulphadoxine Pyrimethamine
TB Tuberculosis
TT Tetanus Toxoid
VIA/VILLI Visual Inspection in Acetic Acid/Visual Inspection with Lugose Iodin

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EXECUTIVE SUMMARY
The Health Sector Reforms supervision exercise was undertaken in June 2014 based on the ministry’s norms
and standards for selected indicators across selected hospitals, health centres and dispensaries in the
Country. The exercise was carried out in collaboration with the County government to establish the progress
of health services under the devolved government and with a view to continually improve service delivery.
This report therefore gives a detailed analysis of the performance in primary health facilities.
KEY RESULTS
Compliance with Service delivery charters – The level of implementation of the service delivery charters in
primary level facilities is at 33.3% with an average 14.4% having departmental charters and characterized
by lack the key components. For example, only 9.1% had a contact person and address and only 10.6% had
the charter in two languages.
Timely Delivery of Health Services (Waiting time) – A majority 87.9% of primary level facilities had not
conducted a survey in the previous six months to inform waiting time. Without this, it would be difficult to
inform average waiting times in the service charters.
Quality Clinical care – On average, health centres scored 8.2% while dispensaries scored 4.3% as per the
evaluation tool. For example, full patient history, was satisfactory in only 7.5% and 3.8% of health centres
and dispensaries respectively. There were no records signed, dated and timed by clinicians in all sampled
health centres and dispensaries. A similar scenario was observed for the treatment sheet in dispensaries
while only 5% of the treatment sheets were clear and signed in health centres.
Improved Nutritional care – From the facilities assessed, 80% of primary level facilities conducted nutritional
assessment with 70% of them offering basic nutritional interventions such as counseling and diet therapy
and 60.6% further offering support with supplemental feeds. Availability of guidelines to standardize care
and ensure quality was in place for 56% of the facilities.
Outreach services - Of the outreach services assessed, over half of the facilities offered these services
with defaulter tracing scoring highest at 80.3%. This is mainly carried out to trace patients defaulting on
appointments for critical services such as immunization, TB patients and those on antiretroviral therapy
so as to improve adherence and reduce drug resistance among the population. However, mental health
outreach services were lowest at 19.7%.
Community Involvement and Participation - Community involvement and participation through campaigns,
dialogue days, action days and community mobilization meetings is in over 60% of the primary facilities
assessed. However, the number of community units linked was only in 33.3% of the facilities.
Emergence preparedness – On average emergency trays in all OPD consultations rooms, injection rooms and
maternity were completely available in only 26.8% of sampled facilities. The availability of fully equipped
crush box was only in 4.5% of the sampled facilities. In addition only 3.0% of primary facilities had a written
emergency plan and only 7.6% had a functional emergency response team in place.
Diagnostic services – The major diagnostic tests such as malaria, blood glucose, urinalysis and stool
examination are widely available varying between 65% to 92% in both health centres and dispensaries for
the individual tests. However, the full haemogram test was only available in 10.0% and 7.7% of the health
centres and dispensaries respectively. It was also noted that, despite an 85.0% availability of blood glucose
test in health centers, the same was only available in 23% of dispensaries.
Commodities and supplies – Less than 50% of the facilities had all the tracer commodities in stock with
47.5% and 26.9% availability of the 16 tracer drugs in health centres and dispensaries respectively. Similarly,
50% of health centres had all the 16 tracer non-pharmaceuticals in stock while only 19.2% of health centres

xvi An Assessment Report for Primary Level Facilities
were fully stocked indicating a major challenge for dispensaries since tracer commodities must be available
in all facilities at all times for efficient delivery of quality services. Regarding expiries, there was a 15.0%
and 11.5% of expired drugs in health centres and dispensaries respectively which was way higher than the
recommended level of 5%.
Child health – Majority of the primary level facilities do not have sufficient equipment for newborn
resuscitation and only 33.3% of the sampled facilities had. However, vaccines are widely available in over
90% of facilities. In addition, a 100% of the health centres sampled had a cold chain infrastructure and
95.8% of dispensaries. Defaulter tracing for children under immunization within the first year of life was in
place in over 85% of facilities. However, documentation on growth monitoring for babies was poor with all
individual indicators below 20%. New born care was worst in dispensaries which scored 3.8% in only two
indicators while health centres scored below 25% for all indicators.
Maternal health – Analysis showed that 82.5% of health centres have a skilled birth attendant at all times
(24 hours, 7 days a week) at the facility, but only 34.6% of dispensaries have. Monitoring of labour was
poor at an average of 24.8%. Over 80% of the primary facilities have supplements available. ANC services
are generally available in over 60% of the facilities with lowest service being post abortive care available
in only 36.4% of primary facilities. Cervical cancer screening was available in 54.5% of facilities and at least
66.7% provided clinical breast examination. Guidelines, posters and job aids were generally available in
over 68% of facilities and family planning methods are widely available in the facilities assessed. A further
analysis shows that the health centers deliver an average 143 mothers per year while dispensaries deliver
on average 16 mothers per year.
Disability mainstreaming – The overall implementation of this indicator in our primary level facilities is at
25%.
Gender mainstreaming – At least 40.9% of primary facilities are offering SGBV services though only 9.1%
have a designated officer for the same with facilities referring between 0 and 25 cases of SGBV in a year (Av.
Of 3 per facility)
Quality of Mental health services – The availability of mental health services in the primary level facilities
is low at 16.7%.
Improved facilities Environment - Primary facilities scored above 50% on facility the majority of compound
indicatorsexceptavailabilityofall-weatherpavementswhichwaspoorestat21.2%.Wastedisposalindividual
indicators scores were below 50% (Av. 41.5%) with availability of a set of 3 color coded bins in wards and
clinical scoring poorest at 30.3%. Water and hygiene scored highly at 61.7% with the poorest score being on
availability of running water in sinks and toilets for staff and patients at 48.5%.
Adherence to safety guidelines - Demonstration of the presence of barrier nursing in the facility was on
average 23.1% with barrier nursing notice available in only 1.5% of facilities. In addition, availability of
firefighting equipment and signage was poor scoring below 17%. From the 66 primary facilities assessed,
only two (2) had an institutional policy guideline on fire outbreak.
Automation - Only 6.1% of the facilities had an integrated information system while 37.9% utilized the DHIS
for reporting.
Efficient Records and Information System - Facilities forward monthly service delivery reports to the
county/sub-county on a timely basis and it was evident that information/data sharing in monthly meetings
took place.
Human Resource Management - Fifty six (56.1%) of sampled facilities are using the performance appraisal
system while 42.4% have continuous development education at least once a month for the staff.

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Only 5% of the facilities had all staff trained. Further analysis indicate availability of an average of 2 clinical
officers and 7 nurses in health centres and one clinical officer and 3 nurses in dispensaries with an average
4 nurses in health centres being partner sponsored.
Facility Assets - Primary level facilities scored poorly on indicators for facility assets with only 10% of the
sampled facilities having title deeds, 7.6% and 10.6% having an annual preventive maintenance plan and list
of idle assets respectively with at least 62.1% having an inventory of facility assets for the current financial
year.
Efficient Healthcare Financing – On average, HC scored 54.7% and dispensaries 32.0% under healthcare
financing. The poorest performing indicator was on monthly bank reconciliation updates with only 40%
and 19.2% for both HC and dispensaries respectively. In addition, only 26.9% and 23.1% of dispensaries had
reimbursements for HSSF and free maternity services respectively.
FacilityPlanning,ManagementandGovernance–Over60%ofhealthcentreshaveannualworkplans&staff
duty roasters in place and are displaying the facility statistics as required, while this was low in dispensaries.
Availability of quarterly facility management committee meetings, monthly facility management team
meetings and monthly infection prevention committee meetings was poor in both health centres and
dispensaries with all individual indicators scoring below 8%.
Innovations - The assessment established that only 30.4% of the primary facilities had at least 2 innovations.

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CHAPTER 1: INTRODUCTION
1.1 Background
The policy framework 2012-2030 and strategic plan 2013-2017 spearheads the Ministry’s agenda on reforms,
investments, and governance of the health system in line with Vision 2030 and the Constitution of Kenya. The
goalofhealthsectorreformsistopromoteandimprovethehealthstatusofallKenyansthroughthedeliberate
restructuring of the health sector to make all health services more effective, accessible and affordable. This
has been a success and there have been tremendous growth with implementation of reforms in the Kenyan
hospitals despite a number of challenges.
The main challenges include dwindling resources for health against the numerous health priorities, increasing
burden of diseases, and inadequate institutional and organizational capacity to effectively respond to the
existing and emerging health challenges.
Following the promulgation of the new constitution 2010 and its implementation in 2013, a new devolved
structure of governance was put in place that impacted on service delivery for the health sector. Major
expectations in the sector revolved around a more responsive health service, closer and widely available
to the masses than before. However, the reorganization and re-structuring of both the national and the
devolved county structures have been met by various setbacks and are still unsolidified. Nevertheless, the
roles of the national and county governments which are distinct and interdependent continue to be exercised
at the two levels of government. It is under this prevailing situation that the reforms exercise was undertaken
in both hospitals and primary level facilities to gauge the performance of the health sector one year after the
devolved structure of governance were put in place.
Reforms have in the past focused on hospitals, being the biggest institutions of service delivery and where
greatest impact was expected. This saw health centres and dispensaries, which are the majority of the
health service delivery points left out in reform supervision. The 2014 annual supervision exercise sought
to initiate reform supervision in primary facilities. The Ministry has 66 primary care facilities ( health centres
and dispensaries) and 155 hospitals.
The primary level facilities which provide the first contact for the community and the health care systems.
They are widely distributed and are structured to provide basic healthcare to the immediate population
that focuses mainly on promotive and preventive services. Nevertheless, varying levels of essential services
are also offered and which have increased over time. This makes it important to institutionalize the reform
exercise in all facilities.
1.2 Objectives and scope of the reforms assessment exercise
The specific objectives include:
• Document gains made one year after devolution of health services
• Identify performance gaps and challenges
• Give recommendations for improvement
• Build capacity of county/facility teams in carrying out assessments

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CHAPTER 2: METHODOLOGY
2.1 Assessment Framework
The National government exercises its constitutional mandate of ensuring standards and regulation of health
services to deliver the highest quality of health services to the population as required in the constitution. This
way, the National government and county level health systems are linked by relating standards and norms to
service delivery.
2.2 Process
The integrated assessment tools for assessment of hospitals were reviewed and in addition, this was
customized for Primary facilities that were being assessed for the first times. The tool’s scope of assessment
was to cover all areas within a health facility. Specifically, the tool addressed up to twenty seven (27) and
twenty two (22) result areas for hospitals and primary facilities respectively. Both the national government
and the county levels contributed in developing the tools as well as carrying out the exercise.
The tools were pretested before use in the field. A facility service data capturing tool was sent in advance to
allow facilities to input data.
The assessment process involved walking through the various hospital departments while observing and
filling the assessment tool. At the end of the assessment, the team had a meeting with hospital managers to
discuss key concerns arising from the activity.
2.3 Sample Size
Sixty six Primary Health Facilities were assessed, 26 Dispensaries and 40 Health Centers across the different
counties.
2.4 Data Processing and Analysis
Data was entered 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 quality of data.
Analysis was done using Stata 13 and the reports generated.

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CHAPTER 3: PRIMARY LEVEL FACILITIES PERFORMANCE
This Chapter gives the primary facility performance as evaluated against the following indicators for the
financial year 2013/2014; facility service charters, quality healthcare including diagnostic services, outreach
and community services, child and maternal health, commodities and supplies, gender, disability, mental
health, nutrition, emergency preparedness, environment and safety, leadership and efficiency in financial
management.
3.1 Human Resource
Average staffing in Health Centers was 1.3 for clinical officers and 5.5 for nurses against recommended
norms of 6 and 36 respectively. Dispensaries had an average of 1 for clinical officers and 1.6 for nurses,
against recommended norms of 2 and 8 respectively. Some facilities reported having no clinical officer
while some did not have any nurse while some had up to 27 nurses.
Table 1 Staffing in Primary facilities
Primary facilities staffing
Cadre Dispensaries Health Centers Overall Min Max
Clinical officers 1 1.3 1.2 0 5
Nurses 1.6 5.5 3.5 0 27
In Primary facilities, about a half had done monthly expenditure returns for HSSF and involved facility
committee and /or staff in budgeting. On the other hand, only 34.8% had evidence of receipts of monthly
reimbursements for free maternity services, a third had done bank reconciliations while 48.5 % had
evidence of receipt of quarterly reimbursements for free primary health services (table 2).
Table 2. Healthcare Financing- Primary facilities
Primary Facilities performance No. %
Presence of an updated cash analysis summary 27 40.9
Facility committee and staff involved in budgeting 38 57.6
Bank reconciliation upto date 21 31.8
Evidence of monthly expenditure returns for HSSF- cash analysis 39 59.1
Evidence of receipt of reimbursements for free primary health services 32 48.5
Evidence of receipts of Monthly reimbursements for Free Maternity
Services
23 34.8

3.2 Compliance with Service Delivery Charter
In line with services available, all facilities are required to develop and strategically display (at the entrance)
a Service Delivery Charter with four columns that provides: - common services offered, obligations of the
customer, charges if any and time which the customer should wait to receive the service. The charter
should indicate mechanisms to seek redress if the client is not satisfied with the services by having a contact
person and telephone in the charter, as well as the contacts for commission of administrative Justice and
be available in at least two languages. In addition, each of these departments must also have individual
charters. Suggestion boxes are important for receiving complaints and suggestions from clients served and
each facility should have a minimum of 2 functional suggestion boxes that must be opened regularly (at least
biweekly) and discussed by the hospital management with reports generated on actions taken.
Figure 1: implementation of service delivery charter
figure 1 above showed that only 33.3% of primary level facilities have implemented service delivery charters
with an average 14.4% having departmental charters. Specifically, only 9.1% of the service charters had
a contact person and address and only 10.6% had the charter in two languages. Suggestion boxes were
available in 28.0% of the facilities with only 15% having a report from suggestion boxes and actions taken.
The main challenge is to sensitize primary level facilities on the guidelines for developing and implementing
the service delivery charters with emphasis on key components of a service charter.
3.2 Timely delivery of health services
Patients queue for health services and in some cases; the long durations taken to receive a service may be
un-acceptable with majority of client complaints gearing towards waiting times. Waiting times are a good
measure of efficiency in service delivery and health facilities are striving to minimize the time taken for a
patient to be served. In line with this, all facilities are required to undertake a baseline survey every 6 months
to establish their waiting time and comply with the minimum norms without compromising quality. None of
the primary facilities sampled had conducted a survey on waiting time in the previous six months.
3.3. Quality Clinical care (OPD)
Evaluation of clinical care was done by assessing 3 Out Patients’ Department patients’ files for quality of
clinical notes, observation of patient assessment processes in the OPD department and completeness of
patient’s records. Specifically, records were evaluated for completeness of patient history, vital signs (blood
pressure, pulse rate, temperature, weight, and height), patient examination, clear diagnosis made with a

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clear name, sign and date for the clinician seeing the patient.
Figure 2: Quality of clinical records (opd)
Figure 2 indicates that quality of care in primary level facilities is poor with all assessed indicators individually
scored below 15% each with an average 8.2% for health centres and 4.3% for dispensaries. Regarding full
patient history, this was satisfactory in only 7.5% and 3.8% of health centres and dispensaries respectively.
There were no records signed, dated and timed by clinicians in all health centres and dispensaries sampled.
A similar scenario was observed for the treatment sheet in dispensaries where no treatment sheets were
signed while only 5% were clear and signed in health centres.
Table 3: Service delivery data (opd)
Service delivery Data
Variable
ALL Dispensaries Health Centers
Mean Min Max Mean Min Max Mean Min Max
OPD - female 7670 231 26286 4974 257 13978 9255 231 26286
OPD - male 7468 188 83080 3960 188 14877 9531 192 83080
OPD -Total 14664 445 47692 9749 445 28865 17275 995 47692
Clients Counseled and
tested for HIV
1778 18 9190 1014 18 5408 2231 48 9190
Clients on HAART 1034 0 17695 185 0 1383 1405 0 17695
+ve malaria tests 912 0 12163 389 0 1477 1198 0 12163
No. of malaria cases 6208 0 208983 1336 0 8679 9400 0 208983
Table 3 above indicate that on average, dispensaries serve between 445 to 28,865 clients in OPD in a year
(Ave. 9,749) while Health Centres serve between 995 to 47,692 OPD clients with an average of 17,275. On
average, dispensaries have between 185 and 1383 clients on HAART and health centres have between 1405
and 17,695 clients cumulatively.
3.4 Improved Nutrition care
The requirement to integrate nutrition care in patient treatment and management has gained significance
withemergenceofconditionssuchasHIVAIDs.Poornutritionalsstatusincludinglackofnutritionmanagement
during treatment can lead to poor clinical outcomes calling for a holistic patient management in our health
facilities.

FIGURE 3: NUTRITION SERVICES
In figure 3, it was commendable to find that a majority 80% of sampled primary level facilities conducted
nutritional assessment with the basic minimum on weight and height. This followed nutritional interventions
such as counseling and diet therapy in over 70% of the facilities while at least 60.6% of the facilities had
supplemental feeds available. In addition, more than half of the sampled facilities, 56% had nutrition
guidelines in place.
The average performance for nutrition services is 67.4%, however, it is important to continue addressing the
concern of availability of guidelines to ensure that quality and standard services are offered. The aspect of
nutrition commodity availability can also be improved.
3.5 Outreach services
Primary level facilities provide an important link between the healthcare facilities and the community/society
and offer primary care health services to the population at their day to day settings such as homes and schools.
Some of the indicators assessed included carrying out home visits, school health, and community outreach
services such as immunizations, mobile clinics, medical camps as well as defaulter tracing mechanisms for
critical areas like TB, ARVS, and Immunization.
Figure 4: Outreach Services
Figure 4 shows that over half of the primary facilities are offering outreach services to the community with
defaulter tracing at 80.3%. The mental services outreach services were poorest at 19.7% perhaps due to lack
of sufficient capacity at the facility.
3.6 Community Involvement and Participation
Primary level facilities have played a key role in implementation of the community strategy by offering health
information on promotive and preventive health as well as to sensitize and create demand for these services.

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This can be done through community dialogue days, community action days, community mobilization
meetings and campaigns whose availability was assessed at the facility.
Figure 5: Community services
Figure 5 above shows that over 60% of primary facilities are actively involving communities and sensitizing
them on health services through campaigns, dialogue days, action days and community mobilization
meetings. However, the number of community units linked was only in 33.3% of the facilities.
3.7 Emergency Preparedness and Timely Response in Facility
Lessons learnt from recent disasters show that most facilities are ill prepared to handle major disasters.
In this regard, facilities were assessed on minimum norms for which an acceptable level of emergency
preparedness can be assured.
Figure 6: Emergency preparedness and response
Figure 6 above shows that on average emergency trays in all OPD consultations rooms, injection rooms and
maternity were completely available in on 26.8% of sampled facilities. The availability of fully equipped crush
box was only in 4.5% of the sampled facilities. A least 65.2% of the sampled primary facilities had access to a
standby ambulance. In addition only 3.0% of primary facilities had a written emergency plan and only 7.6%
had a functional emergency response team in place.
3.8 Diagnostic and Blood Services
The availability of quality, timely and accurate forensic and laboratory services is fundamental to provision
of quality health services by helping achieve correct diagnosis of health problems and eventual proper
management. The evaluation focused on laboratory tests available, availability of standard operating

procedures (SOPs), and presence of supervision from the regional supervisors.
Figure 7: Available laboratory services
table 7 above shows that major diagnostic tests such as malaria, blood glucose, urinalysis and stool
examination are widely available varying between 65% to 92% in both health centers and dispensaries for
the individual tests. However, two tests were noted with major concern; the full haemogram test that was
available in only 10.0% and 7.7% of the health centers and dispensaries respectively. Secondly, despite an
85.0% availability of blood glucose test in health centers, the same was only available in 23% of dispensaries.
A further 33.3% of primary facilities provided other tests such as……
3.9 Commodity supply Management
The primary level facilities are managing an increasing number and scope of medicines among other health
commodities as health services are brought closer to the communities. The main focus for commodity supply
management was on six key indicators which included the availability of the commodities using the tracer
pharmaceuticals and tracer non-pharmaceuticals list; the documentation of the process from receipt to use
as per the guidelines by evaluation the updating of bin cards and delivery notes and presence of quarterly
supervision from the region. The percentage of expiries was also evaluated which is a good indicator of the
commodity management process and to avoid wastage.
Figure 8: Commodity supply management
Figure 8 shows that the percentage of health centres with all 16 tracer drugs in stock at the time of visit
was 47.5% and 26.9% for dispensaries indicating lack of commodity supplies at below 50%. Similarly, 50% of
health centres had all the 16 tracer non-pharmaceuticals in stock while only 19.2% of health centres were
fully stocked. Tracer commodities must be available in all facilities at all times for efficient delivery of quality
services and this was not the case.

11
All facilities must strive to minimize expiry of medicines to an acceptable level of < 5% of the total volume.
There was a 15.0% and 11.5% of expired drugs in health centres and dispensaries which is 3 and 2 times
higher than the acceptable levels respectively. In addition, on average 71.2% of the facilities had updated
bin cards and delivery notes while supervision from the regional pharmacist was available in 57.6% of the
facilities.
3.10 Child Health
Most facilities based child mortality occurs within the first 24 to 48 hours of admission with children below
5 years of age being most affected in which newborns contribute the largest proportion in this age group.
The millennium development goals number 4, 5 and 6 which aim at reducing child and maternal mortality in
addition to combating Malaria and HIV/AIDS epidemic have contributed significantly to the health of mothers
and the children through improvement in services delivery at facility level among other strategies such as
community sensitization and mobilization.
The assessment was guided by minimum norms within the MDG strategies and focused on the following
areas; new born services (new born resuscitation equipment, supplies and guidelines); new born care (the
processes of clinical care, feeding, immunization at birth, weight monitoring and including referrals where
required). The availability of vaccines and supplements were also evaluated.
3.10.1 New born resuscitation
Table 4 below shows the percentage of primary facilities with suitable surface for new born resuscitation
is 42.4% and only 16.7% have a warmer for use during resuscitation. Forty three (43.9%) had a working
valve mask, 39.4% had functional clean suction equipment for new born resuscitation while only 19.7% had
oxygen, flow meter and mask/catheter for use in new born resuscitation. The overall new born resuscitation
indicator is at 33.3%. An increasing number of primary facilities are offering maternal delivery services under
the free maternity program and this assessment is indicative of an urgent need to improve the infrastructure
at these facilities.
TABLE 4: NEONATAL RESUSCITATION
Neonatal resuscitation % of facilities
A firm suitable surface for newborn resuscitation 42.4
Warmer for use during resuscitation 16.7
Working bag valve mask for newborn resuscitation 43.9
Working and clean suction equipment for newborn resuscitation 39.4
Gloves and towels present for drying resuscitation 37.9
Oxygen, flow meter and mask /catheter for use in newborn resuscitation 19.7

3.10.2 New born care
Figure 9: Newborn Care
Figure 9 indicates that quality of new born care in primary level facilities is worst in dispensaries where all
indicators scored zero except for two (immunization at birth and weight monitoring charts) that scored 3.8%.
Health centres scored poorly too with highest score at 25%.
3.10.3 Immunization
The immunization of children within the first year of life against immunizable diseases is essential and
the primary level facilities play a critical role to ensure that every child in the community is immunized.
This calls for a sustainable supply of key vaccines and the cold chain infrastructure as well as supplements.
The defaulter tracing mechanisms for children immunization is also important to increase adherence and
complete coverage.
Figure 10: Available vaccines and supplements
Figure 10 shows a wide and commendable availability of vaccines within the primary level facilities with an
average 94.2% and 91.7% availability in health centres and dispensaries respectively.
A 100% of the health centres sampled had a cold chain infrastructure while the percentage of dispensaries
with a cold chain infrastructure was 95.8%. Defaulter tracing for children under immunization within the first
year of life was in place in 86.1% of the health centres and 85.7% of the dispensaries sampled.

13
Table 5: Immunization service delivery data
Variable
ALL Dispensaries Health Centers
Children fully
Immunized (<1year)
556 1 13227 203 1 720 747 15 13227
Facility based
Neonatal deaths
0 0 2 0 0 0 0 0 2
3.10.4 Growth monitoring
Table 6 below shows that the level of growth monitoring for babies in primary facilities assessed was poor
with all individual indicators below 20%. Specifically, vital signs were completely recorded in 13.6% of the
facilities while the feeding monitoring charts were complete in only 4.5% of the assessed facilities. The
weight monitoring was at 19.7%, immunization at birth monitoring in 16.7% while presence of baby cots and
incubators for referral services were in 9.1% and 6.1% of facilities respectively.
Table 6: Growth monitoring
Growth monitoring
Description Facilities
Vital signs recorded 13.6%
Feeding monitoring chart with minimum 8 entries in
24hrs
4.5%
Weight monitoring 19.7%
Immunization at birth monitoring 16.7%
Presence of a baby cot 9.1%
Incubator for referral services 6.1%
3.11 Maternal Health
Maternal mortality rates in Kenya have remained high at 488 per 100,000 live births due to various
challenges including smaller proportions of skilled health personnel that largely affect the primary facilities.
The assessment evaluated compliance to minimum norms by focusing on the following indicators; clinical
process of monitoring labour, hours of availability of skilled birth attendants in the facility, antenatal care
services (ANC) for both services offered and investigations available, availability of standard guidelines and
family planning.

3.11.1 Monitoring of labour
Table 7: Monitoring of labour
Variable Description Facilities
Mothers condition documented by nurse 30.3%
Fetal condition 24.2%
Progress of labour (cervical dilatation and descent of fetal head) 21.2%
Maternal conditions(vital signs) 22.7%
Table 7 above shows that the monitoring of labour is taking place in primary facilities to some extent with
30.3% of facilities recording the mother’s condition, 24.2% of facilities documented the foetal condition while
progress of labour was documented in 21.2% of the assessed facilities. The average score for monitoring of
labour was 24.8%.
3.11.2 General Maternity availability of skilled birth attendants
Figure 11: Hours skilled birth attendants’ available
Figure 11 show that 82.5% of health centres had a skilled birth attendant at all times (24 hours, 7 days a
week) at the facility, while only 34.6% of dispensaries had a skilled birth attendant at all times. In other cases,
the availability of skilled birth attendants varied greatly.
3.11.3 ANC services
Table 8: Anc services
Services/
investigations
offered at ANC
Percent
ANC Services
Drugs/supplement
offered at ANC
Percent
Reproductive
Health Services
Percent
Provision of ITN 63.6
SP for IPT using DOT
(where applicable)
50.0 Post abortive care 36.4
Hb test 60.6 Ferrous Sulphate 89.4
Breast cancer
clinical exam
66.7
Urinalysis 72.7 TT Injection 90.9
Cervical cancer
screening
54.5
Grouping & Rhesus 72.7 Folic acid 89.4 Pap smear 4.5
PMTCT services 80.3 Multivitamins 48.5 VIA/VILLI 97.4
Table 8 shows that majority of the primary facilities (over 80%) have supplements available with SP for IPT
being available in 50% of facilities mainly those in endemic areas with an exception of multivitamins that

15
were only available in 48.5% of the facilities. A further analysis showed that ANC services are generally
available (>60% of facilities) with lowest service being post abortive care available in only 36.4% of primary
facilities and cervical cancer screening in 54.5%. For cervical cancer screening, Visual Inspection with Acetic
Acid and Visual Inspection with Lugose Iodine (VIA/VILLI) method was the most utilized at 97.4% and pap
smear method being the least utilized at 4.5%. At least 66.7% provided clinical breast examination.
Table 9: Anc service delivery data
Variable
ALL Dispensaries Health Centres
Number of women with at
least one ANC visit
570 0 2586 314 6 1573 709 0 2586
No. that completed 4 visits 163 1 620 101 1 620 196 13 617
New FP clients 425 0 2081 400 0 947 439 9 2081
3.11.4 Availability of guidelines, posters and job aids
Table 10: Available guidelines, posters and job aids
Guidelines availability Facilities
PMTCT guidelines 78.8
Infant and young child Feeding guidelines 71.2
Syndromic Management chart 71.2
Early Infant Diagnosis Algorithm 68.2
ARV Prophylaxis and treatment algorithm/ARV dosing algorithm 68.2
Breast feeding chart 68.2
Information, Education and communication materials 74.2
Table 10 above indicates that guidelines, posters and job aids were generally available in over 68% of assessed
primary care facilities.
3.11.5 Family planning
Figure 12: Family planning
Figure 12 above shows family planning methods are widely available in the facilities assessed however; the
male condoms were lowest at 60.6%.

3.11.6 Reported Deliveries
Table 11: Reported deliveries
Dispensary Health Centre
Overall primary
level
Variable Type Mean Mean Mean
Total Deliveries 15.8 143.0 66.8
Total live births 16.0 140.2 68.0
Fresh still birth rate 5.0 1.7 1.9
Table 11 above shows that the health centers deliver an average 143 mothers per year while dispensaries
deliver on average 16 mothers per year per facility.
3.12 Disability Mainstreaming
Disability mainstreaming entail actively identifying and removing any structural, organizational, physical, and
attitudinal barriers which exist for persons with disabilities within our facilities. It therefore involves putting
mechanisms in place to ensure all disabled persons seeking services are minded. Some of the evaluated
indicators include; functional disability assessment teams, designated car parks, disability friendly toilets,
friendly walkways and delivery bed (appropriately adjustable in labour ward). In addition, there should be at
least 1 wheelchair in OPD for use by PWDs.
Figure 13: Disability mainstreaming
figure 13 above shows that the overall implementation of disability mainstreaming in primary level facilities
is on average at 25% and only 19.7% of the primary level facilities availability had a disability delivery bed.
3.13 Gender Mainstreaming
Disability mainstreaming entail actively identifying and removing any structural, organizational, physical, and
attitudinal barriers which exist for persons with disabilities within our facilities

17
Figure 14: Gender mainstreaming
figure 14 show that at least 40.9% of primary facilities are offering SGBV services though only 9.1% have a
designated officer for the services. Guidelines on SGBV were available in 18.2% of the assessed facilities.
Table 12 below shows that on average, primary facilities are referring between 3 and 25 cases of SGBV
annually with an average of 3 cases per facility
Table 12: SGBV service delivery data
Variable
Number of referred SGBV
cases
3.3 0 25 1.7 0 6 4.3 0 25
3.14 Quality of Mental Health
Facilities were assessed on the provision of basic mental services (counseling, substance abuse and
dependence treatment. Only 16.7% of the sampled primary facilities offered some level of mental health
services (n=64).
Table 13: Mental referral cases service delivery data
Variable
Number of referred mental
health cases
4 0 24 3 0 10 4 0 24
Table 13 indicate that the 16.7% of facilities offering mental health services see on average between 0 to 24
clients in a year with an average of 4 per facility.

3.15 Improved Facilities Environment
A beautiful, well maintained and clean health facility environment free from contamination can help reduce
stress and fatigue in both patients and healthcare workers. The ministry therefore has developed minimum
standards on facilities landscaping, hygiene, safety and waste management which facilities have to adhere.
Table 14: Improved Facility Environment
a) Facility Compound % Facilities
Presence of a fence 78.8
Well-manicured Lawns and flower beds 48.5
At least 10% of the acreage with trees 54.5
Facility generally clean 72.7
All weather Pavements 21.2
b) Waste Disposal % Facilities
A functional incinerator or access to a functional incinerator 42.4
Well protected Compost pit 43.9
Well protected placenta pit 54.5
Well protected ash pit 36.4
A set of 3 color coded bins in all wards and clinical departments 30.3
c) Water and Hygiene % Facilities
Reliable running water in the facility 59.1
Running water available in sinks/toilets for staff and patients 48.5
Clean functional Water closet toilets for patients & staff 51.5
Clean functional pit latrine toilets with handwashing facilities 72.7
Clean functional pit latrine toilets with handwashing facilities 60.6
Clean functional bathrooms for patients 69.7
Alcohol based hand-rubs for staff in clinical areas 65.2
Soap available for staff/client handwashing 66.7
Table 14 above shows that primary facilities scored above average on hospital compound indicators with at
least 78.8% having a fence but scoring poorest on availability of all-weather pavements which was available
in only 21.2%.
Regarding waste disposal, all facilities scored below 50% with an average of 41.5%. Availability of a set of 3
color coded bins in wards and clinical areas was poorest at 30.3%.
Water and hygiene scored highly on individual indicators with an average 61.7% indicating that facilities

19
are clean and well maintained. However, the poorest score was on availability of running water in sinks and
toilets for staff and patients at 48.5%.
d) Power source
Figure 15: Facility Power Source
Figure 3.15 above shows that 74.2% of the facilities have electricity supply with at least 6.1% of the facilities
having generators. Other sources of power include wind in 3.0% and solar in 25.8% of the facilities.
3.16 Adherence to safety guidelines
The facilities were evaluated on adherence to safety which included a demonstration of the presence of
barrier nursing in the facility and mechanisms put in place to ensure fire safety.
3.16.1 Barrier nursing
Figure 16: Barrier nursing
Figure 3.8 shows that other than availability of gloves, the implementation of barrier nursing was low at an
average 23.1% in the sampled facilities. Though isolation rooms were available in 25.8% of the facilities, the
barrier nursing notice was only available in 1.5%.
3.16.2 Fire safety
TABLE 15: FIRE SAFETY

Table 15 indicate that on average, departmental indicators on fire exits signage and fire-fighting equipment was poor
scoring below 20%. Specifically, 24.2% of assessed facilities had at least a fire-fighting equipment in the facility
and only 17.7% of the sampled facilities had at least a form of signage for fire exits.
From the 66 primary facilities assessed, only two (2) had an institutional policy guideline on fire outbreak.
3.17 Automation
This involves an integrated electronic system with necessary functions for capturing and reporting clinical,
supply and financial information among others in the facility. Facilities were assessed on having functional
modules for the key departments in the facility including a billing/financial module, OPD, registration,
pharmacy, laboratory and inpatient (where applicable). Only 6.1% of the facilities had an integrated
information system while 37.9% utilized the DHIS for reporting.
3.18 Efficient Records and Information System
Data is critical for informed and sustainable planning, decision making, long term forecasting and budgeting
in facilities. There is therefore need to strengthen collation of data, capacity building and presentation of
data that can contribute towards informed decisions by the FMT, facilities boards/ committees and the staff.
Table 16: Efficient record systems
Efficient Records systems Mean Std. Dev.
Monthly service delivery reports to sub-county/county 11.1 2.1
Evidence of on data/information sharing in Monthly meetings of
the facility
8.0 4.6
Table 16 shows that facilities forward monthly service delivery reports to the county/sub-county on a timely
basis (mean of 11.1 reports in 11 months; Std. Dev. of 2). In addition, it was evident that there is information/
data sharing in monthly meetings with a mean evidence in 8 meetings in a year.
3.19 Human Resources Management
There is need to equip medical staff with modern skills and techniques to enable them provide quality and
efficient medical services to Kenyans. Facilities are required to enhance human resource management by
ensuring use of performance appraisal systems, establishing functional reward and Sanction system and
competence development through CMEs.

21
3.19.1 Performance appraisals
Figure 17: Performance appraisal systems
in figure 17, 56.1% of sampled facilities are using the performance appraisal system while only 18.2% have
evidence of sanctions and rewards. A further 42.4% of the sampled facilities have continuous development
education at least once a month for the staff. The proportion of trained staff was 26.9% in dispensaries and
52.5% in health centres while only 5% of the facilities had all staff trained.
3.19.2 Staffing in primary facilities
Table 17: Key staff clinical officers and nurses
Variable
Level 2- Health Centres Level 1-Dispensaries
Mean Min Max Mean Min Max
Clinical officer - GOK supported 1.6 0 5 1.2 0 2
Clinical officer -Partner supported 0.9 0 5 0.9 0 1
Total Clinical officers 1.3 0 5 1.0 0 2
Nurses- GOK supported 6.9 1 27 3.2 1 13
Nurses Partner supported 4.1 0 8 0 0 0
Total Nurses 5.5 0 27 1.6 0 13
Table 17 above shows an average of 2 clinical officers and 7 nurses in health centres and one clinical officer
and 3 nurses in dispensaries with an average 4 nurses in health centres being partner sponsored.
3.20 Facility assets
An annually updated inventory should be maintained to ensure accountability for all facility assets including
buildings, vehicles and equipment together with their respective preventive maintenance plan and job cards.
Similarly idle and disposable assets should be identified and disposed according to government regulations.
The facility land title deed is an important document as it has been found that facilities lacking land ownership
have challenges in laying down major development plans.

Figure 18: Facility assets
figure18indicatethat62.1%ofthefacilitiessampledhadaninventoryoffacilityassetsforthecurrentfinancial
year. However, the primary level facilities scored poorly on other indicators for facility assets with only 10%
of the sampled facilities having title deeds, 7.6% and 10.6% having an annual preventive maintenance plan
and list of idle assets respectively.
3.21 Efficient Healthcare Financing
Facilities are required to utilize public funds in adherence to the Government financial regulations with high
level of accountability and transparency which in turn contribute towards an efficient healthcare financing
system.
FIGURE 19: HEALTH CARE FINANCING
Figure 19 shows dispensaries are below 50% on implementation of all health care financing indicators with
health centres performing better. The poorest performing indicator was on monthly bank reconciliation
updates with only 40% and 19.2% for both HC and dispensaries respectively. In addition, only 26.9% and
23.1% of dispensaries had reimbursements for HSSF and Free maternity services respectively. On average,
HC scored 54.7% and dispensaries 32.0% under healthcare financing.
3.22 Facility Planning, Leadership and Management
Good planning, management and governance are critical in facilities reforms and this is evidenced in
governance systems and processes put in place as well as adherence to the same. Specifically, facilities were
assessed for availability of work plans, staff duty roasters, quarterly and monthly management meetings as
well as strategic display of facility statistics.

23
Figure 20: Planning, Management & Governance
Figure 3.20 above indicate that over 60% of health centres have annual work plans, staff duty roasters in place
and are displaying the facility statistics as required, while this was low in dispensaries. However, availability
of quarterly facility management committee meetings, monthly facility management team meetings and
monthly infection prevention committee meetings was poor in both health centres and dispensaries with all
individual indicators scoring below 8%.
3.23 Innovations
Innovations create a means to improve quality as well as increase cost-effectiveness and value addition in
service delivery. Potential innovations considered included energy (solar, wind, bio-gas), water supply (roof
water catchment, borehole), oxygen supply (oxygen concentrators), income generation, waste disposal,
among others. The new innovations were considered for implementation within specified period of two
years.
The supervision found that only 30.4% of the primary facilities had at least 2 innovations (n=34)

25
CHAPTER 4: RECOMMENDATIONS AND CONCLUSION

4.1 Recommendations
Most areas scored poorly for primary level facilities and the key highlighted areas recommended for
improvement include:
• Clinical care: There is an urgent need to address quality of clinical care in all areas; OPD, maternity and
new born care through capacity building. These should be coupled with appropriate documentation.
• Financial Management: Financial stewardship is very crucial to ensure accountability for public funds
and stipulated guidelines should be strictly followed. This should be coupled with strengthening
stewardship and governance in the same line.
• Embrace services that ensure human rights are respected as per the constitutional requirements.
Gender and disability mainstreaming services ensure these groups are not discriminated. The low
uptake of the services in the primary level facilities needs to be fast tracked.
• Human resource; This can be done through hiring to alleviate shortage and management of the existing
staff to offer motivation, a function the County government will require to prioritize under the devolved
structure especially for nurses and clinical officers in primary level facilities.
• Invest in supportive supervision for lower level facilities
The Counties will require investing in and budgeting for regular supervision of lower level facilities to
uphold quality of services.
• Institutionalize the reform agenda for all facilities in the county. This can be done through investing
in and budgeting for the reform exercise that can then be carried out together with the national
government of separately.
• Support generation, use and flow of health information from lower level facilities. While most primary
level facilities don’t have electronic records, health record officers are also lacking. CHRO be supported
to oversee records management coupled with hiring more where required.
• Commodity management supervision role: To avoid under and overstocks coupled with increasing
expiries of the scarce health commodities, lower level facilities require pharmaceutical technologists/
personnel to support the few clinical staff available. This will also require supportive supervision from
the regional pharmacists.

4.2 Conclusion
The primary facilities have undergone reforms supervision for the first time giving a baseline to inform
subsequent exercises. Some of the indicators were new to the facility teams and this provided a good
opportunity to learn while the supervision teams offered on-the job training and mentoring on the reforms
indicators and targets. It is expected that Counties will customize and utilize the tools to improve on the
services.
Some recommendations require immediate action such as quality of clinical care and financial management.
Clinical records suffered greatly perhaps due to poor documentation which can be instituted immediately
while the aspect of capacity gap cannot be ruled out and will require follow-up through identification of
need. Financial management procedures need to be instituted immediately.
Some recommendations may impact cost implications, both huge and small. Other recommendations may
be worked on in the short term and others will require longer duration of time thus it is upon the respective
counties to identify priority areas and develop work plans for resolving the raised concerns. It would be
prudent to ensure budget allocations are provided for where necessary to address the reform agenda.
The major areas of strengths to build on for primary facilities include availability of vaccines and supplements,
defaulter tracing for immunization and outreach services. It is hoped that this strong areas will continue to
be upheld and sustained as primary level facilities take on an increasing scope of services in the restrained
health system.

Primary Facilities Assessment Level Report 2014 _2

Primary Facilities Assessment Level Report 2014 _2

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