7/30/23

Mandera HealthCare Re-imagined…

Every Household identified, reached and

Served with Dignity

 FINDINGS AND
RECOMMENDATIONS
OF THE TASK FORCE
  In fulfillment of his campaign pledge of transforming the health system,
H.E Governor Mohamed Adan Khalif established the Mandera Health
Introduction Reform Task Force and gazetted it on 5th October 2022 vide Gazette
Notice No. 11950.

 The core mandate of the Task Force was to review and propose reforms
in Mandera County health sector.

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TASKFORCE MEMBERS
Members
Secretariat
1. Khama Rogo (Prof.) — Chairman
1. Hassan Ali Ibrahim
2. Khadija Abdalla (Dr.) – Vice-Chairperson
2. Ismail Sheikh Abdikadir (Dr.)
3. Dabar Abdi Maalim (Dr.) – Member
4. Hassan A. Eymoy – Member
5. Stephen Muchiri Ngariu – Member
6. Walter Obita (Dr.) – Member
7. John Kabuchi – Member
8. Janette Karimi (Dr.) – Member
9. Bashir Issak (Dr.) – Member
  The Taskforce assessed the county health sector using both qualitative and
quantitative approach that is structured along the health systems building
blocks - Leadership and Governance; Health Financing; Human Resource for
Health (HRH); Service Delivery and Infrastructure; Health Products and
Technology (HPTs); Health Information System and Research.

Approach  The qualitative approach consisted of a desk review of relevant county

policies, legislation, and operational documents of the department of health,
Key Informant Interviews (KII), Focus Group Discussions (FGDs) and
consultative meetings.

 The quantitative methods mainly consisted of health facility assessment tool

for Level Four and Five, and primary health facility assessment tool for Level
Two and Three. Facility assessment tools were adopted from the National
Ministry of Health (MOH) assessment tools

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  Absence of county’s own health policies, strategic plans and legislation to
guide investment in the sector.

 The county passed a Health Services Act 2019 that is largely flawed and
difficult to implement.
Health Leadership
and Governance  The Annual Work Plan for the department is developed as a ritual(to fulfil the
donor requirements) and remains largely unimplemented.

Key Observations  Poor linkages between the department of public health and medical services

 The Public Health system is not connected to the communities it serves as all
health facilities lack boards and committees.
 Bloated CHMT with unclear JDs, weak unfunded SCHMTs

 The CDH budget was managed by treasury and not by the Chief Officer
Health

7/30/23  There is a disconnect between the CHMT, SCHMT and HMTs of the level 4
  Develop County Health Policy, Strategic Plan and review the Health Services
Act 2019 to capture policy vision, and facilitate the implementation of
recommendations of the Task Force on sector reforms.
Health Leadership
and Governance  Have ONE Chief Officer and TWO Directors (Medical Services and Public
Health) supported by strong technical team of deputy director and heads of
programs.
Recommendations  Enforce respect for hierarchy at all levels (from CECM to facility level and
vice versa).

 The Chief Officer must be autonomous as an accounting officer for the

functions and budget under the department to support CECM in sector
leadership.

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  Review current departmental organogram and cluster CHMT positions
under functions with well-defined ToRs and competitively and
meritoriously appoint the leadership of the functions not exceeding 15
persons who shall comprise core CHMT Members.
Health Leadership
and Governance  Consultatively review the Hospital Boards and PHC facility committees
selection criteria in County Health Services Act 2019 and constitute them
transparently as per criteria agreed upon in the revised Health Act.
Recommendations
 Consider a member of CHMT to support partnerships and public-private
partnerships

 Train and mentor the sector leadership on HRH management.

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  Resource mobilization for health is limited and the department of health
primarily relies on county allocation from the shareable revenue.

 The department of health received 19% and 22% of the county budget in the
FY 2021/22 and FY 2020/21 respectively. HRH took up 46% of the total
Healthcare Financing health budget, 1.1% to preventive promotive health

 The department underperformed in critical revenue mobilization such as all

schemes of NHIF – Supa Cover, Linda Mama and EduAfya, claiming Ksh 50
million in the last financial year compared to Ksh. 295 million claimed by the
Key Observations Private Sector owing to operational inefficiencies(no computers, internet,
clerks for claim management), poor empanelment of the public health
facilities and low NHIF membership.

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  The county is yet to pass legal provisions to guide collection, retention at
source and use of User Fees at Level Four and Five hospitals. User fees are
currently collected by the County Revenue Department as part of the county’s
own revenue.
Healthcare Financing  PHC facilities solely rely on DANIDA’s unconditional grant for O&M, while
the meagre NGOs and UN support are off – budget.

 Sector planning and budgeting process was not compliant with PFM Act
Key Observations 2012, was uncoordinated and crude, and is comparable to pre – devolution
era. The department’s AWP was not PBB compliant, nor was it implemented.

 Budget execution was centralized at the county treasury where all spending
decisions are made to the exclusion of the departments’ leadership.

 There was no oversight and audit of the funds allocated to the department and
hospitals as the hospital boards and PHC facility committees are non-existent,
creating avenues for leakages.
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  Develop county policy/strategy for resource mobilization for health sector
based on the national health financing strategy or policy, including adoption
of the Mandera UHC Goat Scheme, and form a technical working group to
develop the implementation plan for the scheme.

 Invest in increasing NHIF uptake and processing of NHIF claims including

Healthcare Financing hiring clerks particularly to process and submit claims to ensure 100%
payment of claims

 Consult and enact the FIF Bill to provide enabling legal framework to guide
Recommendations funds allocation, clear criteria and management (PBB compliant) including
user fees in compliance with PFM Act. (Recommends a percentage of user
fees collected at level 4&5 facilities to support Community health services)

 The FIF bill to prioritize funding to PHC , recommending 7-10% of total

health budget to support PHC facilities and community units including paying
CHVs

 Implement the Primary Healthcare Financing Transition Plan (2022 – 2025)

7/30/23 before the planned phasing out of DANIDA grant.
  Streamline off – budget support from partners through sound AWP
development and implementation.

 Implement a coaching and mentorship programme spanning two budget cycles

(or FY) for all levels of CDOH leadership on Planning and Budgeting to ensure
development of Comprehensive and well costed AWPs for hospitals, PHC
facilities, SCHMT and CHMT.
Healthcare Financing
 Track quarterly and annual expenditure to monitor budget performance and
ensure proper absorption and reporting of the funds in quarterly department
performance report.
Recommendations
 Appoint, train, and gazette hospital boards and facility management
committees for effective planning and accountability.

 Establish a Health Sector Stakeholders Forum, and establish a similar

arrangement known as Health Sector Working Group (HSWG) as
recommended in the Mid Term Expenditure Framework.
 Conduct a comprehensive Internal or external Audit of the health department,
including AIE receiving health facilities to provide baseline for future audit,
7/30/23 and to inform appropriate financial management reform to be instituted.
  There has been a huge focus on the construction of health facilities to
increase access to health services in Mandera since devolution. However,
some of these facilities are either partially operational or incomplete. (15
Health PHC facilities non-operational)
Infrastructure
 Building health facilities was deemed political and there was inadequate. In
some cases, there was no prior consultation with stakeholders including the
CHMT or SCHMTs and communities to ascertain the need to build new
health facilities.
Key Observations
 The infrastructure norms and standards were not followed in building some
health facility buildings and the user department heads were not consulted.

 Half of the sub-county Level Four referral facilities do not meet the norms
and standards of a KEPH Level Four( Kutulo, Banissa, Lafey)

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  Facilities were built where there are no supporting amenities like water,
electricity, good road network and security, making it difficult to
operationalize them.

 The county procured and distributed modern medical equipment including

Health obstetric equipment to all health facilities in the last five years but lacked
Infrastructure standardized specifications to inform investment in equipment

 Some equipment remained unused, and some were obsolete and littered the
hospital yards and stores.

Key Observations  There were no maintenance plans for medical equipment including cold chain
equipment at all levels and laboratory equipment not been calibrated for more
than a year.

 There was poor asset inventory management across the county. Specifically,
MCRH did not have an asset inventory. None of the facilities had digital asset
tracking mechanism despite availability of computers and internet.

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  Stop construction of new PHC health facilities for the next five years and
prioritize operationalization of existing primary facilities.

 Upgrade the seven existing Level Four hospitals (including MCRH) to meet
and operate as KEPH level 4 following the structural requirements as per the
Health infrastructure norms and standards.
Infrastructure
 Upgrade the health centers in the proposed new sub-counties of Kiliwehiri,
Khalalio, Arabia and Ashabito to fully functional Level 3b facilities.

 Develop, fund and implement annual preventive maintenance plan for all
Recommendations equipment, including incinerators, solar fridges and appliances at

 Develop local solutions for water and power that include improved water
connection, storage and use of solar energy in all health facilities in
collaboration with county department of water and environment/energy.

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  Explore outsourcing maintenance in the short term as
maintenance staff capacity is strengthened.

 Standardize equipment for ease of servicing and related support

Health as well as provision of consumables.
Infrastructure
 Support placed/leased equipment by a full contract for service
and maintenance, and supply of consumables.

Recommendations  Digitalize assets inventory of all hospitals and PHC facilities.

 Proper disposal of obsolete assets to decongest facilities.

 Greening and proper environmental management of all the health

facilities to create a therapeutic environment

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  Government facilities doubled from 54 in 2013 to 112 in the year 2022
hence reducing distance to seek health services
 Number of HCWs also increased from 154 to 1227 currently.
 Specialized services such as renal, ICU, and diagnostic services (CT
scan & Laboratory) expanded at MCRH.
Service Delivery  Oxygen plants installed and functional in MCRH and Elwak Sub-
County Hospital.
 Improvement in key performance indicators, (KDHS 2014 vs KDHS
2022)
Key Observations  MMR 3795/100,000 in 2013 to 385/100,000
 Skilled delivery increased from barely 38.7% in 2013/14 to 54.7%
 Stunting reduced from 26% to 21%
 4th ANC increased from 36.8%% to 40.4%
 U5MR(44-64/1000) and Infant mortality rate(37 to 41/1000) however
increased (could be related to low Penta 3 coverage of 43.8% and
malnutrition)
  Low prioritization and funding of primary health care (PHC), including
community level, Level Two and Three, and public health services which
should ideally be the drivers of Universal Health Care Services. (1.1% to
preventive promotive services)
Service Delivery
 There were only 26 CHUs which were all established by partners and are sub-
optimally operational, against the expected 200 CHUs

Key Observations  Low availability of lab. diagnostic equipment and commodities at level 2 &3
facilities

 Lack of diagnostic radiology equipment and lab tests in some sub-county

hospitals due to lack of equipment or reagents

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  Some comprehensive specialized services provided at hospitals were weak.
No paediatrician, ENT or orthopaedic services at MCRH and the SC Hospitals

Service Delivery  Physiotherapy, dental, eye, ENT and ICU services are sub-optimal at MCRH
and lacking in most level 4 facilities.

 Available specialized clinics (MOPC, GOPC, SOPC) take place only once a
week
Key Observations
 Rehabilitative services are underutilized due to lack of space and equipment

 The community perceived the quality of health services to be poor due to

frequent drug stock outs, disrespectful attitudes of healthcare workers and
long patient queues

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  Establish functional PHC Implementation structures (PHC focal person,
TWG, and multi-disciplinary teams (MDTs) to implement primary care
networks in all the sub-counties in Mandera as per the Kenya Primary
Service Delivery Healthcare Strategic Framework

 Review, enact, and implement the draft CHS Bill 2021 and FIF Bill to guide
county investment in Community Health Services.

Recommendations  Establish and operationalize 200 Community Units over the next five (5)
years aligned to county administrative structures and the draft County Health
Services Bill 2021(Unit cost Ksh757,400 totalling Ksh151.5 million over 5
years)

 Revise FIF Bill to ensure allocation of 7-10% of the health budget to

community healthcare which can be raised from proper utilization of NHIF
in the primary and secondary health facilities.
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  15% of the funds raised from Level Four and Five health facilities should go
towards supporting PHC services and Environmental Health Services

 Provide and expand specialized services such as Orthopedic and Trauma

services, specialized clinics, renal unit, ICU, eye, dental, ENT, occupational
Service Delivery health, diagnostic radiology and physiotherapy at the County and Sub-
County Referral Hospitals.

 Deploy specialists to sub-county hospitals based on need/or arrange

clinics/surgeries in the SC hospitals
Recommendations
 Adopt and provide resources to progressively implement quality
improvement and quality assurance activities

 Establish and strengthen emergency referral structures and mechanisms

across the continuum of care

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  Mandera is up to date with KEMSA payment

 Persistent stockout of HPTs across all levels of care is interrupting service

delivery due to inadequate budgetary allocation.

 KEMSA is the main supplier of HPTs to both primary and secondary

Health Products and healthcare facilities but had a low order fill rate of 48%
Technology  Private vendors under framework contract charged exorbitantly up to almost
700% KEMSA cost for some drugs (IV pen, oxytocin)
Key Observations
 The HPT storage infrastructure is poor across all the facilities including at
the county referral hospital.

 There was no standardized list of medical equipment, accessories, spare parts

and consumables, including laboratory reagents for use across all facilities in
the county. Details on warranty, provision of spare parts, and training on
usage and installation for equipment procured from private entities is not
available.
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  Increase budgetary allocation to HPT procurement and ring-fence it
through legislation

 Work with the county KEMSA focal point to improve the

Health Products and quantification and forecasting of drug needs in a timely manner to
Technology improve the order fill rate.

 Stop all existing framework contracts of medical supplies and choose

Recommendations credible alternative sources of HPTs for the county e.g. MEDs

 Where framework contracts become necessary, prepare a general price

list for all health supplies based on prevailing market prices as a
department to enable local vendors to apply competitively.

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  Adopt quarterly order cycles for both hospitals and primary health
facilities to increase HPT availability.

 Strengthen the use of ICT systems for supply chain and logistic and
Health Products and inventory management to create accountability, and reduce pilferage.
Technology
 Expand storage capacities of the county facilities with more spacious,
automated modern well-managed warehouses within the facilities
Recommendations
 Sensitize healthcare workers on the rational use of HPTs, monitor and
enforce adherence to clinical guidelines and essential lists in diagnosis,
prescription, procurement and use of HPTs.

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  The County has made great progress in the recruitment of healthcare workers
from 154 members of staff at the inception of devolution to more than 1,227
as of December 2022.
Human Resource For
 The recruitment was tainted by political influence and clannism rather than
Health
technical competence and merit.

 Deployment skewed to hospitals. 57% of the HRH staff in Mandera County

is distributed among the seven Level Four facilities and the other 43% work
Key Observation in the 105 PHC facilities which were grossly understaffed.

 Delayed and skewed promotion for the staff working in the department

 The county lacks clear policies and plans on staff training and opportunities
for professional advancement.

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  Management and supervision of medical officers and specialists was
unclear, with medical officers making “local arrangements” hence the
increased number MOs and specialists did not translate to increased
availability of their services in a commensurate manner.

Human Resource For

 SCHMT has a limited role in staff management, transfer or discipline
Health with all decisions made by CHMT leads
 No appraisal of HCWs
 Casual workers paid by DANIDA grants, often delayed more than 6
months
Key Observation
 No community health workers on government payroll
 All the above contributing to low staff morale
  Constitute a team to advice on HRH staff needs and give recommendations for
quick redistribution of available staff members pending planning and
budgeting for recruitment.

 Conduct an assessment of facility inpatient and outpatient workload

Human Resource For (Workload Indicator of Staffing Needs - WISN) and redistribute staff based on
Health county staffing needs per level of care.

 Finalize, launch, disseminate and implement manual developed by the County

Public Service Board (Training guidelines, HR manual, Internship policy and
Disciplinary guidelines) to offer guidance HRH management and training
Recommendations opportunities during employment at the county.

 Disband & appoint new Human Resource Advisory Committee and implement
the Disciplinary Guidelines developed by the CPSB in a transparent manner
through a newly appointed Human Resource Advisory Committee.

 Prioritize recruitment for the PHC level focusing on Nurses, Laboratory

Technologist, Clinical officers among others using WISN
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  Adopt and use Human Resources Information system (HRIS). Deploy free
and open sources iHRIS (https://www. ihris.org) developed by the capacity
project and already in use in Kenya.

 The promotion of specialists and all cadres should be guided by the county
Human Resource For HR norms.
Health
 Employ four key specialists in MCRH (Internal medicine, General Surgeon,
Pediatrician, Obstetrician and Gynecologist) and pursue its registration to
make it an internship center for medical doctors and clinical officers.

Recommendations  Enhance staff morale through regular review of staff promotions,

performance-based reward system and provision of comprehensive medical
insurance schemes.

 Regularize the employment and payment of casual workers

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  The existing human resource for Health Information System are insufficient
to manage data entry, data reviews and data quality audits.

 The health information system in Mandera is almost entirely manual and

without a clear, costed plan for digitalization. There is no Electronic Medical
Health Information Record (EMR) system in all the Level Four and Five facilities
Systems and
Research  The health information unit lacks costed Monitoring and Evaluation Plan,
and a dedicated budget.

 There is no demand and use of data.

Key Observations  Information generated from services delivery points is not used for
decision-making nor for resource allocation.

 Annual Work Planning process is ad hoc and only developed to meet donor
requirements if any.

 Health research was not given priority nor funded from the health budget.
7/30/23
  Re-evaluate the number, capacity and distribution of all HRIOs in the
County. Conduct a skills assessment to identify officers who can form the
county M&E unit to coordinate HIS and M&E activities

 Train staff on KHIS using the KHIS virtual academy

https://elearning.health.go.ke/
Health Information
Systems and  Draw a plan for use of EMR systems starting from MCRH, to the Sub-
Research County hospitals and work towards EMR systems in Level Three facilities.
This should include systems with the patient care modules, financial
management and HPT management modules.

 Invest in internet connectivity, computers, recurrent funding for airtime and

Recommendations training of staff on EMR use.

 Allocate at least 5 % of the health budget to Health Information Unit

including M&E and health research.
 Build capacity for research, allocate specific roles and fund unit of health
research starting with the conducting of annual patient exit surveys and
research output
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THANK YOU

ASANTE