1. Making it Happen (MiH) programme Maternal and Neonatal Health Human Resource Capacity Building
Good morning everyone….thank you Mr Chairman for those kind words of introduction and warm well come.
My name is Charles Ameh clinical lecturer, Obstetrician, public health specialist, deputy Head of CMNH LSTM, a WHO collaboration centre for research in maternal and newborn health with various research activities in 11 countries in Asia and sub-Saharan Africa
I thank the organisers of this meeting for the opportunity to talk about our work in Kenya. I hope to share the experience of CMNH supporting MoH of Kenya to build the capacity of skilled health care workers to provide better quality of care for women and their newborns over the last 8 years
It’s a pleasure to be back in Kenya, supporting the great work of colleagues at the MoH and department of health at the counties
Charles A Ameh MB.BS, MPH, DRH, FWACS (OBGYN)
Deputy Head, Centre for Maternal and Newborn Health

2. Presentation outline Introduction CMNH MNH interventions LSTM in Kenya
Challenges
Opportunities
As we move from promises to action, I hope that at the end of this presentation that I will have described a background to our work in Kenya, our experience supporting MoH at various levels, key challenges and opportunities to accelarate progress
Today is all about how, rather than does it work, so I will keep stats to a minimum

3. Background 98.7% of maternal deaths occur in 15 counties
Only 50% of government own hospitals have ANC, normal delivery and C/S services (n=690)
80% have EmoC drugs
Newborn respiratory support available in 72%
Assisted vaginal delivery available in only 13%
Brief recap of relevant stats from yesterday
Insert differential graph or picture of MMR in Kenya
7% of sample hospitals
UNFPA 2014, KDHS 2008/9, KSPA 2010

4. Background Low EmOC knowledge
N=881 (PPH=7%, Obstructed labour= 5% )
<20%of health care workers be trained in EmONC

5. Determinants of maternal morbidity and mortality
We were reminded by various speakers yesterday that there are several determinants of maternal health and they interact at various levels to affect the outcomes. So we need multidimentional approach to improving maternal health
LSTM intervenes at phase 3 and trys to coordinate with other stakeholders/partners working to prevent phase 1 and 2 delays via MoH fora
Thaddeus and Maine 1994

6. Key CMNH interventions
EmONC training
TOT
Training equipment
Facility improvement fund equipment
CD/quality assurance training
EmONC training Package
Quality improvement workshops
MPDSR
Standard based audits
Quality improvement package
Making it Happen with Data workshops
Monitoring and evaluation +supervision
Monitoring and evaluation
Effect of EmONC training and QI training on
SBR, CFR, EOC Signal functions, deliveries
Knowledge and skills retention study
Operational research

7. EmONC training
“Great emphasis on acquiring skills through repetition and in hands-on practice”
Based on the ‘Behaviorist approach’ to learning
Learners are rich resources
CBT uses a problem rather than a subject centered approach
Adult learning is collaborative
Uses experiential techniques of inquiry (Knowles 1978)

8. Trained trainers and Course Directors
Quality assured process, multidisciplinary, aim to get 10 trainers per county, 8 trainers and 1 Course Director required per course, database maintained of certified trainers by RMHS unit and LSTM

9. Training Equipment/Mannequins
Airway Management Trainer
Uterine Pelvic Model (Boney Pelvis)
Obstetric Phantom & Fetal Doll
Cost
One Full Set of Equipment - £18,500 ≈ Kshs. 2,692,675
Lucy & Lucy’s Mum - £3,000 ≈ Kshs. 436,650
Obstetric Phantom - £700 ≈ Kshs. 101,885
Venous Cut Down Pad - £60 ≈ Kshs. 8,733
Logistics
Items not always available locally
Replacement Mannequins from the UK
Value
No other training equipment at facility/venue
Large numbers of participants trained
Lucy & Lucy’s Mum,

10. Facility improvement fund equipment

11. Making it Happen with Data workshop
One day workshop
To increase the awareness of good quality data collected in facilities
To improve the skills of health care providers to manage and use the data collected
So that is a bit about LSTM, what have we done in Kenya so far

12. LSTM in Kenya MiH II 2012-15 Western Central
EHS 07-10
Nyanza
MiH I 09-11
10 Level 5 HCF
Kenya Harmonized curriculum 2012
MiH II
Western
Central
Competency based training in Kenya since 2007
DFID funded HSS programme, limited to six districts in Nyanza province,
Introduced EmONC Training, equipment, SS, Support to MDR

13. Essential Health Services Kenya
DFID funded HSS programme,
limited to six districts in Nyanza province,
Introduced short competency based EmONC training programme
EmONC training equipment,
Supported MOH to analyze national maternal death reviews
Based on this success of the short EmONC training package, it was to be scaled up and evaluated at level 5 hospitals nationwide

14. LSTM in Kenya MiH II 2012-15 Western Central
EHS 07-10
Nyanza
MiH I 09-11
10 Level 5 HCF
Kenya Harmonized curriculum 2012
MiH II
Western
Central
Competency based training in Kenya since 2007
DFID funded HSS programme, limited to six districts in Nyanza province, Training, equipment, SS, Support to MDR

15. MiH programme
Goal: Reduce Maternal and Child mortality Objective: To improve the availability and quality of Emergency Obstetric Care and Newborn Care
Multi-country
MiH: Maternal and Neonatal Health Human Resource Capacity Building
Aim: The Making it Happen programme, funded through DFID, contributes to a reduction in maternal and newborn mortality and morbidity (MDG4 and MDG5) by increasing the availability and improving the quality of Essential (Emergency) Obstetric and Newborn Care (EOC&NC).

16. ‘Making it Happen’ programme
Introduced and evaluated simultaneously in Kenya and 5 other countries from 2009 (countries in red) and from 2012 six other countries were added all in SSA and Sasia.
This is achieved by delivering a country adapted competency based training package to improve healthcare providers’ capacity to deliver EOC and early NC.

17. University of Zimbabwe
Making it Happen
delivered in partnership with:
FMOH Nigeria
HMB FCT Abuja Nigeria
University of Zimbabwe
Funds for implementation are largely from UK Aid, UNICEF and UNFPA Acknowledgement and implemented through the RH/MNH programmes of the various National governments, UN agencies, research institutions and professional medical associations in these countries
With funds gratefully received from

18. MiH outputs
Output 1: Increased health service provider capacity to provide Emergency Obstetric and Newborn Care (EmONC)
Output 2: Increased availability of EmONC for mothers and babies
Output 3: Strengthened accountability for results with increased transparency
Output 4: Strengthened capacity to sustain improvements in maternal and newborn health service delivery
Output 5: Evidence generated by programme disseminated in order to inform national, regional and global agenda
MIH implemented in country x from 2012 to 2015 has 5 outputs

19. MiH Phase 1: 2009-2011 All 8 provinces 10 level 5 CEmOC hospitals
EmONC training
Master trainers and training equipment
Supportive supervisors
Monitoring and evaluation
So back to Kenya
5 sets of training equipment, distributed to 10 intervention sites, used for primary training and retraining by trained supervisors and Master trainers within those institutions. Capacity of MoH in terms of supervision was strenghtened

20. Lessons learnt from MiH phase 1
Optimal training impact:
Critical numbers need to be trained
Local supervision capacity critical
EmOC equipment provision in sync with training
Pre-service training input required
Health system challenges
Poor coordination of in-service EmOC training
Poor quality of HCF records
Weak maternal death review system
These formed the basis for design of phase 2
Based on the results from phase 1, there was enough evidence and momentum to revised the national uorriculum, and harmonise the various EmOC training packages

21. LSTM in Kenya EHS 07-10 Nyanza 10 Level 5 HCF
MiH I 09-11
10 Level 5 HCF
Kenya Harmonized curriculum 2012
MiH II
Western
Central
But harmonisation of all EmONC training programmes in the country had to be achieved, improving coordination, developing training standards and monitoring these standards

22. National EmONC training Curriculum
The EmONC curriculum was launched in 2012
Standards for EmONC training
Mentorship package
LSTM supported MoH to formally adapt the LSTM EmOC training package, the national curriculum was published in 2012, other training materials have been adapted similarly from the LSTM materials with some input from other existing materials. LSTM has supported MoH to draft standards for running such training based on her extensive experience in internationally and in Kenya
FHI
WHO
Jiepigo/MCIP

23. LSTM in Kenya EHS 07-10 Nyanza 10 Level 5 HCF
MiH I 09-11
10 Level 5 HCF
Kenya Harmonized curriculum 2012
MiH II
Western
Central
Competency based training in Kenya since 2007
DFID funded HSS programme, limited to six districts in Nyanza province, Training, equipment, SS, Support to MDR

24. 15 Counties 3 Provinces Level 3-5 HCFs
MiH phase 2:
15 Counties 3 Provinces Level 3-5 HCFs
Counties located in 3 former provinces were selected for support of MiH by DFH MOPHS

25. MiH phase 2: Key challenges so far
Poor coordination of MNH partners
Low standards of trainings among MNH implementing partners
Poor maintenance of EmOC training equipment
Lack of investment in EmOC training equipment and TOT pool
Obtaining permission for training from MoH in timely manner
Poor retention of trained maternity care workers post training
However key challenges encountered are….

26. Coordination and mapping
Who, what, where?
11 organisation providing EmoNC trainings
3 providing country wide coverage
Most Nairobi & Rift Valley (6)
Least in Eastern/Coast counties (1)
Follow up with partners, to update and share information regularly

27. Key achievements in phase 2
Database of Master trainers created for MoH and counties
CMNH provides technical advice to other EmONC implementation partners
Sharing training equipment
Supports MoH to map and coordinate EmONC training partners
Identify input for support to pre-service training
PS Kenya
DANIDA SC
AMREF
World bank
ICAP
Christian Aid
Funzo Kenya
Universities UoN and Musindo Muliro University
FH/Options Kenya

28. DFID MNH programme (2014-2018) Management oversight role LSTM
EmONC training
National scale up
UNICEF
HSS
Bungoma, Turkana, Homabay
Kakamega, Garissa, Nairobi
Coordination role
TBD SP
Innovations fund
Bungoma county
Management oversight role

29. MiH national expansion phase: 2014-18
All 47 counties in Kenya
Support to National level MPDSR/QI coordination
Support programme M&E
Support pre-service EmONC training
Office expansion consistent with scale up.
By region: all the 5 additional regions in Phased approach
Commences 1 Region Q (Nairobi)
Three additional Regions in Q2 ( NE/RV/Coast )
1 Region in Q 3 (Eastern)
Q3 2014: All regions active.

30. DFID MNH Programme coordination
Steering group
Implementation working group

31. Coordination: County input
DFID Kenya MNH SP
LSTM
UNICEF
SP Innovation fund
County Health forums
CHMTs
MoH
TWG RH/MNH
HRH/RH ICC
Implementing so far started from 15 counties and good welcome, support and engagement with counties so far

32. MiH national scale up phase: Challenges so far
Training quality
Poor selection of trainees
Training impact
Poor staff retention after training
Lack of EmOC equipment post training
Training cost
Security concerns
Lack of investment in training equipment and Master trainers
Training venues

33. Summary Multi-dimensional approach to improving maternal health needed
Quality of care determines 3rd delay
Knowledge and skills of SBA in EmOC is poor
Both pre and in-service interventions required
Structures for sustained in-service training system set up at county levels

34. Recommendations for action and sustainability
National policy to consolidate and sustain intervention
Designated accredited training centres
Compulsory periodic training in EmOC-with shared responsibility
Annual practice license linked to appropriate CPD training
Modified staff rotation policy to ensure staff retention post training

35. Action for counties for accelerated impact
Support/provide venues for training
Proper staff selection for EmONC trainings
Support and synchronize delivery of EmOC equipment with training
Improved coordination of EmOC training partners
Storage and maintenance of training equipment
Advocate with relevant bodies for policies to sustain interventions

36. Acknowledgements Division of family health
Reproductive and Maternal Health Services Unit
County RH coordinators
County Directors of Health
DFID, UNICEF
LSTM Kenya and Liverpool Teams

37. Asante sana!
Thank you

38. Additional slides: Scaling up targets
Regions 3
+ 5
EOC training sites 6
+ 41 (37 additional sets)
EOC
3500 (6200)
5504 (7520)
TOT
180 CD 40
+ 128
MiH data
166
+ 480 QI
Baseline surveys 4 10