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Ministry of Health - GTZ Health Sector Program Deutsche Gesellschaft für Technische Zusammenarbeit GmbH Implementation evaplan GmbH am Universitätsklinikum Heidelberg Consultant PD Dr Michael Marx Mission Report Stock-taking of QM-Component of GTZ-Sector Program “Reproductive Health and Health Financing” July 2008 evaplan GmbH am Universitätsklinikum Heidelberg Ringstr.19b D-69115 Heidelberg Fon 06221-138230
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Ministry of Health - GTZ Health Sector Program

Deutsche Gesellschaft für Technische Zusammenarbeit GmbH

Implementation evaplan GmbH am Universitätsklinikum Heidelberg

Consultant

PD Dr Michael Marx Mission Report Stock-taking of QM-Component of GTZ-Sector Program “Reproductive Health and Health Financing”

July 2008

evaplan GmbH am Universitätsklinikum Heidelberg Ringstr.19b D-69115 Heidelberg Fon 06221-138230

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List of abbreviations

ANC Antenatal care

AOPs Annual Operational Plans

CBOs Community Based Organisations

CHAK Christian Health Association of Kenya

COHSASA Council for Health Service Accreditation of Southern Africa

CPD Continuous Professional Development

DHMT District Health Management Team

DMOH District representative of the Ministry of Health

DRH Division of Reproductive Health

DSRS Department of Standards and Regulatory Services

EBM Evidence Based Medicine

FBO Faith Based Organizations

GDC German Development Cooperation

GTZ German Technical Cooperation

IMCI Integrated Management of Childhood Illnesses

JSP Joint Support Program

JPWF Joint Programme of Work and Funding

HENNET Health NGOs Network

HMB Hospital Management Board

HMO Health Management Organisations

HMT Hospital Management team

KBS Kenya Bureau of Standards

KEC Kenya Episcopal Conference

KENAS Kenya Accreditation Service

KEPH Kenya Essential Package for Health

KEPSA Kenya Private Sector Alliance

KESPA Kenya Service Provision Assessment

KMA Kenya Medical Association

KQAM Kenya Quality Assurance Model

KQM Kenya Quality Model

NHIF National Hospital Insurance Fund

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MDGs Millennium Development Goals

MoH Ministry of Health

NGOs Non-Governmental Organisations

NHIF National Hospital Insurance Fund

NHSSP National Health Sector Strategic Plan

NNAK National Nurses Association of Kenya

PHMT Provincial Health Management Teams

QAO Quality Assurance Officer

QITs Quality Improvement Teams

RH Reproductive Health

SANAS South Africa National Accreditation Service

SBS Strathmore business School

SOP Standard Operational Procedures

SWAp Sector Wide Approach

UN United Nations

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Table of contents

Executive summary ………………………………………………………….......……… 4

1. Introduction……………………………………………………………………….…... 5

1.1. Purpose of the consultancy……………………………………………………. 5 1.2. Methodology………………………………………………………………….…. 6

2. Summary description of the current situation……………………............... 6

2.1. Background……………………………………………………………………… 6 2.2. Quality of health care - the current situation………………………………… 7 2.3. GDC- Sector Program…………………………………………………………. 9 2.4. Component 4 of the “KV Reproductive Health and Health Financing”: Improvement in the quality of health care……………………………………. 10

3. Major Findings: achievements - challenges – recommendations…….. 13

3.1. Capacity Development…………………………………………………………. 13

3.1.1. Political, institutional and conceptual and framework………………. 13 3.1.2. Organisational Change………………………………………………… 17 3.1.3. Capacity Development of Individuals………………………………… 21

3.2. Instruments……………………………………………………………………… 22

3.2.1. KQM……………………………………………………………………... 22 3.2.2. Standards and Guidelines…………………………………………….. 24 3.2.3. Quality Assurance - Assessment - Certification – Accreditation….. 24 3.2.4. Best Practice Service Delivery Processes…………………………... 27

4. Mainstreaming QM throughout the GTZ program and beyond………... 27

5. BACKUP proposal…………………………………………………………………... 28

6. Conclusions and Recommendations for GTZ………………………………. 30

Annexes Annex 1: Terms of reference (TOR)…..……………………………………………. 33

Annexe to TOR…………………………………………………………….. 38

Annex 2: Schedule and persons met……………………………………………….. 44

Annex 3: Report of Quality Management Workshop……………………………… 48

Annex 4: QM Component Workplan 2007…………………………………………. 50

Annex 5: List of references…………………………………………………………... 55

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Executive Summary The MoH of Kenya/GTZ- Health Sector Programme Kenya has commissioned a couple of consultancy services to support the Quality Management Component. This mission consisted of a stock taking (review) of the Quality Management Component.

Priority areas The key priority areas of the stock-taking included capacity development, instruments of the Kenya Quality Model (KQM), Standards and Accreditation Process, and best practice in service delivery processes.

Methods The following methods were applied during the assignment: Analysis of Quality Management (QM) and KQM related documentation, semi structured interviews and discussions with key stakeholders of the KQM-Program, discussions with development partners, focus group discussions with Quality Improvement Teams (QIT), visiting of selected health facilities and a dissemination workshop with key stakeholders.

Achievements Kenya has made a considerable progress in initiating and bringing the process of QM forward with clear advocacy for KQM within the health system. There is a declared commitment of the major stakeholders, KQM is a comprehensive conceptual framework, DSRS being the owner of KQM has delegated it to NHIF in 2005. NHIF has accredited 450 health facilities, with 250 under contract. Linking QM with rebate system may be a leverage for QM.

Challenges The following key challenges were identified: It is still unclear whether the division of the MoH into 2 ministries will have Implications for KQM. There is a plethora of different standards and guidelines, which are not yet binding. Human resources are a determinant of QM, given the still centralised HRM, and the fluctuation of staff. KQM is not very well known (e.g. MoH, health facilities, private sector). The impact of the award scheme on quality has to be shown. Incentives to do QM are still weak. The scope and outreach of KQM is still limited, still leaving out other facilities than hospitals and preventive activities at district level. The interface between DSRS and NHIF is not clearly defined in terms of responsibilities, tasks, division of labour. Assessment procedures have become ritualistic. The private sector is not being sufficiently involved. There are training needs for QM at all levels. There is a need to better market QM.

Recommendations As QM/KQM related activities are owned by the government, these recommendations address the MoH/DSRS in the first place. GTZ can only make propositions and provide support upon request.

1. Organisational development of DSRS: there is an instant need to make the regulatory framework functional including the private sector, civil society and Faith Based Organisations; explore the possibility of integration of Output Based Approach Quality Assurance into KQM; develop capacities of DSRS to take on a stewardship oriented role on standards and guidelines; QM sensitisation and marketing campaign should be organised to give KQM a booster. To this end, a consultative group on KQM created and composed by MoH and different development partners could be acting a catalyst for QM in the short and mid run. 2. KQM should be introduced into the RH component with a strong emphasis on the operational level, involving and supporting PHMT/ DHMT, QIT, QAO in the first place. Cooperation with the private sector should be systematically sought. To this end, again GTZ can mediate between MoH, NHIF and the private for- profit and non-for profit. 3. It is proposed to create an independent accreditation body. Precondition is the introduction of binding standards by DSRS. A feasibility study on accreditation should also assess the status of standardisation and regulation by DSRS. The accreditation process should be clearly linked to the progress of standardisation setting. As long as there is no perceptible move forward, one should not invest in creating a new accreditation body. This activity area will be covered by the BACKUP proposal. The administrative hurdles should be removed in due time, otherwise GTZ may have to negotiate with GTZ- BACKUP about rededication of the fund. This would jeopardise an important part of the current QM component. 4. A comprehensive training concept comprising leadership training, management training, coaching and QM training for post- and undergraduates should be developed and implemented. This activity will also be covered by BACKUP funds. Academic Institutions should be involved right from the start. 5. Mainstreaming QM throughout the GTZ program means also to systematically search for synergies between the different program components, e.g. health-facility-funding mechanisms providing interesting opportunities related to QM. To this end, a dialogue on QM needs to be institutionalised with regular structured meetings and across thematic teams.

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“Quality Management is a journey………….not a destination”

1. Introduction The overall objective of the “German Technical Cooperation to Kenya in the areas of

Reproductive Health (RH) and Health Financing” is: Access to good and affordable health

care, particularly in the reproductive health sector is improved. The German Development

Cooperation Program comprises of five components: (1) Policy, (2) Health Financing,

(3) Reproductive health, (4) Quality Management and (5) Reducing Gender-Based Violence.

The program supports the Kenyan government in implementing the National Strategy Plan in

the health sector and the “Joint Program of Work and Funding” in the above mentioned

thematic areas. By supporting community based approaches, non-governmental

organizations and through appropriate public relations activities it also promotes the demand

for health services.

This consultancy report focuses on component 4 of the program: Improvement in the quality

of health care.

1.1. Purpose of the consultancy

The Ministry of Health (MoH)/ German Technical Cooperation (GTZ) Health Sector

Programme Kenya has commissioned a couple of consultancy services to support the

Quality Management Component. This mission consists of a stock taking (review) of the

Quality Management Component, based on the GTZ offer of the previous program phase

and the offer from 2007, with a focus on policy and conceptual aspects of the component. On

the basis of this review together with a complementary consultancy in August 2008 focussing

on the operational level, the future strategy should be developed and the component further

planned. According to the Terms of reference (see TORs in annex 1) the following areas

should be given priority:

A. Capacity Development (CD) focussing the institutional and policy level, organizational

change and CD of individuals; Incentive Structures;

B. Instruments: Kenyan Quality Model (KQM1), Accreditation Process, Accreditation Agency

Development;

C. Best Practice Service Delivery Processes;

1 KQM was recently renamed into KQAM (Kenya Quality Assurance Model).

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1.2. Methodology

The following methods were applied during the assignment: Analysis of Quality

Management (QM) and KQM related documentation, semi structured interviews and

discussions with key stakeholders of the KQM-Program, discussions with development

partners, focus group discussion with Quality Improvement Teams (QIT), visiting of selected

health facilities (see program and persons met, annex 2). At the end of this assignment a

workshop was organized by the Department of Standards and Regulatory Services (DSRS)

of the MoH assembling important stakeholders. The objective of this workshop was to

disseminate the results of the stock taking study and to share ideas regarding the future

strategy of the QM approach.

Limitations: the present consultancy is not a systematic evaluation, but rather a stock taking

and advisory mission. The analysis and the conclusions are basically drawn from discussions

and interviews with key stakeholders, assessment studies, progress reports and sector

documents. Many of the conclusions and recommendations have been already stated in a

number of reports and documents and can only be reiterated and underlined.

Noteworthy, the conclusions and recommendations of the stocktaking do not necessarily

represent the position of GTZ – they are the consultant’s independent views.

2. Summary description of the current situation 2.1. Background The evaluation of the first National Health Sector Strategic Plan (NHSSPI -1999-2004) in

September 2004 found that its contribution towards improving Kenyans’ health status was

largely insufficient. Most of the health indicators showed a downward trend, e.g. infant and

child mortality rates increased and the use of health services in public facilities declined. The

doctor-to-population ratio declined, the public sector’s contributions to healthcare stagnated,

going from US$12 per person in 1990 to US$6 per person in 2002. Poverty levels also

increased from 47 percent in 1999 to 56 percent in 2002.

The following causal factors were stated:

• Absence of a legislative framework to support decentralisation;

• Lack of well articulated, prioritized and costed strategic plan;

• Inadequate consultations amongst MoH staff themselves and other key stakeholders

involved in the provision of health care services;

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• Lack of institutional coordination and ownership of the strategic plan leading to

inadequate monitoring of activities;

• Weak management systems;

• Low personnel morale at all levels;

• Inadequate funding and low level of resource accountability.2

The second National Health Sector Strategic Plan (NHSSP II -2005-2010) intends now to

reverse the decline in the health status of Kenyans. The vision of the sector is: an efficient,

high quality health care system that is accessible, equitable and affordable for every Kenyan

household.

Goals, objectives and principles Reducing inequalities in health care and reversing the downward trend in health related

impact and outcome indicators are the twin goals of NHSSP II. Six separate but interlinked

policy objectives aim towards the realization of this goal:

• Increase equitable access to health services.

• Improve the quality and responsiveness of services in the sector.

• Improve the efficiency and effectiveness of service delivery.

• Enhance the regulatory capacity of the Ministry of Health.

• Foster partnerships in improving health and delivering services.

• Improve the financing of the health sector.

The basic principles underlying this second strategic plan are: 1. service delivery will place

human capital development and the human rights approach squarely at the core of its

interventions; 2. NHSSP II shifts the emphasis from the burden of disease to the promotion

of individual and community health by introducing the Kenya Essential Package for Health

(KEPH), which focuses on the health needs of individuals. 3. the strategy emphasizes strong

community involvement in health care.

2.2. Quality of health care - the current situation As above described, the quality of health care in Kenya has been on a downward trend

during the last decade. A substantial number of the Health Sector performance indicators are

Reproductive Health related. The Kenyan Service Provision Survey (KEPSA) described in

2004 for the mother and child services alone an alarming situation:

• Antenatal care (ANC), postnatal care (PNC) and tetanus toxoid vaccine services are

available in only a third of all facilities.

2 KESPA 2004

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• Only 36 percent of interviewed ANC clients reported being counselled on warning or

danger signs during pregnancy and 51 percent were counselled on delivery plans.

• Two in five facilities offer normal delivery services, and 39 percent of facilities offering

delivery services have blank partographs. Only 13 percent have medicines for managing

serious delivery complications, and 56 percent have newborn respiratory support (infant

sized Ambu bag).

• Only six percent of interviewed providers of normal delivery services were able to

mention all four signs/symptoms of postpartum haemorrhage (PPH) and 12 percent were

able to mention all four expected interventions.3

• As for the view of the caretakers the major complaints were the waiting time to see a

provider (20 %) and lack of medicines (17%).

As underlying causes are quoted in NHSSP II: overall shortage of health workers; skills

imbalances among the existing workforce; mal-distribution of health workers (between urban

and rural areas, between the public and private sector, between various provinces); poor

work environments (deficient equipment, lack of drugs) and weak knowledge base in skills. In

addition, the contribution of the health management information system (HMIS) towards

evidence-based decision-making has been very limited. The knowledge of the decision

makers (DHMTs) about relevant data and performance indicators within their area is

insufficient. The inability to process and use information for decision making at the local

levels (health centres and districts) affects the quality and effectiveness of district health

planning and provincial monitoring.4

As for private health care services, according to a cost analysis in 2006 many hospitals are

characterized by high per unit costs while utilization levels are low. This can be seen as an

indicator for sub-optimal use of resources.

Moreover low bed occupancy rates ranging from 12% and 15% (group average for small and

big district hospitals) to 29% (small provincial hospitals) indicate that some hospitals are not

utilizing available beds efficiently. On average between 61% and 88% of beds are not

occupied throughout the year, thus involving costs which could be reduced. Hospitals with

high cost structures need to examine areas of rationalisation without compromising on

quality.5

3 KESPA 2004 4 Strategy Paper for the QM Component, I Matthauer, S Ngata 2006 5 Nzoya D., Mattauer I., Flessa S., Cost analysis of Private Health Care Services in Kenya, GTZ- report (unpublished), 2006.

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2.3. GDC- Sector Program In 2005, the Kenyan government together with major donors decided on a sector reform

program in the framework of a SWAp. Through a joint process, the trend towards a further

deterioration of health outcomes should be reversed.

The German Technical Cooperation (GDC) also fits in here. The main objective included in

the Kenyan-German focal area strategy paper (SSP) and the goal of the German contribution

in the Kenyan health sector is aimed at the SWAp objectives (NHSSP II and JPWF) and the

proposal for the Joint Support Program (JSP).

The overall objective of the “KV Reproductive Health and Health Financing” is: Access to

good and affordable health care, particularly in reproductive health is improved.

The program comprises five components: (1) Policy advisory, (2) Health financing, (3) Family

planning/ Reproductive health, (4) Improving the quality of health care, (5) Reducing violence

against women, especially female genital mutilation. The SSP has a time span until 2010, the

total duration of the program extends to 2016.

The program supports up to 6 districts (in Nyanza, Western, Eastern and North Eastern

provinces) in establishing the District Health Plans and taking into account the fields of

“Reproductive Health” and “Improving Services” according to local priorities.

Indicators:

• Increase in the percentage of the poor using basic services particularly of vaccinations

and ante-natal check-ups. Base and target values will be defined in the progress reports.

• Increase in births, which are assisted by trained personnel, from 42% to 90%.

• Increase in the use of modern methods of family planning to 60% of women of child-

bearing age (currently 10%).

• Reduction in the percentage of ”out of pocket” expenditure for health, which users pay

directly to the health service from 53% to 45%.

The input of the German technical assistance contribution comprises policy advisory

services, technical consultancy services, process consultancy services, advisory services in

organizational development and further training through international, regional and local long-

term and short-term experts, inputs of materials, equipment on a small scale as well as

subsidies towards financing of further training programs and small interventions.

By supporting community oriented approaches, non-governmental organizations and through

appropriate public relations activities it also promotes the demand for health services. It is the

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only bilateral project of comparable size in Kenya’s health sector, which combines human

rights aspects such as violence against women, particularly female genital mutilation with

systems support. There is close cooperation with KFW in the areas of family planning/

reproductive health and with DED in the deployment of DED experts in the components 3

and 5.

The term of the current 2nd phase of the offer is three years (01/2008 – 12/2010), with a total

commissioning sum of 6.500.000 EUR. The expected financial cooperation contribution

amounts to 26.500.000 EUR. The total project duration is 12 years (from 01/2005 to 12/2016)

with a total technical cooperation contribution volume of 20.000.000 EUR.6

2.4. Component 4 of the “KV Reproductive Health and Health Financing”: Improvement in the quality of health care. QM is part of SWAp priorities of service delivery. Improved quality of care is one of the

expected outputs. Through SWAp, MoH is expected to take more lead and ownership of

quality issues. Quality assurance is considered as one of the cross cutting issues of all the

themes.

The methodological approach of the QM component comprises policy advisory, technical

and process consultancy services, local subsidies as well as consultancy services in

organizational development in the framework of a systems approach for the area of quality

management.

The implementation of the planned activities is supported by the provision of local subsidies,

whereby small investments and procurements, but also contributions towards recurrent costs

are made, as long as they serve a key function. Training, strengthening of monitoring and

evaluation, promoting targeted reproductive health approaches for the youth, institutional

capacity development and advising provincial structures are further services. The persons

responsible at district and provincial level make use of these, in order to implement

reproductive health activities and quality management. Direct benefits accrued from this are,

that FP/RH services for the general population as well as services for the youth and their

age-specific problems are expanded and improved (RH) and that methods and instruments

for improving the quality of essential health services are introduced.

6 GTZ offer for the Implementation of the Contract (Program: “KV Program Reproductive Health and Health Financing)”, Kenya Project Number: 2007.2038.3

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Objective and indicators of the previous program phase (up to December 2007) were

formulated as following:

Component objective: Improved systems for data management (Kenya Quality Model (KQM) and Health

Management Information System) are applied.

Indicators:

• The KQM has been improved on three aspects (e.g., refined indicators, implementation

approaches, evaluation), which reflect experiences from its implementation in KQM pilot

districts.

• The utilization of data generated from the KQM or HMIS has resulted in at least two

cases in more efficient procedural changes in the pilot provincial district health

administration (e.g., planning, supervision, monitoring).

In the new GTZ offer component objective 4 and the respective indicators have been

reformulated7:

Component Objective 4: Procedures and instruments for improving the quality of essential

health services are introduced.

Indicators:

• Increase in health facilities, which fulfill the quality standards for a comprehensive

consultation in reproductive health, in the target districts by 30% (currently on average

20%).

• A guideline for independent accreditation of health providers is published and is in the

process of implementation.

• Introduction and use of guidelines and processes of quality management (supervision,

quality audits) in at least 60% of health facilities in the target districts.

7 GTZ offer for the Implementation of the Contract (Program: “KV Program Reproductive Health and Health Financing)”, Kenya Project Number: 2007.2038.3

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Table 1

Synopsis of QM activities8 The present state and structure of Quality Management in Kenya can be depicted in some phases, separated according to activities of MoH and activities of NHIF: • In 2001/2002 the QM process in Kenya was started. The Kenya Quality Master and the

Master Checklist were created by the MoH, later completed by the development of the data collection software financed by BACKUP and a first piloting in 50 facilities.

• 2001: sensitisation workshops on standards and the Master Checklist were held in 7 provinces.

• 2002 and 2003: Seven sensitisation workshops on Health Standards and Master Checklist (Components of KQM) were held in seven provinces and piloting was done in 50 facilities in 2003.

• In 2003 health inspectors (MoH) were trained on QM , a congress on Quality Management, medical research and traditional medicine was organised and Quality Assessment Officers (QAO) were recruited by NHIF.

• In 2004, a quality accreditation project financed by BACKUP took place and NHIF and GTZ reviewed the Master Checklist.

• In 2005, NIHF adopted the KQM tool in its accredited facilities. • In 2005 NHIF, MoH and GTZ jointly assessed Quality Improvement Teams, a M&E

framework was developed by GTZ staff, and the SWAp process was started. As well, this year included the accreditation of hospitals and the development of a training curriculum for QIT by NHIF and GTZ.

• In 2006, NHIF and GTZ conducted a pilot training, several sensitization workshops and scale-up training. They also developed a curriculum for training of trainers and auditing, and conceptualized a paper on QM. An impact evaluation was conducted by NHIF and a financing agreement with GTZ established. This was completed by the training of trainers and training for QIT.

• 2006 also resulted in the release of NHSSP II and the start of a more intense collaboration process of MoH, NHIF and GTZ. The consultancy in February/March 2007 on QM activities in the past and future strengthens these efforts towards a new culture of QM.

• By the end of 2007, 157 of the 250 facilities (including Public, Private and FBOs), submitted quarterly self assessment reports to NHIF and are audited at least once per year.

• 2007 KQM review was initiated according to one of the objectives of the AOP3 (DSRS). Working groups were established for different areas to be addressed by the review; a series of workshop were organised until the end of 2007.

• 2008 Due to the post election crisis in the country many activities were delayed by 6 months.

• 2008 KQM renamed in KQAM (Kenya Quality Assurance Model). • A draft KQM review report due to be submitted to the DSRS/MoH in July 2008.

8 Adapted from: Backup Initiative- Consultancy 3/2007- Boecklein, Bodal, Ngata

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3. Major Findings: achievements – challenges - recommendations

According to the TOR only priority areas will be pointed out and analysed in the following.

3.1. Capacity Development 3.1.1. Political, institutional and conceptual and framework There are many achievements to be noted. Kenya has made a considerable progress in

initiating and bringing the process of QM forward with clear advocacy for KQM within the

health system. There is a declared commitment of the major stakeholders (e.g. DSRS/MoH,

NHIF, GTZ, DHMT, PHMT, health facilities, QIT, QAO, CHAK, HENNET) for it. The MoH as

initiator of the QM process – with the KQM providing the conceptual framework- still can be

seen as owner of the model.

The Department of Standards and Regulatory Services (DSRS) of the MoH has the

mandate to develop a quality improvement system for the health services. DSRS staff has

been reinforced since the beginning of QM activities. DSRS is mandated to provide

leadership in quality improvement in the national health system, medical research, traditional

medicine, health laws and policy review. The implementation of the KQM by the MoH did not

go beyond the initial pilot phase until 2005.

The National Hospital Insurance Fund (NHIF) is a semi-autonomous Government

institution related to the Ministry of Health (MoH). It can decide on the partners, can get into

contractual relations with these partners and is entitled to use the generated income for its

own purposes. Its regular tasks are the accreditation of health facilities as contractors and

quality control. NHIF has adopted KQM in 2005, and is since in charge of accreditation,

quality assurance including QA audits, continuous quality monitoring and training with regard

to KQM. This was a decisive step by the DSRS concentrating on its actual mandate and

towards a reasonable division of tasks and labor. Currently, over 450 health facilities are

accredited to NHIF. The Kenya Quality Model was used to prepare these hospitals for

certification. Since, 250 contracts have been signed country-wide stipulating the following

requirements: set up of Quality Improvement teams (QIT), quality improvement plans, quality

improvement activities. It is worth noting that linking rebate payment with quality

management could become an effective leverage for QM and health facilities staff may be

much more motivated to provide services of good quality. In addition, NHIF was mandated to

provide quality assurance to services selected as Voucher Service Providers (VSP’s) for

Output Based Aid (OBA), which was introduced in 2006.

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With support of GTZ, NHIF developed a training curriculum and trained Quality Improvement

Teams (QIT) from the respective health facilities. Most of these health facilities adopted

KQM, in 2008 renamed and referred to as Kenya Quality Assurance Model KQM, as their

quality improvement tool. A “quality audit

concept” was elaborated in 2007 to

monitor KQM indicators regularly. KQM

was supposed to become an integral part

of the “Performance –based Monitoring

and Evaluation System” (introduce in

2007) and the Joint Annual Reviews

(JAR). In 2007, a slight improvement of

process and output indicators could be

found for the first time, e.g. reduction of

service waiting time by 30%,

completeness of data provision increased

by 33%. Despite undeniable achieve-

ments, KQM still faces many challenges:

DSRS After the restructuring of the Ministry of Health -now split into two Ministries- it is still

uncertain what the implications for the KQM program will be, despite the fact that KQM will

stay within the mandate of the DSRS – relating now to the Ministry of Medical Services. The

capacities of DSRS in terms of qualified staff are still limited in the face of the upcoming

challenges.

DSRS as initiator and official owner of the QM program, having delegated the

implementation of KQM to the NHIS is still struggling with its mandate and the tasks related

to standards and regulations. Even where standards exist, they are not binding. There is a

multitude of different standards and guidelines in use, which are not well harmonized thus

creating confusion among the health workers and those who are in charge of quality. For

example, the Medical Practitioners and Dentist Board (KMPDB) develop and enforce clinical

standards and guidelines for hospitals for the purposes of inspection for licensing. But these

standards are not made binding for the daily work and are not adopted by and integrated into

KQM. The DSRS does not have an overview on the various standards and guidelines in use

at the different levels of the health service system.

Table 2: NHIF contract terms and conditions. Accreditation shall be reviewed every two (2)

years and shall be linked to quarterly quality assessments and accreditation manual.

The Provider undertakes to provide quality health care services in a scientific and standardized form by applying the Kenya Quality Model.

The Provider undertakes to set up an internal Quality Improvement Team or Hospital Based Quality Management Team, which shall generate quality improvement reports and availed to NHIF (quarterly).

The Provider’s quality improvement team shall work towards attaining a continuous quality certification from recognized bodies (national and international).

Source: NHIF 2005 Contract with hospitals

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QM Policy A policy for QM clearly addressing the different operational levels of service

provision and guiding the implementation of QM is still missing.

It was only this year that DSRS made an attempt to elaborate a strategy. However, what is

called strategy may rather be interpreted as areas of activities, e.g. "Training of Trainers at

the provincial level to train the ones at the lower levels, or facilitate trainings at the district

level and facility level- facility based trainings”.

In contrast, the following can be accepted as a strategy: “Implement KQM together with

stakeholders in the facilities”.

Regarding scope and outreach of KQM, it addresses only the health facility level so far,

leaving almost out the community level and aspects of disease prevention, except for

immunisation. As prevention is one of the declared priorities of the MoH, it should be

integrated in the KQM.

The potential of other private insurance companies and health management organisations,

now competing with the latter, seems still unexplored and the private sector not yet

sufficiently involved in strategic planning.

NHIF -benefiting from the mandatory contribution and protected by the law- holds -from a

market perspective- a privileged and monopolistic position in the system thus distorting

somehow the market. For public hospitals accredited to NHIF, there are no mechanisms of

withdrawing their accreditation contract, should the facilities not show effort in improving their

quality since all public hospitals which include, district, sub district and provincial hospitals

were automatically accredited to NHIF. Facilities implement KQM based on the NHIF rebate

incentive. Given that common standards and regulations are still missing, it is questionable if

this will be an effective leverage for quality in the long run. As a consequence, there is little

competition in that field.

Sensitization for QM is crucial, not only to attract the interest of providers but also to create

awareness for quality among the users and patients and within the civil society.

NHIS being the main implementer of KQM at present, still has – despite the successful roll

out of the KQM with 250 facilities under contract- limited scope and outreach countrywide.

This means that only 5% of all health facilities are enrolled countrywide. More important than

the sheer coverage is the impact of KQM which still needs to be proved. It may be better to

develop service quality step by step with proved and convincing results –good practice

approach- than rolling out KQM to fast, thus diluting resources and minimising impacts. In

addition, the outpatient services which are supposed to be integrated into KQM and into

NHIF-services, still remain uncovered.

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Stakeholders Although many stakeholders have been somehow involved in the process of

KQM development, only few of these stakeholders have been continuously and actively

invited to the KQM development process.

The following major Stakeholder of KQM were identified and analysed during the workshop

at the end of this assignment: DSRS, NHIF, CHAK/KEC, KEPSA, Kenya Medical

Association/National Nurses Association of Kenya (KMA/NNAK), GTZ, Divisions of the

Ministries e.g. DRH etc , Clinical Officers Board, Kenya Medical and Dentists Board, Nursing

Council of Kenya (Annex 3 workshop report).

In order to develop a future strategy, it is important to clearly define the most important

partners and agents of change. In addition to some of the above mentioned stakeholders,

other important partners for KQM were identified: Health care financing agencies, Insurance

companies, Health training institutions, Kenya Bureau of Standards, Joint Commission for

International Accreditation.

As a result of another group work during the workshop a very plain statement was made

regarding agents of change in the KQM process. Almost all persons identified of being the

most important agents of change were decision makers, managers and leaders, from the

Ministry of Health to the health facility level. It is surprising that almost exclusively the top

management level was addressed, leaving almost out the operational level. This shows

clearly the weak linkage between the executive and the operational level on one hand and

the weak involvement of important decision makers on the other.

During this stock taking mission, it was surprising that KQM is not very well known among

the different stakeholders, especially the private non- for -profit and for- profit sector, but -

more striking- even within the MoH and the health facilities. Very few key persons could

describe KQM and its systemic approach in some detail.

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Recommendations

• A QM policy is needed geared towards the operational level of the district health

system. The existing strategic ideas should be cast into a QM strategy.

• As QM principally calls for a multilevel approach, it needs strong advocacy from all

levels of the health system.

• Therefore, a more active involvement of the decision makers in the further

development of KQM is a prerequisite for a system wide implementation.

• On the other hand, there is need to have the input of the actual services providers,

especially the voices of nurses into the quality management process. They are

involved in the day to day care and are very close to the users. But it is equally

important to increasing their knowledge base and win their support and ownership of

the quality management process.

• A marketing campaign, involving also the mass media, should make KQM better

known.

3.1.2. Organisational Change Besides the conceptual and institutional framework, the organisational set up and the terms

of collaboration between the major players in the KQM development process, e.g.

MoH/DSRS-NHIF-GDC-DHMT/PHMT-FBO-Private Sector, are important to be analysed.

The organisational - conceptual framework is still weak, a prerequisite for a

comprehensive and sustainable approach to QM. A major challenge will be to clarify the

interface between the DSRS and the NHIF regarding responsibilities, tasks and division of

labour and creating synergies. The collaboration between DSRS/MoH and NHIF does not

seem to be institutionalised, but rather a bit erratic. Capacities and instruments from both

institutions could be better interlinked to avoid efforts running in parallel to each other. It is

worth noting that setting standards, mainstreaming guidelines and regulation of the whole

heath service system is one of the genuine tasks of the DSRS and a condition sine qua non

for an effective QM-program and last but not least for accreditation.

It is planned that NHIF will broaden the scope taking in more facilities eventually. But this

must not go to the detriment of quality. Given the many shortcomings in the implementation

of KQM (see chapter on capacities and tools) it might be questioned, if NHIF is having the

human resources in terms of number and qualification to further rolling out KQM.

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Competition among health facilities can lead to higher quality. The private sector, FBO and

private insurance companies still play a marginal role in strategic planning of KQM. They do

not show yet a perspicuous interest in KQM. In order to attract the private sector to buy in,

KQM has to prove its strength and positive impact. As already mentioned above, in terms of

quality assurance the same rules and regulations should be applied to the private as to the

public sector. Therefore it has to be reconsidered whether the MoH and the NHIF are best

placed to offer their own accreditation services to their health facilities. For example setting

up an autonomous accreditation body (see BACKUP proposal), would create more

transparency and trust, thus fostering the competition for better quality within the system. Of

course, the overarching principles of accessible, acceptable and affordable services to the

poor should equally be pursued. Benchmarking may become a driving force for better quality

in the long run.

Motivation for QM is of paramount importance. Effective incentive structures are still

missing. However, an award system is being tested as a pilot in RH to award Continuous

Professional Development (CPD) points on demonstrated quality improvement/ guidelines

and standards adherence using the existing indicators as the baseline. It is too premature to

judge on the effectiveness of the award and how far it will have a sustainable and

comprehensive impact on quality on an institutional level.

An effective incentive scheme for a facility to implement quality management has to take into

account the dimension of costing. There should be clear incentives for health facilities to offer

best quality at lowest costs. At present it is still unclear what QM costs. As long as QM is

seen as add on activities and without proving the value added, it is not likely to change the

performance and the various outputs and outcomes of a facility in the long run.

Linkage between national and district level In 2006, NHIF in agreement with MoH,

introduced Quality Assurance Officers (QAOs) to supervise and assess the performance of

Quality Improvement Teams. An external assessment of the hospital, scheduled quarterly is

to be carried out by the QAO from the respective NHIF area office. NHIF Quality Assurance

Officers are supposed to offer technical assistance in terms of coaching and planning on

request to the QIT.

According to assessment and evaluation reports, this has improved the linkage between the

central and the peripheral level with more regular visits to the QIT, but is fare from being

satisfactory. The supervisory and assessment visits seem to become a mere ritual in just

filling out the checklists and assessment forms, paying very little attention to processes,

problem analysis and support. In one health facility, the author was told by the QIT that the

last QAO visit did not exceed 30 minutes time.

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As mentioned above, NHIF is lacking behind giving substantial, constructive and time-bound

feedback on assessment reports to QIT.

In addition, since the take-over of the supervision of the QIT by the QAOs, there is no formal

contact to the health inspectors who were supposed to supervise the QIT before. There may

be missed opportunities for professional exchange. Possible synergies between QAOs and

heath inspectors could be explored. This relates clearly to the national level to define what

should be done to the districts, hence calling once more for a closer collaboration between

MoH and NHIF.

QIT-QAO- PHMT/DHMT The focus of KQM is said to be on the level of the health facilities

and health care provision. However, despite the system in place which relies on the Quality

Assurance Officers/NHIF (QAO) and the Quality Improvement Teams (QIT) of the respective

heath facilities, too little emphasis is put on supporting these actual “agents of change”. A

substantial support would involve, for example, continuous training, constructive and time-

bound feedback on the QIT reports and, hence improving staff motivation.

There is still a missing link between KQM and the general district health management with its

comprehensive tools and procedures, e.g. HMIS, supervision by health inspectors. This calls

again for a comprehensive QM- policy towards the health district.

DSRS is planning to create a new cadre of Quality Assurance Officers (QAOs) at the district

level who will work closely with NHIF (QAOs) - especially to oversee the lower levels. This is

very questionable as it may add a new parallel structure to the already existing ones, e.g.

health inspectors- district supervisors, QAO. Moreover, it would distract DSRS from its actual

mandate as regulatory institution.

According to observations made by former consultants, no direct link to the District Health

Management Teams (DHMTs) has been established yet. Some of the QAOs do not even

know the members of the DHMT that fell under the jurisdiction of the NHIF area office.9 In

contrast, one District representative of the MOH (DMOH) noted that he was not aware of a

NHIF checklist nor informed of the NHIF quality management initiative.

9 H. Bodal: Quality Management in Kenya: An Evaluation of Quality Improvement Teams in Public, Private and Mission Hospitals in 3 Districts in Kenya; Master’s thesis submitted to the Charité Universitätsmedizin Berlin, FU and Humboldt Universität Berlin, 2007

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Recommendations

• A consultancy on organisational development of NHIF and DSRS is much needed

focussing on priority issues issues like human resource management, organigram,

description of tasks, division of labour, deliverables, deadlines, planning procedures.

This could also be part of a coaching process (see chapter on capacity development).

• Awarding of CPD points to demonstrated quality at individual level should be based

on proven documentation. This is being piloted in reproductive health where

guidelines have been developed. If the award proves to be a successful tool to

improve quality, it is planned to scale it up. However, to measure its impact, a follow

up by action research might be useful (e.g. in collaboration with SBS).

• Plans to create a new cadre of Quality Assurance Officers (QAOs) at the district level

who will work closely with NHIF (QAOs) should be reconsidered. It would negate the

whole essence of QM mainstreaming. Instead, strengthening the already existing

ones at the district level would be more useful.

• The link with DHMT being the main management body responsible for all health

facilities within the district needs to be strengthened. The DHMT should formally be

involved in conceptual, planning and implementation activities related to KQM.

• Ongoing studies on costing related to the essential packages for health (KESPH) may

possibly provide an objective basis to simulate the financial implications of quality

management on the services. This could create more transparency in the system

and thus paving the way for benchmarking, more competition and finally for more

quality of the services. Moreover, having objective indicators and data at hand, it

would help promoting and better selling the QM- model to private facilities and to

other health insurance companies in the future.

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3.1.3. Capacity Development of Individuals “It’s the way parts are put together that makes the engine run”10

The 2nd National Health Sector Strategic Plan 2005-2010 (NHSSP II) has outlined in the Human Resource Development Output that a training needs assessment has to be done to establish training requirements (and identify the gaps within the current training capacity) in the light of Kenya Essential Package for Health (KEPH) and NHSSP II. Eventually, relevant curricula have to be developed. In the same document, the performance and management of professional associations in Kenya in regard to Quality Assurance and Standards in general is considered weak There is little coordination and sharing of information among them. Gaps in knowledge on the on Quality Management are evident. There is a need to institute the culture of quality management during training rather than relying on a few days workshops to train health workers on Quality Management and Kenya Quality Model.

It is widely accepted that human factors have a major impact on deliverance of quality

services. One of the major challenges in Kenya is the high rate of turnover of staff, creating a

discontinuity on work. Despite a general commitment for a decentralised health system, the

control over human resources is still centralised at MoH. The annual staff appraisals do not

seem to be effectively forwarded to the decision- making level at MoH headquarters. In

addition, the awarding system (health professional of the year award) is not well

communicated from the central and regional level. This may affect negatively the motivation

of health workers to do QM.

As already mentioned above, the capacities of DSRS in terms of qualified staff are still

limited in the face of the upcoming challenges. The same may apply to NHIF given the

shortcomings of KQM. According to NHIF staff, the capacity for data processing appears to

be limited to provide a timely feedback to QIT- reports. However, it may be worthwhile to

have an in-depth view into the organisational structure.

At all levels, it appears that the concept of QM is still perceived as and implemented with an

input and tool oriented approach, emphasising more structural aspects than the process, the

output and impact. In addition, there is a tendency to treat the 12 KQM dimensions

separately without recognising the synergistic power they can unfold. This could be seen as

an indicator of a lacking systemic view to approach QM. This again calls for more publicity for

and knowledge about QM.

10 Health Professionals Handbook on Quality Management in Health Care in Kenya.

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Recommendations

• Therefore training on QM at all levels is still badly needed (see also BACKUP

proposal). Training has to be adapted to the specific needs and capacities of staff

involved. It should be in line of MoH capacity building strategies and plans. A future

training program should be based on a needs assessment.

• Training offers should focus on QM but also include management skills and

leadership training for executive level. A tailor made training concept for different

professional levels and purposes is needed, a concept going beyond the scope of

traditional “one-off” training workshops. This should include a follow up and

accompanying measures offered in conjunction with supportive supervision and

continuous coaching of the QIT.

• QM as a concept and tool should be incorporated in undergraduate training of

medical students and nursing staff. A close partnership with academic institutions

with a proved record of new and creative approaches to training, capacity

development and curriculum development could help develop and implement a long

term concept of capacity development. In a consultative process the Ministry of

health, Ministry of Education Kenya Institute of Education (KIE) and training colleges

and Universities should be involved. Hence, the established collaboration with

Strathmore University is promising and should be further explored to this purpose. In

addition, specific inputs by academic institutions, e.g. Moi University and University of

Heidelberg, may be useful for curriculum development and to establish a concept of

continuous coaching.

• It is recommended to organise a workshop for the development of a comprehensive

training concept. This workshop should bring together important training institutions

and selected key stakeholders.

3.2. Instruments 3.2.1. KQM

The Kenyan Quality Assurance Model (KQM) was developed and introduced in 2001 and

provides the conceptual framework for Quality Improvement in Health Care in Kenya. KQM

integrates Evidence Based Medicine (EBM) through widespread use of public health and

clinical standards and guidelines with total quality management and patient orientation. KQM

promotes TQM in a simple and practical way: “apply the 7 KQM principles and use the

Master checklist and you have started already practicing quality management”.

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Integrating two quality improvement approaches is of great importance: 1. a standards and

guidelines approach to ensure delivery of safe and effective health services and 2. the

gradual introduction of quality management to health managers and service providers. Thus,

it is still a useful conceptual framework and provides comprehensive tools.

However, there are various shortcomings. As already stated above, it is too input oriented,

and some of the indicators need a major revision.

As referral is crucial especially in RH and mother and child care, the respective indicator from

KQM needs to be meaningful fulfilling quality criteria for indicators (specific, measurable,

applicable, relevant, time bound): for example, the indicator drawn from KQM measuring

referral: “Availability and use of referral guidelines and protocol…..” is not very significant. It

does not tell us anything about functioning of, medical indication for referral and its impact.

Most of the facilities having adopted KQM as their Quality Improvement Tool complain about

the KQM Master checklist as being difficult to score in some areas. This is partly due to a

lack of standards, to unclear indicators or to weak prescriptive guidance as well. One

example from the Master Checkliste: “Clean toilets or latrines are available for staff …” may

illustrate the difficulty to scoring in the absence of clear standards.11

The Manual with quality standards accompanying the checklist should provide guidance to

best fill out the Master Checklist. Unfortunately it often repeats only the indicator without any

reference to the use of referral guidelines and the ultimate aim, to improve referral.

In this respect, the recent review of KQM has cut a bit short. The revised KQM document

unfortunately has not yet taken into account sufficiently these aspects. Moreover, as

mentioned above, it has omitted the level of community health including prevention, thus

somehow neglecting MoH priorities.

Software An electronic assessment tool – the KQM master software comprising of a data

entry tool and server-based data base was developed by a German software company.

Unfortunately, it does not perform properly, e.g. transfer of data on other medium (USB),

master checklist not storable, comments can not be captured.

11 KESPH (Checklist; quality standards Level 1-6)

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Recommendations

• Community health should be incorporated in KQM. Standards for community health

including prevention have to be developed. The Ministry of Public Health and

Sanitation agreed during the dissemination workshop to take on this task.

• There is need for an assessment of the extent to which the KQM review took into

account some indicators that are too much input oriented and the challenges and

biases occasioned by scoring (scale of 1-5). Reference should be to output or

outcome indicators, e.g. N° of referrals, C-section rate.

• KQM and the Master checklist need be reviewed to suit the different Kenya Essential

Package for Health (KEPH). NHIS and DSRS by involving health professionals

(medics) in the accreditation and quality assessment process should refine its tools

making them more output/outcome oriented and more analytical.

• The electronic assessment software needs major revision and improvement to make

it a practical and workable tool.

3.2.2. Standards and Guidelines

As already stated above, standard lists and other reference documents are not well

introduced to the users. In some facilities the NHIF accreditation manual is being used as

reference document and the checklist is less used. The distinction between the function of

the NHIF accreditation manual and the master checklist is not always clear. Moreover, it is

not known at DSRS/MoH which standards and guidelines have been disseminated by whom,

at which level and how they are being used in which facility?

For instance, according to KESPA 2004 IMCI treatment guidelines and treatment protocols

for sick children were only available and found in 22 percent of facilities offering sick child

services.

Recommendation

• An inventory of all professional standards (e.g. SOP) and guidelines needs to be

done, before binding standards, procedures and guidelines are developed or agreed

upon and introduced at all levels of the health service system.

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3.2.3. Quality Assurance - Assessment - Certification - Accreditation Quality assurance (QA) consists

of a system for monitoring quality

of care, identifying and analysing

problems and initiating changes to

solve the identified problems. QA

requires established standards

against which quality is measured:

activities of QA include for

example medical record audits,

facility-wide review of mortality, supervision of health service system, observation of consultations, problem analysis

processes, analysis of indicators and data from the health management information system

(HMIS).

Quality assessment can be either internal or external. Internal assessment will enable

different facilities and institutions to know their levels of performance as basis for carrying out

appropriate improvements. Certification and accreditation of health facilities are external

processes used to assess institutions and healthcare facilities.

Certification assesses compliance with minimum standards for public safety.

Accreditation sets standards at higher level to stimulate improvements.

Standardisation is precondition for Certification which is precondition for accreditation.12

Recommendation

• Development of standards and certification need to precede the accreditation

process. Thus development of standards for the health sector should be a top priority

for DSRS as it is a prerequisite for accreditation.

Accreditation The National Health Sector Strategic Plan II (NHSSPII 2005-2010) in Kenya has out lined a review of the Public Health Act including registration, accreditation, inspection, and control of public and private health providers as one of the outputs for Quality Assurance and Standards. Accreditation of Health facilities has so far been limited to accreditation done by the National Hospital Insurance Fund (NHIF) for facilities qualifying for rebates and to Kenya National Accreditation Services (KENAS) for laboratories. All the 12 Towards health services Accreditation Framework- Tanzania, workshop report, Morogoro, 2005, GTZ- Report

Table 3: QA activities (KEPSA 2004): • 46% of health facilities countrywide report quality

assurance activities; • 30% have documentation of their QA activities; • the most common QA activities are having a

supervisory checklist for health system components; • routine supervision for child health service providers

was reported in 84 % of facilities, • was less common in private for-profit facilities (69%).

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activities done so far have been uncoordinated with no specific framework to direct the accreditation standards and activities. There is a need therefore to develop, an accreditation system that addresses the quality aspects of the health services providers including, hospitals, clinics, health centres, laboratories and pharmacies. This should be governed by a legal framework ensuring that only the accredited facilities are allowed to operate. The home of the accrediting organ with its legal mandate should also be defined.13

In consequence, there is a need to de-link accreditation from service providers. NHIF

currently assumes various functions and roles as contracting agency, accreditation agency

and as institution in charge of quality assurance. This mixture may bring NHIF into a conflict

of interest. Moreover, it undermines its credibility among private sector and FBO to buy in

the KQM.

Therefore, as stated already many times before, accreditation services should be offered

best by an independent institution.

Three options were discussed during the workshop among the stakeholders:

1. to have an accreditation body that is completely private but linked to Kenya National

Accreditation Service (KENAS); the likely danger with such an arrangement is conflict

of interest that may arise from the for – profit character of such an agency, if a liable

supervision is missing. The idea of having a private entity that does not deal with

health issues like KENAS may not be viable as capacity in dealing with unique health

related issues may be a challenge.

2. to have external institutions to undertake accreditation. These options need a closer

look while bearing in mind the Kenyan context.

3. to have a parastatal-like accreditation body associated with international and regional

accreditation bodies - with a possibility of joint venture and adoption of public private

partnership approach (e.g. Joint Commission, DEKRA Germany).

Recommendation

• Given the complexity of this undertaking, a feasibility study on accreditation should be

done. In addition, lessons could be learned especially from COHASA /South Africa,

an accreditation body specialised in health.

13 Development of an accreditation system: Terms of Reference for Working Group, 2007

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3.2.4. Best Practice Service Delivery Processes

There is apparently a wide diversity among service providers regarding the level of quality.

Lacking a consistent policy of quality including also the private sector, firstly quality has to be

defined with respect to the services provided, secondly standard and guidelines have to be

agreed upon and become binding, before quality can be assessed at a larger scale.

It was not possible during this mission to address this issue more largely. However, visits to

private Hospitals like Nairobi Women's Hospital, Nairobi Hospital, one FBO – Hospital e.g.

Gicabe Hospital, one public hospital e.g. Kenyatta Hospital gave some insight into areas of

good practice delivery.

From the various reports and assessments one can derive that there are quite a number of

well functioning services which could be addressed for assessments, for piloting and testing.

Recommendations

• These well known facilities could possibly be involved in a comprehensive training

concept, offering internships for example or exchange of experience with QM tools.

• In addition, more opportunities could be further assessed to enrol good practice

facilities in the context of new accreditation approaches.

4. Mainstreaming QM throughout the GTZ program and beyond

QM is cross cutting different dimensions, medical disciplines and services. Thus, QM can be

applied to many different facilities and can be easily adapted to make programs as

reproductive health services or preventive services more efficient. This is especially

important for the GTZ program with its health systems approach in Kenya.

Output Based Aid (OBA), introduced and supported mainly by KfW, and its quality assurance

is directly cross- cutting with KQM activities. OBA can be seen as an opportunity to

demonstrate how to reach quality improvement with innovative payment mechanisms.

Unfortunately, NHIF in charge of QA, has not yet managed to integrate OBA into KQM.

However, there are many other partners in the sector involved in different activities related to

quality, e.g. quality assessment, assurance- and management. Technical assistance by

many partners, especially DANIDA, is focussing on the development of standards and on

improvement of quality in various programmes (e.g. RH, HIV/AIDS, HMIS).

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Recommendations

• As for reproductive health (RH), being a priority area of the GTZ program, QM could

be implemented in RH services in the first place.

• For example indicator 1: Increase in health facilities, which fulfill the quality standards

for a comprehensive consultation in reproductive health, in the target districts by 30%

(currently on average 20%). In order to monitor this indicator, it is indispensable that

the division of RH services defines what comprehensive consultation is. The next

step would be to come to an agreement with DSRS and to integrate output indicators

into the master checklist accordingly.

• Moreover, there are possible synergies to be systematically explored between the

different program components, i.e. especially health financing focussing on access

and social security, policy as overarching component, reproductive health and

reducing gender –based violence. The introduction of itemised costing related to the

essential health care packages (KESPH) is an excellent example for a very fruitful

spin- off between the program components. This could ultimately contribute to more

transparency and provide objective data to enable cost simulation of different

interventions, e.g. in the context of KQM. In the long run, this could pave the way for

the introduction of Health technology Assessment (HTA) into the system.

• OBA can be seen as an opportunity to demonstrate how to reach quality

improvement with innovative payment mechanisms. The German Cooperation

(especially GTZ together with KfW) should use its influence on NHIF to integrate the

OBA into KQM. Quality assurance activities and indicators are to be harmonised.

• The same influence should be used to sensitise other development partners for KQM,

to invite them to take a share of KQM and to help instituting a culture of quality.

5. BACKUP proposal

The contract between GTZ/BACKUP Initiative and the MoH has been signed, but the

planned activities have not yet been implemented because of the post-election crisis and still

prevailing administrative hurdles. There are three main activities:

1. To develop a sector owned management based accreditation system for health facilities

2. To initiate QM integration in basic medical training 3. To develop a database system for QM

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With reference to the contract document and the LogFrame, these activities still fit well in the

AOP 4 of the MoH and the MoH- mid term planning:

Recommendations

• Activity 3 has to be revisited by all the partners involved (NHIF-DSRS-GTZ) in the

light of the need for maximum integration of data into the national HMIS.

• After the resolution of

administrative hurdles, e.g.

opening of a bank account

by the MoH, it is important to

get the project started as son

as possible.

• If this administrative

blockade can not be

removed in due time, GTZ

has possibly to negotiate with GTZ- BACKUP about rededication of the fund. This

would question an important part of the current QM component.

• Specific technical assistance should be involved in all three activities right from the

start, e.g. expertise in accreditation processes, and in curriculum development in

graduate and post-graduate training. To this purpose technical assistance could be

searched in Kenya and abroad. It may be important to look for accreditation

companies with an international record and expertise, e.g. in South-Africa or

Germany, right from the start.

Table 4: MoH-strategic planning:

• Pilot and Implement the reviewed KQM

• To develop an accreditation body

• To ensure Quality Assurance Software and Data

base system is in place

• Integration of QM in basic health training

• Concept of linking QM to CPD- pilot in RH

• Develop an award system for health and

individuals based on quality management

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6. Conclusions and Recommendations for GTZ

The following areas and activities should be given priority:

1. Support to collaboration framework (organisational development) with DSRS-NHIF

2. Making QM model outcome and incentive oriented, with a strong focus on the operational

level, e.g. QIT

3. Support to create an accreditation body

4. Development and implementation of a comprehensive training concept

5. Focusing cooperation with the private sector

1. Organisational development of DSRS should be a top priority. Without strengthened

capacity, a clear mandate for the actual tasks and a clear division of labour with NHIF, KQM

will not become a successful and marketable QM model. GTZ should use its influence in the

current policy dialogue to convince and push the decision makers in the MoH and other

development partners to invest into capacity building of the DSRS.

In addition, sensitisation for KQM and even a mass media campaign could give the KQM a

booster to move ahead. This is a genuine task of DSRS.

2. The government should systematically introduce KQM into the RH service delivery with a

strong emphasis on the operational level, involving and supporting PHMT/ DHMT, QIT, QAO

in the first place. There are many opportunities to implement KQM especially into RH

services given the important donor support to reproductive health. Regarding the operational

level of KQM implementation, the upcoming assessment mission focussing on the district

level shall provide more information and details on how best to address this level.

Mainstreaming QM throughout the GTZ program means also to systematically search for

synergies between the different program components, e.g. health-facility-funding

mechanisms providing some interesting opportunities related to QM. To this end, a dialogue

on QM needs to be institutionalised with regular structured meetings and across thematic

teams. However, a mentioned above, many development partners are focussing on the

development of standards and on improvement of quality in various programmes. Therefore,

GTZ should act as advocate or broker for QM, inviting them to take a share of KQM and to

help instituting a culture of quality.

3. and 4. These activity areas will be covered by BACKUP proposal. For their

implementation, there is a need for a continuous backstopping and a long term technical

assistance. The feasibility study on accreditation should also assess the status of

standardisation and regulation by DSRS. The accreditation process should be clearly linked

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to the progress of standardisation setting. As long as there is no perceptible move forward,

one should not invest in creating a new accreditation body.

Moreover, if the administrative blockade of the fund can not be removed in due time, GTZ

has possibly to negotiate with GTZ- BACKUP about rededication of the fund. This would

jeopardise an important part of the current QM component.

5. Cooperation with the private sector should be systematically sought. To this end, again

GTZ should mediate between MoH, NHIF and the private for- profit and non-for profit. The

private sector should be regularly invited to participate to the conceptual and planning

activities and be involved in the implementation of KQM (e.g. training, sharing experience,

exchange of QAO, QIT). Regular structured discussion meetings with all key stakeholders

could provide a forum to critically discuss shortcomings and to develop KQM further in a

participatory manner.

6. A long term technical assistance (GTZ) seems to be indispensable to facilitate and

accompany the process and consolidate the achievements. However, without a clear move

of the government towards quality and without actual commitment for a new QM initiative,

KQM as an instrument risks congealing, not worthwhile to justify further funding. To prevent

this evolution, a consultative group on KQM created and composed by MoH and different

development partners could be acting a catalyst for QM in the short and mid run.

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Annexes 1. a) Terms of reference (TOR)

b) Annexe to TOR 2. Schedule and persons met 3. Report of Quality management workshop 4. QM Component workplan 2007

5. List of references

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Annex 1

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MoH/GTZ Health Sector Programme

TTeerrmmss ooff RReeffeerreennccee ffoorr DDrr.. MMiicchhaaeell MMaarrxx,, EEvvaappllaann

BBaacckkggrroouunndd The overall objective of the “German Technical Cooperation to Kenya in the areas of Reproductive Health and Health Financing” is: Access to good and affordable health care, particularly in the reproductive health sector is improved. The German Development Cooperation Programme comprises of five components: (1) Policy, (2) Health Financing, (3) Reproductive health, (4) Quality Management and (5) Reducing Gender-Based Violence. The programme supports the Kenyan government in implementing the National Strategy Plan in the health sector and the “Joint Programme of Work and Funding” in the thematic areas Reproductive Health, Health Financing, Quality Management, Health policy and Human Rights. By supporting community based approaches, non-governmental organizations and through appropriate public relations activities it also promotes the demand for health services. This consultancy focuses on component 4 of the programme: Improvement in the quality of health care. OObbjjeeccttiivvee ooff tthhee qquuaalliittyy mmaannaaggeemmeenntt ccoommppoonneenntt Procedures and instruments for improving the quality of essential health services are introduced. RReellaatteedd IInnddiiccaattoorrss

• Increase in health facilities, which fulfill the quality standards for a comprehensive consultation in reproductive health, in the target districts by 30% (currently on average 20%).

• A guideline for independent accreditation of health providers is published and is in the process of implementation.

• Introduction and use of guidelines and processes of quality management (supervision, quality audits) in at least 60% of health facilities in the target districts.

Two major activities have been taking place from July 2007:

• Review of the Kenya Quality Model o Central level: - Sensitization workshops on the review of KQM and stakeholder meeting - Selection of a working group o District / Region:

- Workshops held with participants from all the provinces that use KQM in their facilities from Public, Private and FBO facilities in Nairobi, Nakuru and Kisumu. - An editorial team with representatives from all provinces was set up and refined the reviewed KQM.

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• Project on Quality Management integration in Reproductive Health Services linked to continuous professional development

- Central level - Stakeholders meeting, working group formed including representatives of the Quality Assurance and Standards, Continuous Professional Development and Division of Reproductive Health - Preparation for Baseline data collection, tools developed

- District / Region: - Data collectors from the six GDC/ GTZ supported districts (Bondo, Gucha, Butere/Mumias, Vihiga, Tharaka and Wajir) trained.

- Data collection was to take place at the beginning of the year hampered by post election crisis.

The actual status of the component is shown in the attached ‘Projektfortschrittsbericht’.

MMeetthhooddoollooggiiccaall AApppprrooaacchh ooff tthhee CCoommppoonneenntt The methodological approach comprises policy advisory, technical and process consultancy services, local subsidies as well as consultancy services in organizational development in the framework of a systems approach for the area of quality management. The programme supports up to 6 districts (in Nyanza, Western, Eastern and North Eastern provinces) in establishing the District Health Plans and taking into account the fields of “Reproductive Health” and “Improving Services” according to local priorities. The implementation of the planned activities is supported by the provision of local subsidies, whereby small investments and procurements, but also contributions towards recurrent costs are made, as long as they serve a key function. Training, strengthening of monitoring and evaluation, promoting targeted reproductive health approaches for the youth, institutional capacity development and advising provincial structures are further services. The persons responsible at district and provincial level make use of these, in order to implement reproductive health activities and quality management. Direct benefits accrued from this are, that FP/RH services for the general population as well as services for the youth and their age-specific problems are expanded and improved (RH) and that methods and instruments for improving the quality of essential health services are introduced PPuurrppoossee aanndd RReessuullttss ooff tthhee ccoonnssuullttaannccyy The MoH/GTZ Health Sector Programme Kenya commissions consultantcy services, to support the Quality Management Component as follows: PPuurrppoossee Review and strategic further development of the Quality Management Component based on GTZ offer from 2007. EExxppeecctteedd RReessuullttss 1. Conduct situation analysis on where the component stands and recommendations to

strategically further develop the Quality Management Component with respect to the following areas:

Requirements concerning capacity development in order to enhance their contribution in terms of politic, strategies and programmes.

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Recommendations on linkage process between national and district level and also on terms of reference for GTZ quality management activities carried out at district level.

Identification of key persons for all areas of the component.

Recommendations concerning international network development and cooperation with the Strathmore University.

Recommendations concerning involvement of civil society organizations in the activities of the component.

Identification of best practice topics which present quality of health service providers (e.g. equal access, user friendly services etc.).

Recommendations concerning the existing Backup contract between MoH and GTZ which activities could not carried out due to the post-election crisis.

Review of the Backup application form on ‘Quality Management in Health Care Provisions’ and recommendations to avoid overlapping with other contracts between GTZ and the MoH.

Identification of managerial, financial and programmatic capacity and sustainability, including an analysis of the current funding situation.

MMeetthhooddoollooggyy aanndd kkeeyy ppeerrssoonnss Analysis of relevant programme documents and interviews with key persons are supposed to be carried out. The following list of names contains relevant key persons:

• Dr. Klaus Hornetz (Programme Manager of the MoH/GTZ Health Sector Programme) • Dr. Salome Ngata (Senior Programme Officer of the Quality Management

Component) • Dr. Kibaro (Head of Division of Reproductive Health / MoH) • Dr. Ndonga (Head of Division of Quality Assurance & Standards) • Dr. Bwonya (Head of Department of Standard & Regulation Services) • Mark Ayallo (Senior Programme Officer of Mary Stopes Kenya – Organisation which

is commissioned to carry out GTZ activities in districts) • Caroline Blair (OPTIONS, Organisation which is commissioned to carry out GTZ

activities on central level) • Burkard Koemm (Health Care Financing Component) • Dr. Midiwo (National Health Insurance Fund, Quality Assurance Department) • Key persons of Strathmore University, Nairobi (Advanced Health Care) • Key persons of relevant NGOs and FBOs

DDeelliivveerraabblleess

• Report (Strategic further development of the quality management component) by end of June

TTiimmee ffrraammee June 2008 (16 days): 2 days preparation of the mission 10 days mission in Kenya (including journey) 4 days report writing

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TTeerrmmss ooff RReeffeerreennccee ffoorr DDrr.. MMiicchhaaeell MMaarrxx,, EEvvaappllaann

BBaacckkggrroouunndd The overall objective of the “German Technical Cooperation to Kenya in the areas of Reproductive Health and Health Financing” is: Access to good and affordable health care, particularly in the reproductive health sector is improved. The German Development Cooperation Programme comprises of five components: (1) Policy, (2) Health Financing, (3) Reproductive health, (4) Quality Management and (5) Reducing Gender-Based Violence. The programme supports the Kenyan government in implementing the National Strategy Plan in the health sector and the “Joint Programme of Work and Funding” in the thematic areas Reproductive Health, Health Financing, Quality Management, Health policy and Human Rights. By supporting community based approaches, non-governmental organizations and through appropriate public relations activities it also promotes the demand for health services. This consultancy focuses on component 4 of the programme: Improvement in the quality of health care. PPuurrppoossee aanndd RReessuullttss ooff tthhee ccoonnssuullttaannccyy The MoH/GTZ Health Sector Programme Kenya commissions consultantcy services, to support the Quality Management Component as follows: PPuurrppoossee Strategic development of the Quality Management Component based on GTZ offer from 2007 and the situation analysis report from June 2008. EExxppeecctteedd RReessuullttss

1. Facilitate 1-day workshop with key persons in order to develop vision and milestones of the operational plan of the component.

2. Design operational plan and monitoring & evaluation plan based on workshop results and in cooperation with relevant key persons.

KKeeyy ppeerrssoonnss The following list of names contains relevant key persons:

• Dr. Klaus Hornetz (Programme Manager of the MoH/GTZ Health Sector Programme) • Dr. Salome Ngata (Senior Programme Officer of the Quality Management

Component) • Dr. Kibaro (Head of Division of Reproductive Health / MoH) • Dr. Ndonga (Head of Division of Quality Assurance & Standards) • Dr. Bwonya (Head of Department of Standard & Regulation Services) • Mark Ayallo (Senior Programme Officer of Mary Stopes Kenya – Organisation which

is commissioned to carry out GTZ activities in districts) • Caroline Blair (OPTIONS, Organisation which is commissioned to carry out GTZ

activities on central level) • Burkard Koemm (Health Care Financing Component) • Dr. Midiwo (National Health Insurance Fund, Quality Assurance Department) • Key persons of Strathmore University, Nairobi (Advanced Health Care) • Key persons of relevant NGOs and FBOs

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DDeelliivveerraabblleess

• Facilitation of 1-day workshop with key persons to discuss strategic further development (July)

• Report (Vision, Operational Plan and M&E Concept) by end of July TTiimmee ffrraammee July 2008 (18 days): 2 days preparation of the mission 12 days mission in Kenya (including journey) 4 days report writing

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GTZ Health Sector Programme Quality Component – Current Level of Activities

Partners

Public Sector Non-Public Providers and Networks Other Current Activities

MOH Central MOH Regions and Districts NHIF CSO / FBO Private for

Profit Universities

Institutional and policy level (+) (+) + (1) + (1) +

Organizational change + (1) Capacity

Development CD of individuals + + (1) + (1) + (1) ++

Instruments KQM +++ ++

Accreditation Process No activities

Accreditation Agency Dev. No activities

Best Practice Service Delivery Processes; Incentive Structures + (2)

Master Health Economics / Health Management Very limited activities (2)

(1) activities (partly) outside QM component (2) partner-driven process

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GTZ Health Sector Programme Quality Component – Current Level of Activities and Priorities for Designing and Implementing Interventions

Red: High Priority Yellow: Low Priority

Partners

Public Sector Non-Public Providers and Networks Other Current Activities

MOH Central MOH Regions and Districts NHIF CSO / FBO Private for

Profit Universities

Institutional and policy level (+) (+) + (1) + (1) +

Organizational change + (1) Capacity

Development CD of individuals + + (1) + (1) + (1) ++

Instruments KQM +++ ++

Accreditation Process No activities

Accreditation Agency Dev. No activities

Best Practice Service Delivery Processes; Incentive Structures + (2)

Master Health Economics / Health Management Very limited activities (2)

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Strategy Process for GTZ Health Programme Quality Component Management

(*) in close collaboration with Strathmore University

Missions and Key Tasks

Michael Marx 1 June 2008

Michael Marx 2 July 2008

Rainer Kuelker Aug. 2008

Prof. Flessa from Sept. 2008

Current Activities

Central Level Review; analysis and first design options

Central level Design; consensus

building with stakeholders; costing;

work plans

Regional (Province and District) level

Review; analysis; intervention design;

implementation alternatives; costing

Analysis; design; implementation options; costing;

stakeholder process

Institutional and policy level Organizational change Capacity

Development

CD of individuals

Instruments KQM ( )

Accreditation Process

Accreditation Agency Dev.

Best Practice Service Delivery Processes; Incentive Structures (*) (*) Master Health Economics / Health Management (*)

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GTZ Health Sector Programme Quality Component –

Draft Problem Analysis of Current Programme Content – Selected aspects and thoughts Problem Underlying Deficiency Possible Remedy

Institutional and policy level Organizational change

Capacity Development(CD)

CD of individuals

• no comprehensive planning and budgeting for CD

• demotivation of staff • inadaequate / non coherent policies

and strategies

Partner • leadership competence • governance and resulting

structural deficiencies • lack of resources and

unequitable allocation Gtz • expertise and management

capacity

• Develop comprehensive CD plan;

• Adaequate resource allocation

Instruments KQM

• Fragmented process; largely supply driven

• Relevance of KQM for improvements of service delivery???

• Relevance of KQM for level 1 -3 services and preventive / promotive services improvement???

• Use and management for non-public services

• Poverty relevance ?

Partner • KQM design deficient /

unfinished??? • Central level planning and

programming approach • MOH / NHIF collaboration

and coordination GTZ • Until recently focus on

NHIF • Curative orientation? • Inadequate link and “ears”

to the districts and communities

• Review KQM as to its relevance; appropriateness, feasibility for curative and preventive / Promotive service delivery level improvements

• Develop comprehensice KQM model which accommodates decentralization and sector – wide use

• Align GTZ support stronger with GDC values, objectives, target groups

Accreditation Process No activities

Accreditation Agency Dev. No activities

Best Practice Service Delivery Processes; Incentive Structures

Status nascendi; requires strategy; planning; resource mobilization

Master Health Economics / Health Management Status nascendi; requires strategy; planning; resource mobilization

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Annex 2

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Programme: Dr. Michael Marx,- Consultancy on QM Component Situational Analysis, 10th-20th June 2008 (part 1)

Date Time Event Venue 09.06.08 Telephone appointment with

Angelika Pochanke

10.06.08 19.10hrs Arrival, Kenya Staying at Country lodge

10.06.08 Short meeting Dr. Klaus Airport on 10th JKIA 11.06.08 9.00-

10.00hrs Meeting with Salome Ngata- QM Component Senior Programme Officer

GTZ-NHIF conference

10.00-10.15hrs

Meeting with Pauline Gogo- Head Finance and Administration- On Administrative issues

GTZ-NHIF conference

10.30-12.00hrs

Meeting with Maureen Nafula- Advanced Healthcare Management Programme Director- Strathmore University GTZ Consultant -Supplies

GTZ-NHIF conference

12.00- 12.30hrs

Meeting with Anna-Karin Kindamaa (Policy Component) and Maureen Nafula

GTZ-NHIF conference

12.06.08 9.00hrs Meeting with Dr. Ndonga Head of Quality Assurance and Standards Division

Afya Hse Room 401

11.00 Meeting Helen Mbugua- In charge of the award system Ministry of Medical Services/ Public Health Ministry

Afya Hse Room 512

14.00hrs Mark Ayallo - Maries Stopes Kenya(MSK) –Organization contracted to support and monitor RH activities at the District level

GTZ-NHIF conference

13.06.08 9.00hrs Caroline Blair/ Dr. Ominde Ocholla -Options-Consultancy organization supporting the Division of Reproductive Health and FBOs/CSO at the central level in RH

DRH

14.30hrs Dr. Josephine Kibaru- Head, Division of Reproductive Health

DRH

Weekend 16.06.08 9.00hrs Meeting with Burkard Koemn

Deputy GTZ Health Sector Programme and Component Head- Health Financing

GTZ-NHIF conference

12.00 Meeting with Dr. Njoroge NHIF KQM software NHIF 8th Floor 14.00hrs Meeting with Ruth Charo Coordinator Health

NGOs Network (HENNET)/ Peter Nyarango GTZ consultant to HENNET

HENNET Offices AMREF

17.06.08 10.00 Meeting with Ann Ndung’u/ QIT- Kijabe Hospital Kijabe Hospital 15.00hrs Dr. Mwenda- Coordinator Christian Health

Association of Kenya (CHAK) CHAK Offices-Kangemi

18.06.08 9.30hrs Cavin Otieno Programme Officer Support to FBOS/CSOs

GTZ Riverside –Health Office

11.00hrs Nairobi Women’s Hospital – Rahab Ngugi/QIT Nairobi Women’s Hospital.

2.00 Internal Meeting with Salome on BACKUP, Methodology for next mission, TORs for Dr. Rainer Kuelker

GTZ Conference

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19.06.08 10.00hrs Dr. Midiwo, Head- Quality Assurance Department- National Hospital Insurance Fund

NHIF 8th Floor Dr. Midiwo’s office

2.00 Meeting with Ms Lagat/ QIT Kenyatta national Hospital

Kenyatta National Hospital QA Dept

20.06.08 8.30hrs Debriefing GTZ staff GTZ- Office- NHIF-Building

20.06.08 Departure 24.06.08 17.00 Meeting with Prof S. Flessa GTZ-Seminar

on health Policy and economics- Oberursel

25.06.08 12.30 Meeting with Anna-Karin Kindamaa (Policy Component) and Maureen Nafula

GTZ-Seminar on health Policy and economics- Oberursel

26.06.08 12.30 Meeting with Dr Michael Adelhard GTZ-Seminar on health Policy and economics- Oberursel

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Part II: Programme for Dr. Michael Marx Consultancy on QM Component Strategic

Planning, 7th-18th July 2008

Date Time Event Venue Remarks 07.07.08 Arrival, Kenya Staying at

Fairview

08.07.08 9.00 Meeting with Salome Ngata- QM Component Senior Programme Officer

GTZ-NHIF conference

10.00-10.15hrs

Meeting with Pauline Gogo- Head Finance and Administration- On Administrative issues

GTZ-NHIF conference

12.00 – 1.30

Meeting with Dr. Klaus Hornetz- GDC Health Sector Coordinator, Programme Leader GTZ HSP

Riverside Health Office

09.07.08 9.00 Dr. Judith Bwonya – Head, Department of Standards and Regulatory Services- Ministry of Medical Services

DSRS-Afya Hse

11.00 Meeting with Maureen Nafula, Consultant GTZ on Supplies and Advanced Healthcare Management Course Director Strathmore Business School.

Strathmore Business School

14.30 Dr. Midiwo, Head- Quality Assurance Department- National Hospital Insurance Fund

NHIF 8th Floor Dr. Midiwo’s office

10.07.08 2.00-2.45 Lucy Kiama- Gender Based Violence Component

Riverside Office

11.07.08 GTZ HSP Retreat

9.00 Meeting with Dr. Ndonga/Team Head of Quality Assurance and Standards Division

DSRS-QAS

Weekend 14.07.08 9.00 Meeting with Medical Superintendent, Kiambu

District Hospital (OBA facility, Public Hospital) Kiambu Hospital

12.00 Dr. Karanja Chairman Pharmaceutical Society of Kenya

2.00 Mr. Sam Milgo- KENAS Kenya Bureau of Standards Office

16.07.08 10.00 Meeting with Cleophus Mailu, CEO Nairobi Hospital

Nairobi Hospital

16.07.08 2.00 Meeting with Anna-Carin/ Prof Peter Nyarango GTZ-NHIF conference

Dr. Amit Thakker Chairman, Kenya Private Sector Alliance

17.07.08 One Day Strategic Planning Workshop with

stakeholders Silver Springs

18.07.08 11.00 Departure 24.07.08 Departure

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Annex 3

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Ministry of Medical Services and GTZ HSP

Quality management workshop

17th July 2008, Silver Springs Hotel, Nairobi

Report by Ruth Atieno Omondi, Communication consultant

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Table of contents List of abbreviations ........................................................................................................... ii Executive Summary ........................................................................................................... iii 1. Introduction..................................................................................................................... 1 2. Key highlights from introductory remarks by Dr. Bwonya............................................ 1 3. Key highlights from debriefing on stock taking on Quality Management activities by Dr. Michael Marx................................................................................................................ 2

3.1 About the Stock-taking ............................................................................................. 2 3.2 Identified challenges in quality management activities ............................................ 2 3.3 Identified challenges in Quality Management tools and instruments ....................... 4 3.4 Key recommendations .............................................................................................. 4

4. Experience with Quality Management in Output Based Approach Reproductive Health project by Dr. Midiwo......................................................................................................... 5 5. Progress on KQM review process – by Mr. Mumma ..................................................... 7 6. Strategic Vision of Quality Management in Health Sector – by Mr. Mwangangi ......... 8 7. Stakeholders’ SWOT analysis ........................................................................................ 9

7.1 Overview................................................................................................................... 9 7.2 Stakeholders............................................................................................................ 10 7.3 Partners for Quality Management........................................................................... 12 7.4 Dynamic agents of change ...................................................................................... 12 7.5 Arguments for lobbying for KQM.......................................................................... 12 7.6 Gaps, barriers and challenges in implementation ................................................... 13 8. Next Steps ................................................................................................................. 14

Annexes............................................................................................................................. 15 Annex 1. Workshop programme................................................................................... 15 Annex 2. List of participants......................................................................................... 16

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List of abbreviations AOPs Annual Operational Plans CBOs Community Based Organisations CHAK Christian Health Association of Kenya CPD Continuous Professional Development DHMT District Health Management Team DRH Division of Reproductive Health DSRS Department of Standards and Regulatory Services FBO Faith Based Organizations HENNET Health NGOs Network HMB Hospital Management Board HMO Health Management Organisations HMT Hospital Management team GTZ German Technical Cooperation KEC Kenya Episcopal Conference KEPH Kenya Essential Package for Health KEPSA Kenya Private Sector Alliance KMA Kenya Medical Association KQAM Kenya Quality Assurance Model KQM Kenya Quality Model NHIF National Hospital Insurance Fund MDGs Millennium Development Goals MoH Ministry of Health NGOs Non-Governmental Organisations NNAK National Nurses Association of Kenya PHMT Provincial Health Management Teams QAO Quality Assurance Officer QITs Quality Improvement Teams UN United Nations

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Executive Summary The Ministry of Medical Services with support of German Development Cooperation (GTZ) on 17th July 2008 organized a workshop to share the findings of the stock-taking mission on quality management activities in the Kenyan Health Sector. The key priority areas of the stock-taking included capacity development; Instruments of the Kenya Quality Model (KQM), Standards and Accreditation Process; and best practice in service delivery processes.

The key challenges facing quality management activities in Kenya were identified to include among others too many standards and guidelines which are not harmonised; weak incentives to undertake Quality Management activities - the award scheme uses a top down approach; limited scope and outreach of National Hospital Insurance Fund (NHIF) and the fact that it sometimes takes a monopolistic position and hence distorting the market; interface between Ministry of Health’s Department of Standards and Regulation Services and NHIF in terms of responsibilities, tasks, division of labour is still unclear and quality assessment procedures have become ritualistic.

A number of recommendations were given including need to make the regulatory framework functional and inclusive of the private sector, civil society and Faith Based Organisations; explore possible synergies between the different GTZ programme components; explore the possibility of integration of Output Based Approach Quality Assurance into KQM; develop capacities of MoH’s DSRS to take on a stewardship oriented role on standards and guidelines, incentive schemes among others.

It was nonetheless noted that the quality management stock-taking did not capture disease prevention (that is currently the priority of MoH – as outlined in the health strategies) – as discussions largely focused on facilities. There is need to expand the scope of stock-taking on quality management to cover disease prevention activities with a view to provide feedback on successes, challenges and lessons learnt. It was further felt that this and outpatient access to health care should be included in the Kenya Quality Model.

There have been efforts aimed at reviewing the KQM. A 2nd draft of the review is ready and proposes for a change in name from KQM to Kenya Quality Assurance Model (KQAM). Based on feedback gotten from stakeholders on the 2nd review draft, the master checklist and standards have been categorized into 3. The draft has been forwarded to the Permanent Secretary, Ministry of Medical Services and other stakeholders for perusal and comments. It was however pointed out that the revised KQM document has conspicuously omitted level 1 health services. This should thus be incorporated in the KQM document and standards for community health be developed – the Ministry of Public Health and Sanitation to spearhead this.

It was pointed out the development of standards and certification need to precede accreditation process. Thus development of standards for the health system should be a top priority for DSRS as it is a prerequisite for accreditation. There is also need to have the input of the people, especially the voices and needs of nurses into the quality management process as they are involved in the day to day care of patients. This is important in increasing their knowledge base and winning their support and ownership of the quality management process.

The strategic partners for attainment of quality management objectives in Kenya were identified to inter alia include: health care providers, clients, Regulatory bodies, , professional association Ministry of Public Health and Sanitation, Kenya Bureau of Standards, Joint Commission for International Accreditation, Health care financing agencies, Insurance companies, Suppliers for health facilities Development partners – NGOs, UN, GTZ, Pharmaceutical and chemical industries and Health training institutions .

A number of steps to fast-track the process of development and implementation of standards and quality management activities were identified to include: undertaking a quality management consultancy focussing on the district level - August 2008; circulation of revised KQM documents to all players through email for review and comments; there will be a meeting on KQM to discuss emerging issues and inclusion of level one services at the end of July 2008.

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1. Introduction 1. The Department of Standards and Regulatory Services (DSRS) together with key

stakeholders, with support of German Technical Cooperation (GTZ), have been undertaking activities geared towards improvement in Quality Management in the health sector. The Department has now conducted a situational analysis on the Quality Management activities taking place within the sector so far.

2. The workshop was organised to disseminate the results of the situational analysis and

to get the stakeholders’ input on the strategic way forward on quality management. The workshop was organised by the Ministry of Medical Services with support from GTZ and it drew participants from the Ministry of Public Health and Sanitation, Ministry of Medical Services, GTZ Health Sector Programme, public and private hospitals, National Hospital Insurance Fund among others. The workshop was held at Silver Springs Hotel, Nairobi on the 17th July 2008.

3. The workshop aimed to achieve the following objectives:

a) To share the findings of stock taking mission; b) To strengthen the strategic partnership.

2. Key highlights from introductory remarks by Dr. Bwonya 4. Quality assurance and standards is not an exclusive preserve of the Department of

Standards and Regulation Services, but the business of everyone in the health sector; 5. Nonetheless, all the activities on standards in the health sector need to be standardized

in a bid to effectively meet the client’s needs and given that the clients are the same. Quality is as defined by the client – as they dictate what comprises quality.

6. In 2007, the team working on quality management in the health sector examined the

Kenya Quality Model with a view to identify gaps for improvement. It is however noteworthy that a number of people in the health sector do not know of the existence of the model and some do not understand its purpose. A working group was put together to examine the model and the tools and have come up with revised standards – the standards cover human resource, physical facilities, supplies, referral, transport among others. This has been developed taking into account standards for the different Kenya Essential Package for Health levels. A draft model has been disseminated for comments.

7. The department requested GTZ to assist in undertaking an elaborate assessment of the

entire quality management process in the health sector in terms of gaps, lessons among others and give feedback on the same and inform strategies aimed at improving quality in health care delivery.

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3. Key highlights from debriefing on stock taking on Quality Management activities by Dr. Michael Marx 3.1 About the Stock-taking 8. The purpose of the review was to take stock and strategise on further development of

quality management component of GTZ Health Sector Programme. The key priority areas of the review included:

a) Capacity development focussing on institutional and policy level, organizational

change and capacity development of individuals; b) Instruments of the Kenya Quality Model (KQM), Standards and Accreditation

Process, c) Best Practice in service delivery processes including the incentive structures.

9. The review entailed the following:

a) Analysis of Quality Management and KQM related documentation; b) Undertaking semi structured interviews and discussions with key stakeholders of

the KQM Programme; c) Holding discussions with development partners; d) Undertaking focus group discussion with Quality Improvement Teams (QITs); e) Visiting of selected health facilities;

10. It was underscored that the consultancy was not an evaluation of quality management

activities in the health sector but a stock-taking mission. Noteworthy, the conclusions and recommendations of the stocktaking do not necessarily represent the position of GTZ – they are the consultant’s independent views.

11. It was noted that Kenya has made a considerable progress in initiating and bringing

the process of Quality Management forward with clear advocacy within the health system. There is a declared commitment of the major stakeholders including the Ministry of Health (through DSRS, National Hospital Insurance Fund (NHIF), German Technical cooperation (GTZ), District Health Management Teams (DHMT), Provincial Health Management Teams (PHMT), health facilities, QIT, Quality Assurance Officers (QAO), Christian Health Association of Kenya (CHAK) and HENNET for it.

3.2 Identified challenges in quality management activities 12. Challenges were identified in the following categories:

a) Ministry of Health/Department of Standards and Regulatory Services (MoH/DSRS):

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i) Implications of MoH split into two Ministries on KQM – a question on which ministry will be in charge of quality management activities ;

ii) Too many standards and guidelines which are not harmonised; iii) There is fluctuation and migration of staff and human resource

management is still centralised; iv) KQM is not very well known among stakeholders including inter alia

MoH, health facilities, private sector; v) Weak incentives to undertake Quality Management activities; vi) Health inspectors and Quality Assurance Officers work in parallel; vii) Interface between MoH/DSRS and NHIF in terms of responsibilities,

tasks, division of labour is still unclear.

b) National Hospital Insurance Fund (NHIF)

i) NHIF has limited scope and outreach; ii) NHIF takes a monopolistic position and hence distorting the market; iii) Very limited impact oriented approach to accreditation and quality

assessment process; iv) Late and sometimes lacking feedback on QIT reports; v) Capacity of data processing is very limited; vi) KQM still not entirely harmonised with Monitoring and Evaluation

system; vii) The work of QIT and Quality Assurance Officers is tool oriented and

training and coaching needs are not yet covered; viii) There are weak links between NHIF and QITs.

c) Collaboration of MoH, NHIF and Private health providers

i) Collaboration between MoH/DSRS and NHIF is not well defined in terms

of responsibilities, tasks and division of labour; ii) Different rules and regulations applied to private sector compared to

public sector - in terms of registration, licensing and accreditation; iii) Accreditation process is still biased; iv) Potential of private insurances and Health Management Organisations

(HMO) still remains unexplored; v) Integration of Output Based Approach and Quality Assurance into KQM

is still insufficient; vi) Incentive (award) scheme still in pilot phase.

d) Linkage between national and district levels

i) Assessment visits becoming more of a ritual; ii) Possible synergies between Quality Assurance Officers and health

inspectors still unexplored; iii) There is need to define a clear and comprehensive Quality Management

policy towards the districts.

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3.3 Identified challenges in Quality Management tools and instruments 13. These were identified in the following categories:

a) Kenya Quality Model

i) Too input oriented and some indicators need review; ii) Scoring is difficult due to weak prescriptive guidelines and unclear

indicators; iii) KQM software is not performing well.

b) Standards and Guidelines and accreditation

i) Dissemination and introduction still insufficient; ii) Inventory of professional standards still lacking; iii) Standards, and guidelines should become binding for all levels of the

health system; iv) There is need for feasibility study for possibility of independent

accreditation. 3.4 Key recommendations 14. A number of recommendations were given with the aim of improving quality

management in the Kenyan health systems in the following categories:

a) Capacity development at individual level

i) Training on Quality Management at all levels including undergraduate level is very pertinent;

ii) Training offers should not only focus on Quality Management but also include management skills and leadership training for executive level;

iii) Tailor made training concept for different professional levels and purposes is needed.

b) Mainstreaming Quality Management

i) Decentralisation in terms of transforming tasks of public sector including

MoH and DSRS - from service provider to a more stewardship oriented role; Making the regulatory framework functional and inclusive of the private sector, civil society and Faith Based Organisations;

ii) There is need to develop capacities of MoH’s DSRS to take on a stewardship oriented role on standards and guidelines; incentive schemes among others;

iii) Necessary resource allocation to the health sector quality management activities both at central and district levels - this should be undertaken by MoH, GTZ, and other partners;

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iv) Explore the possibility of integration of Output Based Approach Quality Assurance into KQM;

v) There is need for DSRS and NHIF to prioritise marketing and sensitization on KQM;

vi) There is need to foster cooperation with the private health providers. vii) Explore possible synergies between the different GTZ programme

components – for instance introduction of costing related to the essential health care packages ;

viii) Technical Assistance on quality management should be reinforced especially by GTZ;

ix) There is need to make KQM model output/outcome and incentive oriented;

x) NHIF should focus on and strengthen link with QIT and Quality Assurance Officers;

xi) There is need to explore different options for independent accreditation. This could be through undertaking of a feasibility study;

xii) There is need to focus on a comprehensive training concept on quality management for DSRS and NHIF;

4. Experience with Quality Management in Output Based Approach Reproductive Health project by Dr. Midiwo 15. It was indicated that the NHIF’s Department of Standards and Quality Assurance was

formed in 2003 to aid in accreditation process – 450 hospitals are currently accredited. The Kenya Quality Model14 was used to prepare the hospitals for the accreditation process.

16. The KQM addresses issues relating to leadership, human resources, policies,

infrastructure, supplies, equipment, transport, referral systems, records, financial management, results and results. Overall scores are then awarded. The scores are awarded based on the standards – this gives a picture on the difference between respective health facilities in terms of performance on quality management basis. It also shows the health facilities that need intervention - in terms of training. Using the scores, the facilities can be compared in terms of extent of growth – or downward trend.

17. The need to secure the financial autonomy of Government based health care facilities

was underscored noting that such facilities have inadequate financial resources to undertake quality management activities.

18. The key successes of the NHIF quality management approach have been:

a) Positive response to the project by the health facility owners and community; 14 The KQM addresses inputs, processes and outcome and is loosely designed and defined. Thus there is need to put down standards on inputs, process and outcome standards. What are now called standards are simply guidelines on how to make standards.

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b) Proper and better keepings of medical records; c) Formation of more QITs, active Hospital Management Teams (HMTs) and

Hospital Management Board (HMB); d) Positive and healthy competition with a view to improve quality among health

facilities; e) Employment of qualified hospital staff including Nurses, Doctor’s on call,

Laboratory technicians, Clinical officers among others; f) Improvement in client-provider interaction; g) Involvement of management in Quality Management activities, hence better

teamwork; h) Better adherence to policies and safe reproductive health guidelines; i) Increased bed capacity in most facilities; j) Capacity building of staff especially through trainings in quality management;

19. The key challenges faced by the approach include:

a) High staff turnover which hampers efficient and timely implementation of planned quality management activities;

b) Government policies that are not necessarily facilitative of adherence to quality; c) Low staff levels especially in health centers in terms of ratio of nurses to patients; d) Bureaucratic and often tedious Government procurement procedures in

purchasing of equipments; e) Referral/transportation of clients to and from facilities especially where healthcare

facilities are a distant apart is particularly a challenge. Box 1. Issues from plenary discussions

a) The quality management stock-taking did not capture disease prevention (that is currently the priority of MoH – as outlined in the health strategies) – as discussions largely focused on facilities. There is need to expand the scope of stock-taking on quality management to cover disease prevention activities with a view to provide feedback on successes, challenges and lessons learnt. It was further felt that this and outpatient access to health care should be included in the Kenya Quality Model.

b) There should be a quality management policy at the district level that incorporates disease prevention.

c) Quality management as practiced by the health sector is not well known as stakeholders are not aware at which stage the health sector is in terms of standards.

d) It is worth noting that standards are developed by various professional divisions – the Division of Reproductive Health has already developed its reproductive health standards. However, the questions that beg for answers are the extent to which these standards are known at the local levels and whether they are really practiced.

e) This financial year the Division of Reproductive Health will undertake an assessment to determine the extent of awareness and application of the reproductive health standards at all levels.

f) All professionals are expected to come up with guidelines that would be developed into the standards. And the standards should be binding and should come from the specialists themselves.

g) Any training programme on quality management should be based on training’s needs assessment and should adopt a couching approach to foster sustainability.

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5. Progress on KQM review process – by Mr. Mumma 20. It was clear from the presentation that the Department of Standards and Regulatory

Services is committed to improving of quality of health services offered in Kenyan health facilities. This is demonstrated by its Annual Operational Plan III that has prioritized the review of KQM.

21. Since inception in 2001, there have been seven workshops in seven provinces to

sensitise players on KQM. An electronic assessment tool for quality management has been developed. Nonetheless, the implementation of KQM by the then MoH did not go beyond the pilot phase.

22. National Health Insurance Fund (NHIF) adopted the KQM tool in Quality Assurance

and Improvement of its accredited facilities. With support from GTZ, NHIF developed a training curriculum and Quality Improvement Teams (QITs) were trained from facilities. Most of the facilities adopted KQM as their Quality Improvement Tool. From their experience, KQM checklist was cited as difficult to score in some areas and needed to be reviewed to suit the different Kenya Essential Package for Health (KEPH) levels.

23. A number of workshops have also been held with a view to review KQM. The 2nd

draft of the review proposes for a change in name from KQM to Kenya Quality Assurance Model (KQAM). The master checklist and standards have been categorized into 3 for KEPH level 2, KEPH Level 3 & 4, KEPH level 5 &6. The feedback from the stakeholders has so far been positive.

24. The draft has been forwarded to the Permanent Secretary, Ministry of Medical

Services for perusal and comments. Stakeholders are also urged to provide comments aimed at improving the draft and develop an implementation plan for KQAM. Box 2. Issues from plenary discussions a) The revised KQM document has conspicuously omitted level 1health services – community health –

which is a very important aspect of health care as it focuses on inculcating positive health practices among communities so that interventions go to the household levels. This should thus be incorporated in the KQM document. Further, standards for the community health should be developed. Ministry of Public Health and Sanitation was charged with this responsibility.

b) There is need for an assessment of the extent to which the KQM review took into account some indicators that are too much input oriented and the challenges and biases occasioned by scoring (scale of 1-5);

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6. Strategic Vision of Quality Management in Health Sector – by Mr. Mwangangi 25. In an effort to achieve the quality management activities, DSRS has committed in

both its strategic plan and Annual Operational Plan IV to:

a) Pilot and Implement the reviewed KQAM; a) Develop an accreditation system/ accreditation body for the health sector; b) Ensure that Quality Assurance Software and Data base system are in place; c) Integrate quality management and KQAM in basic health training; d) Develop a concept of linking Quality management to CPD; e) Develop an award system for health and individuals based on quality

management. 26. Strategies to implement KQAM were highlighted to include:

a) Implement KQAM together with stakeholders in the facilities; b) Training of Trainers at the provincial level to train the at the lower levels; c) Create a new cadre of Quality Assurance Officers (QAOs) at the district level

who will work closely with NHIF to particularly oversee the lower levels; d) Facilitate trainings at the district level and facility level- facility based trainings.

Box 3. Issues from plenary discussions a) Development of standards and certification need to precede accreditation process. Thus development

of standards for the health sector should be a top priority for DSRS as it is a prerequisite for accreditation.

b) There is need to have the input of the people, especially the voices and needs of nurses into the quality management process as they are involved in the day to day care of patients. This is important in increasing their knowledge base and winning their support and ownership of the quality management process;

c) Awarding of Continuous Professional Development (CPD) points to demonstrated quality at individual level should be based on proven documentation. This is being piloted in reproductive health where guidelines have been developed and if it works, it will be scaled-up;

d) The idea of creating new cadres of Quality assurance officers negates the whole essence of mainstreaming. Instead, strengthening the already existing ones at the district level will be more useful. It is pertinent to ensure that the officers are drawn from specific qualifications/fields and then trained on quality management

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7. Stakeholders’ SWOT analysis 7.1 Overview Four working groups were constituted and tasked with the following: Group Task Group 1 & 2 Stakeholder analysis as shown in grid 7.2 Group 3 a) Who are the most important partners that would engage with

you in QM/ KQM? Who are the most dynamic “agents of change” on different levels of the system?

b) What will be your major arguments for lobbying KQM in the specific context?

Group 4 a) Where are the biggest gaps/challenges in the implementation of policy and strategy priorities?

b) What are the most vulnerable behaviour-linked quality barriers between central level and service-delivery-level

c) What are the most vulnerable behaviour-linked quality barriers between service-delivery-level and population?

The outcomes are presented in the subsequent sections.

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7.2 Stakeholders

Stakeholder of KQM Tasks/relation to QM Strength Weakness Opportunities/interest Threats/risks

DSRS o Coordination o Facilitation o monitoring

o Strategy in place o Developed a

checklist o Partnering with GTZ

and NHIF

o Lack of funding o Staff shortage o Transport constraints

o Strong back-up by Government

o Part of the strategic plan

o First of a kind in the Ministry of Medical Services

o Competitor such as KENAS, KEBS among others

o Work attitude

NHIF o Funding of health care

o Accreditation of health facilities

o Funded by member contribution

o Piloted quality management model

o Differentials in disbursement to private and public facilities with private facilities getting more funds

o Out-patient bill not covered

o Can improve/ scale-up o Partners with

government and donors

o Competition from private insurance providers

CHAK/KEC o Faith-based health care provider

o Well spread in terms of infrastructure

o Well organised

o Turn-over of human resource

o Inadequate/unreliable funding

o Poor management at operational level

o Ability to link with communities

o Competition form government and private sector

o Migration by staff and patients

KEPSA o Provides health care o Manufacture

medicine o Are employers

o Abundant resources o Wide network o Likely to adopt

quality as a marketing strategy

o Difficult to accept and agree on standards

o Penetration by unqualified personnel

o Leadership in quality management

o Keen in getting involved in sector-wide approaches

o Best practices for lesson learning

o Competition from Government and faith-based health facilities

o Conflict of interest

Kenya Medical Association/National Nurses Association of Kenya (KMA/NNAK)

o Umbrella bodies for doctors, dentists

o Act as trade unions or welfare bodies

o Represents majority of doctors, dentists and nurses

o NNAK is well spread – to community levels

o KMA is predominantly made up of urban professionals

o Inability to control migration of doctors, dentists and nurses

o Good entry point in disseminating information regarding quality management

o Brain drain o Shortage of staff

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GTZ o Supporting KQM o Capacity building o funding

o Has funds o Has human resources

o Limited coverage o Unpredictable in terms of

funding

o Can expand their funding

o Can expand coverage

o Competition o Political interference o Change of priorities

Divisions of the Ministries e.g. DRH etc

o Technical arm of Ministry (Ministry of Medical Services and Ministry of Public Health and Sanitation)

o Wide coverage o Binding and

enforcing o Funding

(Government and partners)

o Staff shortage o Poor work etiquette and

attitude o Poor cocrdination

o Set standards o Coordination within

the structures

o Competing priorities o Lack of political good

will

Clinical Officers Board o Registration o Regulation o Licensing o inspection

o Standards in place o Formed through an

Act of Parliament

o Inadequate funding o Human resource

constraints o Lack of enforcing powers o Its operations are highly

centralised

o Wide network of clinical officers

o Influence on curriculum

o Corruption o Political interference

Kenya Medical and Dentists Board

o Registration and inspection

o Supervision of education

o Enforcement of CPD o Advise MoH on

quality health care o Monitor medical

research

o Established through an Act of Parliament

o Standards in place

o Limited funding and non-enforcement of the Act

o Centralised and not spread across the republic

o Have a network of medical practitioners and dentists

o Interference and corruption

Nursing Council of Kenya o Examination and registration of nurses

o Regulation and licensing

o Enforcement of CPD

o Standard examination o Established through

an Act of parliament o Has a data base

o Very centralized operation

o Limited funding and human resources

o Network of nurses o Trade unionism o Political interference

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7.3 Partners for Quality Management 27. Most important partners for Quality Management and KQAM were identified to

include:

a) Health care providers; b) Clients; c) Regulatory bodies; d) Professional association; e) Ministry of Public Health and Sanitation; f) Kenya Bureau of Standards; g) Joint Commission for International Accreditation; h) Health care financing agencies; i) Insurance companies; j) Suppliers for health facilities – drugs, equipment among others; k) Development partners – NGOs, UN, GTZ among others; l) Pharmaceutical and chemical industries; m) Health training institutions.

7.4 Dynamic agents of change 28. Most dynamic agents of change on quality management were identified to include:

a) Permanent Secretaries of the two health Ministries; b) Director of Medical Services; c) Top management of health care institutions and those institutions related to health

care delivery including NGOs, CBOs and FBOs; d) Provincial and district health administrators; e) Top management in training institutions – who decide on what people will be

trained on; f) Regulatory bodies – that make decisions on what is to be followed; g) Professional associations; h) Employee unions and associations; i) Religious leaders; j) Community leaders; k) Political leaders; l) The media; m) Related ministries.

7.5 Arguments for lobbying for KQM 29. The main arguments for lobbying for the KQM were highlighted to include:

a) It will help the country harmonise and review current standards and hence improving standards;

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b) Enhancing the national competitive advantage – best within the region and globally;

c) Improvement in efficiency and effectiveness in healthcare delivery; d) Improve quality of life; e) Aid in achievement of MDGs and vision 2030;

7.6 Gaps, barriers and challenges in implementation 30. Gaps and challenges in implementation of policy and strategies were identified to

include:

a) The very lack of policy; b) Lack of Quality Management component in training curriculum; c) Lack of information, knowledge and communication on quality management; d) No feedback/reporting on quality management; e) Lack of supervisory structure.

31. The most vulnerable behaviour - linked quality barriers between central level and

service delivery levels were identified to include:

a) Lack of motivation at all levels to embrace quality in service provision; b) Resistance to change as quality comes with change; c) Different attitudes at all levels towards quality management; d) Lack of involvement at all levels in policy making (top-down approach) and

hence lack of ownership ; e) Lack of resources as a result of inadequate budgetary allocation for quality; f) Lack of motivation for innovation; g) Corruption in the health sector.

32. The most vulnerable behaviour-linked quality barriers between service-delivery-level

and population were identified to include:

a) Organisational culture; b) Cultural practice of the population; c) Negative attitude; d) Absence of role models in the health sector; e) Service cost which could be expensive; f) Quality of service as perceived by the population and as perceived by service

provider.

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Box 4. Issues from plenary discussions a) Three options were proposed relating to the need for an accreditation body: i) have a parastatal-like

accreditation body associated with international and regional accreditation bodies – with a possibility of joint venture and adoption of public private partnership approach; ii) have an accreditation body that is completely private but linked to Kenya National Accreditation Service (KENAS) (the likely danger with such an arrangement is conflict of interest that may arise); iii) have external institutions to undertake accreditation. These options need a closer look while bearing in mind the Kenyan context. This brings to fore the need for feasibility study and development of clear objectives and parameters.

b) The need for lesson learning especially from South Africa - that has an accreditation body on health was deemed important. Nonetheless, the idea of having a private entity that does not deal with health issues like KENAS undertake accreditation may not be viable as capacity in dealing with unique health related issues may be a challenge.

c) There is need to de-link accreditation from service providers – in which case, there is need to think through how to deal with the case of Government – that is a service provider yet accredits at the same time.

d) There is need for a strategy for reaching out to the senior managers on Quality Management as they are key change agents.

e) Quality Management will be used to assess the performance of the Permanent Secretary for the Ministry of Medical Service – this gives a surety of commitment to the

f) Participation of stakeholders is extremely important to the quality management process in that quality management covers the health sector in its entirety and not just facilities.

g) Quality management should be understood to refer to very ordinary practices. More importantly, quality management should be understood to signify listening to customers – this is to ensure relevance and satisfaction of customer needs.

h) In order to ensure that setting of standards in the health sector is of essence, there is need to pay attention to health financing to ensure enhanced access to health care.

i) The discussions during the workshop will form a very pertinent part of sharpening the strategy of Quality Management.

j) There is need to ensure that the outcomes of the meeting are widely disseminated particularly to the top management, middle management and other institutions.

8. Next Steps 33. The next steps were identified to include:

a) Undertaking a quality management consultancy focussing on the district level - August 2008;

b) Operational planning scheduled for August 08; c) Implementation Annual Operational Plan; d) Development of a sector owned management based accreditation system for

health facilities; e) Integration of quality management in basic medical training; f) Development of a database system for quality management; g) Circulation of revised KQM documents to all players through email for review

and comments; h) There will be a meeting on KQM to discuss emerging issues and inclusion of

level one services at the end of July 2008.

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Annexes Annex 1. Workshop programme Workshop Moderator – Prof Nyarango Time Event Presenter 9: 00 Welcome Dr. Judith Bwonya-

DSRS 9: 15 Debriefing: stock

taking on QM-activities

Dr Michael Marx- Evaplan- University of Heidelberg

9: 45 Discussion Plenary 10: 30 Coffee break 10: 45 KQM-review- update,

Mr. Muma

12.00 DSRS strategy Mr. Mwangangi

12:15 -Stakeholder SWOT analysis - Key questions

Prof. Nyarang’o 4 Working groups (WG)

13: 00 Lunch 14: 00 Presentation+

discussion WG- plenary

15:30 Closure Dr. J. Bwonya

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Annex 2. List of participants

NAME ORGANIZATION CONTANTS EMAIL ADDRESS Dr. Micah O Anyona PSK 0722-576568 [email protected] Sara I Kamamo The Nairobi Hospital 0722-801117/2846026 [email protected]

Francis Muma MOMS Division of QAS Afya house Room 401 [email protected]

Salome Ngata GTZ 0722-498172 [email protected] Paul Kangethe Government Chemist 0722-350979 [email protected] Laura Michele GTZ [email protected] Beatrice M Lugalia MOH-Orthopaedic Technology 0724-876915 [email protected] Micheal Marx University of Heidelberg 0049-06221-138230 [email protected] Burkard Koemm GTZ 020-2725684 [email protected] Dr. George Midiwo NHIF Patrick C Mutsungah Ministry of Medical Services 0722-615451 [email protected] Anna Carin Vandimaa GTZ Policy Component 0712-504771 [email protected] Joseph Githinji NHIF 0722-636005 [email protected] Margaret Kibwii MOMS 0733-424692 [email protected] Julia W Thuo NCK 0722-744470 [email protected] Margaret Chiseka HMIS(HQ's) 0722-247389 [email protected] Valerie Wambani MPHS-Nutrition 0733-908859 [email protected] Dr. E. Barasa Wamwana DMOH CCN 0721-697324 [email protected] George O. Ogoye Division of Clinical Services 0721-408813 [email protected] Harriet Koyoson SBS 0721-628111 [email protected] John Kariuki MP&D Board 0722-631601 [email protected] Dr. Esther A.. Ogara MOMS /PRSRS 0722-610979 [email protected] Dr.Kiima MOH-MMS DMH 0722-845735 [email protected] Fredrick Ngeno Ministry of Medical Services 0720-802308 [email protected] Belina Shisia Ministry of PH&S DHP 0721-444864 [email protected] Dr. Mohamed A Ahmed Mbagathi Hospital 0735-096764 [email protected] Ruth Omondi 0720-442419 [email protected] Barnard M. Mbogoh MOP/S Afya House 0722-310105 Abdalla Maawy Kenya Medical Laboratory T. T Board 0729-493009 [email protected] Daniel C. A Sanga Asst. of Kenya Medical Lab. Scientific Off 0723-911663 Isaac O Omogi Ministry of Health Medical Services 0724-796550 [email protected]

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David A. Ayieko Ministry of Medical Services 0720-752573 Anne Njeru MOP/s DRH 0733-606404 [email protected] Joseph A.W Maina Radition Protection Board 0722-228368 [email protected] Judith E Bwonya DSRS- moms Peter Nyarango HENNET/GTZ 0722-698242 [email protected] Dr.S M Irungu PMOs Nairobi 0722-637655 [email protected] Oyoo T. Otieno KEBS Box 54974 [email protected] Lucy W Mukabi MOH 0722-736169 [email protected] Rebecca MOH Box 30016NRB Dr. Hellen Mbugua MOMS 0721-350542 [email protected] Henry N Wanyonyi DSRS Medical Legal 0712-223441 [email protected] Martin M Owino Medical Organization MOMS Box 30016NRB [email protected] Dr. Jothan Michemi KNH 0722-203343 [email protected] Prof. Z.W.W Ngumi School of Medicine UON 0722-218921 [email protected] Isaac Mwangangi MOMS 0721-836448 [email protected] Daniel O Mosomi MOH 0736-512198

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Annex 4

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Overall Result Area: Monitoring Performance and Provision of Sustainable Integrated High Quality Health Care Services Specific Result Area 1: Review of the Kenya Quality Model Objective: To Review the Kenya Quality Model and the Master Checklist and to make it adaptable for different KEPH Levels Activities Activity Indicator Status Support DSRS in KQM familiarization retreat of key KQM implementers and stakeholders 60 participants

Workshop report Retreat held on 28th/29th August 2008

Facilitate DSRS staff participation in NHIF QM workshops

At least 2 staff from DSRS have participated in at least one QM training with NHIF

This was replaced with DSRS staff having an internal workshop by NHIF to familiarise them with KQM

Support DSRS in KQM review retreat with implementers from the districts and provinces (50 participants)

Workshop Report Replaced by three workshops held in Nairobi on 26th &27th Nov, Nakuru 29th & 30thNov and Kisumu 3rd and 4th Dec 2007

Facilitate a consultant to facilitate the KQM Review Process

Draft KQM in place Done

Additional Activities Stakeholders meeting held on 20th Sep Working group meetings held on various dates between

September and Dec Editorial team on workshop held 13th and 14th Dec 2007 Several ‘Smaller’ editorial team meetings held between

March and May 2007 Circulation of the document to the stakeholders done in

May/ June 2008

QM Component Work Plan 2007

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Specific Result Area 2: QM integration in RH Objective: To Develop a Quality Monitoring Tool for RH services. Activities Activity Indicator Status Review the existing Standards, Tools Guidelines and Audits

Concept approved

Done

Develop a draft tool

Draft Tool in place Done in several working group meetings between September and November 2007

Present the tool to stakeholders in a one day conference

Conference Report

Tool and concept presented to the National Training Policy and Continuous Professional Development Working Groups- Concept incorporated in the National Training Policy

Collect baseline data from selected hospitals

Report in place

Data collection tools developed One day training workshop for data collectors done on 13th Dec 2007 Supervisors for data collection identified Funding for data collection not approved therefore activity stalled

Pilot the tool in selected hospitals

Tool piloted in 6 facilities Not done

Evaluation

Evaluation Report Not done

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BACKUP FUNDED ACTIVITIES(Time Frame 18 Months) Specific Result Area 3: Health facility accreditation system developed and owned. Objective: To review the accreditation system to make it Health Sector owned Activities Activity Indicator Status Stakeholders meeting held on 20th Sep Working group selected

ToRs Drafted Facilitate hiring of a consultant to develop QM management framework

QM framework developed Not done

Review and revise health facility institutions accreditation tool

Tool(s) reviewed Not done

Conduct 3 regional and 1 national sensitization workshops for service users to introduce the tools

No of workshops No. of participating stakeholders

Not done

Specific Result Area 4: QM integration in basic training initiated Objective: To develop a strategy for KQM implementation sustainability Activities Activity Indicator Status

Stakeholders meeting held on 20th Sep

Working group selected ToRs Drafted

Facilitate capacity building for DRSRS head staff

Two head staff have two weeks training in quality management

Not done

Support DSRS in development of advocacy and training materials(Manuals and tools)

Sensitization manuals in place

Not done

Support DSRS in holding 3 regional sensitization meetings on QA and QM with training institutions.

Meetings Reports

Not done

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Specific Result 5: Development of database management system. Objective: To have a KQM monitoring system Activities Activity Indicator Status

Stakeholders meeting held on 20th Sep

Working group selected ToRs Drafted

Facilitate hiring of a consultant to support development of data base management program for QA.

Data base management program developed

Not done

Support DSRS in training 4 officers at MoH HQ in the use of the database management program

Data program in use

Not done

Support DSRS in a one day advocacy workshop for stakeholders at national level on QA activities of the DRSRS

No of stakeholders attending

Not done

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Annex 5

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List of references

Titel Author Date 1. BACKUP Initiative project application form GTZ 2007

2. Business Trip Report Milkowski, Andrea 2007

3. Concept on the KQM Review and Backup Proposal Implementation

2007

4. Experiences in Accreditation Body Setup Kenya - KENAS, „Building Confidence… Evolution and not Revolution“

Chesire, Martin 2005

5. Health Sector Programme – Strategy Paper for the QM Component

Mathauer I, Ngata S 2008

6. Job Description Dr. Salome Ngata 2008

7. Kenya Health Standards and Master Checklist for Health Services and Systems Monitoring and Evaluation

Republic of Kenya – Ministry of Health – Department of Standards and Regulatory Services (DSRS)

2002

8. Kenya Quality Model (KQM) Review Process Progress Report

MoH/DSRS 2008

9. MOH/GTZ Programme Reproductive Health and Health Financing – Review of the Sub-Component Target District Support for Comprehensive ASRH Services Phase I

Terwindt F, Baraza A 2008

10. Offer for the Implementation of the Contract Programme „KV Programme Reproductive Health and Health Financing“, Kenya

GTZ 2007

11. Performance based Monitoring and Evaluation System

Department of Research, Standards and Regulation Services (DRSRS)

2008

12. QM Component Budget May - 2008 GTZ 2008

13. QM Component Work Plan 2008 GTZ 2008

14. QM policy grid 2008

15. Quality Management in Kenya: An Evaluation of Quality Improvement Teams in Public, Private and Mission Hospitals in 3 Districts in Kenya, Master Thesis

Bodal, Huzeifa 2007

16. Report on QM Consultancy in Kenya Buecklein K, Bodal H, Ngata S 2007

17. Report: First National Congress on Quality Improvement in Health Care, Medical Research and Traditional Medicine - 2001

Bodal, Huzeifa 2008

18. Reversing the Trends – The Second NATIONAL HEALTH SECTOR Strategic Plan of Kenya – NHSSP II – 2005-2010

Kenya Ministry of Health 2005

19. Service Provision Assessment Survey 2004 – Maternal & Child Health, Family Planning and STIs

National Coordinating Agency for Population and Development Nairobi, Kenya; Central Bureau of Statistics Nairobi, Kenya; ORC Macro Calverton, Maryland, USA

2005

20. Cost analysis of Private Health Care Services in Kenya

Nzoya D, Mathauer I, Flessa S, unpublished

2006


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