Lwala Public Health Project, Kenya

January 2010
By Caitlin Reiner and James Nardella, Michael Lear and Dr. Martina Fuchs

The mission of the Ochieng' Memorial Lwala Community Health Center is to meet the holistic health needs of all members of the Lwala community, including its poorest. Whenever possible it addresses health problems at their roots through community health interventions. It aims to provide excellent community-based health care, not to become a tertiary care facility. The health center is part of a larger effort to achieve holistic health and development in Lwala, including educational and economic development. The primary beneficiaries are children, pregnant women, HIV infected persons and the elderly. Prior to the establishment of the clinic, there was no immediate access to primary health care or HIV/AIDS testing and care. For this reason, the Lwala health intervention has focused on primary care for children, access to medicines (particularly vaccines and antimalarials), HIV testing and care, public health outreach and safe maternity. The impact has been substantial since opening.
Lwala Village is part of the North Kamagambo Location in Rongo District, Nyanza Province, Kenya. North Kamagambo counts approximately 30,000 people.

In addition to basic primary care services, the Lwala facility provides maternal and child health services such as antenatal and postnatal care, vaccinations, growth monitoring and family planning; treatment of tuberculosis; comprehensive care for HIV, preventative services including PMTCT and male circumcision, counseling and testing as well as ARVs and nutritional support for persons living with HIV.

From August through October 2009, primary care was provided to 3,141 patients; more than 45 children were fully immunized; 198 women received antenatal care visits; 5 HIV positive mothers were delivered and received PMTCT care. A new HIV testing algorithm was implemented in accordance with MoH guidelines. Two Umama Salama workshops were held during which 17 women and 6 men were trained in Safe Motherhood lessons. A Rapid Core Assessment Tool for Child Health (CATCH) survey was conducted. Menstrual hygiene intervention was implemented in a local primary school. A successful measles vaccination campaign was conducted in conjunction with the Ministry of Health in response to a measles outbreak in the country. In addition, in conjunction with FACES, active recruiting for mothers to bring their male babies for infant male circumcision was done. Access to condoms was improved by the placement of condom dispensers in the latrines. Two Children's Club sessions for HIV positive children were held. Also, a proposal requesting a kit of essential drugs from the Ministry of Health was submitted. Approval was obtained to receive both a monthly dispensary and a monthly health center kit which includes essential drugs such as antimalarials and antibiotics.

Maternal and Child Health Clinic

The MCH clinic is open every day beginning between 8 and 8:30am. Services provided include antenatal care (ANC), family planning (FP), immunizations and growth monitoring for children under 5, prevention of mother to child transmission of HIV (PMTCT), and post partum care. Services provided here are integrated, such that if a woman brings her child for immunizations, she will also receive education and counseling on FP and can initiate a method that day. This is unlike many other clinics in Kenya, which operate by only offering services on specific days, thereby turning away clients when they attend on the "wrong" days.
MCH nurse Rose begins each session with health education on relevant topics. Women who bring their children for immunizations are counseled on types of immunizations, into what part of the body each vaccine is injected, how often to bring children, and why it is beneficial to attend the clinic.  Rose also counsels women about family planning methods. Her welcoming demeanor encourages women to ask questions without fear of reproach.
Family planning methods available at the clinic include DepoProvera (injectable), oral contraceptive pills, condoms, and emergency contraception. Women are also counseled about implants and intra-uterine devices (IUDs), which are available in Rongo, Kisii or Homa Bay.

In line with global standards, women are encouraged to come for at least four ANC visits during pregnancy. As this is a time when many women will be tested for HIV, the ANC visits provide an important entry point to HIV care and treatment services for women and their partners.

Following are cases during one routine morning of antenatal care:
A pregnant woman who walked 2 hours to be seen at the clinic.
A 20-year-old woman, attending her 2nd ANC visit. She tested positive for HIV during her first visit and was enrolled in the health center's HIV care and treatment program. This is her third pregnancy. Her husband refuses to wear condoms and refuses to come for counseling and testing. He does not know his status or his wife's status.
A 23-year-old woman, attending her second ANC visit. She and her husband are both positive for HIV and enrolled on care. This is her third pregnancy.
A 16-year-old girl, attending her first ANC visit. She is in secondary school and in the second trimester of her first pregnancy.

Umama Salama (Safe Motherhood) Training

In an effort to teach community members about recognizing and responding to obstetric complications, two workshops were led by Susan Akoth, our Umama Salama instructor, during the last reporting period. Seventeen women and 6 men attended all sessions of the workshop including Basic Information, Women Problems, and Baby Problems.  The participants learned the "3 R's" of problems in pregnancy: "recognize, respond, and refer", and conducted role-plays to practice proper responses to emergencies. The men and women received certificates during a ceremony held to celebrate their participation. Clinical officer John Badia and a nurse aid contributed to the workshops by answering medical questions about pregnancy and childbirth and by encouraging the participants to actively support the care of pregnant women in the community.

Participants Wilfrida and Milicent conduct a role play during Umama Salama training.

Youth Seek VCT Services

On September 25, 7 students (4 boys and 3 girls) from class 8 at Lwala Primary School came to the clinic to be tested and counseled for HIV. They sat together to receive group counseling from lab technologist Mike Ondiek about    testing, sex, HIV, and other sexually transmitted infections. The students demonstrated a remarkable amount of   knowledge in answering Mike’s questions, a testament to the quality of HIV education provided periodically in the schools by the Lwala clinic staff. The students encouraged and supported one another as their blood samples were taken. Each student received individual post test counseling, a bag of condoms, and a date to return for routine testing. Happily, all students tested negative for the virus.

Lucy Atieno

Lucy Atieno came to the Lwala Community Health clinic in labor on the morning of October 3. After laboring for several hours, Nurse Vine determined that the labor was obstructed and referred the patient to Tabaka Mission Hospital for further care. Lwala's ambulance carried Lucy, Nurse Vine, and a community health worker to the hospital, where Lucy safely delivered a little girl. Shortly after, when the Tabaka nurses manually removed Lucy's retained placenta, everyone celebrated the ambulance that had enabled Lucy and her child to access the emergency care they needed. The community health worker visited Lucy in her home the following week where she found a healthy mother and child. Lucy brought her baby to the clinic for immunizations at the encouragement of the community health worker.

Lucy Atieno and her new baby girl

• A Note from Lwala, Spring 2009
• September 2008 photos
• Lwala Progress Report September, 2008
• Lwala Progress Report April, 2008
• Lwala Update Spring 2008
• Lwala Holiday Update 2007
• Lwala Clinic Report by Dr. Young, August 2007
• Lwala Community Alliance Blog
• The Vanderbilt University site on Lwala
• The Pulitzer Center on Crisis Reporting on Lwala
• Morbidity Report, May, June 2007 (pdf)

September 2009
Ochieng Memorial Lwala Community Health Center
By James Nardella and William Young, MD

March 2009
Lwala Community Health Center Continues to Meet Growing Demands of the Community in 2009.
by Joel Wickre and Dr. William Young

In May/June of 2008 Real Medicine Foundation Founder and Executive Director Dr. Martina Fuchs visited the Lwala clinic.

The summer months saw many welcome additions to the Ochieng' Memorial Lwala Community Health Center: two new clinical officers were hired; a new staff house was completed; an improved rain water catchment system is supplying the clinic with clean, running water; a more fruitful partnership with nearby Tabaka Mission Hospital was forged; and a revamped village oversight committee was created. Each of these accomplishments has contributed not only to the quality of care offered by the clinic but also to its likelihood for long term sustainability.

With the departure of clinical officer Peter Ochieng' last spring, a deficit in trained clinical staff was felt at the clinic. As RMF had been funding the salary of Peter Ochieng', it was agreed that any new CO hired would be paid out of RMF funding as well. The search for a new CO was, thankfully, a relatively short one, and resulted in the hiring of two COs, John Badia and Penina. John, who's salary will be provided by RMF, is from the nearby city of Kisumu, and completed his training there, first at Kenya Medical Training College (KMTC), and then through an internship at Nyanza Provincial Hospital. Afterwards he worked at the Patient Support Center, a special clinic for people with HIV/AIDS run by the CDC and PEPFAR in Kisumu. Penina was born in nearby Homa Bay and received her training as a CO there. Her skills are well used in the busy clinic and allow John Badia to spend some time working with the clinic manager in coordinating public health programs. A clinical officer (CO) has a level of training roughly equivalent to that of a physician's assistant. In Africa they train COs because nearly all of the doctors they train leave for greener pastures. COs are trained in symptomatic management, which means they're trained to identify clusters of symptoms and apply decision making guidelines based on those symptoms. They do not have the extensive scientific background that physicians do, but in resource limited settings a CO can be a cost effective way of getting a lot of people treated for basic diseases. The standardization of treatments assures that the most common diseases are treated effectively, even if some of the more rare diseases are missed. In Kenya only the big city hospitals have doctors, and even there are in short supply. In the smaller towns and rural centers, COs are the highest level of clinical staff.

The construction of a new staff house provides the clinic with much needed support for its incredible staff members. One of the problems in retaining clinical staff in the past was the inability to comfortably house staff members and their families. This often meant staff would spend the weekdays in Lwala and return home to their families on the weekends. Such isolation from family inhibited the emotional connection between employee and clinic necessary for promoting a workforce that is dedicated to the health and prosperity of the community. Two additional staff houses are already under construction and the buildings for the HIV/AIDS and maternity services will begin construction in October.

There is a larger mission hospital called the St. Camillus Tabaka Mission Hospital approximately 20km from Lwala. This is a tertiary care hospital providing quality service, but it charges fees prohibitive for almost all people in Lwala. Complicated or emergent cases that come to the Lwala clinic are referred to the St. Camillus Tabaka Mission Hospital. The Lwala Health Center and the Tabaka Mission Hospital have a memorandum of understanding regarding how these cases are admitted, paid and followed-up. Both the District Hospital and the Tabaka Mission Hospital have ambulances which can be called by the Lwala Health Center, but they are not capable of reaching Lwala during rainy weather due to the poor road. Hospital staff providing VCT and HAART to the community.

RMF's financial support of the clinic has been greatly appreciated by the clinic and the community. The community is very pleased with the services; everyone feels they have access because the service is free for most patients and nearly free for the rest. The clinic was voted by the MOH as the best facility in the district, and has been designated a level two facility (basically a sub-district hospital). RMF's purchase and maintenance of the 4x4 emergency ambulance as well as the continued clinical officer salary funding has improved the clinic's ability to handle the monthly patient load of 2000+ people as well as offer more effective emergency care. A recent success story highlighting the impact of RMF's contributions was reported by clinic co-founder Fred Ochieng':

A 16 year old girl was in labor for many hours at her home.  Village people brought her to the clinic at 3 AM and awakened the staff. A Clinical Officer concluded after 2 hours that the labor was obstructed. She was placed in the clinic's new 4 wheel drive ambulance at 5 AM and driven to Tabaka Mission Hospital. The doctors agreed with the CO's dystocia diagnosis and performed a cesarean section. The mother and baby are OK. Obstructed labor is a leading cause of maternal deaths in the developing world. The Lwala Clinic fortunately has skilled clinicians to make the diagnosis, a method to transport a sick patient, and a place that can provide emergency care. Real Medicine provided the ambulance and supports a clinical officer in Lwala. Asante.

Two final positive notes:

To date, 31 babies have been successfully born at the clinic! When the clinic first opened back in April 2007, many women in the community were wary of giving birth at the clinic, preferring instead a more traditional birthing practice in their homes. This news illustrates the increasing acceptance of the clinic by the community as a trustworthy organization. Certainly, the completion of the construction of the maternity services building will only help to improve this aspect of the clinic's positive contribution to the community.

Additionally, RMF has been able to secure a grant from World Children's Fund for the Lwala clinic. This money has been earmarked for use in funding the continuing development of the HIV/AIDS and maternity services at the clinic.

April 2008
By Ian Swan

Since our last update in November, 2007, much activity has surrounded the community of Lwala, Kenya, as well as its new primary health clinic. Beginning in late December, post-election violence rocked Kenya, with a particular focus of the chaos centered in the Western provinces. Long standing inter-tribal conflicts fuelled riots sparked by the questionable polling and vote counting practices. By the time the two feuding political parties had signed a power sharing agreement in late February, more than 1000 deaths and 300,000 displaced citizens had been reported. Throughout these months of turmoil, my thoughts and worries were consistently drawn to the people of Kenya, and particularly to the safety of the community of Lwala. My fears for this beautiful village were thankfully assuaged by the sporadic updates from members of the Lwala Community Alliance (LCA) who were in Kenya when the violence broke out. According to LCA executive director Joel Wickre

"The violence did affect the clinic, though perhaps not in the way you'd imagine. Lwala was peaceful, and for precisely that reason many patients who would otherwise have gone elsewhere walked great distances to get healthcare in Lwala."

Though there was a delay opening after the holiday, the clinic staff took advantage of a relatively peaceful window in mid January to return to the village, and the health center has been running ever since. Because the city hospitals were immobilized by the unrest, the clinic's patient load increased significantly. Well over 2,000 patients per month are now being seen!

The most exciting recent news coming out of the LCA/RMF partnership is the approval by the RMF board of directors for the financing of a vehicle to act as ambulance for the clinic. After many months of searching for a suitable vehicle by people on the ground, RMF received news in mid-March that a well maintained, truck-based 4x4 had been found that, with a few modifications, would serve as a perfectly capable emergency vehicle. Compared to other bids of quotation on other used and new vehicles, this particular proposal clearly stood out due to the quality of the vehicle and the price (including modifications.) The addition of such an emergence vehicle will undoubtedly improve the safety and efficiency with which the Lwala clinic can care for its patients. Past tragic instances speak to the necessity of this ambulance:

[Erastus Ochieng' Memorial Lwala Community Health Center founder], Milton, recalls a pivotal experience as a teenager, when he was called upon in the middle of the night to help push a woman suffering from complicated labor to the hospital in a wheelbarrow. She died on the way, and Milton turned around and wheeled her back home for her funeral.

Another way in which RMF has been actively trying to assist the Lwala clinic is through the procurement of bicycles for use by community health workers (CHWs). The cornerstone of the LCA's proposed HIV/AIDS program is a network of trained CHWs. These CHWs will be recruited from local HIV/AIDS support groups and women's groups. Already, three CHWs have been hired to follow up with patients on ART through partnership with Tabaka Mission Hospital, a quality tertiary care hospital 20km from Lwala. They will be trained at the Lwala clinic in home-based care, ART adherence, and social support for people with HIV/AIDS, using a curriculum designed by Partners in Health. Each CHW will be equipped with a bicycle and basic supplies such as gloves, and will each be paid a small monthly stipend, intended to augment their normal daily activities rather than replace them. Each CHW will be assigned to no more than 4 patients near their home. Every patient on ART from the health center living within a 10km radius will receive daily in-home follow-up and directly observed therapy from a CHW. The CHWs will provide important follow-up to identify drug side effects and reactions, to ensure regular clinic attendance, and to help address threats to patient success as they arise. They will also act as a referral network for new patients.

On a less positive note, the former clinical officer (Peter Ochieng'), whose salary RMF had been funding, recently chose to leave the Lwala clinic in exchange for a government job. Such transient employees are an unfortunate fact of life for this clinic due to its remote location and thus unglamorous lifestyle for its staff. Those in charge of staffing the clinic are well aware of this burden on clinic sustainability and try, at all costs, to employ individuals who have, for whatever reason, a greater commitment to the clinic's continued success. As such, any search for new staff members is tailored to unearth those individuals who express sincere interest in the long-term care and growth of the clinic and its surrounding community.