Kenya

Introduction
Turkana is a vast region of 450,000 migrant herders dispersed over 77,000km². With roughly 6 people per square kilometer concentrated in small villages of about 5,000 or less, it is sparsely populated; some villages are as far as 75km from a major town. Despite the significance separation between population clusters, Turkana’s physicians are nonetheless fewer than most other African nations, numbering less than 1.4 per 10,000 people (versus an average ratio of 2.2 per 10,000 over the continent of Africa as a whole) .

The remoteness of the local villages commonly forces patients to walk 20km to the nearest health clinic, in most cases only to find little emergency care capacity. The main referral health facility, Lodwar District Hospital, is tasked with supplying back-up referral care to the entire local population of 350,000 (approx), and is significantly overstrained. Because other district hospitals in the Turkana region are practically non-functional, in practice, Lodwar District Hospital actually serves surrounding districts as well, bringing its catchment area to over 900 000, straining its thin resource base even further.

Real Medicine Foundation (RMF) realized that its work in setting up health clinics for the drought victims in Turkana would not suffice – many of the more seriously ill patients needed in-patient hospital care or care requiring the use of major equipment which can only be found at a referral hospital. With the generous support of Medical Mission International, RMF decided to launch a ‘Health Systems Strengthening Fund’ to upgrade Lodwar District Hospital to enable it to properly fulfill its role as a referral medical center for the region.

Before starting this new project, RMF conducted a simple qualitative resource needs assessment at Lodwar District Hospital from 24-27 January 2011, described in detail below.
 

Methodology
A semi-structured interview format was used by RMF’s Coordinator, Global Projects, with the following people/groups:
1. Operating theater personnel
2. Biomedical engineer
3. Pediatric ward clinical personnel
4. Hospital management
5. Lab technicians
6. Pharmacy personnel
7. Physiotherapy/occupational therapy personnel

The interviews all followed the same pattern, elucidated here:
1. What can be improved in your ward/area at Lodwar District Hospital?
2. What are the major morbidities that you see?
3. Let’s go through the patient flow of each morbidity. Explain to me where the bottlenecks are at each step for you.

RMF’s Coordinator, Global Projects, first asked an open-ended question to see what were the major complaints and the problems occurring most frequently. These issues were assumed to come up immediately with such an open question. The Coordinator then proceeded to go through, in detail, the patient pathway for each of the major conditions seen by the groups interviewed to better understand where the difficulties were for successful comprehensive treatment of the patient. This method allows the interviewees to systematically go through the steps which they take on a daily basis and illustrate the concrete problems they face.
Results

Operating theater
Aggrey Sitati, Theatre Nurse; Peter Ereng, Theatre Nurse; Dr. Anthony Mutheea, General Surgeon; Julius Chiemba, Anesthetist
The theater staff mentioned that many of the machines often break down (autoclave, anesthetic machine, diathermy) and are usually fixed by the group of Spanish eye doctors who come for a few weeks every year to conduct eye consultations and surgeries. There are no service contracts on any of the surgical machines and equipment as they are prohibitively expensive. The surgical team uses the disposable diathermy tubes provided by the Spanish team when they come by auto-claving it and reusing it until their next yearly visit. Otherwise, disposable items are constantly running out – surgical gloves, face masks, caps, gauze, IV cannulas, spinal needles, vicryl sutures, etc. The team makes do by re-washing items such as face masks and caps even though they are actually disposable. There is no ECG monitor for post-operative recovery control, nor is there a defibrillator for emergency care. A dire necessity is the oxygen concentrator for anesthesia as well as for the large majority of respiratory cases seen in the outpatient department and the wards.

Emergency drugs and anesthetic drugs are in short supply, especially pethidine and ketamine. These drugs are not easy to procure and must often be procured by the patient or their families in case of emergency.

The operating theater itself requires renovation – painting of the walls, new theater lights (at the moment, they are using one single light for each operation), and a new roof. The roof has had a hole for the past several months – since no rains have come for over a year, this has not yet been a problem, but it may be as soon as it does rain.

Medical equipment
Biomedical engineer – Peter Birken
The biomedical engineer affirmed that none of the equipment at the hospital were under any sort of service contracts as these are very expensive. This also meant that if anything broke down, which was a frequent occurrence, all costs had to be borne by the hospital. If the hospital could not pay these repairs right away, the machine went without being used, sometimes for several months. This was currently the fate of an oxygen concentrator which had been lying in his office for want of an ‘oxygen concentrator capacitator’ for 4 months. The hospital did not have the funds for the missing part.
In addition, his tool box needed some new tools as some had become old and worn and needed to be thrown away.
The biggest problem was the maintenance of equipment which is not done on a regular basis, hence there is a high frequency of equipment break-down.

Pediatric ward
Constantine Kaine, pediatric nurse; Towett Samwel, Clinical Officer, Pediatrics
The pediatric outpatient room needs dire renovation, the bench on which patients sit was broken and the paint was visibly peeling on the walls. The pediatric ward staff complained of long hours – there were not enough nurses for anyone to take leave or get nights off after a full day shift. The vast majority of the outpatient cases which they see have diarrhea, malaria, pneumonia, and malnutrition.

Merlin, a UK-based NGO, is supporting Lodwar District Hospital with 2 full-time nurses and a full-time Clinical Officer to run their malnutrition treatment program. This staff is used solely for diagnosing malnourished children and providing food supplements and do not interfere into other pediatric hospital activities. Merlin provides all food supplements as well as equipment needed to diagnose and treat malnourished children.

As for malaria, the vast majority of the time, the children are treated based on their symptoms only as diagnostic tests and reagents are often missing in the lab. The respiratory cases often need the oxygen concentrator, of which there is only one functioning at the hospital at this time.
The pediatric ward itself needs renovations, especially new fans as the patients all sit and sleep outside, exposed to malaria, due to the suffocating heat inside. The fans all broke down over the last several months. In addition, the ward needs a new paint job as well as new sinks. The water lines are available and working but the sinks are broken so there is no possibility to wash oneself.

Consumable items were rarely in stock – IV cannulas, intraosseus needles, gauze and other dressing equipment, etc. They had not been received from KEMSA in a long while, hence the hospital was spending most of its user fee income to purchase these items in the private sector. However, this was usually not sufficient due to the low amount of user fees coming in to the hospital. There was thus usually no other recourse but to send the patient or the patient’s family out to Lodwar town to purchase these items on their own when these items were needed on a patient. If the patient’s family could not afford the consumable items, it often meant that certain paramount diagnostic procedures were not undertaken.

Hospital management:
Dr. Gilchrist Lokoel, Medical Officer for Health, Turkana Central District; Towett Samwel, Clinical Officer, Pediatrics; Dr. Anthony Mutheea, General Surgeon
The hospital management asserted that the major problem facing day-to-day operations were the lack of adequate staff, paltry to non-existent supplies and medicines, and equipment in need of repair. In addition, the infrastructure itself of the hospital needed major renovation. The hospital has a good relationship with both KEMSA and the Ministry of Health (MoH) for the Rift Valley (located in Nakuru) and they try as far as they can to support the hospitals in emergency needs.

There is also a major need for the hospital to separate out the Antenatal and Postnatal Ward. Currently the two have been centralized into one room, causing congestion and confusion. The wards also need linen supply for beds. The last supply the hospital received was 8 years ago. Another major problem was the chronic blockage of the hospital drainage system which needs dire repairs.

The hospital management recommended a Blood Transfusion Centre to be created. Ready blood is not available at the hospital, hence patients must go as far as Eldoret (400 km) for such services.

An Intensive Care Unit (ICU) and a properly functioning operating theatre are huge necessities; the latter could be remedied by regular supplies and adequate equipment.
The topic of additional training also came up, especially for orthopedic surgery and emergency pediatric care. Hospital staff have little exposure and experience in these 2 areas as they end up having to refer these patients due to lack of materials and supplies. If RMF is going to ensure adequate supplies in the future, the staff must have the training to be able to make use of the supplies.

Laboratory
Lab technicians – Peter Lamurukai – Laboratory Deputy in Charge; Henry Ogaro – Laboratory In Charge
The laboratory personnel emphasized the lack of reagents on a regular basis. Especially special enzymes, electrolytes for biochemical tests, and glucose strips were constantly missing. KEMSA had not provided any new reagents since November 2009 so the hospital was trying to manage with the most-needed ones with funds left over from user fees. In addition, the lab technicians complained of long hours as only 4 technicians are on the hospital payroll on a full-time basis. At the moment, the laboratory staff are managing because 1 extra technician is on loan from another lab and the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) is financing 1 more technician. Those on shift take no lunch breaks, do night shifts without the following day off, in order to keep up with the work load.

EGPAF supports the Lodwar District Hospital (DH) laboratory with the 1 said technician, external quality control evaluations, servicing of HIV testing machines, laboratory materials, and anything else HIV-related. A hematology counter and a biochemistry centrifuge as well as a CD4 enumeration machine have been donated by the United States Agency for International Development (USAID) 2-3 years ago. These machines will however be transferred in the summer of 2011 to a new Comprehensive Care Center for HIV patients being set up by USAID in Lodwar.
KEMSA does not provide all the reagents necessary at Lodwar District Hospital, only liver enzymes and creatinine so anything else must be supplied with the user fee funds received at the hospital. These funds are sparse as most of the patients arriving into Lodwar DH end up getting a fee waiver due to their poverty.

Pharmacy
Kiprop Gideong, Pharmacist in Charge; Jeremiah Ondau, Pharmacist Technician
The pharmacy suffers from a great lack of stocks. KEMSA provides supplies extremely irregularly, the situation has gotten worse in the last year. At the moment, any malnutrition-related food supplements are in good stock, thanks to Merlin. The hospital manages to buy some medicines from the user fees patients pay. The pharmacy staff is on the phone with KEMSA regularly to attempt to get whatever stocks possible. The most dire need is a good stock of emergency drugs such as atropine, adrenaline, lignocaine, and diazepam.

As some medicines are more easily procurable from KEMSA, a basic list was drawn up of medicines which need supplemental funding should KEMSA not come through (see annex).

Physiotherapy/Occupational therapy:
The physiotherapist and occupational therapists lamented at the low level of importance accorded to their work at the hospital. Many fractured and injured patients came to see them for rehabilitation therapy but even Plaster of Paris for putting on a caste was missing most of the time. They made do with whatever supplies they had on hand – sometimes they had to request patients to purchase some items they did not have. They were also extremely innovative in their make-shift props and weights – using what was available at hand if these items were not at the hospital. They are also overworked as they are only one each (physiotherapist, occupational therapist) for the whole hospital. Sometimes they cannot see the children on the schedule required due to lack of time and auxiliary staff. Another major problem for the patients is transport to come for regular physiotherapy – as well as lodging in Lodwar. Keeping the patient to complete a full rehabilitation cycle is thus often very difficult.

Conclusion
The interviews conducted during this assessment clearly evince the need for financial and technical support of Lodwar District Hospital, especially in the following areas:
• Rehabilitate the infrastructure at Lodwar District Hospital, beginning with the pediatric ward
• Rehabilitate equipment set at Lodwar District Hospital, beginning with the pediatric ward
• Provide regularity to supplies of basic medical devices, disposables, and pharmaceuticals, complementing the items from Kenya Medical Supplies (KEMSA)
• Provide equipment maintenance and spare parts management
• Organize on-site clinical training, beginning with emergency care

The reason for the emphasis on the pediatric ward is mainly due to limited funding – RMF clearly cannot rehabilitate and renovate the whole hospital with the funds it has. Hence, a somewhat arbitrary decision must be made as to where to start. Children under 5 years of age being a vulnerable population and the pediatric ward being in a bad state, it was decided that RMF would begin here. However, as far as possible, the hospital as a whole should be supported with materials, supplies, medicines, and training. The infrastructure renovation as well as major equipment purchases will concentrate mainly on the pediatric ward, as will the data collection and patient monitoring work.

RMF, together with Hospital Management, put together a detailed list of items which could be provided within the budget allocated by Medical Mission International (see annex).
We propose to hire a ‘Health Systems Strengthening Fund Manager’ to oversee the disbursement of funds, purchasing, and monitoring. Terms of Reference are attached.

For the pharmaceutical list, we focused our list on emergency medicines and those which are not easily procurable through KEMSA. The quantity assumptions we have made have taken into account what is assumed to be provided by KEMSA as a minimum. The same assumptions have been made for the supplies list quantities. We have focused our supplies list on those items which the patients are often requested to buy themselves in town and those items which are needed in emergency cases.

For the laboratory, we have added in all major reagents to the list. A better stocked laboratory would go a long way in improving clinical diagnosis and care, as well as clinical monitoring. Therefore, we tried to include as many vital reagents as possible here, and added more rather than less.  For the equipment list, we focused on the pediatric ward and especially those equipment needed in emergency care.