Health service delivery and healing are central to the

Transcription

1 editorial The mission of the Churh in health are Health servie delivery and healing are entral to the mission of the Churh. Jesus Christ whose teahing and example Christians emulate had a ministry that inluded preahing, teahing and healing. His ministry was non-disriminatory and transended the ultural and traditional barriers of those days to provide ompassionate servie and healing to all partiularly the poor, deprived and vulnerable. When He ommissioned His disiples, Jesus sent them out to the world to teah, preah and heal the sik. He told them: As you go, preah the message, heal the sik, raise the dead, leanse those who have leprosy (Mathew 10:7). Churh health servies are established in response to the mission of Christ. Their main motivation is to reah out and serve the sik and needy as part of evangelism and outreah. The missionaries who brought Christianity to Afria had a wholisti Gospel whih involved preahing, evangelism, eduation, training, health servie delivery, soial servies and eonomi empowerment of loal ommunities. Older mission hospitals in Afria are usually part of a larger omplex that inludes a hurh, shool and the hospital. Examples in Kenya inlude PCEA hospitals in Kikuyu, Tumutumu and Chogoria, AIC Kijabe, Litein and Kapsowar Hospitals, Maua Methodist Hospital, Friends Hospitals in Kaimosi and Lugulu, Anglian Hospitals in Maseno and St Lukes Kaloleni and the AGC Tenwek Hospital. T h e f o u n d a t i o n o f h u r h h e a l t h servies is grounded in Christian teahing and values. The quality of servies provided is further enhaned by the ompassionate approah and desire to express the love of Christ to all patients. Churh health servies also have the attribute of good stewardship in trying to do the most with the resoures enstrusted to them by God. T h i s a p p r o a h t o h e a l t h s e r v i e s d e v e l o p m e n t w a s feasible when the ost of health are was low and signifiant external subsidies were readily available. In those days of plenty, hurh health failities reeived missionary expatriates, essential drugs, medial equipment and unrestrited funds from sister Churhes abroad. In addition, they reeived substantial grants from the Government. Today, the situation has dramatially hanged. The ost of health servie provision is esalating with every passing day while regulatory standards have beome very demanding. In addition, there is a high level of human resoure migration and none or very few missionary expatriates. Subsidies from Government are very limited. Despite these hallenges presented by the operating environment, the mission of the Churh in health has not hanged. Churh health failities remain a key soure of servie delivery to ommunities, partiularly in the rural areas of Afria. In these areas, finaning of health are is diffiult due to the high poverty levels. However despite all these hallenges, the Churh must remain true to its mission whih was founded by Christ. We must therefore explore innovative ways of ontinuing to attrat resoures to support Churh health servie delivery. This issue of CHAK Times showases some innovations in health are finaning to address the sustainability hallenge. We wish you enjoyable reading and welome your feedbak. r CHAK Times January - April 2009

2 from the general seretary CHAK members to benefit from health systems initiative CHAK has launhed a health systems strengthening initiative for member health institutions. The projet is being implemented in partnership with CHF International and Capaity Projet and with funding from CDC. The purpose of this initiative is to address weaknesses in the health servie delivery support systems in Churh health failities in Kenya. Health systems strengthening has been identified as a key pillar for improvement of health servies quality and sustainability. The need for the Health Systems Strengthening initiative was identified from the report of the omprehensive situational analysis study of the Faith Based Health Servies in Kenya vis-à-vis Government Health Servies that was onduted jointly by MOH and CHAK & KEC through the MOH-FBHS- TWG in The study identified the weakness and vulnerability of health servies support systems espeially as regards governane, human resoure management, finanial management, infrastruture, medial equipment, planning and Monitoring & Evaluation (M&E). These are further ompliated by the high human resoures turnover and hallenges of inadequate resoures. The study observed that whereas many faith based health failities were strategially loated in areas where health servies delivery was inadequate, utilization of servies was delining. The Government of Kenya has also gazetted a poliy on health faility governane and finanial management known as the Health Setor Faility Fund Poliy. CHAK will support improvement of health systems in its member network through; 1. Development of health systems strengthening poliy douments 2. Capaity building on governane and management to be ahieved through training, mentorship, tehnial support and networking 3. Continuing to ensure an effiient and affordable Essential Drugs and Medial Supplies prourement system through MEDS 4. Continuing to support souring, installation and maintenane of Medial Equipment through the Health Care Tehnial Servies (HCTS) Programme 5. Development and endorsement of a partnership poliy framework between Faith Based Health Servie providers (CHAK, KEC, SUPKEM) and Government 6. Promoting partnerships at both faility and national levels that provide tehnial support and inputs Several health systems strengthening poliy douments have been developed through a partiipatory proess involving CHAK seretariat, partners, member health failities and CHAK Exeutive Committee (Board). The development proess involved the following key steps: u Identifiation of poliy gaps and issues u Review of the issues and disussion on sope of the poliy needed through a workshop attended by CHAK Seretariat and representatives of member health failities u Development of draft poliy douments through appropriate tehnial support u Review of the draft poliy douments in a workshop of poliy makers from the Seretariat, Exeutive Committee, partners and representatives of member hurhes and member health failities u Approval of the final poliy douments was given by the Exeutive Committee (EXCO) during its meeting held on November 19, u Dissemination of the poliy douments at the National Health Systems Poliy Douments Dissemination Forum held at CHAK Guest House and Training Centre on November photo: CHAK 20, 2008 u Capaity building and tehnial support for poliy douments adoption and implementation The poliy douments developed inlude: u A governane poliy manual for hospitals u A governane poliy manual for lower health failities (dispensaries and health entres) u Human resoure management Partiipants at the National Health Systems Poliy Douments Dissemination Forum held at CHAK Guest House and Training Centre on November 20, turn to page 4 CHAK Times January - April 2009

3 The sustainability hallenge faing hurh health servies By Dr Samuel Mwenda-General Seretary, CHAK Churh health servies remain a major ontributor in health servies delivery in most of the Sub- Saharan Afria ountries. The motivation for hurh involvement in health servies delivery is firmly grounded in the Biblial mandate illustrated by the example of Christ. Churhes partiipate in health promotion and treatment of the sik in response to the great ommission to go out in to the world to teah, preah and heal the sik. In addition, medial are reates opportunity for evangelism and pratiing Christ s love and ompassion. Historially, hurh health failities in Kenya enjoyed support from a variety of soures, enabling them to provide quality, affordable and aessible servies to meet the health are needs of poor and underserved ommunities. Suh support inluded: u Finanial and in-kind donations from sister hurhes abroad u Missionary expatriates who formed the bulk of senior staff in hurh health failities u Government grants from the National Budget u Donated drugs, medial supplies and equipment uuser fees, whih was the least signifiant soure of funding Today, the situation has ompletely reversed posing a huge sustainability hallenge. The main soures of funding for Churh health servies inlude: u Revenue generation from patients fees. This ontributes over 70 per ent finaning of the reurrent expenditure. u Donations are irregular and mostly designated to apital development, equipment or speial programmes like HIV&AIDS u There are very few missionary expatriates who tend to be highly speialized u There are no Government grants. Most government support tends to be in the form of medial supplies and few seonded staff. Among the medial supplied are vaines, TB drugs, family planning ommodities, anti-malarial drugs, HIV test kits and ARVs and dispensary drug kits. turn to page 5 User fees 70% Soures of funding for FBHS in 2004 NHIF 9% Others 7% Donors 14% GOK 0% Soure: FBHS situational analysis study report...ontinued from page 3 poliy manual and HRM tools u HIV workplae poliy u M&E framework and manual for CHAK Strategi Plan u Finanial management and prourement poliy manual u Strategi and operational planning guidelines The poliy douments were developed by CHAK with tehnial support from the Capaity Projet and onsultants from the University of Nairobi. CHAK is grateful to CDC for providing the funding through CHF International. The funding has also been used to equip CHAK Seretariat with ICT hardware and software to enhane effiieny in operations and M&E. The poliy douments were launhed by CHAK Chairman Bishop Joseph Wasonga at the National Health Systems Poliy Dissemination Forum, held at CHAK Guest House & Training Centre on November 20, The Poliy Douments an be downloaded from CHAK Website ( for use by CHAK member health failities. Any other individual or organization wishing to quote or reprodue any part of these douments must seek authorization from the General Seretary, CHAK. A programme for dissemination of the poliy douments and apaity building has been launhed in all the four CHAK regions. The dissemination strategy also involves building linkages with the Ministry of Health (MOH) to strengthen ollaboration and mobilize member health failities to partiipate in the Annual Distrit Health Planning. Site-based mentorship support shall also be provided. A apaity building workshop fousing on governane has already been held for the new St. Lukes Hospital, Kaloleni, Board using these tools with very positive results. The Hospital Board and management are already implementing an ation plan to strengthen health systems and improve quality of servies. r CHAK Times January - April 2009

4 ...ontinued from page 4 Finanial sustainability has thus beome a major hallenge with the situation being further ompliated by the high osts of health are inputs and delining utilization. In an effort to remain faithful to their mission of serving the poor, Churh health failities have aumulated a huge debt burden. The situation analysis study of faith-based health providers vis-à-vis Government health failities onduted in 2007 revealed that the main soures of finaning for faith based health failities in Kenya were patient fees (71 per ent), donations (13 per ent) and National Hospital Insurane Fund (NHIF) (9 per ent). (see hart below). The study further revealed that the trend of revenue generation from patient fees is on a downward trend due to poverty, deline in patient numbers, ompetition and the impat of HIV&AIDS. This trend unfortunately triggers the viious yle of human resoure migration that further ompromises quality of servie delivery. In order to survive the risis reated by this senario and ensure long term sustainability of our mission and servies, Churh health failities in Kenya have to be proative in embraing innovative approahes to health are finaning. We must also identify strategies for enhaning motivation and staff retention. CHAK is exited by the various lessons on best praties in resoure mobilization and staff motivation. Churhes have a Biblial mandate and obligation to ontinue providing health servies. This foundation makes hurh health servies an key partner to MOH in health servie delivery. In order to sustain the good work whih hurh health failities are doing and expand their overage, CHAK reommends several sustainability enhaning strategies. Strategies to enhane sustainability Speial attention should be given to our human resoures by endeavoring to learn from best praties within the Faith Based Health Failities. By saling up and sustaining advoay to photo: Wesley Health Centre, Nakuru Every health faility should identify a nihe or brand for whih it will be reognized in its wider athment area the Government and donors for substantial ommitment to human resoure support, Faith Based Health Failities an ut down on operating osts, releasing funds for other uses. Suh assistane needs to be supported by MoUs or ontrats to ushion hurh failities where a hange of guard ours in Government. Governane of Churh health failities should be strengthened and professionalized to ensure that it has the essential ompetene and skills mix. There is also need to ensure that our governane fouses its business on strategi planning, resoure mobilization and performane monitoring. The operations of the Board and its relationship with management should be guided by a governane poliy manual or by-laws to enhane synergy and avoid onflits. CHAK has provided a Governane Poliy Manual whih ould be adopted to ensure best pratie. Every health faility should identify a nihe or brand for whih it will be reognized in its wider athment area. The nihe servie should be well developed, pakaged and marketed. Some examples that are working well in Kenya inlude Kikuyu Hospital (Speialized Eye Care servies), Kijabe Hospital (Orthopedi surgery and medial training), Tenwek Hospital (Endosopy, oesophageal aner management and ardiothorai surgery) Maua Methodist Hospital (trauma management and ommunity HIV programmes), St Lukes Hospital (ommunity-based health are (PHC)), LightHouse for Christ and Sabatia Eye Hospital (Speialized Eye Care servies). Faith-based health servies should onsider inluding salary support and human resoure development in every projet proposal submitted to donors in order to expand training opportunities for their staff. Along these lines, it may be time to lobby donor partners to support sholarship funds to benefit staff in hurh health failities. Endowment funds an also provide muhneeded resoures for staff development. To enjoy an edge over their ompetitors in the private setor and MOH, faith based health servie providers need to develop human resoure poliies that give priority to staff housing, medial over inluding HIV/ AIDS treatment, are and support. Supporting staff redit North-South partnerships have over the years provided experiened and highly skilled manpower in the form of missionaries and staff supported by FBO partners abroad. turn to page 7 CHAK Times January - April 2009

5 Enhaning effiieny in drug use and supply By John W. Kiambuthi - Field Offier, MEDS The ost of purhasing mediines omes seond after staff salaries among reurrent budget items in most health failities. It therefore follows that, to the extent that is possible, utting expenditure on this major budget item ould have a profound effet on overall osts. Providing optimum are for patients remains the first priority in any health are set-up. Cutting on expenditure while providing optimum health are alls for innovation. Fortunately, there are time-tested systems and approahes for ahieving this. They ome in two major forms - proper management of mediine resoures, inluding prourement, stok ontrol and internal mediine distribution systems, and effiient (rational) use of mediines and other medial resoures by the health are providers and patients. Management of mediine resoures This rather ambiguous term beomes learer one examined in its various omponents whih are seletion, prourement, stok ontrol and storage, and use of the mediines. Seletion Proper mediine seletion involves making informed hoies on what to approve for stoking in a medial faility set-up. The hoie is based on ommon disease patterns, effetiveness of various mediines to treat them, safety of the mediines and ost among other riteria. Sine it is not easy for individual health failities to gather all the information needed to make these hoies, it is advisable to be guided by the hoies that have been made by those with resoures and redibility. Thus, the world Health Organization (WHO) essential mediines list, Kenya Essential mediines list (KEDL) and MEDS stok list are good starting points in developing a list of mediines to stok. Most onerns about effetiveness, safety e.t.. will usually have been dealt with before a drug finds its way into these lists. Prourement Prourement should be based on the list of drugs that is ompiled. One of the greatest benefits that CHAK member units and other hurh failities have is a entralized drugs and medial supplies prourement hannel, MEDS. Purhasing through MEDS automatially addresses the thorny issue of quality of pharmaeutials sine MEDS tests most stoked items to ensure aeptable quality standards. Thus, health failities don t have to worry about fake drugs and ounterfeits that are ommon in the market. Another benefit of this entralized prourement system is low pries due to the bulk purhase disounts that are passed on to health failities through MEDS. Distribution and storage While it s easy to see the link between poor storage and drug deterioration, wastage, theft or even ontamination, the ontribution of poor stok ontrol to inreased expenditure on mediines and by extension, patient are, has not always been appreiated. In its simpler form, stok ontrol involves stoking just enough to avoid stok-outs while also avoiding over-stoking and wastage of resoures. In an established stok ontrol system, the quantity of an item to order is the differene between the maximum stok level and the quantity in stok at that time. The maximum stok level is determined by adding up the following: u Safety stok: This is the stok that you plan to insulate you against temporary upsets suh as delay in supply of what is ordered or an inrease in the usage of an item during a period. It is sometimes taken to be one month s stok of the item. u Amount of the item that is used as you wait for your order to be supplied (lead time): This waiting or lead time depends on the distane between you and the suppliers and is derived from past experienes u Quantity of the item that is used between plaing one order and the next (order interval): Orders an be plaed weekly, monthly, bi-monthly et depending on units preferenes. Thus, the maximum stok level is the sum of the above three estimates. For example, a unit that uses about ten turn to page 7 CHAK Times January - April 2009

6 ...ontinued from page 3 tins of amoxiillin in one month, waits two weeks for their mediines after plaing an order and makes it s order every two months will have it s maximum stok level for this item as 10 (safety stok) + 5 (amount used as order is awaited) + 20 (quantity used between plaing one order and plaing the next order) = 35. Thus if they want to plae an order and they have 60 tins in stok, they should order for = 25tins. Stok ontrol is also important in the other user departments inluding wards and the dispensing pharmay. Large savings on drug osts have been ahieved by simple stok ontrol measures in these units suh as onverting from a system of supplying mediines to the wards as ward stoks to supplying to individual patients in the ward. Effiient use of mediines and other medial resoures Normally referred to as rational use of mediines, this approah advoates for use of mediines that are: u Appropriate for the medial ondition u At doses that are appropriate and at the appropriate period u Reasonably pried u Aompanied by adequate and aurate information about these mediines and the diseases they are used to treat. The first requirement alls for vigilane on the part of the liniian to arrive at the right diagnosis during eah enounter. This is probably the most hallenging part. Besides alling upon liniians to always have urrent knowledge on diseases, skills and the right attitude are fundamental to suess. Laboratory and other diagnosti support are also key photo: CHAK A benefit of the entralized drugs prourement system through MEDS is low pries due to bulk purhase disounts passed on to health failities. elements as is the right working atmosphere (environment). Other requirements present a typial ase for the need for teamwork among liniians, pharmay personnel and the larger management. Ahieving effiient use of mediines and other medial supplies in a health unit alls for onerted efforts among liniians and other staff. This is most often ahieved through a Mediines and Therapeutis Committee (MTC). A Mediines and Therapeutis Committee is an eduational and advisory body whose members inlude representatives from the liniians, pharmay, nursing and hospital administration. The hairman is usually a respeted liniian turn to page 25...ontinued from page 5 shemes and/or miro finaning has proved a useful way of retaining and motivating workers. North-South partnerships have over the years provided experiened and highly skilled manpower in the form of missionaries and staff supported by FBO partners abroad. Intense advoay an dispel assumptions that the FBHS in Kenya are self-suffiient and do not need support from partners abroad. It may also be prudent to build strategi partnerships with health finaning initiatives and professionals in various speializations to ensure our lients have aess to speialized medial servies. Promotion of FBO-private partnerships involving members of sponsoring hurhes of our health failities an also assist us to tap expertise in the private setor. Other strategies to improve and expand health are finaning inlude: u Building apaity in finanial management to enhane effiieny in revenue generation and alloation u Computerization of health information and finanial management systems to enhane effiieny and ensure aurate and timely information to support deision making u Evidene-based osting of our servies to identify full ost for reovery. This should reognize any in-kind donations. Servie users should be provided with full information to appreiate the ost of the servie they have reeived and the subsidy whih has been extended through partner or government support. The full ost information should be used for advoay and for negotiating funding support and insurane ompensation. u Promoting ommunity enrollment in soial insurane shemes suh as NHIF and ommunity-based health finaning initiatives. u Supporting staff welfare and team building and miro-finane ommunity initiatives for eonomi empowerment u Fostering good relations with MOH and other stakeholders u Introduing Inome Generating Ativities (IGAs) u Demanding that partners desiring to work with us provide meaningful support inluding finanial, human resoure, ommodities or apaity building The mission health setor needs to utilize available information to reflet on its performane and future. Churh health servies an weather the urrent storm if they respond strategially to hanges in their operating environment and maintain their fous on their mission and faith in God who has ommissioned them. r CHAK Times January - April 2009

7 Costing medial servies in mission hospitals By Moses Mokua Non-governmental organizations (NGOs) providing health servies in Afria fae sustainability hallenges. In 2008 and five years going forward, it is preditable that mission hospitals that do not hange their business models will lose down. Assessing osts and fees harged for servies will be a ritial sustainability strategy. Understanding ost A ost is what you give up in order to gain something. It is the value of the alternative that one forgoes. It is the prie we pay to enjoy a servie or aquire a good. A patient pays transport, stops his regular work inluding providing servies for the family and pays at the hospital ash point to get treatment. Suh a patient pays ash and foregoes opportunities. The sum total of all these ash payments and value of forgone alternatives is the total ost of the treatment that he gets. A hospital must be able to assess with this level of preision all its osts and reover the same in the provision of its servies, within some margin, either diretly from the ash that patients pay, from donations or government grants. A laim to national health insurane funds and health management organizations must be based on the average ost of servie provision arrived at arefully by knowledgeable people, involving hospitals to determine those osts in aggregate and then determining averages. Donors will need to get reports on how muh the servie osts to reimburse the same. The PEPFAR grant is losing phase 1, and five years after it was started, only a few if any hospitals in Afria PEPFAR ountries an make laims to the grant based on well alulated per servie osts. All stakeholders in health finaning will appreiate data and proessed information on servie osts. Global eonomi meltdown The global eonomi melt down that started in 2008 is projeted to go on for another four years or so. Grants and donations to the health setor in developing ountries will diminish in frequeny and size. Governments and ommunities in Afria and other developing ountries will need to shoulder a greater share of the osts of providing health servies to ommunities. Largely, rural and urban ommunities have high poverty levels. In Kenya, 54 per ent of the population lives in abjet poverty out of a population of 36 million; Nigeria has 60 per ent of its population of 160 million people living in poverty while Rwanda has 52 per ent with a population of 10 million. These ountries show how ritial the need to support the health system as a method of poverty alleviation is. Needless to say, disease, poverty and illiteray are found in the same households. Mission hospitals provide lose to 40 per ent of health servies in developing nations. To survive, they will have to ome up with new business models. They will need to determine apital and servie osts, market their servies, differentiate priing, raise funds, negotiate better rates from insurers and have strong governane strutures. Strategi plans will have to be restrutured to ensure survival and sustainability. Conepts that were used to found mission hospitals and raise funds from abroad will need to be reviewed drastially and new onepts rafted from the neessity of the urrent times. photo: CHAK/ourtesy of Copti Hospital One annot determine the ost of a servie without reognizing the ost that omes with fixed assets and reurrent osts suh as equipment maintenane. turn to page 9 CHAK Times January - April 2009

8 ...ontinued from page 8 photo: CHAK/ourtesy of Kiandegwa Health Centre Fixed assets A hospital requires land, buildings, pavements, waiting areas, fening, vehiles, among others, to be operational. These are alled fixed assets and require large apital outlays. One annot determine the ost of a servie without reognizing the ost that omes with fixed assets. A small portion of the apital osts needs to be alulated and spread over lients who seek servies. Sine apital assets are aquired at different times and depreiate at different rates, good reords are vital in ost evaluation. Land osts, onstrution osts among others must be based on existing reords. Some of these assets were aquired many years ago and values may have appreiated. It may therefore be important to revalue suh assets and represent balane sheets in a true and fair manner. Most mission hospitals have grossly undervalued their assets due to lak of funds to revaluate them, the osts involved and lak of appreiation of the importane of this exerise. This is part of the new thinking that the governane of mission hospitals must adopt. Valuing assets orretly an, for example, enable a hospital to take out a loan for equipment finaning. A hospital that wants to raise funds from the publi should show that it is doing business as a modern, rational businessman should, making prudent deisions, presenting up to date finanial data that an stand the test of srutiny and professional review. Reurrent osts Reurrent osts should be added to apital osts to arrive at the value of what a hospital forgoes to provide treatment. Reurrent osts inlude variable and fixed osts. Variable osts inrease or derease based on ativities. Drug onsumption, food osts, laundry and nursing osts, water and eletriity are based on the number of patients and are a variable ost. Mediine is an evidenebased profession and its finaning and osting needs to borrow from this idea. Fixed osts do not hange with the volume of ativity. However, they inrease or derease based on other fators like passage of time, agreement revisions or statutory pronounements. They inlude rent, liene fees, repair and maintane. Patient Flow Analysis follows the patient from entry to a hospital to exit and osts all servies given in the proess. Costs should be verifiable, urrent, reasonable, and fair. There should be third party doumentation that fully aounts for the ost whih should have been arrived at after due proess. Costs inurred by an all powerful prourement offier who has the baking of an even more powerful hospital administrator may not be useful in assessing osts as intended. It is reommended that osts be based on evidene. The following are some advantages of evidene-based osting: u Controls osts: If we identify where expenses are most inurred, management an target ation to redue wastage and osts. u Assess urrent levels of ost reovery: Knowing urrent osts will assist a hospital to ompare them with the fees harged and determine if a loss or gain is being made. u Advoay: Evidene-based osting an assit hospitals to advoate for inreased funding from donors and Ministries of Health. u Building apaity: Staff of mission hospitals and national Christian organisations should be trained in osting tehniques. Capaity building speifially involves transfer of skills in projet planning, data olletion tehniques, tool development, analytial approahes and interpretation/ presentation of data. These tehniques an be retained and used in subsequent ost analyses at faility level. u Dissemination of the tehnique: Loal staff trained should be engaged in disussions of results to enable them develop skills to explain the data and answer questions. Suh questions will ome in handy when negotiating for donor and insurane funds. These organizations will usually test the rationale of the methods used in osting. u Identify servies being subsidized by member institutions and determine the level of subsidy: Hospitals provide servies in reprodutive health, surgial, maternity and so on. Eah of these servie have different osts and fees. Per servie analysis of ost helps to identify servies that Importane of evidene-based osting Mediine is an evidene-based profession and its finaning and osting needs to borrow from this idea. turn to page 10 CHAK Times January - April 2009

9 ...ontinued from page 9 are being subsidized and to what extent. One an also tell whih servies are making gains to subsidize the loss making ones. Hospitals an then use suh information to make sustainability deisions. u Identify auses of finanial defiits: A hospital that is onsistently making defiits in inome statements will use osting to identify auses and take orretive ation. Methods of osting There are many osting methodologies based on the priniples that the method should be simple, onsistently used and onsider all osts. Two approahes to osting are: Patient flow analysis (PFA) This method follows the patient from entry to a hospital to exit and osts all servies given in the proess. For example, osts of linial personnel whih usually are the largest omponent of total osts - are alulated using this approah. Patient Flow Analysis provides data on the amount of time spent by providers on different types of lient visits. This should be done for several patients presenting similar onditions for an average to be determined. Costs of visit-speifi mediines and supplies should be olleted via key informant interviews onduted with servie providers. Current prie lists of national suppliers of drugs would be useful. Other information olleted would inlude administrative data suh as lini and support staff payroll, expenditure data, servie utilization statistis and inventories of linial equipment and furniture. Homan et al (2002) explain that alulating the eonomi ost of a servie involves four proesses: 1) Identifiation of the resoures used to produe the servie, regardless of who pays for them 2) Valuation of the resoures 3) Alloation of the resoures to speifi servies 4) Dividing osts assigned to a servie by volume of servies provided to obtain the unit ost estimate. Inputs an be lassified as diret (defined as diretly involved in the prodution of the servie) or indiret (playing more of a supporting role in produing the servie). The identifiation stage involves making a omprehensive list of all the diret and indiret resoures (suh as linial and support staff labor, mediines and supplies, operating and maintenane inputs, and apital inputs inluding infrastruture and equipment) that are used in providing eah servie. The next stage is to assign an eonomi value to the inputs. If the hospital purhases these inputs, the eonomi value will normally be the same as the finanial expenditure. In the ase of donated inputs, an eonomi value is assigned based on the market value of the resoure. One the resoures have Information on ost of servies is ruial for organisations that are serious about improving finanial sustainability been identified and valued, their osts are alloated to different servies in line with the amount of the input used, and summed to produe the estimate of unit ost per servie. Average osting This will enable one ahieve the following: u Determine the average ost of outpatient are u Determine the average ost of in-patient surgial are u Determine the average ost of inpatient non-surgial are Random sampling is used to selet failities from strata, based on loation and size to be used to determine the averages. As an example, one may selet small hospitals within distrits, big hospitals within distrits, small hospitals in provine apitals and big hospitals in provine apitals. Cost and finanial data is olleted by the hospital staff, verified by a third party, then entrally entered into a spread sheet for analysis. Data is entered into exel analysis templates whih are designed to generated average osts per patient per day for surgial, non-surgial and outpatients, for eah faility. Administrative and linial data is used to alloate overheads to the three ost enters (OPD, surgial and non-surgial). Physial measures and appropriate alloation keys are used to harge osts to the ost enters. These keys may inlude square footage, diret osts, mileage, lient volume, and number of lighting points and so on. Conlusion Finanial sustainability is ahieved though inome generation (i.e., ost reovery, donor and government ontributions) and ontrol of osts. Most mission hospitals urrently do not know the osts of the servies they provide. Thus, there are no eonomi benhmarks to use to evaluate efforts to ontrol osts; there is no denominator to use to alulate ost reovery for different servies; and there are no empirial data on servie osts that ould be used to approah donors and the Government with requests for funding. Information on ost of servies is ruial for organizations that are serious about improving finanial sustainability. About the writer The writer has worked in Chogoria mission hospital, Nairobi Womens hospital and is urrently a Grants and Compliane Manager in Nigeria, working on a $40 million PEPFAR projet for mission hospitals that offer HIV treatment. He has also served as a CHAK Board member and been involved in more than four osting studies as a senior onsultant. Referenes Homan, Rik K., Caroline West, Sathiyavan, A.K. Ganesh, Sri Priya, P. Duraisamy, Benjamin Franklin, Dr. Sunti Solomon, Chris Castle (2002). Estimating the Cost of Servies at YRGCARE. Unpublished. Mokua M et al (2004). Cost analysis of Essential Curative Health Servies in Churh Health Failities, Christian Health Assoiation of Kenya (CHAK) P.O. Box , Nairobi, KENYA r 10 CHAK Times January - April 2009

10 Credit ontrol and debt reovery Strategies used by Maua Methodist Hospital feature By James Gikemi - CEO, Maua Methodist Hospital Maua Methodist Hospital is owned by the Methodist Churh in Kenya. The Methodist Churh had identified health are as an essential need of the loal ommunity and in 1928, the British Methodist Churh approved the onstrution of a 50-bed hospital at Maua. Sine then, the hospital has grown into a 275-bed faility providing health servies suh as dental, surgial, physiotherapy, palliative, among others. Why redit ontrol unit was started. The Kenyan health setor has undergone many hanges sine independene. Before and immediately after independene, Kenyans were promised free medial are in publi health failities. Medial supplies were always available in mission failities with generous Government support through grants and external donor funding. Following a delining eonomy, the Government began a gradual redution of its grants whih stopped altogether in At the same time, external funds dwindled as donor fatigue set in. The generous grants and donations had with time aused a dependene syndrome within our athment area. When the missionaries eventually pulled out, the hospital found itself in a situation with no money to support servies formerly offered through support by mission partners through donor agenies. This situation fored the management to request the loal ommunity to meet the full ost of medial servies offered to them. This did not go down well with the ommunity who resisted this hange. The hospital therefore began eduating the ommunity to ensure they understood that the subsidized medial are formerly offered by the mission partners ould not be sustained, given that donor and Government support had been withdrawn. The management learned from this experiene that a number of people within the athment area were apable of meeting their healthare expenses but were unwilling to do so as they had got used to highly subsidized servies made possible by missionaries support. The hospital at this point had inurred a huge debt burden whih made it diffiult to meet its overhead and operational osts. It therefore beame neessary for the management to ome up with a system that ould help redue the inreasing debt burden to avoid the hospital s losure. Thus a debt ontrol unit headed by the debts ontroller was established. A ommittee omprising the CEO, Finanial Controller, Chaplain, Nursing Offier In-harge, Internal Auditor, all wards unit In-harges and MCH departmental head was formed to regulate debt with regard to patients admitted at the hospital. The ommittee would identify patients who were unable to pay for medial are and whose expenses needed to be written off as bad debts. Sine 1999, the hospital has been working to make itself sustainable though redution of general debts from 30 per ent to per ent and improve ash payment and NHIF over. Debt ontrol strategies Among the strategies developed by the hospital to ontrol inpatient debt are: (1) All admissions are required to pay Ksh4,000 for surgial patients and Ksh3,000 for other wards. Those unable to pay are onsidered for transfer to a Government hospital one their medial ondition has stabilised. (2) Red flags and home visits: Patients who are unable to pay a deposit for admission at the out-patient unit are onsidered as red flags after taking their soial and eonomi history. When a patient s soial and eonomi history is determined as poor, the ase is alled a red flag and a home visit is done to alert the relatives. Inpatients are required to pay turn to page 12 CHAK Times January - April

11 ...ontinued from page 11 MAUA METHODIST HOSPITAL DEBT CONTROL MEASURES FLOW CHART OBJECTIVE Have as many apatients as possible pay their hospital bills in ash, NHIF or institutional invoie STEP I OPD 1 ST day during admission proess demand full deposit. Treat as OPD if not very sik aommodate to bring money the following day. Transfer to GH if money is not paid or institutional ommittal. -Admit -Give Estimated ont -Give estimate days. -Full guarantors form -Inform or progressive payment Do not admit if not very sik Aommodate for transfer of very sik Ask for full deposit to stop transfer. STEP II WARD DAY 1-5 TO DOD Constantly demand progressive payment. Transfer non payers Do home visits Daily ash paid by IP report Regular provisional statement and disuss with patient and relatives. Reommended for transfer but not affeted poor and destitute ase List be produed daily -assign different senior offiers to Interview ontinuously - Involve hiefs -Introdue NHIF -Home visits -Give them enouragement by reminding of ash disounts -Introdue NHIF to them. -List to be disussed with in-harge -ase with>30,000/= list for HMT weekly. -Introdue NHIF ASSESS THE OUTCOME= CASH SUMMARY Able but refusing to pay STEP III DISCHRAGES Daily aged shedule Pester them to pay the bills Cluster tem in Days 0-3 day 4-6days 7-10days 11days inform HMT. Value diffiult ases>kshs.30,000 ategory able but refusing to pay. Poor and destitute Not visited/known Poor and destitute Willing and able to pay -Demand payment daily list involve the hief. Use different People to talk to them i.e. w i/ debts ontroller Aountant, I.A Matron, CEO, et Introdue NHIF Enourage them to pay and get 5% ash disount- Introdue NHIF Look for somebody to either be responsible -Home visit -Enourage hief to involve the ommunity in harambee -look for NGO to support e.g. hurh et -NHIF information ASSESS THE OUTCOME =CASH SUMMARY STEP IV INVOCING PROCEDURE Home visit form fully filled by ward debt lerk and disussed with debts ontroller. Shedule of proposed ases to be disussed by debt lerk, w i/ and debts ontroller, for invoiing the following day. Case with>30,000 refer to HMT weekly and 1 reommendations Chiefs letter and sworn affidavit to be provided Cases approved to be signed by debts ontroller or aountant. turn to page CHAK Times January - April 2009

12 ...ontinued from page 12 their bills progressively as they ontinue with treatment. A red flag ase is identified using the following pointers: u When the patient is not visited on the first, seond to the third day. u When the patient was bought to the hospital by a good Samaritan u When the progressive payment is not honoured as agreed upon u When the patient or relatives indiate they intend to organize a harambee to pay the hospital bill u When the patient is an RTA ase and the owner of the vehile is expeted to pay the bill, and has ommitted himself/herself in writing. In all the above ases home visit is done to establish the truth on the ground. The patient is also onsidered for transfer to a Government hospital. The red flag and home visit strategy is able to ontrol debt at the soure. Under this strategy, the hospital is able to filter patients into various groups suh as: u Those to be transferred to a general hospital u Those to treat and wait for payment before release u Those to be allowed to pay a portion of the bill with the differene being paid as per agreement written by a lawyer. u Those to treat as bad debt abinitial. u Those to keep in the ward till payment is made in full. This is espeially in ases where the family has the means but is refusing to pay. u When to involve the provinial administration, the hurh or relatives. (3) Ward interview The hospital has employed a debts ontrol lerk for eah ward. The lerk is usually in the ward during visiting hours to interview speifi relatives on the progress of payment regarding partiular patients. Before the visiting hours, the lerk interviews the patient to ompare the two versions of the story to ensure the proper deision is made with The red flag and home visit strategy ontrols debt at the soure regard to the patient. (4) Involvement of hurh pastors, hief or assistant hiefs. Where the information is very lear regarding the patient, the hospital may involve the pastor or the provinial administration i.e. assistant hief, hief or Distrit Offier as need be. (5) Transfer to a general hospital. Those not able to pay their medial bills are transferred to a Government hospital to ontinue treatment. Suh transfers are done twie a week i.e. Thursdays and Tuesdays and have ontinued sine (6) The NHIF self-employed registration The hospital has been struggling to mobilize the ommunity to enroll in NHIF sine We thank the Almighty God beause the Government has supported this effort and MMH has a omprehensive over. In view of this, every patient who is released on an invoie has to register with the NHIF self-employed sheme. The hospital has set aside a vehile and prepared a shedule in order to ondut NHIF enrollment within its athment. We aim to register over 70 per ent of the eligible households in our athment area in the next three years. Open days The hospital organizes regular open days to ultivate loyalty within the loal ommunity. The ommunity is also updated on servies offered by the hospital. Cliniians in the athment area are involved in organising the open days, hene forging loser working relationships. Interdenominational open days are also held and hurhes operating in the athment area involved. The provinial administration is roped in. We have also reahed out to the loal ommunity with the message that: u Medial bills must be paid without fail. turn to page 14 CHAK TIMES issue 31 Call for Artiles The topi for the next issue of CHAK Times is Lifestyle diseases We invite artiles, photographs, experienes and letters from our readers on this subjet. CHAK member health units are also invited to send information about the servies they offer, training ativities, new projets, job vaanies and other developments that they wish to share with the rest of the network. Send your artiles to: The Editor, CHAK Times P.O. Box GPO, Nairobi [email protected] To reah the editor by April 2009 CHAK Times January - April

13 Clients waiting for registration outside the NHIF offie....ontinued from page 13 u Every household needs to register with NHIF (self employment sheme) u Patients must produe an NHIF ard on admission. u Patients who are not enrolled in NHIF must pay a deposit of Ksh20,000. This money should be replenished one Ksh15,000 has been used up. u Patients without an NHIF ard and unable to raise Ksh20,000 within the first two days after admission will be transferred to a government hospital. The HMT reviews these strategies from time to time. Debt ontrol is done through teamwork of admitting liniians, OPD nurses, who have the first ontat with the patients, ward nurses, ward dotors, debt ontrol staff, administration and haplainy, all of who work towards debt redution. Debt reovery strategies In general, debt reovery is major problem in all businesses. At the national level, poor ountries have over the years photo: CHAK photo: Maua Methodist Hospital pleaded with the rih nations to write off their national debts. Maua Methodist Hospital arries a huge debt owed by patients or general debtors whih has aumulated to over Ksh100 million and ontinues to grow by about Ksh2 million monthly. In view of the above, the hospital has employed the following debt reovery strategies: 1) A member of staff has been assigned to follow involved debts as they fall due. All debts should be paid within 90 days. The hospital has also alloated a vehile for this exerise. Area hiefs aompany our staff to the homes of the debtors and where neessary intervenes to ensure the debt is paid. 2) Engaging the servies of lawyers: Durin the proess of invoiing, debtors swear an affidavit, undertaking to pay the entire debt in three months. It is disappointing that over 90 per ent of these debtors do not honour the affidavit. The hospital has engaged the servies of a lawyer to reover the outstanding debt. However, this strategy is yet to bear fruit. 3) Enouraging debtors to organise harambees: During the home visits and ward interviews, some relatives have been enouraged to organise harambees and have been invoied on this strength. Initially, money raised did not reah the hospital, foring MMH to send staff to suh harambees. Challenges Debt ontrol hallenges Admission deposits and guarantee for payment of medial bills: There is a remarkable improvement sine 1999 and the ommunity is fully aware that: u If no deposit is paid upon admission, the patient shall be transferred to a government hospital the following Tuesday or Thursday. Here, hallenges arise if a patient is admitted on Thursday after 11am given that the next transfer day will be the following Tuesday, five days after. u Most patients are bought to the hospital at night and very sik hene it may not be possible to transfer them. Patients are not usually denied treatment. u Most people who aompany the patients allege that they are good Samaritans and not responsible for the bill. u Most patients from marginalised areas allege that they annot afford to pay their bills and want the government or the hurh to pay for their medial expenses. u Illiteray and low levels of eduation within the athment Medial workers attend to a young patient at Maua Methodist Hospital. turn to page CHAK Times January - April 2009

14 Dishonesty among lients is a major hallenge and denies the hospital aurate information needed for deision making population u A belief that mission hospitals are fully supported by the missionaries seen within the hospital ompound, hene there is no need to pay for servies. Ward interview and home visits During admission the patient and the guarantor are expeted to give information to enable informed deision making. Both are required to produe their national identifiation ards but many laim not to have these. As exemplified in the following instanes, information given or reorded on the guarantors form is sometimes inaurate. u A lady who separated with her husband over 10 years ago put his name down as the person footing her bill, yet he did not reognise her as his wife. u An adult who left home 20 years ago and has not been seen sine reorded that the parents were responsible for paying the bill. u In several inidenes, patients have given wrong names and even intentionally heated as regarding their loations, sub-loations and villages and therefore annot be easily traed. u To avoid being transferred to Government hospitals, patients and relatives indiate they are wealthy, only for the hospital to disover they are poor and destitute during visits or after disharge. In summary, dishonesty among lients is a major hallenge and denies the hospital aurate information needed for deision making. responsible for paying the debt but allowed their names to be put in the reords so the patient ould be disharged. u Some debtors have died. u Some debtors are extremely poor. u In some instanes, the hief refuses to assist the hospital reover its debt despite the debtor having property that an be attahed. u Sometimes the ommunity hides the debtor (s). Engagement of lawyers The field debt olletor has ompiled a list of debtors who are in a position to pay but refuse to do so. The HMT has reommended engagement of the lawyer to reover the hospital debts through the ourts. However, the proess of litigation has proved quite tedious. The lawyers have not delivered as expeted, sending a negative message to the ommunity that the only way the hospital an attempt to reover debt is through the provinial administration. Way forward for sustanablity of Churh health falities Mission hospitals played a key role in health provision before independene in developing ountries. Today, Churh health failities are also expeted to ontribute in the ahievement of Millennium Development Goal number five (averting maternal deaths and disability) and millennium goal number one by providing health servies for the world to have healthy and strong workers in order to redue extreme poverty and hunger by Churh health failities must be run as sustainable business entities governed by the priniple of ompetitiveness and able to address the five market fores of Mihael Porter s theory - ompetitors, new entrants, substitutes, suppliers and onsumers. In order to ahieve sustainability, pratial redit ontrol and debt reovery strategies must be developed. Revenue generated needs to be adequate to meet operation osts and improve failities, hene improving servie delivery and attrating and retaining lients. r Debt reovery halleges In 1997, non-payment for hospital servies (debts reovery) was identified as a major hallenge for sustainability. Hene, the Hospital Board asked the Health Management Team to address the issue urgently. Strategies were formulated but the following hallenges are being experiened: Field debt reovery In 1999, the hospital intensified field debt olletion by assigning one vehile and one staff, who worked losely with the provinial administration to reover debt. Debtors shedules were worked on aording to loation. u It was and still is very diffiult to trae the debtors beause many of them give wrong information regarding their identities u Those found in most instanes allege that they are not A board showing patient fees harged by the hospital. CHAK Times January - April

15 The role of missionaries in sustainability AIC Kijabe Hospital whose staff has onsisted of missionaries sine its ineption shares its experiene By Justus Marete - Exeutive Diretor, Kijabe Hospital Historial bakground of Kijabe Hospital On Otober 17, 1895, a mission team arrived at the port of Mombasa from the USA. The team led by young Peter Cameron Sott pressed inland to plant missions and share the gospel. Margaret, Peter s sister, was also part of the group. A few years earlier, Peter had led a team of seven young Christians that inluded his brother, John, into the Congo to share the gospel. John died of malaria within a few months and Peter personally buried him. Peter himself was sik and had to go to England to reuperate. However, God s all for Peter was strong enough to overome extreme diffiulties and ome bak to Afria in His own death at the age of 29, within 14 months of his arrival in Kenya, would ordinarily have disouraged others from venturing into Afria s interior. Sott was a very determined and single-minded man. He is reputed to have walked 2,600 miles in one year during his work 1. His grave stone at Mahakos, Kenya is a reminder of the many missionaries who gave their lives in order to bring the gospel to Afria. With God s help, many missionaries followed soon afterwards and a mission station was established at Kijabe in Kijabe is 2,700 meters above sea level and also above the malarial zones. A small medial faility was started at the station in Over a period of 93 years, the faility has developed to beome A.I.C Kijabe hospital with an inpatient apaity of 260 beds urrently. It is 60 kilometers west of Nairobi in rural Kenya. The bed oupany ranges between 90 per ent and over 100 per ent. The outpatient reeives an average of 300 on regular working days. Medial failities and programmes 1. The hospital runs a growing HIV/AIDS are program that is urrently taking are of 5,400 patients. The staff in this program have developed links with the ommunity so that many work and live in the ommunity. Patients have formed support groups to enourage one another. This model of are has been developed with the tehnial input and expertise of missionary staff speialized in internal mediine and with a vast interest in holisti healthare. 2. The hospital runs a rehabilitation program that is foused on alleviating the suffering of hildren with disabilities. Many with hydroephalus, spina bifida and other deformities reeive surgial interventions that are followed up in linis near their homes spread all over Kenya and in refugee amps in northern Kenya. One of the missionary Front view of the Kijabe Hospital OPD. staff in this program has devoted his entire medial areer to this work and many lives have been transformed in the proess. Myths regarding disabilities have been dispelled. The major portion of osts are defrayed using funds donated by individuals and organizations. 3. There are five Operating rooms that managed to aommodate about 8,400 surgial proedures in Six of our nine surgeons are missionary staff. Apart from the tehnial skills, our missionary staff are able to soure for valuable supplies and equipment that ome to us as donations. 4. Working in the ommunities around us, we have developed neo-natal programs that empower mothers in the reprodutive age to manage their pregnanies better and prepare for safer deliveries in health failities. This preventive healthare is only possible due to donations. 5. Pathology servies: Our laboratories provide pathology servies to more than 40 hospitals that are mostly CHAK member units. A group of pathologists provides this servie throughout the year. Using a donated web amera and software, a pathologist is able to seek a seond opinion from olleagues around the world from his/her desk. Responses ome instantly depending on time zones. More reently, we have aquired omputer software that enables one to speak diretly into a mirophone and produe a written report while working on gross materials instead of hanging gloves frequently. 6. Kijabe Hospital is ommitted to sharing the Good News of Jesus Christ with eah patient in a aring and ompassionate manner. The spiritual health of our staff turn to page CHAK Times January - April 2009

16 ...ontinued from page 16 and patients is ruial. An average of forty patients make a ommitment to invite Jesus Christ into their lives eah month in the hospital. Some of the ativities of the haplainy department inlude daily devotions in the wards and for the general servies staff, Monday morning senior staff devotions, Wednesday morning devotions, Friday and Sunday evening fellowships, Bible studies and prayer meetings held during the week. The haplainy organises outreah ministries in various parts of the ountry and spiritual emphasis week for the staff. Eduation programmes 1. The longest running eduation program is training of high shool graduates in nursing are. Sine the launh of this program in 1980, our shool of nursing has trained more than 700 students. Initially, the faulty was entirely missionary staff. Some of the students eventually beome exellent tutors and the quality of graduates has been maintained at fairly high standards. The setting and maintenane of these standards was possible through selfless servie by missionaries. 2. The hospital aepts medial offier interns for a one year training program from the medial shools. Eah year there are eight positions available and many of the dotors who have passed through these programs have advaned quikly both in the publi servie, hurh health setor and private pratie. Many of our missionary dotor speialists have vast interests in eduation and ontinue links with their home ountry universities and medial failities. In this way, we are able to keep abreast of most reent developments in medial are. 3. Working with Moi University and other government authorities, the hospital initiated a master s level training of dotors in Family mediine after nearly ten years of dialogue. This speialty of mediine has been in the western ountries for many years and it is through the efforts of our missionary partners that it is now in Kenya. 4. Beginning 2007, the hospital has been training registered Community health nurses in providing anesthesia in operating theatres. Given the regional shortage of this adre of staff, this is a major development that has been made possible by the leadership of a missionary staff in the field of anesthesia. We had nine KRCHN graduates with a post graduate Diploma in KRNA in September The seond bath of nine students is due to graduate later this year. 5. Apart from providing HIV/AIDS are to many patients, the hospital reeives many health are workers for short ourses in HIV/AIDS are. Working with the University of Mary land in the USA, we have on going training and tehnial support available to more than 25 health failities in Kenya that are providing HIV/AIDS are. Hospital budget About 85 per ent of hospital operations are finaned using patients fees and a signifiant 15 per ent is omposed of donated servies by our missionary staff. In the year 2007, the human omponent of donated servies was approximately Ksh45,862,080 (573,276 US dollars). Many bring in signifiant amounts of supplies and equipment. By poliy, our apital budget is finaned through donations. Major fixtures suh as staff housing development, theatre equipment and other medial equipment, plants and installations, and major renovations are finaned by friends of our missionary staff and organizations. In this way, we are able to keep our fees low enough so as to reah poor people who would ordinarily find it diffiult to deide to ome to us. Cultural exhange One of the strongest points in having missionary staff with us in Kijabe is the appreiation of ultural diversity and the quik realization that the ommonness that we have as Christians far transends the vast differenes that there are in ultures. Many have ome to realize that diversity and the deliberate building of tolerane of people with different ulture an greatly enrih life. turn to page 20 Theater staff examining a patient (left) while (left) a nurse and a shool of nursing student taking vitals from a patient. CHAK Times January - April

17 Ensuring affordable servies through internal fundraising Lighthouse for Christ Eye Centre, Mombasa, turned hallenges into opportunities by establishing an Appointment Clini to ater for the high-end market while rasing money to fund the operations of the general lini By Emmanuel Mbaga - Nurse, Lighthouse for Christ Eye Centre Introdution Lighthouse for Christ Eye Centre was founded by Dotor Bill Ghrist, an Amerian ophthalmologist in His desire when he moved to Mombasa was to help the needy in the entire oastal region. The vision he worked by was to heal physial and spiritual blindness in the oastal region. All people who ame regardless of their tribe, rae or religious bakground were welome. However, as a haritable organization, finaning was and has remained a real hallenge. At the onset, he sought help from friends and donor organizations who shared the same burden. Psalms 123: 1 whih says Unto thee I lift up my eyes.. was his faith statement. This has remained Lighthouse For Christ s faith statement to date. Evangelism to share the good news about our Lord Jesus Christ and offering exellent speialized eye are are our goals. The ost of servies and dwindling donor funds over time demanded a rethink of how to finane the eye entre servies. To make the founder s dream of making professional eye are aessible and affordable to all who visited the lini a reality, a way to raise more funds had to be sought. Among those who visited the lini inluded a few people who were able and willing to pay for servies reeived albeit on ertain onditions. This offered an exellent opportunity for internal loal fundraising. The appointment or private lini was therefore established in the late 1990s and later reloated to our new faility in 2003 as speial program. Before the onstrution of the new wing, all linial servies were arried out in the old lini building. The new faility was built to improve on servie delivery. The entre is situated in the busy ity of Mombasa. Front view of the appointment lini. available at speifi onvenient times u Providing patients with an opportunity to see dotors of their preferene u Constant demand for the latest ophthalmi servies The new faility had to put into onsideration these hallenges. The Appointment Clini A dediated unit at the entre to serve as appointment lini has been able to serve the busy and no time to waste demanding lients who find it diffiult to join or wait on long queues at the general lini. Sine the introdution of the appointment lini, it has proved to be popular for this group of lients as they are served photo: Lighthouse for Christ Challenges or opportunities? The hallenges faed offered an opportunity to establish the appointment lini. Among suh hallenges were: u Availing adequate privay for lients who needed to see the dotors in the absene of other patients u Catering for busy sheduled patients who were only at onvenient times within the working hours. The new wing is built on the ground floor putting into onsideration the disabled, the blind and the partially blind turn to page CHAK Times January - April 2009

18 ...ontinued from page 18 patients. The neatly arranged flower beds, grass and palm trees on the front view give the entire plae a fine ambiene. The lini is fully furnished with exellent and modernized eye are failities to help provide effiient effetive servie to our lients. A major hallenge with the lini s lientele is the demand for immediate attention and onstant pressure for the latest servies whih are generally ostly. The lients also tend to need personalized attention with visits taking muh more time than with other lients. High demand for servies at the appointment lini has resulted in onstant appraisal of the quality of servies offered photo: Lighthouse for Christ A volunteer dotor examines a patient at Lighthouse for Christ Appointment Clini. to lients at Lighthouse for Christ Eye Care Centre. Although fees harged at this unit are higher than that at general lini, it is muh heaper than most health failities offering eye are servies in the open market. Clients have an added advantage of being able to see their preferred dotor, whether resident or visiting. Servies offered The Appointment Clini offers a wide range of speialized eye are servies from general omplete eye examination, glauoma, diabeti, hypertension, infetions inluding HIV & AIDs, paediatri, squints and atarats evaluation and management among others. Eye servies at the entre are of international standards. Orthoptis and refrative servies whih deals with fousing, position and eye movement assessment is also offered. Optial servies inluding a wide range of spetales are available as are laser surgery and ounseling. Visual field assessments and laboratory servies are all under one roof. The Appointment Clini is open between 8am and 4pm. Clients fix appointments at their onveniene either by telephone or on a walk-in basis. All preliminary evaluations are done before the patient sees his or her preferred dotor. Due to the exellent failities at the lini, examination and basi proedures are all performed under one roof. The patient is afforded adequate time for examination, treatment and disussion of their ondition to their satisfation. This is referred to as lient managed or oriented are. Adequate reading materials are provided and gospel musi played at low volume for both entertainment and evangelism. Benefiiaries Inome from the lini provides muh-needed funds to subsidize the ost of servies provided in the general lini. The Appointment Clini has assisted in raising funds to aid in running of the entire institution. With the rising osts of living, this unit has been able to enhane and sustain the low-fee out patient lini by providing medial and surgial requirements. It has also atered for staff up keep, maintenane of equipment, vehiles and daily overheads without servie fee adjustments. LightHouse for Christ Eye Care Centre has also been able to streth its hand and extend servies to the needy and less privileged in the ommunity during mobile linis and outreah ampaigns. Patients oming from poor ommunities outside the ity are transported to the entre where they are provided with free eye are, surgery and post operative follow up. The inome from the Appointment Clini ontributes signifiantly to the running of the entre and it is onsidered a loal donor. The exellent servies offered together with the aessibility of modern eye are equipments at this new private wing has seen its popularity inrease sine its ineption in The quiet environment and the availability of dotors have also built onfidene in patients. The faility has proved to be helpful to the ommunity in many ways. Apart from patients getting quality servies, the region has been able to aess quality eye are onveniently. Patient attendane has been on the rise to a point that often, one needs to fix an appointment day in advane. The quality of are has over time attrated a large number of orporate lients within the region and now nationally in the past few years. Future plans As dynami as is the pratie of mediine, Lighthouse has plans of expanding and availing more speialized servies within and without the region. An example is a pediatri (Children) turn to page 28 CHAK Times January - April

19 The role of MEDS in sustainability of Churh Health Failities By James Mwenda - Customer Servies Manager - MEDS To sustain, aording to Oxford advaned learners ditionary, is to make something ontinue for some time without beoming less. In this ontext, sustainability has to do with the ability of a hurh health faility to provide enough of what it needs to in order to live or exist. This means meeting the needs of patients, workers and its stakeholders. This is indeed a tall order espeially when one onsiders that most of the failities serve ommunities living in resoure limited settings. It is important to appreiate that donor support to hurh health failities has ontinued to dwindle over time. These failities are faing insurmountable hallenges to remain afloat. Yet, we all appreiate the indispensability of these failities in meeting the immediate health needs of the poor and vulnerable in our soiety. To mitigate this hallenge alls for a paradigm shift, a hange in the mindset of health faility managers. It alls for effiient use and management of the limited resoures available as well as a new approah to resoures mobilization for sustainability. Critial aspets of sustainability revolve around provision of quality essential servies, rational use of mediines, ost effetive souring of supplies and proper management of resoures, inluding human resoures. MEDS was established over two deades ago as an instrument for sustainability of hurh health failities. It has over the years played this role fairly well. In this artile, I shall enumerate the key roles that MEDS has and ontinues to play in its endeavour to support sustainability efforts of mission health failities in Kenya over the last twenty two years. Provision of quality essential servies is the ornerstone of sustainability for any enterprise. Health failities, too, are expeted to provide quality essential healthare. Reeiving quality health are an help a person stay healthy and reover faster when he/she beomes sik. However, we know that often, people do not get high quality health are. A 2004 study of 12 large US ommunities found that just over half (54.9 perent) of people were reeiving the are they needed. But quality means different things to different people. Some people think that getting quality health are means seeing the dotor right away, being treated ourteously by the dotor s staff, or having the dotor spend a lot of time with them. While these things are important to all of us, linial quality of are is even more important. Think of it like this: getting quality health are is like taking your ar to a mehani. The people in the shop an be friendly and listen to your omplaints, but the most important thing is whether they fix the problem with your ar. turn to page 21...ontinued from page 17 On the question of sustainability at AIC Kijabe Hospital Sustaining the signifiant inputs from missionary staffing is a major issue for Kijabe Hospital. If the support that we get were to be withdrawn suddenly, our servies would be redued to very elementary medial are while the training element would be wiped out ompletely at the moment. With this in mind, all stake holders are working towards assuring sustainability of a muh needed servie. Up to the 2002, all of the hospita s onsultants were missionaries. At the end of 2002, the first Kenyan onsultant surgeon started work at Kijabe. Dr. Peter Nthumba had been trained through the Medial internship at Kijabe in 1996 and is therefore able to arry on with similar work ethis and high level of professionalism. Other Kenyans have sine joined the hospital in obstetris and gyneology and internal mediine. We are urrently training medial personnel in plastis and reonstrutive surgery. It is not in the hospital s strategi plan to phase out missionary staffing in the near future. Rather, our plan is to inreasingly reate a balane between loal staffing and expatriate personnel. This later strategy will allow for ontinued diversity in ulture whih is so muh appreiated here. With regard to the material resoures that are available through our partnerships with individual donors and foreign organisations, it is realized that the threat of donor fatigue is real. We are ontinually reminded that no hospital in the world an sustain good quality servies without donations In reognition of this foregoing fat, the hospital plans to hange its strategy on how it gets donations instead of fatoring them out of the equation ompletely. We are therefore exploring the establishment of foundations that an invest and generate non-patient related inome for the hospital in the future. r Referenes. 1. Bela B. Kalumbete, AIC Tanzania. 2. A.I.C Kijabe hospital reports. 3. History of Christianity 20 CHAK Times January - April 2009

20 ...ontinued from page 20 MEDS role in promoting aess to quality health are in Churh health failities Prourement and distribution of life-saving mediines and other supplies needed in health are delivery requires areful planning and management to ensure adequate supply of ommodities. Lak of planning an lead to emergeny situations that esalate osts and risks. MEDS offers a systemati, well oordinated approah to meet health failities demands on a timely basis. MEDS works losely with lients, suppliers and projet partners to ensure that all lients get appropriate pharmaeutials and supplies how, when, and where they need them. Quantifiation In partnership with others, MEDS has been quantifying the needs of the health failities taking into onsideration the disease burden, treatment regimens and buffer requirements to avoid stok outs. Through this elaborate effort, MEDS has been able to ommuniate aurate projetions with suppliers and manufaturers, thereby ensuring prioritization of MEDS orders in the prodution proess as well as timely delivery of stoks. MEDS stok list is reviewed periodially by a formulary ommittee omprising experts in the various health disiplines from hurh health failities, Ministry of Health, medial training institutions and MEDS pharmaists. The MEDS quality ontrol laboratory. Prourement MEDS has a stringent and transparent prourement system that ensures that all produts proured meet internal quality standards. To ahieve this, MEDS has a system of validating suppliers/manufaturers with a key riteria being approval by a stringent regulatory authority. MEDS also visits existing and prospetive suppliers to ensure ompliane with good manufaturing praties. Bulk purhases allow MEDS to enjoy eonomies of sale. The prie benefits realized are always passed to hurh health failities, thereby making MEDS the lowest-ost photo: CHAK MEDS warehouses are built and managed to meet the highest level of standards. supplier in Kenya. Over the years, MEDS has built a strong mutual relationship with the suppliers resulting in low ost of ommodities to the health failities. Quality assurane MEDS does not only rely on the stringent government regulatory authority approvals but also maintains an elaborate quality assurane system that ensures that items are sreened on reeipt and randomly sampled for hemial analysis in the in-house laboratory. Feedbak from users is highly valued as it helps in monitoring quality and satisfation from the health failities. This ensures that only quality produts are proured and distributed to the health failities. Distribution MEDS distribution network overs all parts of Kenya, the Horn of Afria and the Great Lakes Region. This effiient distribution system is realized by use of MEDS vehiles, ontrated transporters and ourier servies. The distribution networks ensure geographial reah to all lients irrespetive of their loation at no extra ost to them. The distribution is based on a pull system. Through this, MEDS has managed to ensure aess to quality mediines and medial supplies to patients through out Kenya and beyond. MEDS door to door poliy ensures that healthare failities are spared the unneessary agony of worrying about when and how the ommodities will reah them and are therefore free to fous on their ore business of attending to patients uninterrupted. Storage and warehousing MEDS warehousing apaity ontinues to expand with inrease in level of operations. The warehouses are built and managed to meet the highest level of standards. All warehouses are managed by highly qualified pharmaeutial speialists. In-built old storage failities have been put in plae to ensure effiient storage of heat sensitive produts. Cold hain is also maintained during transportation of heat sensitive produts. turn to page 22 CHAK Times January - April

21 ...ontinued from page 21 Storage and warehousing is fully omputerized. Metal raks are in plae in all the warehouses to ensure durability and safety of the warehouse staff. The raking system is well organized to ensure quik and onvenient proessing of orders and storage of stoks. Human resoures MEDS has a team of highly qualified and ommitted staff. The staff training and development program is elaborate and inludes ontinuous updates through seminars, university programs and workshops among others. This is done to enhane knowledge, impart new skills, update the staff and hange attitudes or work behaviour, thus empowering them to make informed deisions in delivery of servies to health failities. Training MEDS offers elaborate training programmes to various segments of healthare providers in different aspets of health inluding HIV/AIDS management, health faility management, logistis supply and management, finanial management; health projet management, resoure mobilisation, rational use of drugs, stok management and sound presription praties. In the last three years, MEDS has trained over 4,000 health workers of different adres (dotors, nurses, pharmaeutial tehnologists, linial offiers, and laboratory staff among others) on different subjets inluding HIV/AIDS, malaria, TB, drug use and management, team building, among others. MEDS also delivers NASCOP approved trainings on Voluntary Counselling and testing (VCT), Prevention of Mother To hild Transmission (PMTCT),Compliane and Adherene to ART, Paediatri ART, Home Based Care and ommunity support. Pharmay Assistant Training (PAT) Qualified personnel are neessary for sustainability. MEDS in partnership with Eumenial Pharmaeutial Network (EPN) provided a two-year training for pharmay assistants to fill the human resoure gap in hurh health failities. MEDS was a pioneer in hosting and managing the training for the three East Afrian ountries (Uganda, Tanzania and Kenya). About 163 students graduated from the two year ertifiate ourse. The objetive of the training was to provide hurh health failities with a adre of pharmaeutial personnel whom they ould afford and retain. The staff would have the requisite knowledge, skills and attitudes for the implementation and maintenane of Essential Drugs Shemes (EDS); and the promotion of rational drug use and ultimately improve the quality of health are among the target failities. MEDS, EPN, UNICEF, University of Aberdeen and University of Western Cape (UWC) jointly developed the PAT urriulum. Publiations MEDS provides regular up-to-date drug information to the health failities through quarterly publiations; MEDS Update and Partners in Ation. These publiations omplement training and field servies by providing updates on medial, pharmaeutial and general management information. The publiations are distributed to all MEDS stakeholders at no harge. Both publiations ontinue to empower and update health workers to provide quality healthare to patients. We at MEDS believe that in health there is no substitute to quality and making quality servies and produts a guiding priniple will lead to abundant benefits. The regular updates, field support visits and training programs ontinue to empower staff in hurh health failities for sustainability. Designing priing strategies for health servies The real issue is value not prie - Robert T. Lindgren Priing plays an important role in finanial sustainability of an institution. All profit organizations and many non-profit organizations set pries for their produts or servies. Prie goes by many names and is all around us - you pay rent for your offie; tuition for eduation and a fee to your physiian or dentist; the bank harges you interest for money that you borrow; a seminar failitator harges you an honorarium to tell you how to doument what you do everyday; the prie of an exeutive is a salary; the prie of a salesperson may be a ommission while the prie of a worker is a wage. In our health failities, prie operates as the major determinant of buyer (patient) hoie. Despite the inreased role of non-prie fators in the modern marketing proess, prie remains a ritial element of the marketing mix. It is the only element in the marketing mix that produes revenue as the other elements produe osts. Prie is also one of the most flexible elements of the marketing mix and an be hanged quikly, unlike produt features and hannel ommitments. It is easier for a hospital to hange the prie of its servies than to hange the servies or its loation. The impliation here is that if properly handled, prie an influene the suess of a health faility. Health faility priing and exemption poliies are ritial for ensuring that patients in need of essential drugs and medial supplies reeive them and that the hospital does not deapitalize. These two requirements pull in opposite diretions, reating a onstant tension. Pries, as well as the aompanying poliies with regard to exemptions, are the mehanism by whih the neessary balane is ahieved. turn to page CHAK Times January - April 2009

22 ...ontinued from page 22 Priing strategies Priing for health failities involves two related questions: 1. What type of drug fees should be harged? 2. What should the level of fees be? Type of drug fee Alternatives inlude ourse-of therapy fee, presription fee, item fee, multilevel item fee (prie bands), and viable item fee. These mehanisms an be ompared with respet to the following riteria: a) Impat on presribing praties: Does the fee reate inentives for presribing more drugs or fewer drugs, higherost or lower-ost drugs? b) Impat on patients: Is the fee likely to dissuade patients from buying needed drugs, or does it reate inentives for patients to use drugs more ost effetively? Will patients feel that they have paid a fair prie? ) Ease of olletion and aounting: How easy is it for health staff to alulate the required payment, to give hange, and to keep aurate payment reords? d) Balaning drug osts and revenue: How losely do the fees reeived for individual drugs balane the atual ost of drugs dispensed? Is it easy for hospital administrators to ensure that the olleted funds are suffiient to re-supply the drugs dispensed? The impat of fees on presribing habits depends on whether health staff salaries or bonuses depend on revenue derived from drug fees. Like private pratitioners, government and mission health are providers are likely to presribe more drugs and at higher pries if their inome depends on drug sales. Course- of- therapy fees, multilevel item fees and variable item fees an all differ for individual drugs. In suh instanes, the fees harged to patients an be based on the atual ost of the drug, an assessment of the health impat of the drug, or a ombination of the fators. With this approah, vital drugs an be sold at pries lower than their replaement ost. With the variable item fee, the prie an be based on a fixed perentage mark-up over ost, a variable perentage mark-up, atual ost plus a fixed dispensing fee, or another formula. For example, higher ost drugs or drugs with a greater health impat may have a lower mark-up. It is important to onsider ease of olletion and aountability, beause administrative and aountability problems are major onstraints on the suess of mission health failities. Unfortunately, ourse-of-therapy and presription fees whih are the easiest to implement and are in some respets the most equitable make it diffiulty to ensure that revenues olleted are suffiient to pay for drugs dispensed. One approah is to begin with fees that are easy to implement and then move to more omplex but finanially sustaining fees as the faility evolves. More omplex fees require staff training and more sophistiated aounting systems, whih an be implemented over time. The sustainability of Churh Health Failities largely depends on sound management of the limited resoures available and willingness of all stakeholders to embrae a paradigm shift in line with hanging times and realities Level of Drug Fee What level of fee is appropriate? With an item fee, for example, should the fee be equivalent to Ksh20 per item, Ksh25 per item or Ksh30 per item? If the system is first introdued in rural health failities, pries an be set on the lower side, and patient response an be monitored. Pries an be adjusted aordingly during first year or two, before moving to the next level. In determining priing strategies, it must be remembered that the sustainability of the faility depends on overing all or some of the osts of the system. The objetive is not to maximize profits but to maximize servie delivery at a ertain basi quality level. Willingness to pay is as important as ost data in determining drug pries. Priing deisions must be made in full reognition of the tension between ost-reovery objetives and soial poliies regarding aess to are. At the same time, administrative requirements for olleting fees must be onsidered. Most experienes in pharmaeutial ost reovery suggest that when equity oriented exemption poliies and administrative realities are onsidered, it is often a struggle to reover the full ost of drugs and delivery. Cost reovery is determined ultimately by patients willingness and ability to pay for drugs and not by a poliy that mandates a speified mark-up. Finanial sustainability of a health faility drug fund depends on keeping drug fee in line with hanges in the ost of drugs. During periods of high loal inflation and foreign exhange flutuations, frequent prie adjustments may be required. Fee inrement may present a short term hardship to patients but unless it is ertain that the government or a donor will finane the shortfall, suh inreases are imperative for the survival of the health faility. In onlusion, it has been demonstrated that the sustainability of Churh Health Failities largely depends on sound management of the limited resoures and willingness of all stakeholders to embrae a paradigm shift in line with hanging times and realities. r CHAK Times January - April

23 Finaning health are for poor ommunities: The Jamii Bora model By Jak Kinuthia - Jamii Bora Trust Preamble Jamii Bora Trust has been in existene sine November The organization piked the drive to move from a group of women who had been begging on the streets of Nairobi. These women were enouraged by one Mrs Ingrid Munro, who would give to them generously. On retiring from her job, she told the women that she ould no longer afford to give out money as she was now out of employment. However, the women refused to aept this argument. They told Mrs Munro that they regarded her as their mother and had never heard of a mother retiring from motherhood. Faed with this senario, Mrs Munro had to ome up with a way of assisting the women. She advised them to save at least ten shillings everyday from the money they got after begging. They would eah get double the amount of their savings as a loan payable in fifty weeks to set up businesses. The savings would be used as a safety net if a member ran into finanial diffiulties. The women were advised to form redit groups of five members eah so as to motivate eah other and at as guarantors for members in the same group. They also agreed to reruit other people into the sheme. Health are finaning These women started to save and to borrow as per the arrangement disussed above. However, after a while, some of them started falling bak in their loan repayments. Asked why this was the ase, many of them had a ommon exuse: they or their hildren were sik and had used the loan money to pay for treatment. This presented a serious problem as even those in a position to pay bak would use the same exuse and fail to repay the loan. The solution lay in finding medial insurane for the women. However, given their meagre resoures, no insurane ompany ould aommodate them. The management therefore deided to start an in house medial sheme for the members. At the rate of Ksh1,000 per person per year payable at twenty five shillings inlusive of administrative osts per week, a member and four of their biologial hildren under 18 years would be fully overed for inpatient hospitalization at St Mary s Hospital, Langata, whih agreed to partner with Jamii Bora Trust. The premium has however been raised to Ksh1,200. To date, there are over fifty hospitals partnering with Jamii Bora Trust all over the ountry, most of them mission hospitals. The sheme has reorded phenomenal growth. By the end of 2008, the health sheme had over 200,000) members of Jamii Bora on a voluntary basis. However, all members who benefit from loans are required to enroll in the sheme. The sheme overs all illness inluding surgery and maternity. There is no limit or exlusion on the over. The sheme has thus far been sustained only through the Ksh1,000 premium paid by members. The story of Shadrak Kayian Silipo Shadrak is a bright 20-year-old student from Kisanju in Kajiado Distrit and the fourth born in a family of eight hildren; five boys and three girls. As a 17-year- old high shool, student Shadrak fell sik. His limbs began to swell and he got very weak. His parents were devastated when they were informed that the boy had a serious heart disease and his only hane of survival was an expensive heart surgery that would ost over Ksh200,000. Being poor, they saw no hope for their beloved son. However, they realized that their health over in Jamii Bora would over the ost of the operation at Kenyatta National Hospital. They ould not believe it when the operation was suessfully done and Jamii Bora paid the entire bill. Today, Shadrak is healthy again. His parents and the entire ommunity are grateful that he is alive. Upon ompleting high shool, Shadrak sored very good grades and has been aepted to Medial Shool at the University. We are grateful to the founder Trustee Mrs Ingrid Munro for her vision, sarifie, ommitment and hard work that saw an idea grow rapidly from humble beginnings to beome a soure of hope, support and health are assurane for thousands of poor Kenyan families. The Jamii Bora experiene indiates that soial health insurane an be a sustainable mehanism for failitating aess to quality health are for poor ommunities. r The Jamii Bora sheme overs all illnesses inluding surgery, as well as maternity servies. 24 CHAK Times January - April 2009

24 The role of ICT in sustainability Lessons from PCEA Kikuyu Hospital By James M.Wanjau - ICT Manager, Kikuyu Hospital Introdution Information Tehnology is redited with introduing many novel onepts into our lives. Rereation and entertainment are now through Internet. Multimedia, virtual reality and 3D graphis have taken up their roles as eduation and entertainment providers. Information Tehnology has also redued the neessity of going to the offie to work, bringing about onepts like Small Offie Home Offie (SOHO). It has also redued the need to travel through onepts like net meetings and video onferening. Through e-ommere, it is now possible to do business over the Internet. Urban and rural populations, elite and nonelite setions of soiety ontinue to benefit from IT. The goal of Information and Communiation Tehnology (ICT) in a modern health are organization is to find sustainable ICT solutions for the health setor. The starting point is a reative and partiipative development of a vision for hospital and identifiation of future patient needs. A key question here is: what are the urrent and future information and ommuniation needs of patients, dotors, nurses, liniians, surgeons, e.t.. and how an we find more sustainable solutions to meet these needs? Sustainability riteria inlude dematerialization, integration of funtions, modular, upgradeable ICT systems/servies/ produts or the redution of soial exlusion in aess to information. The ICT solutions should support day-to-day proesses in hospitals, the healing proess, the well-being of ICT solutions should support day-to-day proesses in hospitals, the healing proess, the well-being of patients and redue osts for providers and users patients and redue osts for providers and users. This artile disusses how tehnology, partiularly ICT, has hanged the lives of people and made work more fulfilling and enjoyable in the health setor. Impat of ICT on health Health servies touh everybody and hene should be given priority. Computer-based patient reords may improve the availability of individual medial histories for deision-making by authorized health are providers and redue osts. The PCEA Kikuyu Hospital ICT projet began in The projet has helped pharmaists, nurses, ashiers, billing lerks, and other hospital staff redue paper work and introdue a tehnology oriented reporting struture. The following are some of the benefits that the staff and ommunity surrounding Kikuyu hospital have derived from the omputerization of health servies. Benefits of ICT E n h a n e d p a t i e n t s r e o r d s management Management of health reords has been signifiantly enhaned by use of ICT and other underlying tehnologies. Retrieval and arhiving of patient health reords has also been modernized to suit urrent health reord needs. This has been made possible through use of databases and health systems that assist in gathering and storing patients turn to page 26...ontinued from page 7 who is familiar with the loal medial setup in the faility. Sine the suess of the ommittee depends on him to a great extent, he should be ommitted and apable of motivating the other members. The main duty of this ommittee is to establish, update and popularize a list of mediine approved for use in the health faility. This list whih is usually alled the Essential Mediines List (EML) should be prepared by onsensus. The main riteria of inlusion of a drug in this list should be its effiay, safety, availability and ost. The work of the MTC whose seretary is usually the pharmay in-harge inludes getting information related to this inlusion riteria so that deisions are based on fats and not personal opinions or hearsay. Other tasks of the MTC are to: u Establish, update and popularize a standard way of treating ommon diseases. This is also referred to as treatment protools or standard treatment guidelines. They assist liniians to harmonize the way they treat ommon onditions, usually using mediines in the essential mediines list. u Organize eduational ativities targeting health workers, patients and the ommunity. u Regulate the ativities of medial representatives to ensure only wholesome drug information is passed to liniians u Detet, investigate and doument mediation errors and adverse drug reations. r CHAK Times January - April

25 ...ontinued from page 25 photo: CHAK reords from various speialties offered in the hospital. Our patients no longer need to arry with them the small manually prepared ard previously used to retrieve their health reords. Use of ICT has made it possible to walk in and out of Kikuyu Hospital without paper douments being used to retrieve or update the patients reords. Keeping trak of the number of patients who visit the faility has never been easier. Numerous reports are generated from the health system for a variety of users and onsumers of health information. This has been made possible by the way the staff and patients of Kikuyu Hospital have embraed this tehnology and made it part of their lives. Patient appointments Appointments for patients are now easier to fix and reshedule. Patients are now given appointments based on availability of dotors or surgeons as well as the required failities in ase of an operation or speialized servie. The reords staff are able to generate appointment shedules for dotors way ahead of the due date to allow for ompletion of prior arrangements neessary before a patient s arrival. Patients appointments an be resheduled with ease through use of integrated tehnologies in ICT. Stok management Through use of ICT, stok management, stok ontrols on usage and aountability have signifiantly been enhaned. Various ontrol measures have been put in plae to ub misuse of valuable inventory (drugs and surgial) and also keep a reord of onsumption. The use of an eletroni inventory system has saved the hospital huge losses resulting from drugs and other stoks disappearing from our stores. Use of ICT has also failitated smooth running of stores and ut down on staffing needs of the hospital. Patient diagnosis history We now are able to keep trak of patients diagnosis history without muh trouble. The ICT system in plae is able to keep a reord of the diagnosis per episode of treatment and also the treatment reeived for that visit. This has been made possible by a motivated team who update suh reords daily and produe reports needed by various health institutions for purposes of statistial analysis. Patient billing Generating bills for patients admitted in our faility is faster, aurate and time saving for our patients guarantors and aounts personnel among other stakeholders. This is made possible by use of the Integra health system that is in plae. The use of ICT systems has failitated sharing of information and improved on deision making proesses. Information dissemination and feedbak from patients and staff has been baked up by use of other support tools like The ICT system in plae is able to keep a reord of the diagnosis per episode of treatment and also the treatment reeived for that visit. intranet and internet servies. This has enhaned information flow within and without of PCEA Kikuyu Hospital. Cash flow management Sine ICT has failitated easy and effiient ash management, the need for extra time to proess ash flow statements has been redued and the proess simplified. The finane department an quikly determine how muh ash is available for use. This has also enabled the hospital management to plan ahead and make projetions about future ash needs of the hospital. Finanial statements (Books of Aounts) Preparation of finanial statements is now simplified beause almost all the business proesses (reeiving ash, banking, payments, debtors and reditors management among others) have been omputerized, thus minimizing the amount of time required to generate reports for management and audit review. The system keeps trak of all transations arried out within the aounting period and generates reports as neessary. The hallenges of ICT Despite the numerous gains that ICT has brought in the health are setor, there are several hallenges that aompany this tehnology. Kikuyu Hospital has had its share of these hallenges. Hardware and software requirements The overall ost of equipping the hospital with ICT hardware and software has been one of the biggest hallenges that the hospital management enountered. The ost of hardware and turn to page CHAK Times January - April 2009

26 ...ontinued from page 26 software in last deade was punitive for the hospital. This hallenge was overome through donations from well wishers and friends of Kikuyu Hospital in the USA. Initial osts were met through onsolidated efforts of various donors. Staff training and resistane to hange Before introdution of ICT in Kikuyu Hospital, the hospital was running its business proesses manually and had all ategories of staff. There was therefore need to identify ore areas that needed immediate omputerization. Staff were also trained to failitate smooth implementation of the ICT projet. This hange was met with resistane from staff other stakeholders who feared they would lose their jobs and business opportunities. This hallenge was however overome through disussions and onsultations with the affeted parties so as to enourage, reassure and onvine them of the benefits of ICT in the hospital setup. The management worked hard to sell the idea that ICT would not endanger jobs but would improve servie provision, effiieny and produtivity. Stakeholders were also informed that gains from ICT would be evident with time. Software use and maintenane The implementation of a health information system and use of the same are two distint ativities that need to be addressed differently in order to ahieve the desired results and reoup investment within a reasonable time. Putting to proper use the available ICT resoures an be of great assistane to a hospital and to the ommunity being served. Users feedbak and management follow up on implementation is paramount if any ICT system is to ahieve its stated objetives and ensure the investment is benefiial. Ensuring optimal use of the ICT system took some time before the gains were realized beause of un-oordinated implementation and lak of proper follow up on various hallenges and short omings that arose one the system was in plae. The software vendor and hospital management ould not immediately establish the real ause of slow implementation of the ICT projet and subsequent delays in ahieving the desired results within the stated time. Software upgrades to aommodate new features and hanging needs of a hospital is a neessity to any institution that has embraed ICT as means of enhaning servie delivery. This has been so for Kikuyu Hospital. The hospital through the ICT department has failitated numerous hanges to the health system in plae in order to meet our urrent needs. A few hallenges have been enountered inluding below standard support servies from the vendor, lak of a feedbak mehanism from the end users, lak of proper training for support staff, and un-oordinated dissemination of the demands of a growing institution. These among other hallenges also ontribute to delayed modernization of health systems in the health setor. Users feedbak is ritial as it failitates the neessary hanges that are vital for an effetive and effiient system. The future of ICT in health are How an ICT improve health are? u Hospital management u Equipment traking u Patient traking u ICT training and support for hospital personnel u Reorganization of proesses u Patient data u Interoperability of patient data / eletroni health reords u Privay and ownership u Health information systems u Telemediine and remote health monitoring u Virtual dotors u Patient orientation of medial are Users feedbak is ritial as it failitates the neessary hanges that are vital for an effetive and effiient system Where do we want to go? ICT ontributes to the quality and effiieny of healthare delivery. Afria in General and Kenya in partiular needs to pool its resoures to develop advaned ICT whih will: u Halt the rising ost of healthare without ompromising quality and effiieny u Inrease the quality of are and save lives through optimized treatments, fewer medial errors and prevention and predition of diseases u Failitate better management of hroni diseases and transfer of knowledge to linial pratie u Lead to safer drugs and medial devies u Enable early warning and improved management of large-sale health rises through better risk predition, assessment and management u Bridge the gap between linial researh and medial pratie through better ollaboration between the pharmaeutial industry, healthare IT industry, aademi institutions and healthare providers u Develop Afria s exellene in the use of information systems in biomediine and moleular mediine u Boost the ehealth market and reinfore Afria s ehealth industry by making Afria more attrative for researh in related industries, inluding the pharmaeutial setor. How do we get there? While the global ehealth industry is growing, Afria turn to page 28 CHAK Times January - April

27 ...ontinued from page 27 is fragmented into various markets. Overoming this fragmentation will give Afrian industry the eonomies of sale it needs to grow, and will bring greater health benefits to all Afrians. The idea is to fous on the essential work that has to be done at an Afrian level and to pool Afria s resoures together. The aim is to bring together universities, researh institutions, small and large ompanies and governmental organizations aross Afria into strategi, ross-border and interdisiplinary researh projets. Afria will fous ation on three speifi aspets of e-health systems: u Personal Health Systems Personal Health Systems (PHS) offer the means to follow patients health using wearable, portable or implantable systems, thus enabling them to live a more normal life. These PHS are used by patients in their homes, workplaes or on the move and are onneted to hospitals or are entres via telemediine links. They provide health professionals with omprehensive monitoring and diagnosti data, helping them to make more aurate deisions and offer more effetive are to their patients. This PHS is ahieved by ombining several ICTs suh as biomedial sensors, miro and nano systems, mobile and wireless ommuniation, user interfaes and intelligent signal proessing and knowledge management. They ombine the monitoring of health parameters as diverse as vital body signs and biohemial markers and the patients soial and environmental ontext with expert biomedial knowledge to diagnose, treat or manage diseases effiiently within the patient s preferred environment. The fous is on the provision of high quality, personalized are through better use of the available resoures. Partiular attention will be paid to the interoperability with hospital information systems and with eletroni medial reords aross multilingual environments in Afria. u Patient safety and risk assessment Innovative ICT solutions an lead to safer surgery through improved training and omputer-aided surgial interventions. This involves modeling, simulation and visualization of surgeries as well as developing realisti models of tissues and organs. The tools will also help with planning and prediting the outome of operations. Integrated medial databases will aggregate linial information to enable health professionals to predit, detet, and monitor health problems. Linking eletroni health reords with linial researh information systems is essential to ahieve this objetive. Systems for the early detetion of publi health risks will use innovative data analysis tehniques suh as text mining and free text interpretation. Muh of this information an be retrieved from the media, but audio and video information will have to be onverted into searhable information soures. u Virtual Physiologial Human The Virtual Physiologial Human will revolutionize the way health knowledge is produed, stored and managed as well as the way healthare is urrently delivered. The VPH seeks to translate all funtions of the human body into a oherent set of multi-sale omputer models. The modeling sale ould span from the whole body down to the ells and the proteins they synthesize. The VPH framework will provide ICT tools for developing patientspeifi omputer-based models and simulations using speifi patient data allowing for personalized and preditive healthare. These multi-sale models will be used to develop integrative approahes to predit the risk of developing a disease and then diagnose and treat it. During drug development, these model organs ould be used to assess the effet of drugs on speifi populations. Results will inlude personalized disease predition, early diagnosis, better surgery planning and training and a better understanding of the link between genes, disease and treatment. The preditive models will signifiantly improve the diagnosis, treatment and monitoring of the patients. Collaborative efforts are needed in order to ahieve the desired tehnologial development in health are industry that will failitate some of the issues raised in this artile and make these issues a reality and a living testimony of what is ahievable via ICT tehnology in today s world....ontinued from page 19 speialized unit whose establishment is already in progress with staff already being trained. Other targeted speialized servies are diabeti speial linis and ouloplasti linis. Conlusion and aknowledgment Given the urrent trend in limited disposable funds among donor organizations oupled up with inreasing osts of medial servies, haritable failities have to identify ways to sustain their servies. Poverty within the ommunities we serve has made matters worse. Clever ways of getting those who an afford medial servies to share with the poor are urgently needed. For LightHouse for Christ, the appointment lini has offered a good solution. Although not the only solution, the lini has played a useful role in fundraising to meet the osts of the institution. It is our hope that it will ontinue to provide enough resoures for the lini to be self sustaining. We appreiate and aknowledge the great and unique role played by missionary Dr. Roger DeHaven, Board of Diretors, Mission Diretor Reverend Timothy Ghrist, Medial Diretor Dr. Ibrahim Matende, and entire Lighthouse staff that jointly and supportively makes the lini a wonderful and professional work plae. r r 28 CHAK Times January - April 2009

28 The business of health are Upper Hill Eye & Laser Centre shares its experiene By Dr Kibata Githeko - Eye Surgeon & Consultant Ophthalmologist I one read that in business you must never ignore your ustomer and ompetitor. This wisdom applies if one takes health are provision as a business. Health are that does not make business sense may never progress. Every hospital has fixed osts that must be paid irrespetive of the number of patients presenting to the faility. The ommon approah is to look for donors to provide finanial support to enable a faility to meet its expenses. However, this reates dependeny and ultimately, the faility engages in programs that are determined by donors and not their ustomers. In this senario, the programs quikly ollapse one donor funding ends. This artile explores the business model adopted by Upper Hill Eye & Laser Centre (UHEAL) in order to make world lass eye are available and affordable. The eye entre is situated in Upper Hill Medial Centre, Ralph Bunhe Road, Nairobi and onsists of two onsulting rooms, a diagnosti entre with modern eye equipment and a fully equipped operating room fitted to handle the most ompliated eye surgeries. The UHEAL hopes to roll out an outreah program targeting patients with diabeti eye disease. The objetives of the program are to address existing barriers to are namely: 1. Ignorane among the patients and health are givers on the devastating effets that diabetes has on the eyes 2. Distane to enters that have both the equipment and human resoures neessary to deal with diabeti eye disease. 3. Cost of travel and speialized eye are. 4. Unavailability of laser equipment that is ritial in the management of diabeti eye disease. By providing a mobile eye van equipped with modern laser mahines, we will be able to visit any diabeti lini in the ountry and offer laser eye treatment immediately to any patients diagnosed with advaned diabeti eye disease. However, this servie annot be pried at more than $3 onsidering that over 50 per ent of the working Kenyan population earns less than a dollar a day. This introdues the hallenge of how to ensure a return on the investment and sustainability. To ahieve both of the above, an assessment of the ustomer was done, keeping in mind that in any business, the ustomer is king. One must understand who the ustomer is. It beame apparent that it was not only patients who needed the servies but also other eye dotors needed to use the modern equipment It was realized that whereas there were many diabetis living on less than one dollar a day, a signifiant number was able and willing to pay a premium for quality, world lass eye are. The hallenge was how to apture this latter group of ustomers in suffiient numbers to generate enough inome to subsidise the outreah program. To ahieve this, an analysis of the ompetition as arried out. There was need to be better than the ompetition in order to attrat lients with the ability and willingness to pay. In doing this, it beame lear what equipment and servies were needed. Thus UHEAL was born. The entre aims to be as well equipped as any in India or South Afria, whih are our immediate ompetitors in terms of world lass eye are. One a ustomer analysis was undertaken, it also beame apparent that it was not only patients who needed servies. Other eye dotors needed the modern equipment for their use. As a result, a deision was made to open the UHEAL eye theatre for use by other eye dotors for a fee. The dotors an also aess other equipment available at the eye lini suh as retinal lasers. In analysing the ustomer base, it is important to onsider whether to offer a differential servie and harge a premium for it. For example, most banks have some form of exlusive banking longer banking hours, personalized ustomer are and tea on the house - for whih many ustomers willingly pay more. It is important to understand the different needs of ustomers and aim to meet as many of them as possible. The other strategy adopted by the entre is to speialize in a ertain aspet of eye are and be among the best if not the best in the region in that partiular aspet. By doing so, the entre is assured of a onstant flow of referral patients. The UHEAL is a for profit organization. It is therefore paramount that it remains profitable if it hopes to provide this world lass eye are to those that are not able to ome to Nairobi or/and annot afford to pay the fees harged at the eye entre. The lini is set up on a solid business plan with lear targets for eah of the inome lines. However, it is ruial in all this to determine what God s all is. Just as He has a all on individuals, He will also have a all on institutions. The bible is lear that when a mans ways please the Lord, He makes even his enemies at peae with him. God s all must be sought after and pursued even at a orporate level. We must seek to multiply our talents in doing the work of God. r CHAK Times January - April

29 update Blending Christianity, ulture and health Over 300 youths graduate from the Methodist Churh male medial irumision programme By Dr Samuel Mwenda - General Seretary, CHAK The Kaaga Synod of the Methodist Churh in Kenya held a olourful graduation eremony for 342 young men of integrity on Deember 19, The youths undertook a three week programme involving safe male medial irumision and training in essential life skills at the Kaaga Boys High Shool in Meru. This was the fourth suh event and was graed by Churh leaders, Government representatives, politiians and partners. The ommissioning devotion was delivered by the retired Presiding Bishop of the Methodist Churh in Kenya Bishop, Dr Lawi Imathiu, while the Guest of Honour was CHAK General Seretary, Dr Samuel Mwenda. The event was also attended by thousands of relatives, friends and Christians. The programme has witnessed the transition and empowerment of more than 2,000 young men sine its ineption. The Methodist Churh, Kaaga Synod established this annual ativity as part of its Boy Child Development Programme. The rite of passage blends Christianity with health and the positive aspets of the Meru ommunity s ulture. The programme targets to empower young boys during the ruial transition from hildhood to teenage and adolesene. The three-week residential programme enompasses surgial irumision by health workers, eduation on HIV prevention, reprodutive health, hallenges in adolesene, dangers of drug abuse, positive aspets of the Meru ulture and Christian values. The boys are also ounseled on the value of good eduation and the need to beome responsible itizens. The event takes plae during the Deember holiday, whih is the longest in the shools alendar, and is onduted through a dynami partnership between the Methodist Churh led by Kaaga Synod Bishop Rev. William Muriuki, Kaaga High Shool teahers and staff, Meru Distrit Hospital staff, Provinial Administration and the private health are providers. Retired Presiding Bishop of the Methodist Churh in Kenya, Dr Imathiu, delivered the ommissioning message based on the biblial passage of Joshua hapter one. He informed the graduands that they were being sent out into the world to be leaders of today and tomorrow and advised them to stand firm like Joshua. Be strong and ourageous. Do not be terrified, do not be disouraged, for the Lord your God will be with you wherever you go. (Joshua 1:9). He hallenged the youths to always aim high in their aademis and life aspirations and advised them to put God first if they were to beome suessful. photo: CHAK CHAK General Seretary Dr Mwenda presents a ertifiate to one of the young men who graduated from the male medial irumision programme. Do not let the Book of the Law depart from your mouth; meditate on it day and night. (John 1:8). All the boys had also suessfully undergone sarament lasses. CHAK General Seretary Dr Mwenda delivered the key note address. He ommended the Methodist Churh, Kaaga Synod for taking leadership in the development and implementation of the boy hild development programme whih blends Christian values with health promotion and positive aspets of Afrian ulture. He also applauded the effetive partnership between the Churh, Government, politial leaders, eduation institution and ommunity. Dr Mwenda noted that the youths spent three weeks in selusion with the first week involving safe surgial irumision and healing and the remaining two weeks intensive teahing, mentorship and ounseling. He ommended the Churh for taking the lead in empowering the boy hild and laying a strong foundation for today and the future. He reported that the Government had reently launhed a National Poliy on Male Cirumision whose intention was to provide a broad framework for the integration of male irumision into existing HIV prevention programmes. The Kenya AIDS Indiator Survey (KAIS) results of 2007 published in 2008 had learly shown that safe male irumision had a signifiant impat in HIV transmission redution. The poliy therefore reommended safe male medial irumision to be added as another prevention strategy to redue the inidene of HIV. turn to page CHAK Times January - April 2009

30 update...ontinued from page 30 Dr Mwenda noted that the Poliy that has just been released endorsed the good work that the Methodist Churh was doing and thanked the Churh for this visionary leadership. The Male Cirumision Programme of Kaaga Synod develops young boys into Men of Honour and Integrity and provides them with ritial life skills. In addition, it empowers and mentors them to beome responsible itizens and Christians of high moral values. The young men are also enouraged to reognize their God-given leadership skills and hallenged to begin applying those skills immediately. Eah graduant was issued with a Certifiate of Reognition following ompletion of the programme. Congratulating the youths, Dr Mwenda advised them to take responsibility for leadership wherever they went and hallenged them to always stand out as men of honour and integrity. He onluded by giving them a passage from the Bible that teahes us to live photo: CHAK The graduands queue to take their seats during the eremony. as hildren of light. Ephesians 4:17-5:15 Be imitators of God, therefore, as dearly loved hildren and live a life of love, just as Christ loved us and gave himself up for us as a fragrant offering and sarifie to God...Be very areful, then, how you live not as unwise but as wise, making the most of every opportunity, beause the days are evil. Therefore do not be foolish, but understand what the Lord s will is. r The National Poliy on Male Cirumision Purpose To provide a framework for safe, aessible and sustainable male irumision servies Guiding priniples u To ensure that male irumision is performed by well trained pratitioners under safe onditions u To ensure that male irumision is promoted and delivered to males of all ages in a manner that is ulturally sensitive to minimize stigma u To ensure that male irumision does not replae other known effetive HIV prevention methods u To ensure that ommunity and individual eduation programmes provide suffiient and orret information on the partial protetion provided by male irumision and the ontinuing need for other HIV and sexually transmitted infetion prevention measures u A male Cirumision Taskfore has been appointed by the MOH/NASCOP to advise the ountry on the management of integrated reprodutive and sexual health and HIV prevention programmes providing male irumision servies CHAG offiials on learning visit to Kenya By Mike Mugweru - Afria CHAs Platform Senior staff from the Christian Health Assoiation of Ghana (CHAG) paid CHAK a visit on Deember 1 and 2, 2008, to learn appliable praties in health information systems, health finaning, human resoure development and the support given by CHAK Seretariat to its membership. The team omprising the CHAG Exeutive Diretor Philibert Kankye and tehnial adviser Charles Gerhardt were making a brief stop-over in Nairobi on their way bak to Ghana after attending a onferene in Maputo. CHAK General Seretary Dr Mwenda briefed the CHAG team about the history of CHAK and how it urrently relates to its member health units. The guests were also taken on a tour of the new CHAK Guest House & Conferene Centre. The team sought to know the fators that had led to the fast growth of the CHAK network. Dr Mwenda informed them that CHAK members benefitted from trainings in governane and tehnial health issues, health setor updates, networking opportunities, dispensary kits from the entral Government, advoay, among others. The guests were informed that CHAK members also reeived ommodities suh as vaines, mosquito nets and drugs from the entral Government. Mission health failities ould also purhase drugs from MEDS at reasonable pries. In-kind donations from the Government to protestant hurhes health failities were also given on reommendation from CHAK. On the other hand, owning hurhes relied on CHAK in engaging the Government as CHAK had the wherewithal to bring together heads of hurhes, senior Government offiials, politiians and tehnorats to disuss issues relevant to faith based health servies. CHAK in turn relied on the hurhes to mobilize their health units. The CHAG team had sought to know how CHAK justifies turn to page 32 CHAK Times January - April

31 update CHAK staff attend planning and team building retreat By Anne Mbugua - CHAK Seretariat CHAK staff took four days off from their usual duties to attend the annual planning and team building retreat. The Seretariat staff led by General Seretary Dr Samuel Mwenda travelled to the Sarova Shaba resort in the arid eastern part of the ountry to review the year that was and plan for the year ahead. The retreat whih was held on January 14-17, 2009, saw CHAK staff deliberate on the various programmes and projets of the organization in a bid to enhane synergy in the New Year and take stok of the ahievements and hallenges of the previous year. All departments and units of the organization presented their report ards on the programmes and projets undertaken in the ourse of the last year as per the objetives set out in the Revised CHAK Strategi Plan In addition, plans for 2009 were unveiled, taking into onsideration the global eonomi reession and its likely effets on the NGO setor worldwide and in Kenya. The departments also disussed their respetive fund raising and resoure mobilisation strategies. The staff took time to deliberate on ways of improving servies to the CHAK network by ensuring improved effiieny in the organisation s operations. In addition, ways of addressing hallenges faed were sought. As has been the tradition, planning for the CHAK Annual Health Conferene and Annual General Meeting kiked off at the retreat. This year will also see the offiial opening of the new CHAK offie blok and guest house. Daily morning and evening devotions underlined the foundation of CHAK as a Christian organisation running on Part of the CHAK team that partiipated in the staff retreat. godly values while taking into onsideration professional ethis. Early morning and late evening game drives to view Kenya s rih wildlife heritage, the beautiful landsape and breath taking roky terrain enabled the team to relax after a hard day s work. The annual staff soial welfare annual general meeting was also held with members deliberating on ways of bettering their lot. The staff retreat has been a part of the organisation s ativities for several years and provides an opportunity for staff to plan together and soialize away from the offie environment in a bid to foster team work. We thank the CHAK Exeutive Committee (EXCO) and Management Team (MT) for availing resoures for this essential ativity. r photo: CHAK...ontinued from page 31 the salaries of health faility staff in its budget proposals. The General Seretary told them that this was part of CHAK s advoay strategy as the organisation offers valuable information and statistis regarding the projets it undertakes. He noted that health faility staff were entral to projet implementation and reporting, hene it was justified to pay their salaries. The team also toured Mission for Essential Drugs and Supplies (MEDS) premises where they were reeived by the Managing Diretor, Pashal Manyuru. Mr Manyuru explained that MEDS had sought legal status to enable it import drugs. He further noted that quality assurane was one of the key reasons that health failities purhased drugs from MEDS. He intimated that MEDS was seeking quality ontrol ertifiation from the World Health Organization (WHO). MEDS also onduts training programs in drug supply management, Adult Retroviral Therapy, diagnostis and laboratory pratie, pharmay and drug management, Voluntary Counseling and Testing among others. The hairmanship of MEDS rotates every three years between CHAK and the Kenya Episopal Conferene (KEC), who jointly own the drugs supply ageny. Mr Manyuru further noted that there was virtually no ompetition between MEDS and Government drugs supply ageny, KEMSA, as the two omplemented eah other. He added that MEDS defered to the authority of the Government, given that it was the setor regulator. To enable it to regularly update its drugs list, MEDS on oassion brings together representatives from the World Health Organisation (WHO), aademiians in pharmay and liniians to disuss the effiay of various drugs. Mr Manyuru added that MEDS pries had remained low as it harged just enough to over operational osts. Bulk purhasing leading to reasonable disounts had also enabled MEDS to keep the ost of drugs low. r 32 CHAK Times January - April 2009

32 profile Namasoli Health Centre Comprehensive Care Clini Namasoli Health Centre is loated in Kwisero Division in Kenya s Western Provine. The health enter serves a athment population of about 20,000 with most lients oming from Kwisero. The health enter offers laboratory servies, pharmay, Maternal Child Health, maternity, Family Planning, outpatient and inpatient servies. Staff ondut ommunity outreahes offering integrated servies at least one a month while a small operating theatre serves lients requiring minor proedures. The health enter reently benefited from a Parte CD4 Count Mahine (CyFlow SL_3) from CHAK, ourtesy of Global Fund to Fight AIDS, TB and Malaria. The equipment, whih is only one of three of its kind within the CHAK network, is expeted to push up patient volumes in the Comprehensive Care Clini. The Comprehensive Care Clini The Kenya Government has put HIV/AIDS prevalene in Western Provine at 5.2 per ent. Wife inheritane has been ited as one of the fators leading to the spread of HIV/AIDS in Kwisero division. Early sexual debut among the youth and sexual immorality, blamed on high poverty levels within the athment population and surrounding areas, have also ontributed to the spread of the virus. In response to the prevailing HIV/AIDS situation in its athment area, Namasoli Health Centre started a Comprehensive Care Clini about one year ago. The lini urrently has 250 adults and 15 hildren on are while 59 adults and four hildren are on ARVs. The health enter has a VCT enter whih urrently reeives a daily average of 10 lients. The health enter has an ative Provider Initiated Counselling and Testing (PITC) programme. Patients who visit the health enter, espeially pregnant mothers seeking antenatal are, are enouraged to take a HIV test through the PITC programme. To effetively undertake PITC, all nurses working at Namasoli Health Centre have been trained as ounselors while rapid HIV test kits from photo: CHAK Clinial Offier In Charge Mrs Rose Muhanda in a session with the PMTCT support group. All nurses working at Namasoli Health Centre have been trained as ounselors while rapid HIV test kits from MOH are readily available MOH are readily available. An average of 15 lients are tested per day under the PITC programme. The health entre s PMTCT programme has19 lients and was initiated by the Catholi Medial Missions Board (CMMB). The organisation is also supporting a nurse under the programme. Four HIV-negative babies have so far been born to HIV positive mothers. Infetion of newborns with HIV an be attributed to lak of supplements for breast milk. Support groups The CCC has three support groups: Jikaze for PLWHAs, Kids Club and another one for PMTCT lients. PMTCT The PMTCT support group meets one a month. Mothers are advised on nutrition for both themselves and their newborns and how to live positively and are also enouraged to bring their spouses to the meetings. Kids Club The Kids Club, a support group for pediatris, meets one a month. A playhouse has been prepared to keep the hildren busy while their guardians partiipate in the sessions. The hildren are required to be aompanied by a guardian when they attend the Kids Club sessions. As the hildren engage in play therapy, a failitator takes their guardians through issues around nutrition, adherene and how to dislose to the hild that he or she is HIV-positive. Given hildren s natural uriosity, most of the Kids Club members have a basi understanding of their ondition by the age of six, thanks to informed dislosure by their guardians. A key hallenge faed by hildren living with HIV/AIDS is stigma and disrimination within the shool setting. With assistane from CHAK, Namasoli Health Centre is urrently turn to page 34 CHAK Times January - April

33 profile...ontinued from page 33 photos: CHAK arrying out behaviour hange ommuniation trainings for teahers to address this hallenge. Sharing of experienes during the psyhosoial support group meetings also helps to enourage suh hildren. Jikaze Support Group T h e J i k a z e S u p p o r t G r o u p undertakes several ativities aimed at empowering its members. The support group has proven itself a model worthy of emulating and has been visited by other groups from Butere for lesson learning and experiene sharing. The group, whih onsists of 15 men and 30 women, tends a kithen garden within the health enter grounds on whih they grow traditional vegetables to supplement their diet. The piee of land serves as a demonstration garden for the group members who are expeted to repliate the lessons learned on their individual plots at home. An agriulturalist trains the group on how to inrease produtivity on the small piees of land and the nutritional value of the vegetables. Exess produe is sold to loals to generate some inome. A traditional vegetable, amaranth, is one of the rops grown by the group members. Amaranth seeds are ground to make a nutritious flour used to ook porridge. The kithen garden was initially supported by CHAK and has also been supported by the Western Region Christian Community Servies (WRCCS). The WRCCS supported the group with funds to purhase, mill and pakage amaranth seeds. The flour is given free to the Jikaze Support Group members who also divide the amaranth seeds harvested from the demonstration garden among themselves to plant in their individual kithen gardens. The group rears hikens whih it sells to raise money to buy farm inputs while exess inome is saved in a bank aount. This inome generating ativity is an initiative of the PLWHA in the group, eah of who donated a hik at photo: CHAK Members of the Jikaze support group and ommunity health workers sensitise loals about HIV & AIDS through song and dane during a eremony to dediate the CD4 mahine donated to Namasoli by CHAK through Global Funds. Charts showing enrollment in the CCC in the first half of the projet s ineption. Some of the inome has been used to onstrut hiken houses as the projet ontinues to expand. The hospital supports the group with hiken feed whih is quite ostly. To further supplement their diet, the group onsumes the eggs got from the hiken projet. Members have been enouraged to repliate the hiken projet in their own settings in order to raise their individual inomes. A merry-go-round in whih all members partiipate enables the group to visit eah homestead, reduing stigma. Eah group member ontributes Ksh50 to ater for meals and drinks during the visits. Members explain to the host family and where appliable neighbours the reason for their visit, effetively dealing with dislosure issues. However, members are enouraged to personally dislose their HIV status to their loved ones. The home visits whih take plae one a month are also used to monitor implementation of the different projets initiated by the group and repliated in the members homes suh as the kithen garden. The ounselors working at Namasoli are also part of the support group, enabling them to understand the members individual irumstanes and respond aordingly in are and treatment of the patient. The support group takes part in ommunity mobilization and partiipates in outreah events for stigma redution. The group members have undergone training in agriulture and nutrition as well as adherene ounseling. They enourage other PLWHAs. Challenges faing the CCC u Inadequate staff: there is need for a staff member to handle eah setion of the CCC. Currently, there are only four staff who also have to attend trainings and other events, sometimes leaving some setions unmanned. u Treatment of opportunisti infetions is quite expensive for the PLWHAs. Organizations supporting HIV/AIDS ativities and MoH do not ater for opportunisti infetions in their support. u Nutritional support is needed for PMTCT lients to ensure more babies remain HIV-negative. Most mothers who visit the health enter annot afford food supplements for their babies. u Pediatri ART remains a hallenge due to irregular supplies. u Inadequate infrastruture despite inreasing ativities. u Debtors r 34 CHAK Times January - April 2009

34 tea break Word searh puzzle By Carol Trahsel - Formerly of Tenwek Hospital Win or lose 1-i 2-b 3-g 4-5-a 6-b 7-f 8-a 9-j e 12-a 13-b 14-d 15-e 16-b 17-g 18-f 19-b 20-d, 21-h 22-d 23-e 24-i 25-e 26-g 27-f g 30-a 31-i 32-f 33-a 34-j 35-i 36-d 37-i 38-d 39-a 40-b 41-g 42-a j h 47-j 39e 49-a 50-f 51-h 52-h 53-j. 54-j 55-a 56-i 57- Lyndon B. Johnson a. Higher than a hill b. Ways; highways Like quinine d. Penned e. People sounds f. Smells g. Awaken h. Moving parts i. A tale j. Like a fleee Answer to the puzzle CHAK Times January - April

35 tea break MEDICAL QUIZ Send your responses to: The Editor, CHAK Times, P.O. Box Nairobi; The first five orret entries will reeive a CHAK gift pak Remember to inlude your name, health faility, mobile phone number and full postal address 1. Define the following: a) Community Unit b) Community Health Extension Worker ( CHEW) ) Distrit Health Stakeholders Forum d) Kenya Essential Pakage for Health e) Pentavalent (1 mark eah) 2. Desribe how you would use Government support in the form of essential drugs and supplies to ensure sustainability of your health faility. (5mks) 3. Explain your response to a massive aident/ tragedy that unfortunately ours next to your health faility on a Friday evening. (10 mks) Answers to Medial Quiz Write the following abbreviations in full. (6 mks) a) KAIS - Kenya AIDS Indiators Survey b) PEP - Post Exposure Prophylaxis ) OI - Opportunisti Infetions d) GAVI - Global Vaines Initiative e) PITC - Provider Initiated Testing and Counseling f) NNRTI - Non Nuleotide Reverse Transriptase 2. Desribe how stigma and disrimination against People Living With HIV & AIDS (PLWHA) an be redued. (7mks) Stigma and disrimination against PLWHA an be redued by taking the following steps: u Eduating and onstantly updating the populae with fats and figures about the disease u Provision of quality, onfidential and effiient pre and post HIV-Test ounseling. u Enouraging dislosure to loved ones, intimate olleagues and employers for support. u Eah employer to have a written HIV/AIDS workplae poliy. u Dissemination of the HIV/AIDS prevention and ontrol At 2006 as well as applying harsh penalties against ats of disrimination of PLWH. u Giving hope and talking positively about HIV infetion using all forms of media and soial strutures in plae u Providing omprehensive are and treatment servies. 3. Explain the key priniples of the home-based are strategy for PLWHIV. (7 mks) This inludes the following suggested interventions: u Promotion of Counseling, Testing and subsequent spontaneous dislosure u Empowering and building apaity of PLWH for self are at home with supervision of ommunity health workers u Family and ommunity involvement in are, support and treatment of PLWHIV u Establishing an effiient referral, lient traing and reporting system u Providing quality affordable OI drugs, nutritional supplements and simple treatments u Formation of peer lient support groups for psyhosoial support u Promotion of human rights and paralegal support to the PLWHIV and their families Medial Quiz 29 winners Mary Wangui Mburu AIC Kijabe Hospital P.O. Box Kijabe Patrik N. Njoroge AIC Kijabe Hospital P.O. Box Kijabe Rose W. Mwahuma FGCK Kipsigon Health Centre and CBHC P.O. Box Chwele Winners should get in touh with the editor on telephone to arrange to ollet their prizes. 36 CHAK Times January - April 2009

36 the Samaritan samaritan A good samaritan stopped to help a stranger. he took on the burden of aring for someone he did not know. If you have a burden that you annot bear on your own, share it with the Samaritan. Send your questions to: The Samaritan, CHAK Times, P.O. Box , Nairobi. [email protected] Q Dear Samaritan, I am a middle-aged born again Christian and a teaher in the ity. I also work as a ounselor, mostly ounseling my olleagues and my students at shool. Reently, a olleague invited some friends and I for prayers at her house but we were too busy to go. Some people gave exuses that they were going upountry to be with their families while others said they had urgent matters to attend to. Over the holidays another olleague invited all the teahers - me inluded - to go and fellowship at her house. I thought this was a great idea and went gladly. On reahing the house, I met everybody gathered and seated and I made myself omfortable next to my olleague (the one who had invited us earlier but where nobody went). Immediately I sat down my olleague started insulting me, ausing me of being a hyporite. She said that I was pretending to be an interessor while I favoured some people. She said I had refused to go and pray with her beause she was poor and had nothing to offer. I felt so bitter and angry that no words ame out of my mouth. Everybody present paid attention to what my olleague was saying and this spoilt the day; we neither fellowshipped nor drunk the tea that had been prepared for us. I feel so betrayed and embarrassed that things had to happen that way beause of me. This has spoilt our relationship and I wonder if I should stop praying for people? Angry lady A Dear Angry Lady, Thank you for sharing your experiene with me. You have an emotional problem. Emotions have both physiologial and ognitive elements and tend to hange behaviour. Beause of this, emotions must be expressed, beause if not they have some effet on the individual. You are experiening bitterness and anger beause you think that your olleague has treated you unfairly. Anger an be a positive or negative emotion. If hanneled positively and in the right diretion, anger is good, but if hanneled negatively, anger is bad and has bad effets and feelings for them that experiene and are affeted by it. Intense anger whih is inwardly direted, i.e. bitterness and an unforgiving heart an lead to depression. This results when one does not have effetive mehanisms of dealing with anger and there is no plae for forgiveness in one s life. When we are hurt we should not hurt in return. We should disourage any ations direted at revenge. When a person is angry he or she spends more alories than when alm. It would be good if you disussed the issue with your olleague and to find out why she behaved the way she did and why she said the things she said. That would be the beginning and would maybe initiate some dialogue. Try to empathise with your olleague, and try to reason with her. She must have had a reason for behaving the way she did. After disussing the issue with your olleague avoid living in the past. Do not dwell on past injusties beause this will only inline you to revenge, whih is ounter produtive. Move on and rebuild your friendship. It is important to learn oping tehniques if you an t resolve some issues. One must have internal peae with him/herself and the prevailing environment. Learn to live with your olleague beause after all you work in the same shool and spend a lot of time together. Note that it is not possible for you to be happy throughout your life. Life is full of ups and downs. In order to experiene happiness, you must experiene other emotions like sadness and anger to some degree nearly every day. Therefore you should work towards aepting what you are and who you are, i.e. self awareness. About praying for others, what is your belief? What is God ommanding you to do? He ommands you to love your enemies and that means praying for them. Pray without easing for that is the will of God. Live positively. Positive living is only possible if we are dependent on God. Follow Him wherever he leads. Happiness needs to be earned, worked for and appreiated. Be angry but do not sin, do not let the sun go down on your anger (Ephesians 4:26) Lastly you an share your issues with a ounselor or a lose onfidant who will help you express your emotions in a onstrutive way. This will make you feel relieved. r CHAK Times January - April

37 devotional Sustaining spiritual growth among believers By Joseph Oyongo - CHAK Seretariat Kenya has one of the highest number of neonate deaths in the Afria region with 43,600 of neonate deaths per year, equal to a neonate mortality rate of 33 per 1,000 live births. This means that one in every 14 babies born in Kenya will die before their first birthday and about one in 9 before their fifth birthday. The main auses of neonatal death in Kenya are: severe infetions (27%), birth asphyxia (27%), preterm birth (26%), ongenital anomalies (8%), neonatal tetanus (2%), diarrhea (2%) and other onditions (8%). (Child Survival and Development Strategy: ) When we keenly look at the above information, it beomes evident that there is a serious threat to the sustainability of human life. God gifted us with life and purposes that we live it to the fullest (John 10:10). Sustainability of a life starts at oneption when growth and development ommenes. Neonates die due to lak of onditions neessary for optimum growth and development suh as: u Protetion from threats suh as disease u Food and water u Love, are and support The Word of God tells us that if a person is in Christ he or she is a new reation (I Cor. 5:17). There is need to sustain spiritual life in the same way that we try to sustain physial life in an offspring. This is partiularly vital in the early moments of salvation when the enemy an laim easy prey. Young believers need protetion from unbelief and immorality that threaten the new faith. In the book of I John 5:4-5, the Bible tells us that whatsoever is born of God overometh the world. It further elaborates that for us to oveome the world, we need to have faith in Jesus the Son of God. Further, the book of Revelations 12: 11 tells us: They overame devil by the blood of Jesus and their testimony. In Christ, we have redemption and forgiveness of sins (Eph. 2:7). Do you believe in God s total protetion from all danger? If so, there is no need to fear as God will fight for you. What believers need is sustained balaned spiritual food in the form of the Word of God and leansing by the Holy Spirit for optimum growth and development. This spiritual nourishment also makes the soul resistant to spiritual offensives and aids healing of old wounds. Further, the book of Ezra 7:12 delares: We shall not die but live to give a testimony of what God has done. As Christians, we need to study the Word of God, live it and tell others about it. Finally, there is need for warmth and fellowship with loved ones. This an be ahieved by intimate fellowship with God through praise, worship and meditation on His Word. We an then reflet these experienes in our fellowship with other people by sharing love, are and support. Love, are and support promotes good health, prevents stress and strengthens oping mehanisms. r The atheist and the lion An atheist was walking through the forest, thinking to himself, How beautiful the animals are! How majesti the trees are! How powerful the rivers are! As he walked along the river, he heard rustling in the bushes behind him. He turned and saw a huge lion heading towards him. He ran along the path as fast as he ould, but when he looked over his shoulder, he saw that the lion was losing in on him. He kept running, but when he looked over his shoulder again, the lion was even loser. Then he tripped and fell on the ground. The lion was right on top of him with his right paw raised to strike him. At that instant, the atheist ried, God help me! Time stopped. The lion froze. The forest was silent. A bright light shone upon the man and a voie from the sky said, You ve denied my existene for all these years and have taught others that I don t exist. You ve even redited reation to a osmi aident. Why would you expet me to help you out of this prediament? Are you now a believer? The atheist looked into the light and said, Well, I would be hyporite to suddenly ask You to treat me as a Christian now, but ould you, maybe, make the lion a Christian? Very well, said the voie. The light went out. The sounds of the forest resumed. The lion lowered his right paw and brought both paws together. He bowed his head, and said: Lord, bless this food whih I am about to reeive from Your bounty through Christ our Lord, Amen. 38 CHAK Times January - April 2009

38 Notie of CHAK Annual Health Conferene and AGM 2009 Notie is hereby given for the CHAK AHC/AGM 2009 Dates: April 14-16, 2009 Venue: Jumuia Conferene & Country Home, Limuru, Kenya announement Conferene theme Sustainability of Churh Health Servies: Enhaning effiieny, quality and sustainability through innovative health finaning strategies and Health Systems Strengthening Conferene objetives i. To reflet on the role of Health Systems Strengthening in enhaning health are quality, effiieny and sustainability ii. To share ase studies of best praties around innovative health are finaning strategies and health systems strengthening iii. To review the potential of NHIF and other emerging soial health insurane initiatives by Jamii Bora Trust, Kenya Women Finane Trust and Community health finaning initiatives in reating sustainable health are finaning iv. To review potential of partnerships in health are finaning and sustainability strategies v. To disseminate the draft MoU between Government of Kenya and Faith Based health servie providers and review it s impliation for Churh health failities vi. To launh and disseminate CHAK Health Systems Strengthening Poliy douments and Tools Conferene sessions The Annual Health Conferene programme will feature bloks of sessions under the following themes: a) Health systems strengthening strategies and Poliy douments by CHAK b) The sustainability hallenge in Churh health failities ) Partnering with Ministry of Medial Servies, NHIF and other soial health insurane initiatives d) Partnerships for health systems strengthening and health are finaning e) Innovations/best praties in health are finaning and health systems strengthening from CHAK member network f) Launh of CHAK Health Systems Strengthening Poliy douments g) Offiial opening of CHAK Guest House & Training Centre Conferene partiipants The Annual Health Conferene targets all CHAK member Churhes, health failities and programmes, Seretariat staff, Governane of CHAK, partners in the health setor in Kenya and from other ountries and any interested Christian Health Assoiations from Afria. These groups enjoy a subsidized registration fee. Any other interested individual or institutional partiipants may be allowed but have to meet the full ost. Details of the Registration fees an be obtained from CHAK Seretariat on the following address: [email protected]. For more details about the event visit Answer to word searh puzzle: Yesterday is not ours to reover, but tomorrow is ours to win or to lose. - Lyndon B. Johnson CHAK Times January - April