Article Text
Abstract
Context How do you deliver primary and public health care in communities where there is no water, where tribal boundaries meet and insecurity is high, where there are ingrained cultural health beliefs?
A three way collaboration between the NGO Northern Rangelands Trust, The University of Plymouth and Isiolo County Government (with University of Nairobi) has undertaken a series of health scoping and needs assessment exercises in North Eastern Kenya to improve health outcomes for the communities.
The area lies to the north east of isiolo and reaches to within 60km of the Somalia border.
The group consisted of an International health consultant, Global health doctor, Kenyan public health doctor, Kenyan community and peace specialist, a water and rangelands expert, and Kenyan female community chief.
The aim being to build capacity in existing government through well thought out and functional projects, that integrate community and environmental solutions to health.
Issue/Challenge Current health facilities in North Eastern Kenya are failing and health outcomes of the communities, particularly maternal and child health, are poor.
The team visited Level 2 (dispensary), Level 3 (primary care rural clinics) and Level 4 (secondary care) services.
Directed interviews and focus group discussions gathered the following information:
Healthcare workers of all levels lacked morale and motivation for their work.
The facilities frequently had no water or power, tribal fighting led to destroying of water pipes and solar power. Drug supplies were sporadic due to poor roads and lack of government funding. Health workers felt unsafe outside the hospital complex due to tribal fighting and cattle rustling.
Members of the community felt distrust in their health facilities due to lack of available care, and were unable to access the Level 4 hospitals due to cost.
Assessment of issue and analysis of its causes
Northern Rangelands Trust collaborated with University of Plymouth Global health leads and the Kenyan county government of Isiolo to undertake a health scoping and needs assessment exercise in North Eastern Kenya.
This collaboration led to identification of key issues needed to address health outcomes, and the involvement of other stakeholders to support sectors such as water, malnutrition and maternal health.
Prior to the health scoping exercise stakeholders met in Isiolo county. This included representatives from the community, woman’s group and health professionals working in the rural facilities. These representatives accompanied the health scoping exercise to be the voice for their community and give insight into the ongoing challenges.
Data was collected from health records in each facility, and through interview and focus groups with the community chiefs and womens group, health-workers, CHVs and government leads.
Information was disseminated through an open access meeting at the Isiolo county health headquarters and through presentations and recordings sent to all groups.
An agreed and jointly owned health strategy for the region was prioritised by those in the meeting including providing water to all facilities and engaging with in country specialists to bring peace in conflict areas.
Impact Funding is not the only answer to improve these facilities; a deep understanding of the environmental, social and health challenges is needed before careful planning of how interventions should be implemented.
Through engaging with specialists in other sectors vast improvements can be seen in health outcomes. Water specialists with access to funding and NGOs can improve water supply to the clinics. Rangelands experts can improve grasslands and grazing on land near the clinic so nomadic pastoralists do not have travel so far from community health and education facilities. Peace organisations work with all tribes to reduce conflict which both reduces trauma presentations to remote health centres and supports health workers feeling safe in their place of work.
Facilitating education and outreach services improves morale of health workers in enabling them to deliver these services to their communities.
Intervention This project involved bringing together leaders in different sectors of health and environment to work together in improving health outcomes in remote communities.
These are essentially different ‘tribes’ with their own priorities and language.
It was necessary to facilitate conversations between all groups, to support one another and identity those ideas which would be most effective given the time and funding available.
This project gave us in-depth understanding of the leadership skills needed to achieve the sustainable development goals and insight into what can be achieved if all sectors collaborate towards a common goal.
this work is reproducible across all health systems. Prior to embarking on a ‘health project’ purely because that is what has been asked for, or ear marked for funding, take a step back and look at the casual factors. Why are communities not using their facilities; why are health workers not motivated; why are maternal outcomes so poor? Once an understanding of the wider factors involved in health behaviours is understood it might be that simple, more cost effective interventions will see a huge impact.
Involvement of stakeholders, such as patients, carers or family members:
There were patient representatives involved at all stages of the project .
Community chiefs and women leads from the elders group joined the planning meetings, field scoping project and follow up meetings at the government offices. They also helped to facilitate the interview and group discussions including helping with translation from local dialect.
Key Messages To understand remote health systems and their challenges, you must first gather deep understanding of the priorities of the communities that use them. If there is no water, poor grazing for livestock, insecurity from fighting then these factors must be addressed to see any improvement in health outcomes.
Careful facilitation of discussions amongst all stake holders including government, NGOs and communities, including representatives from different tribes. Ensuring a shared ownership of the project amongst all stakeholders is vital for ongoing collaboration and success of the project.
Lessons learnt For those of us who work at 100mph all the time, have access to high speed internet and can zoom call on our way to and from work it is important to learn that hours spend sitting under a tree with a cup of chai in hand simply listening to what the community elders have to say is not time wasted, If anything it is time gained for the future.
We frequently felt as though we had not achieved anything for days however gaining the guy in and trust of all the stakeholders, and ensuring they equally have the trust of one another takes time, and a skill in itself is to bring these groups together.
Barriers arise with discrepancy in government commitment and funding. Aligning to national strategies and involving governments is essential however, even with MoUs in place, delivering on agreed actions may not occur hence the need to find ways around, over or under these hurdles needs a thinking outside the box approach.
Measurement of improvement Ethics approval is in progress for a formal impact assessment to be completed by University of Plymouth and University of Nairobi. Impact will be measured using Kenyan PHCPI (primary health care performance indicators) as our measurable data. Interviews with community and health care workers will give a qualitative representation of impact.
Strategy for improvement Concurrent steps include: to finalise funding available for the project through Kenyan government matched by grants; gaining ethics approval to measure impact (stalled by recent elections in Kenya); engage contracts with water, grazing and peace experts.
Two of the above have already been completed, ethics is still underway.
Plumbing and water technology is now available to the clinics however the recent drought and famine in northern kenya and the horn of Africa has proved to be a huge challenge in water access.
Peace takes time to build but initial steps have been taken in open channels of communication.
Funding has been secured to offer joint CPD meetings for nurses working alone in remote facilities. This has already improved morale.
Meetings held every 3 months and facilitated by a Kenyan NRT lead open to all stakeholders and community representatives give opportunity for feedback.