“MOTHER AND CHILD HEALTH REFERRAL NETWORK” &

1. "Valutazione degli interventi di cooperazione sanitaria internazionale"- Esempi ed esperienze di valutazione di progetti, punti di forza e criticità- Firenze, 18 Settembre 2015 Gianfranco Morino, World Friends Kenya gianfranco.morino@worldfriendskenya.org

2. “MOTHER AND CHILD HEALTH REFERRAL NETWORK” & “Facilities advancement and referral enhancement” projects Thanks to previous projects and many years of experience in the slums of Nairobi, World Friends came to realize that, despite the presence of many dispensaries and health centers in the slums offering Primary Health Care, there is a huge gap when it comes to referrals of patients for more advanced care, especially in emergency situations. In fact more than half (56%) of the emergencies received at referral hospitals, such as RUNH, arrive on foot or by public transport. This is why and how the idea of creating a referral network, inclusive of ambulance service, between lower level facilities and RUNH started. Since 2013 the project aims at enhancing the integration and the referral system across different level healthcare facilities.

3. Where: Korogocho, Mathare, Baba Dogo, Dandora, Huruma ( slums of Nairobi North-East) Beneficiaries: 5 lower-level mother-and-child healthcare facilities, operating in the slums, and their patients, particularly mothers and children < 5 RUNH Catchment Area

4. Activities: • Empowerment of 5 lower lever MCH facilities located in the slums: - infrastructural renovation of the facility - purchase and installation of MCH equipment - training for Health Personnel 2) Creation of a referral network with the 5 lower level facilities and RuarakaUhaiNeema Hospital: - free referrals to RUNH for mothers during pregnancy, delivery, post natal (1,071 in 15 months) - free referrals to RUNH for children (236 in 15 months) - general referrals and referrals for specialized care • Setting up of a 24/7 ambulance service (475 transports in 16 months) • Extension of RUNH Maternity Department (11 more beds) and constructions of a second operating theatre • Research, development and piloting of a health micro-insurance package

5. Training 1) IMCI – Integrated Management of Childhood Illnesses – MoH and KPA (3 editions) 2) IMAM – Integrated Management of Acute Malnutrition – MoH 3)EmONC – Emergency Obstetric and Newborn Care – MoH and LSTM 4) Sustainable infections prevention and waste management within hospital environments – NEMA 5) Support of Women in Labour, Use of Partograph and Helping Babies Breathe - ACNM 6) Post Partum Hemorrhage, Dating Pregnancy, Essential Care for Every Baby, Shoulder Dystocia – ACNM 7) ETAT – Emergency Triage Assessment and Treatment - KPA

6. Monitoring 1) Baseline data collection was carried out before the beginning of the project 2) Indicators and Targets were set to reach through the project 3) A training in M&E was conducted for all the partners 4) A specific monitoring tool was developed to keep records of outputs vis-à-vis the provision of “priority services” (i.e. RH, MAT, PAED, HIV/AIDS). T.A. by an M&E expert from Abt Associates contributed to refining the tool and avoiding (or isolating) double-counting. Data were collected and inserted in the tool on a quarterly basis.

7. Evaluation (1) – External, Overall Evaluator: Ipsos Synovate Objective: to assess the impact of the intervention among direct beneficiaries, i.e. mothers from the target communities accessing services at the partner facilities and/or at RUNH Methodology: Focus Group Discussions (FGDs). Evaluation (2) – External, Specific Evaluator: the Healthcare Network Abt Associates Objective: to evaluate the specific and challenging components of the intervention Methodology: Key Informants Interviews (KIIs)

8. IPSOS is an International Research Agency who carried out an overall evaluation of our project targeting our direct beneficiaries: pregnant mothers or mothers with children from the slums. They organized Focus Group Discussions in which patients who benefitted from our services could openly give a feedback. The response was good and the feedback was positive: women were happy with the services received, appreciated the care received at RUNH and they said if it was not for our ambulance and our hospital they would have been in a very unsafe situation with no other means to reach or afford another hospital. Negative: they also said that they didn’t know RUNH was a hospital for people coming from the slums; it looks too nice and clean so they thought it was a private expensive hospital. This helped us in planning interventions to improve our visibility and communication strategy to reach our real target population.

9. Evaluation (3) – Internal, Specific Evaluator: Dr.Luca Scali, Centro di Salute Globale, Regione Toscana Objective: to evaluate the effectiveness and efficiency of the referral mechanisms within the network, with focus on the ambulance service Methodology: Assessment Tool and Key Informants Interviews (KIIs)

10. The results of its assessment show that the ambulance service works smoothly and with very minimal hiccups, for example when the ambulance is needed in more than one facility at the same time, but this is something we are already working on, in fact we added another ambulance vehicle and we are planning to have in future two complete ambulance teams to be on duty 24/7. Negative: all the project partners agreed on the gap which is still present at the community level. Some women still do not attend ANC, or do not want to deliver in a health facility, instead they prefer delivering in the house. This leads to delays in actions when a complication arises and poor outcomes. We need to identify new interventions to address this aspect.

11. Evaluation (4) – Internal, Overall Evaluators: RUNH, WF Project Managers and Project Partners. Objective: to carry out joint, endogenous and qualitative assessments of the project, to provide/receive updates, seek /provide clarifications, exchange feedback and agree on action plans to address emergent challenges on clinical and management aspects Methodology: monthly meetings

12. Conclusions 1) Having a continuous M&E activity is crucial for the organization to be conscious of the project, of its strengths but also the weaknesses to address. Besides being accountable to the donors and to the beneficiaries, this is critical for the follow up and sustainability of the project in the long run once the project period is over 2) Continuous overall and specific, internal and external evaluations greatly helped to rectify problems in time and/or plan for and eventually take additional necessary actions (implementing recommendations) within the project period

13. Miriam Makeba: Sudafricana, anti-apartheid, perseguitata dal regime sudafricano, dal 1959 vive come cittadina del mondo Sigmund Freud: in fuga dall’Austria, dove viveva, annessa al Terzo Reich nel 1938. Trova rifugio politico a Londra. Albert Einstein: Dalla Germania, si rifugia in Belgio dopo la salita al potere di Hitler nel 1933. Si rifugia poi in Gran Bretagna e Stati Uniti. Isabel Allende: nipote del Presidente cileno Salvador Allende. Dopo il colpo di stato di Pinochet nel 1973 dal Cile si rifugia in esilio in Venezuela. Ora vive negli Stati Uniti.

14. “La paura dei barbari e’ cio’ che rischia di renderci barbari. Ed il male che ci faremo sara’ maggiore di quello che temevamo di subire”. T.Todorov