Wilson Liambila and Timothy Abuya-Population Council Fred Were and Kezia K’Oduol- KEPRECON

1. Addressing possible serious bacterial infection among sick young infants in Kenya where referral is not feasible: Where are we now?Dr. Felicitas MakokhaPaediatrician, Bungoma County Wilson Liambila and Timothy Abuya-Population Council Fred Were and Kezia K’Oduol- KEPRECON Jesse Gitaka –Mount Kenya University Kenya Paediatric Association 2019 Annual Scientific Conference Mombasa, 9th to 12th April 2019

2. Introduction • Kenya has high NNM rate (22 per 1000 live births) with sepsis contributing up to 20% of deaths • Poor care seeking, dysfunctional referral pathways and negative cultural beliefs worsen situation • Reducing this burden requires timely case identification & initiation of suitable antibiotic treatment • Clinical trials of simplified treatment regimens in Asia and Africa (2011-2013) showed: • high refusal rates for referral by caregivers (Kenya 89%) • simplified antibiotic regimens for SYIs provided at PHC level when referral is not feasible are effective and can save lives.

3. WHO Guidelines Developed to Respond to Clinical Trial Results

4. Implementation Approach -Three-Phase

5. PROJECT PROGRESS IN PAST ONE YEAR

6. Implementation Milestones for scaling PSBI in Kenya Co creation workshop Jan 2017 Update of IMNCI and newborn protocols Jan-may 2018 Provider induction on IMNCI/PSBI Quarterly follow up & tracking Dissemination and revision of work county plans Sept-Oct 2018 National level advocacy Oct 2017 IMNCI Induction Jan-March 2019 1 2 3 8 4 11 5 6 7 13 10 12 9 Revision of concept and full proposal development August-October 2017 Six monthly follow up Formative phase June-July 2018 Dissemination of Job aids/follow up forms March 2019 Development of job aids/pamphlets Jan-March 2019 Addis Ababa advocacy meeting Jan 2018

7. USE OF EVIDENCE FOR IMPLEMENTATION

8. Project is using Implementation Research(IR) Approach to: • Create foundation for learning • Generate evidence for action • Develop a measurement framework through periodic monitoring of performance or implementation activities

9. Foundation for Learning • Formative assessment in project sites, June – July 2018 • Technical Advisory Group meeting, August 2018 • Establishment of Community of Practice (CoP), October 2018. • Join CoP at: psbi@communities.harpnet.org • Quarterly monitoring system

10. Formative Assessment

11. Results of the Formative Assessment: Organizational Capacity Index (OCI) scores by Health System Domains

12. Overall Organizational Capacity Index

13. Results of the Formative Assessment: Communities’ understanding of causes of illness among infants Cultural practices Myths and misconceptions Infants born out of wedlock Use of family planning Eating foods such as wild fruits Overworking during pregnancy Mother sleeping outdoors during pregnancy • Infants rejecting the allocated names • Witchcraft or sorcery • Bad omen • Bad/ evil eye or • Statements made about the infant • Presence of an owl in the homestead Harmful practices • Delayed breastfeeding while waiting for naming ceremony (religious or cultural) • Placing exposed young infant outside the home to prevent them from dying like other siblings • Use of cultural practices to protect against the evil eye

14. ……Causes of illness among infants….Cont’d: Practices during pregnancy and breastfeeding • • Germs from people and dirty surroundings • - Failing to observe hygiene • (unwashed hands, unclean breast) • - Exposing umbilical cord to dirty razor, string, grass, ash, dung, soot • - Cutting baby’s skin and applying herbs or other traditional treatment • • Exposing the young infant to cold • • Complications during childbirth • Some birth defects or abnormalities • Delaying breastfeeding • Giving other foods other than BF • Missing immunization • Delivery outside a health facility • Delivery by unskilled persons • Poor diet during or after pregnancy NB: Correct practices or perspectives are emphasized or reinforced by health providers

15. Results of the Formative Assessment: Communities’ understanding of causes of illness among infants “Hunger is the major cause of illness in infants, when the mother is hungry, infants will always become sick. We can only improve the way we provide healthcare of the mother when the mother gets good nutrients, and this is very important in ensuring the child get the necessary nutrients from the mother when they breastfeed” FGD, Men> 35 years Turkana :“ R1: Another thing that could make babies sick is lack of a clean environment. Maybe the child is staying in a dirty environment. The baby is not being cleaned. Also, the baby’s mother may not be keeping herself clean. Maybe she is not taking regular showers or washing her breasts properly. So, when the baby feeds, automatically the baby will be sick, nothing else” FGD, Young mothers 15-18 year, Turkana

16. Results of the Formative Assessment: Symptom recognition and triggers for action at the community level Care seeking is preceded by seeking a second opinion due to persistence of the condition or severity then the action is taken based on understanding of cause of illness

17. Why clients refuse to take up referral for sick infants (Community perspectives Cont’d)

18. Results of the Formative Assessment Cont’d: Community Health System • CHVs across all counties create awareness, educate the community on newborn care, link the community to the health facilities, serve as referral agents. “R4: When a CHV conducts a home visit, he or she will make this decision depending on the condition of the baby, if the baby is critically ill, then they will be referred to the hospital immediately. If the baby is unwell but the condition is not serious then as a CHV we can just give out panadol or any other medicine and then follow up after 3 days to see whether the baby’s condition has improved” FGD, CHV, Turkana “P: When we get into the house that we visit, there are a few things that we normally ask. Like if there is a sick person or if there is an expectant mother who has not yet started clinic, or if there are those who started the clinic and defaulted, then I teach them and refer them to go to the hospital. And if there is a sick person, we check on the symptoms and if there is a sign of malaria, …and if not malaria I refer them to the hospital to be treated” Bungoma FGD CHVs. • Inadequate number of CHVs, capacity gaps makes it hard for them to reach newborns and mothers • Transport and logistics affect service delivery at community level

19. Results of Health Facility Assessment: Functionality- Health Centres

20. Results of Health Facility Assessment: Stockouts of pharmaceuticals Amoxicillin Dispersible Tab No. of facilities

22. IMPLEMENTATION ACTIONS BASED ON FORMATIVE DATA

23. Developed provider and caregiver Pamphlets

24. PSBI Follow-up Tool and Provider Flowchart

25. IMNCI Training/Updates • IMNCI training materials have been revised/ updated to incorporate PSBI • In Mombasa and Kilifi counties, majority of providers have received updates on the revised IMNCI/PSBI materials • In Bungoma-IMNCI training for TOTs has just been completed and plans are underway to train the providers • Providers in a few sub-counties in Turkana including Turkana Central have received updates on IMNCI/PSBI

26. Routine Monitoring • Quarterly routine monitoring. • Project team working with County, Sub-county and Facility quality improvement teams to assess the quality of care.

27. Periodic Iterative Data Collection • IR data collection cycles involve conducting case narratives with women who use PSBI and those referred from the community by CHVs, and in-depth interviews with active CHVs and frontline providers. • Project team will continuously document the number of PSBI cases seen and the treatment given as well as referral practices for purposes of generating additional evidence to guide scale up and future revisions of national IMNCI/PSBI guidelines.

28. Implementation Challenges • Shortage of staff especially in lower HFs • Barriers such as negative cultural practices contribute to delays in care seeking for SYIs with PSBI • Weak linkage between HFs/providers & CHV activities contribute to poor follow up of SYIs with PSBI • Some HFs do not have community health units (CUs) - hence no active CHVs to assist in following up SYIs. • Erratic supply of some key antibiotics such as Gentamycin, Amoxicillin dispersible tablets, etc NB: There is need for the MOH/C&sub county teams to involve the private sector providers in the training of IMNCI/PSBI

29. What support are we seeking from pediatricians in scaling up PSPBI? • County pediatricians to support roll out in their respective counties • Advocate for IMNCI implementation • Training and induction of providers • Documentation of management • Enhance role out of PSBI guidelines in the private sector • Middle class population increasingly refusing referral • Inclusion of private sector providers in updates and training on IMNCI

30. Acknowledgements Kenya Paediatric Research Consortium • Fred Were • David Githanga • Joe Mbuthia • Doris Kinuthia • Kezia K’Oduol Mount Kenya University • Jesse Gitaka • Alice Natecho • Samuel Mungai • Peter Mwaura • Jackline Nyaberi Population Council • Wilson Liambila • Timothy Abuya • Charity Ndwiga • George Odwe • Charlotte Warren Institutions • Newborn, Child & Adolescent Health Unit - MOH • County and Sub-County Health Management Teams – Bungoma • County and Sub-County Health Management Teams – Turkana • County and Sub-County Health Management Teams – Mombasa • County and Sub-County Health Management Teams – Kilifi • Health Facility Management Teams – Project Counties • USAID-for providing financial resources

31. THANK YOU