2011 Grant Recipient 
Kenya
MSPH Program, Department of International Health, JHSPH
As part of the ACCESS-Uzima mandate in Bondo District in Kenya's Nyanza Province, a comprehensive clinic and community-based baseline assessment was conducted in March and April 2010. Preliminary results were compiled in May 2010 and a report prepared. An intern would be of immense help to carry this process forward to the next level, with specific activities to include:
1. Learn about ACCESS-Uzima and healthcare systems challenges in Kenya, specifically those pertaining to Bondo District
2. Review quantitative and qualitative preliminary baseline assessment results
3. Identify gaps in data, or areas for further exploration, particularly related to community-facility linkages
4. Conduct analysis of service delivery data to inform improvements in service delivery
5. Conduct targeted follow up to address gaps and/or areas of further interest to the ACCESS-Uzima team (through desk review, stakeholder interviews, field visit to Bondo District, focus group discussions, etc)
6. Assist with design and implementation of a follow up assessment
7. Participate in data collection and validation
8. Participate in data entry using Epi data and validation
9. Undertake analysis of the data using SPSS and excel as required
10. Prepare preliminary follow up assessment report
11. Present the findings to Jhpiego staff in the Nairobi office
12. Work with ACCESS-Uzima team to refine intervention approaches to address issues highlighted in baseline and follow up assessment reports.
Personal Narrative:
Going into the field of public health, I always envisioned returning to my home country, Kenya, where I could contribute towards the improvement of Kenyan’s health outcomes- especially the in lives of mothers and children. When the opportunity arose for me to do my master’s practicum in Kenya through the Center of Global Health, I was ecstatic! For two months (June-July 2011), I was privileged to intern with Jhpiego Kenya, a global health leader, under the ACCESS-Uzima program. I arrived in Nairobi early on a Sunday morning, during what many Kenyans like to call the “Kenyan winter”. As my family welcomed me at the Jommo Kenyatta International Airport, I felt immediately at home. My drive home gave me the opportunity to re-familiarize myself with the ever-changing Nairobi landscape. I was particularly impressed by the road developments with heavy-duty machinery lining Nairobi’s major highways, resting after a long week of construction. Nairobians spoke with anticipation of the soon to be completed eight-lane Thika superhighway, which they hoped would ease traffic in Nairobi city. Until then, Nairobi residents will have to contend with the heavy traffic that has become synonymous with Nairobi, “the city under the sun. Well before 7am, the city is already bustling and vibrant with schoolchildren playing as they walked to school, business people religiously set up shop, and young men discussing the prior day’s political happenings over steaming cups of tea as they wait to start their workday. As a pedestrian on my daily walks to and from the internship site, I watched hard working Kenyans commute to work, and was particularly grateful to the diligent traffic police officers who took command of the traffic, much to the dismay of car passengers, who always seemed to be in a hurry. At the Jhpiego offices, I was received into the Jhpiego family. I was immediately impressed by the ease with which everyone at the office interacted, with the Kenyan hospitality shinning through. I was assured that my internship would be broad and comprehensive owing to ACESS-Uzima’s far reaching result areas. The ACCESS-Uzima program (Uzima being a Swahili word for wholeness) serves as the technical arm of Jhpiego, offering pertinent technical advice to other programs operating at the district level. At the national level, ACCESS-Uzima collaborates with the ministries of health, supporting them in the development of orientation materials, national guidelines and dissemination of those guidelines to the provincial and district levels. Within the first week, I was orientated these national guidelines (many of which were developed in collaboration with Jhpiego) concerning reproductive health, malaria, infection prevention and HIV/AIDS, gaining more insight on the Kenyan government’s stance on these health issues. While conducting a cervical cancer screening facility assessment in the greater Nairobi area, I was surprised to learn that although not spoken about openly, cervical cancer is the most common genital cancer among Kenyan women. Current findings estimate that 2,454 women aged 15 and older are diagnosed with cervical cancer annually, with 1,676 women dying from the illness every year in Kenya. While screening options are available, some screening methods offer limitations in their effectiveness on cervical cancer management, as some women do not return for their screening results. For this reason, there has been a push towards integrating treatment options with screening in a single visit approach, where screening and treatment are conducted in one visit, eliminating the need for a woman suspected of having cervical cancer retuning to a health facility for treatment. This is especially important in low resource settings where women may have competing tasks that hinder them from returning to seek treatment. While the ACCESS-Uzima head office is located in Nairobi, they have a field office in Bondo district of Nyanza province where we conducted a data constraints survey. Among all regions in Kenya, Nyanza province fares poorly on a majority of the health indicators. For policy makers at the national level to allocate adequate resources to the district, they require accurate data, reflecting the health needs of the district residents. The Kenyan health system is organized into five levels: National, Provincial, District, Facility and Community. At each level, data is collected, aggregated and passed on to the next health level. Therefore, health facilities forward their data to the district, the district to the province and the province to the national level. Where there is poor data quality, inaccuracies are propagated all the way to the National level. The survey brought to light crucial breaks in information flow from the health facilities to the district level, offering points of intervention. The lifetime risk of maternal death in sub-Saharan Africa is 1 in 22. While this is a sobering statistic, one begins to understand the reason behind the high risk when you visit Bondo district. Pregnant women in Bondo district experience all three delays described in the three-delay model. On the first day at Bondo district, the Jhpiego driver and another Jhpiego colleague brought a woman to the Bondo district hospital where the Jhpiego offices are located. They explained that the teenage girl had been in labor for four days and while the team was distributing health materials, they came across her. A traditional birth attendant, who initially attempted to assist in the young girl’s delivery, was unsuccessful in maneuvering the complicated delivery. On arrival to the hospital, a cesarean section was conducted and both mother and child survived. In the days that followed, we saw laboring women being brought to the health facility using motorcycles and bicycles- a mode of transport that is normally uncomfortable let alone during labor and on rough roads! One could not help but empathize with the women who traveled long distances on rough roads to seek care. At the same time, one had to question how many women were unable to make the journey to deliver at a health facility. The problem of transportation was even more apparent while visiting the Mageta island dispensary, where the only form of transport in and out of the island is by boat. The dispensary is the only facility on the island, and it is not equipped for surgery. Women requiring surgical procedures need to travel by boat to the mainland to receive treatment. To encourage women to deliver at health facilities and in the presence of skilled birth attendants, innovative solutions must be sought. During our data collection activity, I could not help but notice health messaging in and around the facilities we visited. After learning about the importance of oral rehydration therapy (ORT) in tackling diarrhea and curbing under five mortality, I was impressed to see ORT corners in many of the facilities we visited. I was even more impressed by an advertisement for free male circumcision on the door of one of the facilities we visited. I was relieved that the Luo community, a traditionally non-circumcising ethnic group in Kenya, is beginning to embrace the value of circumcision as a mechanism to reduce the risk of HIV infection. When addressing HIV/AIDS care in Kenya, the CDC pre-service team sought to assess the training needs of health care workers nationally, specifically those going through pre-service training at Medical Training Colleges (MTCs) and other smaller-sized colleges. They noted that many health care workers graduating from these institutions are unable to provide quality HIV/AIDS services without undergoing further in-service training, suggesting inadequate pre-service training. I joined the team that conducted this training needs assessment in the coastal town of Mombasa where we interviewed a wide spectrum of individuals in the medical colleges, ranging from policy makers (such as principles) to students. One of ACCESS-Uzima’s result areas centers on infection prevention (IP). I was privileged to join the IP team during a national policy and guidelines dissemination activity in the North Rift Valley. In collaboration with NASCOP, Jhpiego developed a detailed orientation packet aimed at increasing infection prevention awareness. The dissemination effort was targeted at health facility staff and providers throughout the country. These providers are disproportionately at risk of infection during their line of work. It was interesting to note that currently, IP strategies are primarily discussed in relation to HIV infection prevention. In my opinion, IP should be discussed in a broader context. Hepatitis infection is rarely discussed, despite the fact that it is more infectious than HIV. My time with Jhpiego, and specifically with ACCESS-Uzima, gave me a unique look into the health of Kenyans, enriching my understanding of health issues in Kenya, especially as they concerns reproductive health; bolstering my resolve in public health, and specifically in maternal and child issues in Sub-Saharan Africa. Moreover, this internship has shown me that there are effective, evidence based solutions to the major health issues facing Kenya. Through this experience, I have gained unique skills that I could not have gained elsewhere. Specifically, I have gained report-writing skills (through writing weekly reports and contributing to the data constraints report), improved my interviewing skills and improved my managerial skills. Additionally, interning with ACCESS-Uzima availed me the opportunity to network with Ministry of Health officials (especially in the Department of reproductive health) and with other NGOs working on health issues in Kenya. For me, ACCESS-Uzima epitomizes the idea of teamwork - in a field where diseases and solutions cut across multiple levels, ACCESS-Uzima has formed a symbiotic relationship with the MOH and other health organizations to improve the lives of Kenyans. I will forever be indebted to the ACCESS-Uzima team who diligently oriented me on the program while treating me as an equal member. I would especially like to thank my immediate supervisor, Dr. Nancy Kidula, whose passion for women’s health is incalculable. I would also like to thank the Jhpiego Kenya colleagues and the greater Jhpiego family for so warmly welcoming me into their family. Photo Album:  | The ACCESS-Uzima Bondo Field office |  | Colleagues from the ACESS-Uzima team and I talking to a MCH nurse about the challenges she faces in complaining and reporting her facility’s data to the district |  | En route to Mageta Island from mainland Bondo using a ferry. There is only one health facility in the island- it does not have electricity. Women living in Mageta island requiring a cesarean section and other specialized services, travel by ferry/boat to the mainland to receive these service |  | A poster advertising free male circumcision. Traditionally, the Luo community living in Bondo district have been a non-circumcising community |  | A fully stocked oral rehydration therapy corner at a dispensary in Bondo district. |
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