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Afya Ziwani

COUNTY ORGANIZATIONAL

CAPACITY ASSESSMENT REPORT

Homa Bay County

10th to 14th September 2018

This county Organizational Capacity Assessment (OCA) was conducted by the Afya Ziwani project in close collaboration with the County Government. Afya Ziwani is a United States Agency for International Development (USAID) project that is funded by the Presidents Emergency Plan for AIDS Relief (PEPFAR) and implemented by a PATH-led consortium of Kenyan Non-governmental Organizations (NGOs) and American small businesses.

Disclaimer

The views expressed in this report do not necessarily reflect the views of USAID or the United States Government (USG).

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`Table of Contents

Abbreviations ...... 1 1. County OCA Overview ...... 2 1.1 Introduction ...... 2 1.2 OCA Purpose ...... 2 1.3 OCA Approach ...... Error! Bookmark not defined. 1.4 OCA process description ...... 4 2. County OCA Key Findings and Critical Gaps ...... 6 2.1 OCA Summary of Scores ...... 6 2.2 Domain 1: Governance and Leadership ...... 7 2.3 Domain 2: HIV Service Delivery ...... 8 2.4 Domain 3: Human Resources for Health (HRH) ...... 9 2.5 Domain 4: Access to HIV Essential Medicines & Other Commodities ...... 10 2.6 Domain 5: Health Information ...... 11 2.7 Domain 6: Health Financing ...... 12 2.8 Domain 7: Community Health ...... 13 2.9 Domain 8: Research and Development ...... 14 3. Emerging Capacity Gaps and Proposed Interventions ...... 14 4. Lessons Learned ...... 15 5. Recommendations ...... 16 6. Appendices ...... 16 Appendix 1: OCA Scores – County and Sub-Counties ...... 16 Appendix 2: Capacity Development Plans – Homa Bay County and Sub-Counties ...... 16

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Abbreviations

AIDS Acquired immune deficiency syndrome CHEW Community health extension worker CHMT County Health Management Team CHV Community Health Volunteer CU Community units DHIS District health information system DQA Data quality assurance EMMS Essential medicines and medical supplies FTE Full time equivalent HFMC Health facility management committee HIV Human immunodeficiency virus HMB Health management board HRH Human resources for health HSDSA C1 HIV Service Delivery Support Activity Cluster 1 HTS HIV testing services ICT Information, communication and technologies IHRIS Integrated Human Resources Information System IT Information technology KHQIF HIV/AIDS Quality Improvement Framework KHSSP Kenya Health Sector Strategic and Investment Plan LMIS Logistics management information system M&E Monitoring and evaluation MOH Ministry of Health NACOP National AIDS Control Programme OCA Organizational Capacity Assessment OJT On-the-job training PBB Performance based budgeting PFMA Public Finance Management Act QIT Quality improvement team SCHMT Sub-county Health Management Team SCM Supply chain management SOP Standard operating procedure TOR Terms of reference TWG Technical working group WIT Work improvement team

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1. County OCA Overview

1.1 Introduction

This report presents the results of the OCA conducted for Homa Bay County and its Afya Ziwani supported subcounties of Kasipul and Kabondo Kasipul. It includes a detailed analysis of key findings as well as the Capacity Development Plans (CDP) recommended by the county officials to address the gaps identified through the OCA.

Homa Bay County is one of the forty-seven counties in Kenya. It is made up of 8 sub counties namely: Kasipul, Kabondo Kasipul, Karachuonyo, Rangwe, Homa Bay Township, Ndhiwa, Mbita, and Suba. The county has a population of 1,101,901, comprising of 530,272 males (48%) and 571,629 females (52%). Children below 15 years constitute 47% of the population, while youth aged 15-24 years constitute 21% of the population1. HIV prevalence in Homa Bay, at 26.0%2, is nearly 4.5 times higher than the national prevalence. The prevalence among women in the county is higher (27.8%) than that of men (24.0%), indicating that women are more vulnerable to HIV infection than men in the county. The county contributes 10.4% of the total number of people living with HIV in Kenya, and is ranked the second highest nationally3.

1.2 OCA Purpose

Western Kenya has the highest HIV prevalence in Kenya. Afya Ziwani aims to support the counties of Kisumu, Homabay, Migori, and Kisii in western Kenya to achieve the global 90-90-90 goal for HIV/AIDS service delivery. Strengthening county health systems to better plan and budget for HIV service delivery, improve the availability of appropriately skilled human resources, strengthen the distribution of quality commodities, enhance the effective use of data for decision-making, and operationalize national quality assurance and improvement mechanisms is essential if the counties are to achieve the 90-90-90 goal by 2020. To improve the sustainability of HIV/AIDS service delivery in the five counties, Afya Ziwani provides support to county and subcounty governments to strengthen health systems. The purpose of the Afya Ziwani conducted county organizational capacity assessment (OCA) process is to implement a structured approach to establish a baseline for health systems performance, develop specific and agreed upon systems strengthening interventions, and conduct measurement of systems strengthening over time.

1 Kenya National Bureau of Statistics Population Projections, 2015 2 National AIDS and STI Control Programme, Kenya HIV Estimates, 2015 3 National AIDS and STI Control Programme, Kenya HIV County Profiles, 2016 2

1.3 OCA Approach

The OCA approach used by Afya Ziwani is to facilitate counties to conduct a self-assessment framed around the USAID developed county OCA tool. The process enabled Afya Ziwani and county staff to systematically evaluate essential county health system elements in a structured manner. The OCA tool outlines eight key capacity domains of health systems: 1) governance and legislative framework, 2) service delivery; 3) human resources for health, 4) health infrastructure, 5) health products and technologies, 6) health information, 7) health financing, and 8) research and development. Each domain is further divided into standard elements that encompass critical issues identified as essential for capacity to be sufficient.

During the OCA, participants assessed the capacity of the health system in their respective counties and subcounties by reviewing the standard elements under each domain, discussing existing practice and evidence, and gaining consensus on the appropriate score for each assessed standard and domain. In order to reduce subjectivity in scoring, each standard element under each domain has 5 clearly measurable categories, scored from 0 - 4, where 0 is no capacity and 4 is high capacity. Appropriate evidence and verification was provided by the participants to support each score, and the issues underlying the scoring were identified and documented. These scores were then aggregated as an overall score, which measures the capacity of the health system. Scores for individual domains and overall capacity are presented in a dashboard using traffic lights as per the OCA Likert scale in table 1 below.

Table 1: OCA Likert scale

0% - 39% Health System has limited capacity requiring significant support

• 40% - 69% Health System has some capacity but there are areas requiring 0 additional support

70% - 100% The health system is managed well and has the capacity to deliver its mandate

During discussions, capacity issues were summarized along with any needed technical assistance, which formed the foundation of the county CDP. A local consultant and project technical advisors guided county participants through the OCA process and ensured thorough documentation of the scores, issues and the action plans.

The outcome of this process was a quantitative and qualitative baseline and a detailed action plan to guide capacity development and technical assistance over the next year to strengthen health systems. The OCA is designed to be repeated annually to assess county organizational capacity progress over time and guide ongoing systems strengthening technical assistance.

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Western Kenya has the highest HIV prevalence in the country. The USAID-funded Afya Ziwani Project aims to support the counties of Kisumu, Homabay, Migori, Nyamira and Kisii in western Kenya to achieve the global 90- 90-90 targets for HIV/AIDS service delivery. Strengthening county health systems to better plan and budget for HIV service delivery, improve the availability of appropriately skilled human resources, strengthen the distribution of quality commodities, enhance the effective use of data for decision-making and operationalize national quality assurance and improvement mechanisms is essential if the counties are to achieve the 90-90- 90 goals. To improve the sustainability of HIV/AIDS service delivery in the five counties, Afya Ziwani Project provides support to county and sub-county governments to strengthen health systems. The purpose of the Afya Ziwani county organizational capacity assessment (OCA) process is to implement a structured approach to establish a baseline for health systems performance as well as specific, agreed, systems strengthening interventions and measurement of systems strengthening over time.

1.4 OCA process description

Afya Ziwani Project conducted the participatory county OCA process for Homa Bay County and 2 Sub- Counties namely; Kasipul and Kabondo Kasipul between September 10th – 14th 2018 at the Royal City Hotel in Kisumu. A total of 27 participants were engaged in the process. Eight of the participants were Homa Bay CHMT representatives and 10 Sub-CHMT representatives were from Kasipul and Kabondo- Kasipul Sub-Counties. Nine representatives from the Afya Ziwani Project facilitated and coordinated the OCA process. Table 1 provides the names and titles of the participants.

Table 1: Participants List Name Title Work Station

County Representatives Joseph Kapundo SCHAO Homabay CHMT Edward Aseda SCAC Homabay CHMT Rose A Amoko CHRO Homabay CHMT Joshua Manase SCHRIO Homabay CHMT Paul Agwanda CHPC Homabay CHMT Dr Iscah Moth CASCO Homabay CHMT Milka Adhiambo SCCHFP Homabay CHMT

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Emmah A Oloo F.O Homabay CHMT Sub-County Representatives Margaret Akoth HRIO Kasipul Subcounty Olago Osborn SCPHARM Kasipul Subcounty Ouma Sylus SCACC Kasipul Subcounty Pamela Awuor SCPHN Kasipul Subcounty Casper Ndole SCTLC Kabondo Subcounty Christine Otieno SCHRIO Kabondo Subcounty Benard M Gichaba SCHAO Kabondo Subcounty Dickens Otieno SCCO Kabondo Subcounty Paul Mathews Otieno SPF Kabondo Subcounty Dr Ray Kajwang SCMOH Kabondo Subcounty Afya Ziwani Staff Cenan Ojunga TC Kisumu Afya Ziwani Office

Dennis Kimanzi TA HRH Kisumu Afya Ziwani Office

Dr.Linet Nyapada HSS Advisor Kisumu Afya Ziwani Office

Stephen Washington Research Assistant Kisumu Afya Ziwani Office

Sylvertone Clare Research Assistant Kisumu Afya Ziwani Office

Vincent Kisukwa Research Assistant Kisumu Afya Ziwani Office

Lilian Oronje Research Assistant Kisumu Afya Ziwani Office

Mercy Apiyo Research Assistant Kisumu Afya Ziwani Office Catherine Nderi OCA Advisor

In order to promote sharing of best practices and learning between counties, the Homa Bay OCA was conducted alongside the OCA for . Though the two counties and their respective sub-counties were organised into separate groups during the OCA, they were brought together during presentation and validation of OCA results and their CDP. This enabled the counties to learn from each other and also share best practices on actions they could take to address gaps identified.

Members of the County Health Management Team (CHMT) and subcounty representatives made themselves available throughout the 5-day workshop. On the first day, Monday 10th Sept 2018, the participants were taken through a brief overview of Afya Ziwani, as well as an overview of the OCA process and how it links to Health Systems Strengthening (HSS). Plenary discussions on the OCA and CDP tools were held on the same day, allowing the participants to give suggestions on which standard elements were applicable to the county and

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subcounties, and to give suggestions for minor adjustments to the tool. On day 2 and 3, the participants were organised into teams according to their counties and subcounties and then conducted the OCA self-assessment exercise. Team members provided crucial information regarding the strengths and weaknesses of the health systems in their respective counties and subcounties and provided scores for each of the domains. On the 4th day, participants developed CDPs for their specific counties and subcounties to address capacity needs identified through the OCA. Review, validation and presentation of scores and CDPs were done by the participants on the 5th day, Friday 14th Sept 2018. The OCA results for Homa Bay County and the 2 subcounties assessed are presented in section 2 of this report. Completed score matrices and notes on the evidence to support the scores are attached in Appendix 1, and the completed CDPs are attached in Appendix 2.

2. County OCA Key Findings and Critical Gaps

2.1 OCA Summary of Scores

This section analyses the findings and gaps identified from the OCA conducted by Homa Bay County, Kasipul and Kabondo- Kasipul Sub-Counties. Table 2 below presents a summary of the OCA scores for all the 8 domains for Homa Bay County and the 2 sub-counties assessed.

Access to HIV Governance Human Essential HIV Service Health Health Community Research and Score as Summary of OCA Results and Resources Medicines & Delivery Information Financing Health Development percentage Leadership for Health Other Health Commodities Homa Bay County 10 11 11 16 11 14 7 0 0 61% Maximum score possible 16 16 24 20 16 16 12 12 Performance score 0 63% 0 69% 0 46% 0 80% () 69% n 88% 0 58% • 0% Kasipul Sub-County 12 13 5 13 8 11 9 0 54% f------11Performance score l=-1. 75%------+::,----81% -+=-I. ---+21% b:::------r,:65% b,-----+=------+=------+=l50% 69% 75% .-t=-10% ° ---I

Kabondo-Kaispul Sub County 11 13 4 13 14 12 7 0 56% f-----~Performance score b1=- 69%------+::,-----+=-I81% . ---+17% b:::------r,:l65% ,-----+=-----+ 88% 75% b:::------+=l58% .-t=-10% ° ---I

Table 2: Summary of OCA Results

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Figure 1 below shows the overall capacity of the health system in Homa Bay County, and Kasipul and Kabondo- Kasipul subcounties under all the eight key capacity domains. Homa Bay County had the highest overall capacity, at 61%, followed by Kabondo -Kasipul Subcounty with 56%, and Kasipul Subcounty with 54%. This means that overall, the health systems in the county and subcounties have some capacity, but there are areas requiring additional support, as per the Likert Scale in Table 1 above.

Figure 1: Overall Capacity (all domains) Overall Capacity

Homa Bay County 61

Kasipul Sub-County 54

Kabondo-Kasipul Sub-County 56 Capacity Capacity in % 50 52 54 56 58 60 62 County/Sub-County

The section below gives a breakdown and analysis of each of the 8 key capacity domains. The key gaps identified through the OCA are also discussed in detail.

2.2 Domain 1: Governance and Leadership

The capacity of the Governance and Leadership health system in Homa Bay County and the 2 sub-counties is illustrated in Figure 2 below. Homa Bay County scored 63%, Kasipul Sub-County 75% and Kabondo-Kasipul 69%.

Figure 2: Governance and Leadership Governance and Leadership

Homa Bay County 63

Kasipul Sub-County - 75 Kabondo-Kasipul Sub-County 69 Capacity Capacity in % 55 60 65 70 75 80

County/Sub-County

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In regard to the availability of the legislative framework, the Homa Bay County and subcounty teams reported that they have adopted current National HIV laws, policies, guidelines, and SOP's, but dissemination of these to the subcounties through mentorship and On-the-Job Training (OJT) remains a challenge. Some of the most recent policies and guidelines are therefore yet to be disseminated to the subcounties and facilities. These include Kenya ARV guidelines 2018, HIV Testing Services 2017/2018, and PMTCT guidelines. The county has also developed a County HIV and AIDS Strategic Plan, but the implementation of the plan remains a challenge, with the plan yet to be disseminated to the subcounties. HIV related activities are mainly partner supported as the county lacks enough funds to support the same. Sensitization on performance contracting has been done through partner support, but a number of staff is yet to be sensitized. Signing of the performance contracts is yet to take place. The county reported that performance contracting targets have not yet been set by the county, and they require support to do this. Health facility management committees and hospital boards have been selected, gazetted and trained. Training of newly formed boards has not been done as the county is currently seeking support from partners for the training. The county and subcounty boards also recommended that issues of gender balance in the board’s representatives be addressed.

2.3 Domain 2: HIV Service Delivery

The variance in the scores between the county and the two sub-counties is notable, with sub-county scores being higher than county scores mainly because a number of development partners are supporting HIV service delivery at the sub-county level. Homa Bay County scored 69%, Kasipul 81% and Kabondo Kasipul: 81% as illustrated in Figure 3 below.

Figure 3: HIV Service Delivery

HIV Service Delivery

Homa Bay County 69

Kasipul Sub-County 81 -- - -- Kabondo-Kasipul Sub-County 81 ----

Capacity Capacity in % 60 65 70 75 80 85

County/Sub-County

In terms of HIV testing and care, the county reported to having about 57% of its population tested as at July 2018. Out of the tested, 74% are already enrolled for treatment. Teenage testing is still low due to the lack of youth-friendly facilities that will attract the younger population. Community HIV outreaches are not done as the county lacks adequate support to, for instance, conduct the testing at the community level. This means 8

that the testing is only done at the facility level. There were notable challenges in the stock outs of HIV essential medicines and shortages of testing kits, which in turn affects the uptake of treatment. More than 50% of the facilities in the subcounties do not have adequately trained personnel to handle HIV patients. Adherence to treatment by patients is poor, and more awareness creation and stocking of facilities with the HIV essential medicines would help curb this challenge.

The county has developed a referral strategy, which is being implemented. Referral is mainly done from community to facility, and facility to hospital. However, more awareness on facility to community referral needs to be created. Selected staff have already received training on referrals, but the tools to track the referrals are not always sufficient. In terms of support supervision, the county receives support from partners such as Afya Ziwani, but there are instances when the supervision is supported by the county department of health. The supervision is normally integrated but done in an ad hoc manner based on availability of funds to facilitate this. Service charters are available and displayed in most facilities. Suggestion boxes are also in some facilities, while others are missing. Strengthening the current Quality Improvement Teams (QITs) is needed. Other action points proposed revolved around increased advocacy for budget allocation for support supervision, training of remaining staff on referrals, and facilitation of the Community Health Volunteers (CHVs) through monthly stipends so as to strengthen the referral system.

2.4 Domain 3: Human Resources for Health (HRH)

The scores at both the county and subcounty levels were relatively low in the HRH domain. Homa Bay County had a score of 46%, while Kasipul scored 21% and Kabondo Kasipul scored 17%, as per Figure 4 below.

Figure 4: Human Resources for Health (HRH) Human Resources for Health

Homa Bay County 46

Kasipul Sub-County 21

Kabondo-Kasipul Sub-County 17 Capacity Capacity in % 0 10 20 30 40 50

County/Sub-County

The assessment revealed a number of challenges and shortcomings. The Integrated Human Resources Information System (iHRIS) has been launched and is only in use at the county level, but not within the subcounties. Staff in administrative departments has been trained on iHRIS and are using it, though not 9

adequately. iHRIS training has been carried out at the county and subcounties, but the relevant staff require refresher training and user rights to be able to use the system adequately. It was reported that the resources available to support Human Resources for Health (HRH) activities are inadequate, hence there are major gaps in the staffing and distribution of health workers in the county. The HIV services are purely supported by partners and the county does not have a budget for this. Mechanisms for rewards and incentives have not been comprehensively put in place. However, in Kasipul Subcounty, some cadres, such as the nurses’ union, have developed their own rewards mechanism, and they are already implementing it. The subcounties are also planning to develop mechanisms to award staff with trophies based on their work performance.

In regard to training, a training unit has been established at the county level but not at subcounty level. A training database has also been developed at the county level, but information on this database is not updated as regularly as required. Most trainings are done selectively and not based on information available in the database. Partners support most trainings, e.g. Kasipul team mentioned that a number of their officers have been trained on setting targets with support from Afya Ziwani. In terms of staff appraisals, only staff contracted by partners are appraised annually. To address this, the county has developed its own appraisal tools, but implementation is yet to be done. There are plans to review the HRH strategy in the course of this year, which will fast track its implementation. Schemes of service for all cadres are available and accessible through the MOH (Ministry of Health) website. Staff job descriptions are also available through a booklet that clearly stipulates roles and responsibilities of each cadre. Notably, the assessment established that performance monitoring for county HRH is being done using score cards.

2.5 Domain 4: Access to HIV Essential Medicines & Other Commodities

The capacity of the health system in regards to Access to HIV Essential Medicines & Other Commodities is illustrated in Figure 5 below with Homa Bay County scoring 80%, and Kasipul and Kabondo Kasipul each having the same score of 65%.

Figure 5: Access to HIV Essential Medicines & Other Commodities Access to HIV Essential Medicines

Homa Bay County 80

Kasipul Sub-County 65

Kabondo-Kasipul Sub-County 65 Capacity Capacity in % 0 20 40 60 80 100 County/Sub-County 10

The OCA established that the county has a commodity security team and commodity Technical Working Group (TWG) supported by a USAID implementing partner, Chemonics International. Funding for procurement of ART commodities is, however, inadequate and stock outs are experienced regularly. Ideally, procurement of commodities is supposed to be done on a quarterly basis, but most times this occurs on an annual basis. The commodity management system is being utilized at both the county and subcounty levels with some subcounties still using the manual system. The commodity management system is utilized for the stock-keeping record, consumption/usage register, transaction record, and distribution of commodities. Hence, the county requires support to cascade the electronic commodity management system to the remaining subcounties. This support is in the form of staff training and provision of the necessary infrastructure. In addition, the warehouses for storage of commodities have limited space and expansion is needed. Quality Assurance (QA) is carried out by specific individuals, mostly the officers receiving the commodities. It is requisite to include the QA function in the job descriptions of the commodity TWG members.

2.6 Domain 5: Health Information

In regard to Health Information, Homa Bay County scored 69%, Kasipul 50%, and Kabondo Kasipul: 88%, as illustrated in Figure 6 below

Figure 6: Health Information

Health Information

Homa Bay County 69

Kasipul Sub-County 50

Kabondo-Kasipul Sub-County 88 ------

Capacity Capacity in % 0 20 40 60 80 100 County/Sub-County

This domain encompasses the availability and use of information/data for planning and decision making. Overall, the Health Information Systems (HIS) policies and guidelines are available and in use at both the county and the two subcounties. Resources for this domain are mainly provided by partners. However, challenges remain in the printing and distribution of the essential reporting tools. Facility monthly data reviews

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are done on a monthly basis, but this needs to be strengthened through frequent facilitation. Infrastructure e.g. internet connectivity to aid access to the MOH District Health Information Systems (DHIS-2) database is inadequate, which leads to delays in submitting the monthly reports. The data availed is not always of good quality and training will help in equipping the HIS personnel with better skills and knowledge. The teams also require mentorship on data analysis/use so that data can be analyzed and utilized in planning and decision making, which is currently not the case.

2.7 Domain 6: Health Financing

Figure 7 below shows the capacity of the health system in relation to health Financing. Homa Bay County had the highest score of 88%, with Kasipul at 69%, and Kabondo Kasipul: 75%.

Figure 7: Health Financing

Health Financing

Homa Bay County 88

Kasipul Sub-County 69

Kabondo-Kasipul Sub-County 75 Capacity Capacity in % 0 20 40 60 80 100

County/Sub-County

Annual work plans and budgets are developed on a yearly basis as per the government planning cycle. However, there seems to be a disconnect between the county and subcounties in regard to the planning and budgeting process. In most cases the CASCO, SCASCO and some key managers in charge of departments at county and subcounty levels are not involved in the planning and budgeting process, and are therefore not aware about the HIV budget allocation and expenditure. At the county level, the budget has over 90% utilization rate on funds set aside to support HIV activities. Information on health budgets and expenditures is not updated and available on the DHIS-2, and is only captured through reporting templates available to the county and subcounties.

There have been some mechanisms on accountability that have already been established, e.g. Kasipul Subcounty reported that health facilities report their monthly expenditures to the relevant officers who review and record this information. There is, however, a gap as most in-charges in the subcounties are not trained on book keeping and accounting, and therefore lack the required skills. Both teams also reported that the process of developing the Annual Work Plans (AWPs) and budgets has become a mere routine, as the budgets are

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prepared and not implemented as per the AWPs. There is a challenge in disbursement of/receiving funds from the county to the subcounty and the little funds availed to the subcounties are inadequate and can only be used for basic utilities. The CHMT and SCHMTs identified low capacity in financial management as an area that needs to be addressed, as well as the strengthening of the health economist role to support the planning and budgeting process. In addition, increase in the overall health budget for development versus recurrent expenditures is requisite.

2.8 Domain 7: Community Health

Homa Bay County scored 58%, Kasipul 75%, and Kabondo Kasipul 58% in relation to community health, as illustrated in Figure 8 below.

Figure 8: Community Health

Community Health

Homa Bay County 58

Kasipul Sub-County 75

Kabondo-Kasipul Sub-County ------58

Capacity Capacity in % 0 10 20 30 40 50 60 70 80

County/Sub-County

The OCA established that the county has developed a Community Health Strategy (CHS). The CHS Bill has been gazetted and disseminated to the county assembly, and there are plans to disseminate it to the subcounties. Support in the form of resources to facilitate the dissemination to the subcounties is required. Other areas that require support in regard to the CHS is OJT and mentorship of staff on the implementation of the bill. It was noted that linkage between the community and the facilities occurs mainly through the Community Health Volunteers (CHVs), who play a critical role in community health. However, challenges around the CHVs are several, including: lack of stipends to support their facilitation and motivation, and low capacity on HIV service delivery/management--as only 25% have received the training and OJT required.

The reporting tools are not always sufficient, and this interferes with the reporting, which is supposed to be done on a monthly basis. Some of the tools that are inadequate are MOH 514, 513 and 100. Amidst all the challenges though, most of the CHVs are still working and helping in conducting referrals as required. In terms of the Community Units UCU) coverage in the county, it is almost 100%. Most of these CUs are, however, partner supported, which implies that if the partners leave the county, the CUs would stop functioning. This is

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because there is no adequate budget allocated by the county to support the establishment and operations of the CUs. Support supervision is irregular and requires strengthening through training and facilitation of the QITs so that the supervision is conducted more regularly, and the reports developed are used for informing decisions.

2.9 Domain 8: Research and Development

All the scores on this domain were at 0% i.e. Homa Bay County: 0%, Kasipul: 0%, and Kabondo Kasipul: 0%, as illustrated by Figure 9. This shows that there is low capacity in the research and development component in the county. The teams recommended the need for support to establish and operationalize a research committee at both the county and subcounty levels. Mentorship and OJT on research and development will aid in strengthening the committee to perform its mandate.

Figure 9: Research and Research and Development Development

Homa Bay County 0 Kasipul Sub-County 0 Kabondo-Kasipul Sub-County 0

Capacity Capacity in % 0 0.2 0.4 0.6 0.8 1

County/Sub-County

3. Emerging Capacity Gaps and Proposed Interventions

Table 4 below shows the key emerging gaps identified through the OCA and the CDPs proposed by the CHMT and SCHMTs to address these gaps.

Table 4: Emerging Capacity Gaps and Proposed Interventions HSS Pillar Proposed Capacity Development Emerging Capacity Gaps Interventions Targets for performance contracting not Lobby for support from county Governance and Leadership set. Inadequate resources for conducting and partners to support, with performance contracting and appraisals resources, for performance contracting. Support integrated supervision Support supervision conducted irregularly HIV Service delivery through availing resources and based on resources available capacity building of the teams.

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HRH management and development plan and job HRH management and development plan Human Resources for Health descriptions to be reviewed and and job descriptions not reviewed disseminated to the lower levels for implementation. Continued lobbying for additional Inadequate budget allocation to procure Access to HIV Essential funds to cater for HIV related ART commodities and provide general services. Medicines & Other Health support the HIV program.

Commodities Establish functional quality QA No QA teams for commodity management teams with clear TORs Establish a mentorship plan and No structured mentorship plan for monitor the implementation monitoring and evaluation on process. implementation of HIS policies.

Health Information Mobilize funds to support monthly Inadequate funds to support data reviews data review meetings that create monthly. a platform for feedback. Inadequate funds for HIV services and poor Advocate for implementation and implementation of the AWPs and budgets. adherence to the budgets.

Health Financing Limited capacity in planning and budgeting Training and mentorship on processes planning and budgeting required

Domesticate the CHS and develop The CHS has not been domesticated and Community Health a dissemination plan to facility disseminated. level. Research & Development No structured R&D committee with a Establish and functionalize a budget to facilitate research activities for committee to undertake research

the county validation and analysis.

4. Lessons Learned

• In order to promote sharing of best practices and learning between counties, the OCA was conducted by two counties at the same time. Though the two counties were organised into separate groups during the OCA, bringing them together during presentation and validation of OCA results and CDP enabled the counties to learn from each other and share best practices.

• Engagement with county senior health leadership at the beginning of the OCA process to discuss the OCA technical approach, tool, and process was very important as it enhanced commitment towards the process. It will also be important to engage with senior leadership during the dissemination of the OCA results and CDP to enhance ownership of the results and actions needed to address the gaps.

• Conducting the OCA at the county and subcounty Level and bringing the county and sub-county officials together to discuss HSS issues was beneficial in that it raised awareness on current HSS activities at both county and subcounty levels. Involvement of the subcounty officers in the OCA 15

process was also very important as they are directly in charge of service delivery at the subcounty level

• Sourcing, collection, and evaluating appropriate evidence during OCA is essential as it supports the verification of the scores and findings and limits response bias.

5. Recommendations

• Feedback mechanisms between the county and the subcounty seem to be inadequate and need to be enhanced to enable efficient delivery of services. In some cases, the subcounties do not know what is happening at the county level and vis-versa, e.g. some key officers at the subcounty level are not involved in the planning and budgeting process.

• It would be beneficial to harmonize the functions and roles of the county and subcounty officers with the set rules in the County Governments Act, and also to look at the implementation of the Act.

• The Public Finance Management Act sets the rules for how the government at national and county levels can raise and spend money, and therefore understanding the Act and implementing it will ensure a smoother planning and budgeting process at the county and subcounty levels.

• Health Systems Strengthening should be mainstreamed at the county, subcounty and facility levels to ensure more efficient and effective health service delivery.

6. Appendices

Appendix 1: OCA Scores – Homa Bay County and Sub-Counties

Final OCA Homa Bay County, Kasipul

Appendix 2: Capacity Development Plans – Homa Bay County and Sub-Counties

Final CDP Homa Bay County, Kasipul

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